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大学・研究所にある論文を検索できる 「腱板修復困難例に対する反転型人工肩関節置換術後と上方関節包再建術後の肩挙上時における筋活動解析：Positron Emission Tomography（PET）による検討」の論文概要。リケラボ論文検索は、全国の大学リポジトリにある学位論文・教授論文を一括検索できる論文検索サービスです。
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腱板修復困難例に対する反転型人工肩関節置換術後と上方関節包再建術後の肩挙上時における筋活動解析：Positron Emission Tomography（PET）による検討

品川 清嗣 東北大学

2021.03.25

概要

背景
肩関節における最も重要な動作の一つが上肢の挙上動作であり、特に肩甲骨面での挙上動作は三角筋や腱板構成筋群にかかる負担が少なく、日常で最も使われる動作である。腱板断裂は、中高年者において肩痛を生じる代表的疾患である。安静時や運動時における痛みや挙上困難のみならず、睡眠障害を起こすほど強い夜間痛を訴える患者も稀ではない。治療においては、保存治療が奏功しない場合は手術治療が選択されるが、断裂が大きいものや腱板筋群の脂肪変性が強い症例では修復後の機能改善が悪く、また再断裂率が高いことから未だ様々な方法が議論されている。近年、そのような症例に対し、反転型人工肩関節置換術や上方関節包再建術が選択肢として注目されている。しかし、これらの術後の肩周囲筋の筋活動について生体で網羅的に評価した研究は報告されていない。
　これまで、肩周囲筋の筋活動評価には筋電図が用いられてきた。しかし、針電極による侵襲を伴うこと、再現性が低いこと、深部に存在する筋の評価が困難であること、一つの骨格筋内の限られた領域しか評価できないこと、運動時痛を生じるため運動の制限が生じてしまうことなどの欠点が指摘されている。一方、positron emission tomography(PET)を用いた筋活動の評価法では、糖代謝の観点から筋活動の網羅的な定量評価が可能で再現性が高いことから、これまで正常肩の挙上運動や内外旋運動、腱板断裂症例における挙上運動の筋活動評価が行われている。

目的
　本研究の目的は、腱板断裂に対する反転型人工肩関節置換術や上方関節包再建術の術後症例における肩挙上運動時の肩周囲筋の筋活動を、PETを用いて明らかにすることである。

方法
対象症例
　腱板断裂に対して反転型人工肩関節置換術もしくは上方関節包再建術を行い術後1〜2年経過した症例のうち、本研究に参加し書面での同意が得られた患者を対象とした。除外症例は、①糖尿病・糖尿病関連疾患のある患者、②絶食や運動などのプロトコールを遂行できない患者とした。対象症例の対側において、肩痛の既往がなく腱板断裂がなかった肩を対照（正常群）とした。
PET投与前は最低12時間の絶食を行い、18F-fluoro-deoxyglucose（18F-FDG）投与前30分から、肩甲骨面（冠状面から30˚前方に傾いた面）における両上肢挙上運動をそれぞれ10分間行った。運動の内訳は、毎秒90˚の速さで挙上と下降を20回ずつ行う計40秒間の反復運動と、20秒間の休憩からなる1分間を1セットとし、10セット（計10分間、200回）とした。18F-FDGは約2mCi（75MBq）分注して経静脈投与し、投与後に再度前述の挙上運動を10分間行い、投与後50分の時点でPETスキャンを行った。得られたPET画像はCT/MRIと重ね合わせを行い、16箇所の筋区画それぞれのstandard uptake valueを算出して3群間で比較検討した。

結果
3群間のstandard uptake valueを比較すると、反転型人工肩関節置換術群、上方関節包再建術群の両群ともに、三角筋前・中・後部の全区画において正常群より有意に高い値を示していた。中でも、反転型人工肩関節置換術群では三角筋前部線維において高値だった。肩甲骨周囲筋については、僧帽筋上部線維では反転型人工肩関節置換術群では正常群より有意に高く、前鋸筋と肩甲挙筋では反転型人工肩関節置換術群では上方関節包再建術群や正常群と比べて有意に高値だった。また、上腕二頭筋短頭/烏口腕筋も反転型人工肩関節置換術群では上方関節包再建術群や正常群に比べて有意に高い値だった。

考察・結論
本研究では、腱板修復術が困難な腱板断裂患者に対して選択肢の一つとなっている反転型人工肩関節置換術や上方関節包再建術の術後における筋活動を、18F-FDG-PETを用いることで生体において評価することができた。正常肩における挙上運動は三角筋と棘上筋の筋活動が重要であると考えられているが、両再建術において、正常肩と比較して断裂した棘上筋の筋活動が低下し三角筋の筋活動の増加がみられたことより、挙上運動において三角筋が中心となっていることや三角筋にかかる負荷が大きいことがわかった。反転型人工肩関節においては、三角筋のみを考えると術後にモーメントアームや三角筋長が増加することで効率的に動かせるようになるため三角筋が少ない筋活動で挙上を可能にするとされているが、肩全体として考えると挙上運動での三角筋の筋活動負荷が大きくなっているものと考えられる。また、反転型人工肩関節置換術において肩甲骨周囲筋の筋活動が増加していることより、挙上運動において肩甲胸郭関節の関与が大きくなることや、正常肩や上方関節包再建術と比べて三角筋前方線維が重要である可能性や、これまでに報告されている合併症に対して再建術後の各筋の筋活動変化が影響している可能性が示唆された。

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