肩关节后方不稳的诊疗现状

肩关节后方不稳发生率明显低于前方不稳,但是临床上诊疗难度大,误诊和漏诊率较高。其病因、临床表现治疗策略与前方不稳完全不同。因此,深入认识肩关节周围解剖结构、掌握检查方法、基于解剖和受伤方式对肩不稳进行分型对提高诊断准确率具有关键作用。CT三维重建对肱骨头及肩盂骨缺损的评估和核磁共振造影(magnetic resonance angiography,MRA)对于后方盂唇及关节囊病变评估有助于精确诊断。治疗方法分为保守治疗及手术治疗。对肌性不稳建议保守治疗。创伤性及发育不良性不稳建议手术治疗,具体根据肩盂侧或肱骨头侧损伤行不同术式。肩盂侧损伤根据骨缺损情况行软组织手术、植骨手术或截骨手术来重建后方稳定结构;肱骨头侧缺损则根据前方骨缺损面积行植骨术或肩胛下肌填塞术。手术方式有开放手术和关节镜手术,前者优势在于学习曲线短,固定牢固;后者优势在于微创操作及可以多角度观察病变部位并精确控制骨块位置。本文对将上述问题加以综述。

Current diagnosis and treatment of posterior shoulder instability

The incidence of posterior instability of shoulder joint was significantly lower than that of anterior instability,but the clinical diagnosis and treatment was difficult,and the misdiagnosis and missed diagnosis rate were high. Its etiology,clinical manifestation and treatment strategy are totally different from the anterior instability. Therefore,the deep understanding of the anatomical structure around the shoulder joint,the mastery of the examination method,and the classification of the shoulder instability based on the anatomy and injury mode are of great importance to improve the accuracy of diagnosis. CT three-dimensional reconstruction is helpful to evaluate the defect of humeral head and glenoid bone,and MRA is helpful for the accurate diagnosis of posterior glenoid lip and joint capsule. The treatment was divided into conservative treatment and surgical treatment. Conservative treatment is recommended for muscular instability. Surgical treatment is recommended for traumatic and dysplastic instability. Different operative methods should be performed according to the injury of glenoid side or humeral head side. According to the condition of bone defect,soft tissue operation,bone grafting or osteotomy were performed to reconstruct the posterior stable structure of the glenoid injury; according to the area of the anterior bone defect,bone grafting or subscapular muscle packing were performed to the head of humerus defect. The former has the advantages of short learning curve and firm fixation,while the latter has the advantages of minimally invasive operation and the ability to observe the lesions from multiple angles and accurately control the location of bone masses. This paper summarizes the above problems.