全镜下Latarjet手术治疗复发性肩关节前脱位伴严重肩盂骨缺损的早中期疗效分析

目的观察全关节镜下Latarjet手术治疗复发性肩关节前脱位合并严重肩盂骨缺损的早中期疗效。 方法对2015年4月至2017年2月在佛山中医院收治的复发性肩关节前脱位合并严重骨缺损行全镜下Latarjet手术患者病例资料进行回顾性研究，随访资料完整的共12例，其中男性10例、女性2例，左侧7例、右侧5例，平均年龄31.89岁（19~69岁），术前前方恐惧试验均为阳性, 平均脱位14.5次（9~30次）。所有患者均是根据术前双侧肩关节三维CT扫描对比测量计算其肩盂骨缺损程度>健侧肩盂宽度的25%，术中肩关节镜下对肩盂前缘骨缺损的范围和程度二次评估，所有患者肩盂呈倒梨形，且均合并Off-track Hill-Sachs损伤，所有病例均采用全关节镜下Latarjet术式加Bankart修补术进行重建，随访时采用美国肩肘外科医师评分 （American shoulder and elbow surgeons，ASES）、肩关节功能评定法 （constant-murley-score，CMS）、Rowe评分、视觉模拟评分法（visual analogue scale，VAS）和关节主动活动度评估术后患者肩关节功能，并且通过术后CT平扫和三维重建评估喙突植骨块的位置和吸收情况。 结果所有病例术后平均随访16.6个月（13~24个月），12例患者术后均未出现再脱位，术前与末次随访时前屈上举（142.00±4.88）°和（169.50±5.56）°相比较，差异有统计学意义（t=12.50，P<0.05）；术前与末次随访时内旋至T8和T9相比较，差异无统计学意义（t=2.29，P>0.05）；术前与末次随访时平均体侧外旋（59.00±4.20）°和（52.57±2.99）°相比较，差异具有统计学意义（t=6.97，P<0.05）；术前与末次随访时平均外展90°外旋（87.29±4.72）°和（79.00±7.53）°相比较，差异具有统计学意义（t=6.35，P<0.05）；术前与末次随访时ASES评分（69.20±3.42）分和（97.90±3.51）分相比较，差异具有统计学意义（t=779.24，P<0.05）；术前与末次随访时Constant-Murley评分（90.86±1.57和（96.57±2.99）分相比较，差异具有统计学意义（t=8.40，P<0.05）；术前与末次随访时Rowe评分（39.29±7.32）分和（92.86±2.67）分相比较，差异具有统计学意义（t=17.68，P<0.05）；术前与末次随访时VAS评分（7.21±1.54）分和（4.31±2.34）分相比较，差异具有统计学意义（t=17.68，P<0.05）,术后CT检查见有2例骨块有劈裂，但位置尚好，1例骨块位置较低，最后随访时7例患者骨块上端出现I级吸收，2例出现II级骨吸收。 结论在严格掌握适应证的前提下，对于复发性肩关节前脱位合并严重骨缺损的患者，采用全镜下Latarjet手术加Bankart修补术，能较好地恢复肩关节的稳定性，且创伤小，早中期疗效好，然而由于此种手术学习曲线较长，肩关节周围结构破坏较大，远期对肩关节的影响尚需进一步随访观察。     

关节镜下自体髂骨移植治疗复发性肩关节脱位伴严重骨缺损临床及影像学结果分析

目的探讨关节镜下自体髂骨移植治疗复发性肩关节前脱位合并严重骨缺损的临床疗效及影像学结果。 方法对2016年1月至2018年12月在佛山市中医院运动医学科收治的复发性肩关节前脱位合并严重骨缺损行全镜下自体髂骨移植重建肩关节盂的患者病例资料进行回顾性研究,随访资料完整的共30例,其中男性23例、女性7例;左侧11例、右侧19例;平均年龄49.45岁（17~77岁）。术前脱位次数7~104次。所有病例均取自体髂骨移植行肩关节镜下肩盂重建术,术后通过三维CT扫描和重建评估移植骨块的位置。随访时肩关节功能和稳定性采用美国肩肘外科协会（American shoulder and elbow surgeons,ASES）评分、Constant-Murley评分、Rowe评分和关节主动活动度进行评估。 结果所有患者术后均获得随访,术后随访时间6~28个月,平均随访（17.67 ±10.17）个月,所有患者均未发生切口感染、关节腔积血及再脱位等临床并发症,其中1例患者术后出现髂骨取骨侧髂棘撕脱骨折。术前及末次随访时平均前屈上举（146.13±43.43）°和（163.23±13.21）°,平均内旋至T7和T8,平均体侧外旋为（53.91±8.60）°和（58.91±3.63）°,平均外展90°外旋（87.32±5.54）°和（88.12±6.12）°,术前和末次随访时前屈上举、体侧外旋差异具有统计学意义（P<0.05）,而平均内旋和外展90°外旋差异无统计学意义（P>0.05）;术前及末次随访时平均ASES评分为（71.32±18.12）分和（93.45±7.87）分（P<0.05）,Constant-Murley评分为（82.54±15.31）分和（92.52±7.67）分（P<0.05）,Rowe评分为（39.56±6.75）分和（94.23±7.23）分（P<0.05）。最后随访时三维CT上按4:30为骨块中心评估：良好26例、过高2例、过低2例;CT横断位按与关节盂相平评估：良好28例、偏内1例、偏外1例,所有患者均能返回运动,无脱位和不稳感。 结论关节镜下自体髂骨移植重建肩关节盂是治疗合并严重骨缺损的复发性肩关节前脱位的有效方法,镜下髂骨移植操作简便、安全,是复发性肩关节脱位的终极解决方案。     

关节镜下改良弹性固定Latarjet术治疗一例慢性锁定性肩关节前脱位

目的总结关节镜下改良弹性固定Latarjet术治疗1例慢性锁定性肩关节前脱位的经验。方法 2016年7月收治1例因摔伤致右肩疼痛、畸形、活动受限8周的49岁男性患者。伤后曾于外院行肩关节复位,未成功。术前美国肩肘外科协会(ASES)评分22分,肩关节功能Constant-Murley评分37分,疼痛视觉模拟评分(VAS)8分。影像学检查示右肩关节锁定性前脱位、肩袖损伤、Hill-Sachs损伤。术前诊断右肩关节慢性锁定性前脱位伴肩袖损伤。全关节镜下彻底松解关节盂、肱骨头、肩胛下肌腱周围及肱三头肌止点软组织,关节复位后以改良双袢法弹性固定Latarjet术。结果术后切口Ⅰ期愈合,无重要血管及神经损伤等并发症发生。患者获随访24个月。影像学复查示盂肱关节恢复正常对位关系,无脱位复发。右肩关节功能恢复正常,24个月时ASES评分及Constant-Murley评分均为94分。结论关节镜下改良弹性固定Latarjet术治疗慢性锁定性肩关节前脱位疗效满意。     

关节镜下复位联合有限切开改良McLaughlin术治疗肩关节后脱位合并反Hill-Sachs损伤

目的 观察关节镜下复位联合有限切开改良McLaughlin术治疗肩关节后脱位合并反Hill-Sachs损伤（肱骨头前方压缩性骨折）的临床疗效。方法 回顾性分析自2017-10—2020-06诊治的8例肩关节后脱位合并反Hill-Sachs损伤,采用关节镜下复位联合有限切开改良McLaughlin术治疗。牵引下经关节镜后下入路用交换棒复位肱骨头,探查并处理后方盂唇、盂肱关节软骨面及肩袖组织损伤,将带有肩胛下肌腱的肱骨小结节撕脱骨折块转位用2枚空心钉固定在反Hill-Sachs缺损部位,外旋位缝合肩袖间隙,将肱二头肌长头腱复位至结节间沟,修复横韧带。结果 8例均获得随访,随访时间20～26个月,平均24.2个月。随访期间均未出现肩关节脱位复发情况,1例出现轻度创伤性关节炎表现。末次随访时肩关节UCLA评分为28～32分,平均29.8分;肩关节功能Constant-Murley评分为78～82分,平均79.6分。末次随访时肩关节前屈活动度为150°～170°,平均159.8°;外展活动度为125°～148°,平均135.8°;外旋（中立位）活动度为40°～50°,平均45.1°。结论 采用关...     

关节镜下双袢法Latarjet手术后喙突骨块塑形的研究

目的应用CT观察关节镜下双袢法Latarjet术后喙突骨块塑形变化过程，报道一种新的不同于传统螺钉固定Latarjet术后喙突骨块的塑形方式。 方法2014年10月至2016年10月，70例肩关节复发性前脱位患者接受了关节镜下双袢法Latarjet手术治疗。根据术后CT上喙突骨块与关节盂平面的水平关系分为：高于关节盂平面组（A组，n=28）和与关节盂平面相平或低于关节面5 mm以内组（B组，n=42）。所有患者术后1个月、3个月、6个月和12个月时进行CT检查并观察喙突骨块的塑形过程。随访时肩关节功能采用美国肩肘外科协会评分（American shoulder and elbow surgeons，ASES）和ROWE评分系统进行功能评估。 结果1例患者在术后6个月失访。从CT横断面观察，A组患者高于关节面的骨质被吸收，最终与关节面呈同心圆的弧形，均达到骨性愈合，未出现肱骨头与喙突骨块撞击形成的盂肱关节骨关节炎。B组骨块外缘与关节盂距离随着时间延长有轻度的吸收，平均（0.32±1.10）mm，最终也为骨性愈合，未出现盂肱关节骨关节炎。从CT三维重建en-face面观察，A组和B组 喙突骨块上下缘均发骨痂形成，骨块-关节盂之间的骨质相互融合现象，多余的骨质被吸收，形成与健侧关节盂"梨"形结构类似的形态。所有患者术后随访时间12~24个月，平均（14.0±2.8）个月，所有患者均恢复正常生活，无再脱位和不稳感，恐惧试验和再复位试验阴性。61例（90%）患者可进行剧烈对抗运动。A组术前及终末随访时平均ASES评分为（60.8±18.1）分和（90.7±15.5）分（P<0.01），ROWE评分为（48.4±10.5）分和（88.6±17.5）分（P<0.01）。B组术前及终末随访时平均ASES评分为（58.7±13.2）分和（85.4±17.8）分（P<0.01），ROWE评分为（40.4±9.8）分和（87.3±15.4）分（P<0.01）。 结论关节镜下双袢法Latarjet手术后喙突骨块的塑形过程不同于螺钉固定法。喙突骨块放置高于（偏外）关节盂平面后，高于关节面的骨质逐渐被吸收，最终形成与肱骨头同圆的弧形关节盂，不会发生撞击而导致肩关节退变；喙突骨块的上下缘产生大量骨痂形成与骨构建，趋向于形成en-face面正常关节盂"梨"形态。     

MIPPO技术联合PHILOS治疗Neer 2部分肱骨近端骨折的疗效分析

目的探讨微创经皮钢板内固定（minimally invasive percutaneous plate osteosynthesis,MIPPO）技术联合肱骨近端锁定钢板内固定（proximal humerus internal lockingrn osteosynthesis system,PHILOS）治疗Neer 2部分肱骨近端骨折的疗效。 方法纳入自2014年1月至2016年3月,使用PHILOS治疗并获得1年及以上随访的20例患者研究。2部分外科颈骨折10例,男5例,女5例,平均年龄（42.10±13.79）岁;2部分大结节骨折10例,其中男7例,女3例,平均年龄（49.80±8.13）岁。所有骨折均为闭合性骨折。术后定期复查并记录患者肩关节功能,影像学检查复位效果及愈合情况。用美国肩肘外科协会评分（rating scale of the American shoulder and elbow surgeons,ASES）、Constant-Murley评分及视觉模拟评分法（visual analogue scale,VAS）等指标评价肩关节功能。采用SPSS 22.0软件对数据进行分析,以P<0.05为差异有统计学意义。 结果20例患者获得12~24个月的随访,平均（15.50±9.66）（12~24）个月,其中外科颈骨折患者随访平均时间为（14.40±10.88）（12~24）个月,大结节骨折患者随访时间平均为（16.05±7.92）（12~24）个月。2部分外科颈骨折与2部分大结节骨折患者手术时间分别为（120.50±27.43）（90~160）min和（133.90±46.41）（60~200）min （P=0.442）;骨折愈合时间分别为（2.25±0.54）（1.5~3.0）个月和（2.60±0.81）（1.5~4.0）个月（P=0.270）;VAS评分分别为（0.40±0.52）（0~1）分和（0.50±0.53）（0~1）分（P=0.673）;ASES评分分别为（94.64±3.31）（90.0~98.3）分和（91.65±5.76）（85.0~98.3）分（P=0.172）;Constant-Murley评分分别为（95.10±3.12）（91~99）分和（92.60±5.62）（83.5~99.0）分（P=0.235）;术后前屈上举角度平均为（174.00°±5.16°）（170°~180°）和（167.00°±9.49°）（150°~180°）（P=0.055）,外旋角度分别为（43.00°±8.23°）（30°~50°）和（34.00±10.75）（20°~50°）（P=0.050）,外展角度平均为（158.00°±13.98°）（130°~180°）和（149.00°±19.69°）（110°~170°）（P=0.254）。 结论2部分肱骨近端骨折采用MIPPO技术联合PHILOS治疗收到了良好的效果,在2部分外科颈与2部分大结节骨折病例中,在术后外旋角度恢复方面前者与后者差异有明显的统计学意义,但在手术时间、性别、年龄及其他术后恢复情况,差异无统计学意义。     

半肩置换治疗老年肱骨近端骨折疗效分析

目的分析应用半肩关节置换术治疗老年肱骨近端NeerⅢ、Ⅳ部分骨折的手术方法及临床疗效。 方法纳入2012年1月至2016年1月应用半肩关节置换术治疗的老年肱骨近端NeerⅢ、Ⅳ部分骨折患者进行回顾性分析,排除病理性骨折。对术后8周、12周及48周疼痛视觉模拟评分(VAS)和Constant-Murley评分以及肩关节主动活动度进行分析。采用ANOVA单因素方差分析比较组间结果,以P<0.05为差异具有统计学意义。 结果共纳入27例患者并均获得随访,年龄平均(70.3±5.5)岁,其中3部分骨折11例(包括4例肩关节脱位),4部分骨折16例(包括12例肩关节脱位),随访时间平均(25±6)个月。术后48周随访VAS评分(1.3±0.7)分;Constant-Murley评分(81.2±5.7)分,肩关节平均活动范围：前屈上举(113±15)°,外展(97±4)°,内旋(50±13)°,外旋(39±12)°,后伸(42±14)°。所有患者术后无神经损伤、异位骨化及感染等并发症发生。 结论半肩关节置换术是治疗老年肱骨近端NeerⅢ、Ⅳ部分骨折的有效方法,成功的关键在于术中准确的重建肱骨长度,有效地修复损伤的肩袖以及术后长期、规范的康复训练。     

改良关节镜双袢法Latarjet术治疗严重骨缺损的复发性肩关节前脱位

目的研究改良关节镜双袢法Latarjet术治疗严重骨缺损的复发性肩关节前脱位的临床疗效并评估喙突骨块的位置和愈合情况。 方法2014年10月至2016年10月,深圳大学第一附属医院共收治50例严重伴骨缺损的复发性肩关节前脱位的患者,年龄15~45岁,平均（27.2±2.1）岁,接受了三入路双袢防旋转固定关节镜下Latarjet手术。通过术后三维CT扫描观察喙突骨块位置及愈合情况。随访时肩关节功能采用美国肩肘外科评分（Amreican shoulder and elbow surgeons,ASES）、ROWE和Walch-Duplay评分系统进行功能评估。 结果所有患者术后均得到随访,随访时间6~24个月,平均（13.2±3.6）个月,49例患者恢复良好,1例患者因为骨块分离需要进行再次手术固定。骨块位置情况：三维CT上按4:30为骨块中心评估,良好45例、过高2例、过低3例;CT横断位按与关节盂相平评估：良好43例、偏内1例、偏外6例。骨块吸收情况：术后骨块吸收稳定时间2~6个月,平均（3.3±0.6）个月,骨块吸收比率15%~60%,平均（27.5±3.8）%。术后无神经损伤并发症,所有患者在最后随访时骨块均愈合（包括1例翻修）。终末随访时所有患者无主观不稳,客观检查（恐惧试验/再复位试验）阴性。术后ASES评分、ROWE评分和Walch-Duplay评分较术前得到明显改善：ASES评分为（80.2±16.2）分vs.（95.2±5.6）分（P <0.05）,ROWE评分为（40.2±9.8）分vs.（94.5±2.7）分（P <0.05）,Walch-Duplay评分为（67.5±10.2）分vs.（95.6±3.2）分（P <0.05）。 结论改良关节镜下双袢法Latarjet术治疗严重伴有骨缺损的复发性肩关节前脱位操作简便,术后喙突骨块位置良好、愈合率高,无神经损伤等并发症,术后临床疗效满意,可作为传统Latarjet术的可靠有效的替代方法。     

关节镜下自体髂骨植骨治疗伴骨缺损的创伤性复发性肩关节前向不稳

肩关节肱骨头较大而肩胛盂较小,在拥有较大活动度的同时也容易出现不稳。在创伤性肩关节前向不稳中,Bankart损伤是其最常见的病理改变,主要表现为肩关节前下盂肱韧带复合体损伤,通常可采用关节镜下Bankart损伤修复术进行治疗。Karlsson等应用传统关节镜技术治疗肩关节前向不稳的术后复发率为15%,而Kim等采用现代关节镜手术（缝合锚钉技术）治疗肩关节前向不稳的术后复发率为5%。Tauber、Burkhart、Boileau等认为Bankart损伤修复失败的主要原因为肩关节存在较大的骨性缺损。Itoi等提出当肩胛盂骨缺损超过其宽度的21%时,单纯修复Bankart损伤可能会引起术后肩关节不稳复发及活动度受限。Yamamoto等提出肩胛盂轨迹（Glenoid Track）的概念,强调除Bankart损伤外,对肩胛盂骨缺损和Hill-Sachs损伤等骨性缺损也应给予处理,否则术后复发率高。可分析肩胛盂、Hill-Sachs损伤的骨缺损程度,结合ISIS评分选择合理的治疗方案。根据移植物和固定方式的不同,有镜下髂骨植骨、镜下喙突转位等多种成熟的手术方式。我们运用的关节镜下自体髂骨植骨术适用于单纯肩胛盂骨缺损程度>20%,或肩胛盂骨缺损程度在10%~20%,但伴有明显的Hill-Sachs损伤及术后存在较高再复发风险的患者,也可应用于单纯Bankart修复术后肩关节不稳复发的患者。2013年3月至2017年1月,共入组采用该术式的患者24例,其中男18例,女6例,平均年龄24.9岁,平均随访时间28.6（12~48）个月。临床结果显示,术前ASES、Constant和Rowe评分分别为（78.8±7.6）、（74.2±11.7）和（39.9±8.20）分;末次随访时以上评分分别为（90.3±3.1）、（94.0±5.5）和（87.2±6.9）分。术前与术后评分的差异具有统计学意义（P<0.01）,且骨块愈合率为100%,无脱位和不稳复发的患者。但文献报道关节镜下手术可能存在骨块固定位置不理想、骨块骨折、神经损伤、感染、骨不连和骨溶解等问题。     

自体髂骨移植肱骨头重建内固定治疗肩关节后脱位反Hill-Sachs损伤

目的分析自体髂骨移植肱骨头重建内固定治疗肩关节后脱位反Hill-Sachs损伤的临床疗效。方法回顾性分析自2016-01—2020-01采用自体髂骨移植重建肱骨头内固定治疗的5例肩关节后脱位伴反Hill-Sachs损伤,术中取自体大块髂骨,经修整后植入骨缺损处,充分植骨后使用Herber钉及空心钉固定。结果 5例均顺利完成手术并获得完整随访,随访时间12～36个月,平均24.4个月。末次随访时X线片显示肱骨头植骨愈合良好无塌陷,未见骨质吸收,盂肱关节无关节炎表现。5例肩关节功能恢复良好,各方向活动较术前明显好转。末次随访时肩关节活动度前屈136.5°～157.2°,平均145.7°;外展121.3°～150.1°,平均142.8°;外旋33.6°～50.1°,平均41.0°;Constant评分82～91分,平均85.8分;按Neer功能评分评价疗效:优1例,良4例。结论自体髂骨移植肱骨头重建内固定治疗肩关节后脱位反Hill-Sachs损伤能够重建肱骨头形态,配合术后规律的康复锻炼能获得良好的临床疗效。     

Hill-Sachs Remplissage手术治疗骨缺损性复发性肩关节前脱位

目的 探讨关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗存在明显骨缺损的复发性肩关节前脱位的疗效.方法 回顾性分析随访2年以上的应用关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗的复发性肩关节前脱位49例患者的病例资料,男42例,女7例;接受手术时年龄16.7～54.7岁,平均28.4岁.49例均为单向不稳定,合并明显的肩盂骨性损伤及巨大的Hill-Sachs损伤.术中采用金属缝合锚钉行Bankart修补,辅助后方冈下肌腱固定填充Hill-Sachs损伤.全部病例随访24～35个月,平均29.0个月,随访时采用ASES评分、Constant-Murley评分、Rowe评分进行功能评估,观察肩关节活动度变化.结果 术前及终末随访时肩关节平均前屈上举162.9°±17.1°和170.9°±7.4°(P=0.007),平均体侧外旋56.0°±17.6°和54.1°±17.1°(P=0.511);ASES评分为(84.7±11.3)分和(96.0±3.4)分(P=0.000),Constant-Murley评分为(93.3±8.7)分和(97.8±3.6)分(P=0.005),Rowe评分为(36.8±8.5)分和(89.8±12.5)分(P=0.000).终末随访时1例患者出现复发脱位,3例患者出现半脱位,失效率8.2%(4/49).此4例患者恐惧试验阳性.结论 肩关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术是治疗存在明显骨缺损的复发性肩关节前脱位的有效方法之一.手术适应证的正确选择、熟练的关节镜下操作技术以及术后长期、严格的功能康复锻炼是手术成功的关键.

Abstract：

Objective The purpose of our study was to report the results of using arthroscopic Remplissage and Bankart repair in patients who had an engaging Hill-Sachs lesion with significant glenoid bone loss. Methods We retrospectively reviewed 49 consecutive patients who underwent arthroscopic Remplissage and Bankart repair for anterior shoulder instability with a mean duration of follow-up of 29.0 months (24-35 months). At the time of surgery the mean age of 42 men and 7 women was 28.4 years. All patients were diagnosed as recurrent anterior shoulder dislocation with a bony lesion of glenoid and an engaging HillSachs lesion. An arthroscopic Remplissage and Bankart repair using metal anchor was performed in all cases.ASES score, Constant-Murley score and Rowe score were used to evaluate the stability and the function of the shoulder. Results Patients' active forward elevation significantly(P=0.007) improved from 162.9°±17.1°preoperatively to 170.9°±7.4° at final follow-up. The external rotation was 56.0°±17.6° before the surgery compared with the 54.1°±17.1° postoperatively(P=0.511 ). The ASES score, Constant-Murley score and Rowe score was 84.7±11.3, 93.3±8.7 and 36.8±8.5 preoperatively compared with 96.0±3.4, 97.8±3.6 and 89.8±12.5 postoperatively. Significant difference could be found with regard to ASES score (P=0.000), ConstantMurley score (P=0.005) and Rowe score (P=0.000). One redislocation happened and a subluxation was noticed in three patients (8.3%). Conclusion Arthroscopic Remplissage combined with Bankart repair can achieve satisfactory for recurrent anterior shoulder dislocation accompany with engaging Hill-Sachs lesion.     

Remplissage Versus Latarjet for Engaging Hill-Sachs Defects Without Substantial Glenoid Bone Loss: A Biomechanical Comparison

Background

Recurrent shoulder instability is commonly associated with Hill-Sachs defects. These defects may engage the glenoid rim, contributing to glenohumeral dislocation. Two treatment options to manage engaging Hill-Sachs defects are the remplissage procedure, which fills the defect with soft tissue, and the Latarjet procedure, which increases glenoid arc length. Little evidence exists to support one over the other.

Questions/purposes

We performed a biomechanical comparison of the remplissage procedure to the traditional Latarjet coracoid transfer for management of engaging Hill-Sachs defects in terms of joint stiffness (resistance to anterior translation), ROM, and frequency of dislocation.

Methods

Eight cadaveric specimens were tested on a shoulder instability simulator. Testing was performed with a 25% Hill-Sachs defect with an intact glenoid and after remplissage and Latarjet procedures. Joint stiffness, internal-external rotation ROM, and frequency of dislocation were assessed. Additionally, horizontal extension ROM was measured in composite glenohumeral abduction.

Results

After remplissage, stiffness increased in adduction with neutral rotation (12.7 ± 3.7 N/mm) relative to the Hill-Sachs defect state (8.7 ± 3.3 N/mm; p = 0.016). The Latarjet procedure did not affect joint stiffness (p = 1.0). Internal-external rotation ROM was reduced in abduction after the Latarjet procedure (49° ± 14°) compared with the Hill-Sachs defect state (69° ± 17°) (p = 0.009). Horizontal extension was reduced after remplissage (16° ± 12°) relative to the Hill-Sachs defect state (34° ± 8°) (p = 0.038). With the numbers available, there was no difference between the procedures in terms of the frequency of dislocation after reconstruction: 84% of specimens (27 of 32 testing scenarios) stabilized after remplissage, while 94% of specimens (30 of 32 testing scenarios) stabilized after the Latarjet procedure.

Conclusions

Both procedures proved effective in reducing the frequency of dislocation in a 25% Hill-Sachs defect model, while neither procedure consistently altered joint stiffness.

Clinical Relevance

In the treatment of shoulder instability with a humeral head bone defect and an intact glenoid rim, this study supports the use of both the remplissage and Latarjet procedures. Clinical studies and larger cadaveric studies powered to detect differences in instability rates are needed to evaluate these procedures in terms of their comparative efficacy at preventing dislocation, as any differences between them seem likely to be small.     

复发性肩关节前脱位关节镜手术治疗进展

复发性肩关节前脱位的手术治疗是运动损伤医学领域中的一个难题,其主要原因在于无法较好地恢复肩关节动力性及骨性约束。目前国内外大多采用关节镜手术治疗,术后总体效果满意,但具体术式的选择仍存在较大争议。临床中需根据关节盂及肱骨头骨性缺损的有无及大小,选择不同方案治疗。笔者建议:无关节盂骨性缺损或关节盂骨性缺损20%,选用Bankart术;关节盂骨性缺损20%伴Hill-Sachs骨性缺损40%,选用Bankart术联合Remplissage术或ASA术;关节盂骨性缺损20%～25%,选用"Sling"术;关节盂骨性缺损25%～40%,选用Bristow-Latarjet术;关节盂或Hill-Sachs骨性缺损40%或Bristow-Latarjet术修复失败,选用骨移植术。此外,若存在盂肱韧带肱骨撕脱(humeral avulsion of glenohumeral ligaments,HAGL)损伤,则选用HAGL损伤修复术。除考虑骨性缺损这一重要因素外,还需结合患者年龄、运动水平及术者技术来综合选择最佳术式。     

Frische und habituelle Luxationen des Schultergelenkes

In case of the most common anterior-inferior dislocation of the shoulder joint the humeral head is forced out of the glenoidal cavity and tears the capsule. In about 20% of cases the dislocation is complicated by tears of the rotatory cuff, avulsion fractures and lesions of vessels and nerves. Reduction as soon as possible according to the method of Arlt or Hippokrates is recommended to avoid further damage. X-ray examination in 2 directions is necessary to confirm the position of the head. Clinical examination must be done to detect lesions of nerves or vessels caused by the procedure. In cases of recurrent dislocation a Hill-Sachs lesion and/or a Bankart lesion is responsible for instability of the shoulder joint. The elevation of the margin of the glenoid by autologous bone grafting (Eden-Hybinette, Trillat) and/or the derotation of the humeral head (Weber) reliably avoids redislocation. Except rare infections no severe complications are known. The operative correction of the severe disability should be recommended to all patients suffering from recurrent dislocation of shoulder joint.     

Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.     

Pathomorphologie der Schulterinstabilität

In cases of a traumatic anterior first-time dislocation of the shoulder, pathomorphological changes may initially occur at three different sites: at the capsule itself, at its origin or at its insertion. The typical injury is an avulsion of the labrum and the capsule from the glenoid and is called a Bankart lesion. There is a tendency to underestimate the amount of plastic deformation of the capsule and alternative injuries, such as avulsion of the capsule from the humeral head (HAGL lesion). Bony deformities at the humeral head or at the glenoid are of utmost importance for the prognosis of shoulder instability. In the dislocated position the anterior glenoid rim may notch the posterior surface of the humeral head (Hill-Sachs lesion). Bony defects of the glenoid may be caused by a fracture or due to chronic wear (fracture or erosion type). If bony defects exceed a certain size, isolated reconstruction of soft tissues does not guarantee stability of the shoulder.     

Osseous Defects Seen in Patients with Anterior Shoulder Instability

Shoulder surgeons need to be aware of the critical size of the glenoid or humeral osseous defects seen in patients with anterior shoulder instability, since the considerable size of osseous defect is reported to cause postoperative instability. Biomechanical studies have identified the size of the osseous defect which affects stability. Since engagement always occurs between a Hill-Sachs lesion and the glenoid rim, when considering the critical size of the Hill-Sachs lesion, we have to simultaneously consider the size of the glenoid osseous defect. With the newly developed concept of the glenoid track, we are able to evaluate whether a large Hill-Sachs lesion is an "on-track" or "off-track" lesion, and to consider both osseous defects together. In case of an off-track Hill-Sachs lesion, if the glenoid defect is less than 25%, no treatment is required. In this case, the Latarjet procedure or arthroscopic remplissage procedure can be a treatment option. However, if the glenoid defect is more than 25%, treatment such as bone grafting is required. This will convert an off-track lesion to an on-track lesion. After the bone graft or Latarjet procedure, if the Hill-Sachs lesion persists as off-track, then further treatment is necessitated. In case with an on-track Hill-Sachs lesion and a less than 25% glenoid defect, arthroscopic Bankart repair alone is enough.     

关节镜下Bankart损伤修复联合Remplissage填塞术治疗合并Hill-Sachs缺损的成年人复发性肩关节前脱位

目的:探讨关节镜下Bankart损伤修补术联合Remplissage填塞术治疗复发性肩关节前脱位合并Hill-Sachs损伤的方法和临床疗效.方法:回顾性分析2016年3月至2019年3月行关节镜下Bankart损伤修复治疗关节盂骨缺损＜20％的复发性肩关节前脱位患者106例,其中男76例,女30例;年龄18～45(2...     

The roentgenographic evaluation of anterior shoulder instability

Retrospective evaluations of roentgenograms of 83 patients with unilateral shoulder instability were surveyed to evaluate the usefulness of various radiographic projections and to correlate the information with the osseous pathology associated with prior glenohumeral dislocation. The Hill-Sachs and the osseous Bankart defects were considered pathognomonic radiographic signs of glenohumeral joint instability. Based on history, physical examination, and examination under general anesthesia, patients were divided into three categories--(1) dislocation group, (2) subluxation group, and (3) combination group. Roentgen projections evaluated included the anteroposterior view with the humerus in internal and external rotation, axillary view, West Point view, Stryker notch, and Didiee view. The Hill-Sachs defect on the posterolateral aspect of the humeral head was best demonstrated on the combination of an internal rotation and a Stryker notch view. The osseous Bankart defect on the anteroinferior glenoid rim was best documented on the Didiee and West Point views. The external rotation and axillary view did not add significantly to the preoperative radiographic findings. In a patient with an unstable shoulder, a radiographic series that includes an internal rotation, a Stryker notch view, and either a West Point or a Didiee view would maximize the diagnostic yield per radiographic cost, time, and exposure.