重新认识肩关节骨折脱位

创伤性肩关节脱位合并骨折临床常见,可导致肩关节不稳定,在处理骨折的同时应注意检查肩关节软组织结构是否有损伤。Bankart损伤是指肩关节盂唇前下方在前下盂肱韧带复合体附着处的撕脱性损伤,多由肩关节前脱位引起,是造成习惯性前方不稳定和脱臼的常见损伤。Bankart损伤经常发生关节囊的异常,多数患者会有前下盂肱韧带复合体的延长及松弛。由于盂肱韧带复合体在维持肩关节稳定中起重要作用,当患者首次脱位时年龄30岁,再次脱位的可能性80%,建议手术治疗。目前经典的修复方式是肩关节镜下修补撕裂的韧带及盂唇。对于骨性Bankart损伤应引起大家的重视,这种损伤下盂肱韧带盂唇复合体损伤同时伴有关节盂前下方的撕脱性骨折。由于关节盂前下方的骨质缺损,可以导致梨形的肩盂变为"倒梨形"结构(inverted pear),是出现肩关节不稳的主要因素。当肩胛盂骨性结构缺损25%时,单纯依靠软组织重建,往往不能达到稳定,应进行肩胛盂骨性结构重建。常用的修复方法有Latarjet手术,异体肩胛骨移植等。对于创伤性肩关节脱位的患者,应注意排除有无肩袖损伤、Bankart损伤、大结节骨折等。对于年轻肩关节脱位患者,应着重关注患者肩胛盂前下方结构有无损伤,而老年患者应注意排除后上方大结节、肩袖等有无损伤。     

游离骨移植治疗肩关节不稳伴严重骨缺损的研究现状

肩关节稳定由多个因素协同维持,当脱位发生时,可能会造成骨性Bankart损伤,甚至伤及肩盂前方及下方的关节软骨、盂唇组织和肩关节盂的骨质,使肩胛盂直径缩小、深度减少、前倾增加,破坏了凹面-挤压机制及盂肱平衡,导致肩关节不稳定,在较小的作用力下就会引起复发性肩关节脱位,增加关节盂骨的损伤.当关节盂骨缺损范围达到20％～2...     

骨性Bankart损伤的修复

<正>骨性Bankart损伤为肩关节盂唇前方的骨折或伴有肩关节复发性前脱位的盂唇缺损~[1-2],常见于创伤性肩关节前脱位或前下脱位,占盂肱关节创伤性不稳中的5.4%~70%~[3-5]。一、骨性Bankart损伤分类Porcellini等~[4]将骨性Bankart损伤分为急性与慢性损伤,病程3个月者为急性损伤,3个月者为慢性损伤。多数学者认为,损伤在3个月内的急性盂肱关节脱位合并前方     

肩关节不稳：前方软组织损伤

肩关节不稳定临床常见,肩关节前方软组织损伤如Bankart损伤、HAGL损伤、肩袖损伤、GAGL损伤等是引起肩关节不稳的常见原因。Bankart损伤是创伤性肩关节前向不稳定的常见损伤,其损伤机制为肩关节过度外展时关节盂受到轴向压力而无外旋,包括纤维Bankart损伤和骨性Bankart损伤。影响其修复效果的因素包括肩关节盂缺损的大小、有无Hill-Sachs损伤、有无肩关节囊松弛、盂肱下韧带有无牵拉以及术中修复损伤时使用锚钉的数量。ALPSA损伤是指肩关节盂唇关节囊骨膜袖状撕脱损伤,临床诊断较为困难,需注意与Bankart损伤进行鉴别。HAGL损伤指肩关节囊从肱骨侧撕裂,其损伤机制为肩关节过度外展、外旋。盂肱下韧带是肩关节外展90°外旋时的主要前方稳定结构,其前部起点为2点到4点,后部起点为7点到9点。该结构在肱骨侧的止点可分为两种类型：一种是围领型,其止点均至于关节面边缘;一种是V型,其前后束止于关节面边缘。有研究表明,盂肱下韧带可能撕裂的3个位置分别是肩胛盂起点（40%）、体部（35%）、肱骨侧止点（25%）。Wolf前瞻性观察了64例肩关节前方不稳定患者,发现Bankart损伤47例（73.5%）、关节囊松弛11例（17.2%）、HAGL损伤6例（9.3%）。导致创伤性肩关节不稳软组织损伤的类型多样,根据其损伤类型不同,其治疗方法也有所区别,不同类型的损伤术后复发率也不同。     

骨性Bankart损伤的诊疗现状

盂肱关节是人体所有关节中活动度最大也是最不稳定的关节,由于肱骨头大而肩胛盂浅呈碟型,完全依靠骨性结构的完整性,以及肩关节周围的关节囊、韧带和肌肉维持其稳定性。而骨性Bankart损伤由于肩盂前方骨缺损和关节囊损伤,严重影响其稳定性,治疗不当容易常常发生复发性肩关节脱位。本文就Bankart损伤治疗的研究作一概述。     

肩关节前向不稳的诊疗现状及进展

肩关节是全身最容易脱位的关节，其中95%以上为前脱位。初次脱位后处理不当，极易转变为复发性肩关节前脱位或前向不稳，保守治疗效果较差。肩关节前脱位时会损伤维持肩关节稳定性的软组织结构及骨性结构，其中骨性结构是影响肩关节稳定性的最重要因素。诊断需结合患者病史、查体及辅助检查，目前三维CT为最常使用的辅助检查手段，而基于三维CT和关节盂轨迹理论的各种骨缺损测量及术前评估方法各有利弊，尚缺少金标准。目前主流治疗手段包括Bankart修复术、喙突移位术、游离骨移植关节盂重建术、Bankart联合Remplissage术及肩胛下肌腱捆绑填塞术等术式，各有利弊。对于肩关节前向不稳的诊治，仍充满太多未知，需要进一步的研究探索。     

复发性肩关节前脱位治疗的研究进展与热点问题

盂肱关节是全身各个关节中最容易出现脱位的一个关节.盂肱关节的过度活动可呈病理性,从而影响肩关节的功能并导致患者出现肩关节不稳定,其中以前方不稳定居多.肩关节前脱位是肩关节运动损伤中的常见疾病,治疗不及时或者方法不得当会导致较高的复发率.本文针对肩关节前脱位的流行病学特点、非手术治疗和手术治疗方式以及术后脱位复发的危险因...     

镜下肱二头肌长头腱转位修复盂部分缺损

[目的]探讨关节镜下Bankart修复联合肱二头肌长头腱转位治疗合并部分肩胛盂骨缺损的复发性肩关节前向不稳定的疗效。[方法] 2016年9月—2018年1月,本科收治14例伴有部分肩胛盂骨缺损的复发性肩关节前脱位患者,其中男10例,女4例,年龄24～47岁,平均（30.22±3.77）岁,患者有肩关节不稳症状和反复脱位病史,采用关节镜下Bankart修复联合肱二头肌腱转位进行治疗。[结果]手术切口均愈合良好,12例患者获得随访,随访时间12～28个月,平均（21.38±3.49）个月,末次随访时,肩关节恐惧试验、前抽屉试验均为阴性,肩关节无再脱位,肩关节ASES评分和Rowe评分均优于术前（P<0.05）。[结论]关节镜下Bankart修复联合肱二头肌腱转位术,可以有效增强肩关节前方的稳定性,是治疗伴有部分肩胛盂骨缺损的复发性肩关节脱位的有效方法。     

复发性肩关节前脱位的非解剖性修复

复发性肩关节前脱位是创伤性盂肱关节前脱位的常见后遗症,首次脱位造成的解剖结构损伤和异常是后续脱位的主要原因。这些解剖异常主要包括前方关节囊盂唇复合体损伤(Bankart损伤)、肩胛盂骨缺损(骨性Bankart损伤)、肱骨头凹陷性骨折(Hill-Sachs损伤)等。理论上,进行解剖修复是恢复肩关节稳定性的主要措施。但许多情况下解剖修复无法实现或不适宜进行解剖修复,非解剖性修复始终是复发性肩关节前脱位治疗中的常见选项。部分非解剖性修复甚至能取得比解剖修复更好的效果。非解剖性修复主要包括针对前侧结构缺陷的喙突转移术、肩胛下肌短缩术、肩胛下肌静态化,以及针对后侧结构缺陷的肌腱填充术、肱骨头旋转截骨术等。该文对复发性肩关节前脱位的非解剖性修复作一综述。     

Bankart损伤

Banka~损伤是肩关节盂唇前下方在前下盂肱韧带复合体附着处的撕脱性损伤。因肩关节前脱位引起,是造成习惯性前方不稳定和脱臼的基本损伤。     

Airway obstruction involving a laryngeal mask airway during arthroscopic shoulder surgery

Several earlier reports have described life-threatening airway obstruction during arthroscopic shoulder surgery performed under regional anesthesia, caused by the leakage of irrigation fluid out of the shoulder joint space into the surrounding soft tissues and then the neck and the pharynx. Here, we present a case of airway obstruction that occurred in a patient under general anesthesia. A 77-year-old woman with a rotator cuff rupture who was to undergo right-shoulder arthroscopic surgery was anesthetized with fentanyl and propofol. Her airway was secured with a flexible laryngeal mask airway (LMA). During surgery, the compliance of her breathing bag became gradually poorer, and finally we were not able to ventilate her at an airway pressure of 60 cmH₂O. We found that her chest wall, neck, and face were swollen and tense. Laryngoscopy revealed massive swelling of the pharyngeal soft tissues. The vocal cords were not visible. Her trachea was intubated blindly, and adequate ventilation was re-established. She was placed in the Fowler position and furosemide was given intravenously. Her neck and chest swelling were reduced over the next 2 h and she was extubated without any problem. We recommend that physicians should periodically examine the neck of any patient undergoing arthroscopic shoulder surgery, especially when general anesthesia is used, because anesthetized patients cannot complain of breathing difficulty and the airway swelling may progress until it becomes life-threatening.     

Age as a predictive factor for in-patient admission following day-case shoulder arthroscopic sub-acromial decompression - a district general hospital audit

INTRODUCTION

Admission following day-case surgery can be problematic for both the patient and the health service. The purpose of this study was to identify any factors predictive of admission following arthroscopic sub-acromial decompression (ASAD) of the shoulder planned as day-case procedures.

PATIENTS AND METHODS

A postal questionnaire provided data for 27 patients undergoing ASAD as a day-case procedure between June 2002 and June 2004.

RESULTS

Eighteen (66.7%) questionnaires were returned. Of respondents, 38.9% (mean age, 58 years) felt the procedure required in-patient admission due to postoperative pain. These patients had an older mean age than those (61.1%) content with a day-case procedure (mean age, 49 years; P = 0.04). Of patients 55 years and older, 67% felt that the procedure should have an in-patient admission due to postoperative pain compared to 11% of patients under the age of 55 years (P = 0.04).

CONCLUSIONS

Patient age may be useful as a predictor of the likelihood of postoperative admission for pain control following day-case shoulder surgery and should be taken into account when planning day case lists.     

The Oxford shoulder score revisited

The validated, patient-reported Oxford shoulder score (OSS) was introduced around 10 years ago, primarily for the assessment of outcomes of shoulder surgery (excluding shoulder stabilisation) in randomised trials. Its uptake has steadily increased in a number of countries and its use has also been extended. Recently a number of issues have been raised in relation to other related patient-reported outcome measures which were devised around the same time as the OSS. This included recommendations to change the scoring system. This paper reviews issues concerning patient-reported outcome measures that apply to the OSS and makes some recommendations (including changes to the scoring system) as to how it should be used.

肩关节外科领域的发展与现状

肩关节外科作为骨科学的一个分支，在国外发达国家发展迅速，但国内至今尚未形成一个成熟的体系，只有少数大医院成立了独立的肩关节外科专科。关节镜技术的发展完善及人工肱骨头置换的应用，使肩关节外科的治疗手段更加多元化，以往那些所谓的禁忌证逐渐都可以进行手术得到解决。本期《中华创伤骨科杂志》介绍了肩关节外科部分的治疗方法与经验，包括肩关节脱位、肩胛骨骨折、肩峰撞击征、肩关节不稳等手术治疗。在不增加患者经济负担的前提下，微创、最佳的肩关节功能恢复是医生及患者的追求与目标。     

Informed consent in shoulder surgery

Informed consent is an essential tool for diagnosis and therapy in medicine, and is of fundamental importance in surgery, where it underpins the operation itself. Its origins can be traced back to US forensic medicine but is now incorporated into the Italian legal system, with different consequences depending on the context in which it is applied. This article describes our experiences in shoulder surgery, with suitable references to legislation and analysis of the literature studies in this area.     

Analysis of factors that affect shoulder balance after correction surgery in scoliosis: a global analysis of all the curvature types

Purpose

To identify factors that can affect postoperative shoulder balance in AIS.

Method

89 adolescent idiopathic scoliosis patients with six types of curvatures who underwent surgery were included in this study. Whole spine antero-posterior and lateral radiographs were obtained pre- and postoperatively. In radiograms, shape and changes in curvatures were analyzed. In addition, four shoulder parameters and coronal balance were analyzed in an effort to identify factors significantly related to postoperative shoulder balance.

Result

In general, all the four shoulder parameters (CHD, CA, CRID, RSH) were slightly increased at final follow up (t test, P < 0.05), although there was a decrease in Lenke type II and IV curvatures. However, pre- and postoperative shoulder parameters were not significantly different between each curvature types (ANOVA, P > 0.05). Moreover, no significant differences of pre- and postoperative shoulder level between different level of proximal fusion groups (ANOVA, P > 0.05) existed. In the analysis of coronal curvature changes, no difference was observed in every individual coronal curvatures between improved shoulder balance and aggravated groups (P > 0.05). However, the middle to distal curve change ratio was significantly lower in patients with aggravated shoulder balance (P < 0.05). In addition, patients with smaller preoperative shoulder imbalance showed the higher chance of aggravation after surgery with similar postoperative changes (P < 0.05).

Conclusions

Significant relations were found between correction rate of middle, and distal curvature, and postoperative shoulder balance. In addition, preoperative shoulder level difference can be a determinant of postoperative shoulder balance.     

Arthroscopic treatment for septic arthritis of the shoulder in an infant

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, débridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40°C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and débridement, may be one of the options for treating septic arthritis of an infants shoulder.