肩关节镜下简化双滑轮双排缝合锚技术治疗肩盂前缘大块骨折

目的探讨肩关节镜下简化双滑轮(double-pulley)双排缝合锚技术治疗肩盂前缘大块骨折的临床疗效。方法回顾性分析2014年1月至2017年7月,采用肩关节镜下简化double-pulley双排缝合锚技术治疗24例肩盂前缘骨折患者资料,男13例,女11例;年龄(50.14±10.60)岁(范围,34~67岁);均为IdebergⅠa型骨折。其中单纯肩盂前缘骨折8例,伴肱骨大结节骨折4例,伴肩袖损伤5例,伴肩关节前脱位、肱骨大结节骨折4例,伴肩关节前脱位、肩袖损伤2例,伴肩关节前脱位、同侧桡骨远端骨折1例。肩盂前缘骨块面积占肩盂面积的28.91%±5.35%(范围,25.1%~38.5%)。肩关节镜下根据骨块大小,以1枚内排缝合锚置于肩盂前缘骨折床的内缘,2~4枚外排缝合锚置于肩盂关节面边缘,从低到高依次置入缝合锚,通过简化double-pulley技术复位固定。术后观察骨折复位及愈合情况、并发症发生情况。采用Constant-Murley评分、上肢功能障碍评分量表(Disability of Arm,Shoulder and Hand,DASH)对上肢功能进行评价,采用视觉模拟评分(visual analogue scale,VAS)评估疼痛程度。结果24例患者均获得满意骨折复位及内固定,均获得随访,随访时间19.5个月(范围,12~36个月)。手术切口均一期愈合,无一例发生感染、切口愈合不良等;骨折均愈合,愈合时间(2.7±0.6)个月(范围,2.1~3.2个月)。末次随访时,VAS评分为(0.8±0.8)分(范围,0~2分)。术后患肩关节活动度:前屈上举161.00°±5.77°(范围,145°~180°);体侧外旋46.43°±6.63°(范围,35°~60°);内旋拇指触及棘突水平为L3~T10。Constant-Murley评分(88.1±3.7)分(范围,81~93分),DASH评分(8.4±4.7)分(范围,0~40.4分)。除1例患者术后6周CT检查显示肱骨头向前下略移位外,其余患者肩关节对应正常,无脱位和不稳定表现。术后即刻及术后3、6、12个月CT检查均未见骨折块移位。CT检查评价关节面复位情况,术后即刻19例关节面台阶<2 mm,5例2~4 mm;末次随访时19例关节面台阶<2 mm,4例2~4 mm,1例>4 mm。术后6周,1例患者CT检查示肱骨头向前下略移位,但术后3个月CT检查示盂肱关节对应关系基本正常,关节面台阶5 mm。末次随访时,24例患者均未见严重骨关节炎表现,其中1例67岁患者存在轻度骨关节炎表现。2例伴肩关节前脱位及肩袖损伤者肩关节活动明显受限。结论对于大的肩盂前缘骨折,采用肩关节镜下简化double-pulley双排缝合锚固定技术治疗,创伤小,术中镜下视野清晰,骨折显露安全、充分,复位、固定稳定可靠,可获得满意疗效。

Arthroscopic simplified double-pulley double row suture technique to fix the bigger glenoid anterior edge fracture

Objective To investigate the clinical results of arthroscopic double-pulley double row suture technique for the treatment of bigger Ideberg Ia glenoid fracture.Methods From January 2014 to July 2017,data of patients with Ideberg Ia glenoid fracture who were treated by arthroscopic double-pulley double row suture technique were retrospectively analyzed.Totally 24 patients were enrolled of whom 13 were males and 11 were females.The mean age was 50.14±10.60 years(range,34-67).In those patients,there were 8 cases of glenoid fracture alone,4 cases of glenoid fracture associated with greater tuberosity fracture,5 cases of glenoid fracture with rotator cuff tear,4 cases of glenoid fracture with shoulder anterior dislocation and greater tuberosity fracture,2 cases of glenoid fracture with shoulder anterior dislocation and rotator cuff tear,and 1 case of shoulder anterior dislocation with ipsilateral distal radius fracture.The fragment accounts for 28.91±5.35%(range,25.1%-38.5%)of the glenoid articular surface.According to the size of the fragment,one medial row anchor was used to implant at the medial edge of the fracture bed of the anterior edge of the glenoid;two to four lateral row suture anchors were used to implant at the margin of the glenoid joint surface sequentially from low level to higher level,and simplified double-pulley technique was finally used to fix the fragment.The situation of fracture reduction and healing and the post-operative complications were evaluated.The Constant-Murley,DASH and VAS were also recorded.Results Satisfactory fracture reduction and fixation were achieved in all 24 patients.The mean follow-up time was 19.5 months(range,12-36).Mean VAS was 0.8±0.8(range,0-2).The range of motion at the latest follow-up was:anterior flexion 145°-180°(mean,161.00°±5.77°),external rotation at the side 35°-60°(mean,46.43°±6.63°),internal rotation L3-T10 level.The mean Constant-Murley score was 88.1±3.7(range,81-93),and mean DASH score was 8.4±4.7(range,0-40.4).All cases except one showed no dislocation or disability of the shoulder.The CT scans showed:19 cases of which the step-off of articular surface was less than 2 mm;4 cases of which the step-off was between 2 mm to 4 mm and 1 case of which the step-off was more than 4 mm.No severe osteoarthritis was identified at the latest follow-up,and only 1 patient at the age of 67 showed slight osteoarthritis.Two patients with shoulder anterior dislocation and rotator cuff tear committed significant restricted shoulder range of motion.Conclusion The arthroscopic simplified double-pulley double row suture technique was identified safe,effective and reliable for treating the bigger Ideberg Ia glenoid fracture.The technique is able to provide clear visulization of the fracture and achieve excellent clinical results.