切开复位联合Latarjet手术治疗陈旧性肩关节前脱位

Open reduction combined with Latarjet procedure for treatment of obsolete anterior shoulder dislocation

目的评估切开复位联合Latarjet手术治疗陈旧性肩关节前脱位的临床疗效。方法自2012年1月至2018年1月共14例陈旧性肩关节前脱位患者(16个肩关节)纳入本研究,其中男8例、女6例;年龄30~70岁,平均51.2岁;脱位时间为8~22周,平均10.2周。受伤原因为:摔伤10例,车祸伤4例。合并Hill-Sachs损伤12例,缺损占肱骨头的比例平均为32%。合并骨性Bankart损伤11例,缺损占肩胛盂的比例平均为13%。合并肩袖损伤9例,合并肱骨近端骨折6例,无一例合并神经血管损伤。术前检查肩关节活动度(前屈、外展、内旋、外旋)并记录视觉模拟评分法(visual analogue scale,VAS)、美国肩肘外科(American shoulder elbow surgeons’form,ASES)评分、美国加州大学肩关节系统(University of California at Los Angeles,UCLA)评分。术中均采用胸大肌三角肌间沟入路,彻底松解挛缩的关节囊和周围软组织,清除盂窝内的瘢痕组织后复位,再行Latarjet术重建肩胛盂弧度维持复位,同时依据损伤情况处理伴随的Hill-Sachs损伤、肩袖损伤和肱骨近端骨折等。结果14例患者均获随访,随访时间10~22个月,平均18个月。随访期间肩关节均未出现再脱位。1例患者术后出现肩部麻木,考虑腋神经损伤,1个月后恢复正常。无感染、医源性骨折及其他血管神经损伤等并发症。与术前相比,末次随访时平均前屈角度由(65.9±10.4)°升至(112.1±13.3)°(P=0.000),平均外展角度由(41.1±9.7)°升至(63.3±13.6)°(P=0.000),平均内收位外旋角度由(10.7±4.3)°升至(22.1±5.1)°(P=0.000),平均内收位内旋角度由(52.6±5.3)°升至(54.0±6.0)°(P=0.081),VAS评分由(5.4±1.4)分降至(1.7±1.1)分(P=0.000),ASES评分由(34.1±10.6)分升至(70.8±12.3)分(P=0.000),UCLA评分由(10.1±3.2)分升至(22.6±4.6)分(P=0.000)。除内旋外,手术前后肩关节活动度和功能评分的差异均有统计学意义。结论对于陈旧性肩关节前脱位,切开复位联合Latarjet手术可有效重建肩关节前方稳定性。同时术中正确处理伴随损伤及术后早期规范康复锻炼也是提高手术疗效的重要因素。

Background Obsolete anterior shoulder dislocation refers to the first dislocation of glenohumeral joint for at least 3 weeks.Its incidence rate is extremely low.The long duration of dislocation results in the contracture of the muscle and joint capsule around glenoid tendon and the formation of fibrous tissue and scarring.It is often accompanied by the bone defect of the anteroinferior border of glenoid(bony Bankart injury)and the compression fracture of posterosuperior humeral head(Hill-Sachs injury).The above pathological changes of obsolete anterior shoulder dislocation lead to poor conservative treatment effect,difficulty of closed reduction and high recurrence rate.Therefore,open reduction becomes the prior choice.However,the maintenance of reduction is extremely difficult after operation.The previously reported transarticular fixation will destroy articular surface and aggravate joint stiffness.The joint capsule contraction or Bankart repair surgery has a high rate of redislocation and will significantly affect rotation.Through transplanting the coracoid process fragment attached with conjoint tendon to anteroinferior scapular neck,Latarjet procedure increases the curvature of glenoid and forms a mechanical barrier,which can effectively avoid redislocation and has little effect on the mobility of shoulder joint.Numerous studies have confirmed that Latarjet surgery is superior to other procedures in the treatment of recurrent anterior shoulder dislocation.However,its application for the treatment of obsolete anterior shoulder dislocation is barely reported.Objective To evaluate the clinical efficacy of open reduction combined with Latarjet procedure in the treatment of obsolete anterior shoulder dislocation.Methods From January 2012 to January 2018,14 patients(16 shoulders)with obsolete anterior shoulder dislocation were involved in this study.There were 8 males and 6 females.The age ranged from 30 to 70 years with an average of 51.2 years.The duration of dislocation was 8-22 weeks with an average of 10.2 weeks.Causes of injury:fall damage(10 cases)and traffic accidence(4 cases).12 cases were combined with Hill-Sachs injury,and the average proportion of humeral head defect was 32%.11 cases were combined with bony Bankart injury,and the average proportion of glenoid defect was 13%.9 cases were combined with rotator cuff injury,and 6 cases were combined with proximal humeral fracture.No neurovascular injury was found.The range of motion(anteflexion,abduction,internal rotation and external rotation)and functional score(VAS,ASES and UCLA)of shoulder joint were examined before operation.The deltopectoral approach was used to completely release the contracture of joint capsule and surrounding soft tissue.After the removal of the scar tissue in glenoid fossa,the glenohumeral joint was reduced.Then,the Latarjet procedure was performed to reconstruct glenoid radian to maintain the reduction.Meanwhile,concomitant complications such as Hill-Sachs injury,rotator cuff injury and proximal humeral fracture,etc.were treated as well based on the condition of injury.Results All the 14 patients were followed up for 10 to 22 months with an average of 18 months.During the follow-up period,no redislocation of shoulder joint was found.One patient developed postoperative shoulder numbness and was considered to have axillary nerve injury,and the condition recovered 1 month later.There was no complication such as infection,iatrogenic fracture or other neurovascular injury.During the last follow up:the mean flexion angle increased from(65.9±10.4)°to(112.1±13.3)°(P=0.000);the mean abduction angle increased from(41.1±9.7)°to(63.3±13.6)°(P=0.000);the mean external rotation angle at adduction increased from(10.7±4.3)°to(22.1±5.1)°(P=0.000);the mean adduction and internal rotation angle increased from(52.6±5.3)°to(54.0±6.0)°(P=0.081);the VAS score decreased from(5.4±1.4)to(1.7±1.1)(P=0.000);the ASES score increased from(34.1±10.6)to(70.8±12.3)(P=0.000);the UCLA score increased from(10.1±3.2)to(22.6±4.6)(P=0.000).Other than internal rotation,there were significant differences in the range of motion and the function of shoulder joint before and after operation.Conclusion For obsolete anterior shoulder dislocation,open reduction combined with Latarjet procedure can effectively reconstruct the anterior stability of shoulder joint.Meanwhile,the correct treatment of concomitant injury during operation and postoperative early rehabilitation exercise are also important factors to improve the surgical curative effect.