改良关节镜双袢法Latarjet手术治疗癫痫患者复发性肩关节前脱位的疗效观察

Therapeutic effect observation of modified arthroscopic double-Endobutton Latarjet procedure for treatment of recurrent anterior shoulder dislocation in epileptics

目的研究改良关节镜双袢法Latarjet手术治疗癫痫患者伴复发性肩关节前脱位的临床疗效。方法自2014年10月至2016年10月,共有9例伴发严重骨缺损的肩关节前脱位癫痫患者在深圳大学第一附属医院接受了改良关节镜双袢法Latarjet手术,患者平均年龄为(26.3±3.1)岁,术前均进行超过半年的抗癫痫治疗,术后继续进行抗癫痫治疗1年。术后立刻行CT检查观察骨块位置,分别于术后3、6、12、24个月随访行CT检查观察骨块吸收、愈合情况;并记录患者的美国肩与肘协会评分系统(American shoulder and elbow surgeon’form,ASES)评分、Rowe评分以及Walch-Duplay评分并进行肩关节功能评估。结果共8例患者得到全程随访,平均随访(20.1±4.2)个月,3例患者术后再发癫痫(未按时服药),分别为术后2、6、8个月,其中1例(术后6个月癫痫复发)失访,其余2例复发者CT显示骨块明显移位,随后经保守治疗后再次愈合。全部随访患者骨块愈合良好,6例恢复对抗运动,2例恢复正常生活,无肩关节不稳感,CT检查显示移植骨块最终塑形差异较大,其中4例吸收5%~75%,3例较原始状态面积扩大,1例无变化。术前及末次随访时平均ASES评分为(76.75±7.41)分和(94.68±5.02)分(P<0.05),Rowe评分为(43.75±5.82)分和(93.13±5.30)分(P<0.05),Walch-Duplay评分为(76.13±6.98)分和(93.00±2.00)分(P<0.05)。结论改良关节镜双袢法Latarjet技术对于癫痫患者合并肩关节前脱位具有良好的短期临床疗效,且复发后有再次愈合的可能。但更应注意癫痫患者的术后病情控制,尽可能防止癫痫再发作导致手术失败,肩关节复发脱位。

Background During epileptic seizures,a series of injury caused by the fall event as a result of muscle spasms has always been the therapeutic difficulty in clinical practice.From the perspective of orthopaedic doctor,the instability of shoulder joint caused by fall damage is the focus of our attention.It has been reported in literature that the incidence of shoulder dislocation caused by seizures is approximately 0.6%.Considering that a large number of patientsare missed,we believe that the actual incidence rate is much higher than this value.It has been previously thought that the posterior shoulder dislocation caused by strong muscle contraction in the patient with epilepsy is more common.However,the truth is that the proportion of patient with anterior shoulder dislocation is not low,and it is even reported that the incidence rates of anterior and posterior shoulder dislocationsare 50%and 50%respectively.Currently,there are many surgical methods for the treatment of anterior shoulder dislocation including soft tissue repair surgery and bone repair surgery.Among them,the Latarjet procedure in bone repair surgery is the most widely applied technique.Objective To explore the clinical efficacy of modified arthroscopic double-Endobutton Latarjet procedure for the treatment of recurrent anterior shoulder dislocation in epileptics.Methods From October 2014 to October 2016,a total of 9 epileptics(9 shoulder joints)suffered from anterior shoulder dislocation with severe bone defect received the modified arthroscopic double-Endobutton Latarjet procedure in our hospital.The mean age was(26.3±3.1)years old.All patients received anti-epileptic treatment for over half of a year before surgery,and the anti-epileptic treatment was continued for 1 year after operation.Immediate postoperative CT scan was performed to detect bone graft position.Then,CT scan was performed at the 3rd,6th,12th,and 24th months to evaluate the status ofbone graft absorption and union.The ASES score,Rowe score and Walch-Duplay score were recorded during each follow-up to assess patients’shoulder function.Results Eight patients were followed up for anaverage of(20.1±4.2)months,while 1 patient ofright shoulder was lostfor follow-up.Three patients had recurrent epilepsy 2 months,6 months and 8 months after operation respectively due to absence of taking medicine.Among them,1 case was lost for follow-up atthe 6th postoperative month,and the remaining 2 patients with recurrence showed a significant displacement of bone graft and then healed again after conservative treatment.A total of 7 patients received complete follow-up,and the bone grafts healedduring the last followup.Six patients returned to competitive exercise,and 2 patients returned to normal life without complaint of shoulder joint instability.The CT scans showed significant difference of bone graft plasticity.The bone absorption rate in 4 cases was between 5%and 75%.Three cases had the area expanded compared to the original state,and 1 case had no obvious change.Before operation and during the last followup:the mean ASES scoreswere(76.75±7.41)points and(94.68±5.02)points respectively(P<0.05);the mean Rowe scores were(43.75±5.82)points and(93.13±5.30)points respectively(P<0.05);the mean Walch-Duplay scores were(76.13±6.98)points and(93.00±2.00)points respectively(P<0.05).Conclusion The modified arthroscopic double-Endobutton Latarjet procedure has a good short-term clinical effect on epileptics with anterior shoulder dislocation,and this technique has the potential of reunion after recurrence.The patient satisfaction is high,and this technique is worth of promotion and application.However,we should pay more attention to the postoperative control of epileptic seizure and the prevention of epilepsy recurrence to avoidoperation failure and recurrent shoulder dislocation.