肩关节前脱位合并骨性Bankart损伤、肩袖损伤及腋神经损伤的关节镜治疗

Treatment of concurrent rotator cuff tear and axillary nerve palsy associated with anterior dislocation of the shoulder and glenoid rim fracture

目的探讨肩关节镜下治疗肩关节前脱位合并骨性Bankart损伤合并肩袖损伤及腋神经损伤的治疗策略和术后早期疗效。方法2017年5月至2020年6月郑州市中心医院骨科共收治14例肩关节前脱位合并骨性Bankart损伤、肩袖损伤及腋神经损伤的患者。6例患者为首次肩关节前脱位,8例伤前有肩关节反复脱位病史,末次脱位导致骨性Bankart损伤。所有患者均在全关节镜下松解腋神经后,一期修复骨性Bankart损伤及肩袖损伤。术后应用美国肩肘协会评分系统(ASES)、视觉模拟评分(VAS)和Constant-Murley评分对患者进行功能评价,评估疗效。结果14例患者均获得随访,平均随访18.36个月。术中松解腋神经后,术后第3天所有患者的上臂麻木症状及神经性疼痛明显减轻;术后3个月复查时,所有患者上臂感觉异常均消失,三角肌肌力均能恢复至3级以上,肌电图检查示腋神经功能恢复13例,运动传导波幅偏低1例;术后1年复查时有4例三角肌肌力恢复至4级,10例恢复至5级,肌电图检查示腋神经感觉及运动传导波幅均恢复正常。术前ASES、Constant-Murley、VAS评分分别为(27.1±8.5)、(24.3±8.9)、(7.0±1.3)分,术后1年随访时分别为(86.4±6.8)、(85.3±6.6)、(1.4±1.2)分,3种评分的手术前后均存在统计学差异(P<0.05)。结论肩关节前脱位合并骨性Bankart损伤、肩袖损伤及腋神经损伤时,应常规探查四边孔区域,全关节镜下松解腋神经后再修复骨性Bankart损伤及肩袖损伤,疗效肯定。

Objective To investigate the arthroscopic treatment for simultaneous lesions of the rotator cuff,bony Bankart and the axillary nerve caused by shoulder dislocation.Methods From May 2017 to June 2020,14 cases presented bony Bankart injury associated with rotator cuff tear and axillary nerve injury caused by shoulder dislocation in Department of Orthopaedic Surgery,Zhengzhou Central Hospital,were selected.Among them,6 patients had the first shoulder anterior dislocation;and 8 patients experienced recurrent shoulder anterior dislocation.All patients underwent one-stage repair of bony Bankart injury and rotator cuff tear after arthroscopic release of axillary nerve.All the patients were assessed and analyzed by visual analogue scale(VAS),rating scale of the American Shoulder and Elbow Surgeons(ASES)and the Constant-Murley score(CMS).Results The mean follow-up of the 14 patients was 18.36 months.The symptoms of upper arm numbness and neuropathic pain were significantly alleviated in all patients 3 days after arthroscopic release of axillary nerve.At 3 months after operation,the sensory abnormalities of the upper arm disappeared in all patients,and the deltoid muscle strength recovered to gradeⅢor more.Electromyography(EMG)examination showed that the axillary nerve recovered in 13 cases while the motor conduction amplitude was low in 1 case.One year after operation,the deltoid muscle strength of 4 cases recovered to gradeⅣand 10 cases recovered to gradeⅤ.EMG showed that the sensory and motor conduction amplitudes of axillary nerve returned to normal.The preoperative scores of ASES,CMS and VAS were 27.1±8.5,24.3±8.9 and 7.0±1.3 respectively,and 86.4±6.8,85.3±6.6 and 1.4±1.2 respectively at one-year follow-up.There were significant differences between the three scores before and after operation(P<0.05).Conclusion The arthroscopic treatment of simultaneous lesions of the rotator cuff,bony Bankart and the axillary nerve,the quadrilateral foramen area should be routinely explored,and the axillary nerve should be released.The modified arthroscopic procedure is reliable and effective.