向明 楊國(guó)勇 陳杭 胡曉川 唐浩琛

Latarjet兩種術(shù)式治療肩關(guān)節(jié)復(fù)發(fā)性前脫位伴重度骨缺損3～5年隨訪的比較研究

向明 楊國(guó)勇 陳杭 胡曉川 唐浩琛

目的研究Latarjet手術(shù)治療肩關(guān)節(jié)復(fù)發(fā)性前脫位伴重度骨缺損患者的療效。方法結(jié)合三維CT掃描和肩關(guān)節(jié)鏡對(duì)肩關(guān)節(jié)復(fù)發(fā)性前脫位的肩盂前緣骨缺損和肱骨頭后外側(cè)的Hill－Sachs損傷的范圍和程度進(jìn)行評(píng)估，如肩盂呈倒梨形（骨缺損大于肩盂寬度的25%）合并或伴有Engaging Hill－Sachs損傷，即通過三角肌胸大肌入路運(yùn)用Latarjet技術(shù)進(jìn)行重建，治療伴有重度骨缺損的肩關(guān)節(jié)復(fù)發(fā)性前脫位37例。其中2006年4月至2007年12月采用喙突內(nèi)旋90°轉(zhuǎn)位術(shù)式，隨訪資料完整的共16例；2008年1月至2009年10月采用喙突平行轉(zhuǎn)位術(shù)式，隨訪資料完整的共21例。男性23例，女性14例，平均年齡26．5歲（17～46歲）。術(shù)前Apprehension sign均為陽性，平均脫位次數(shù)13．5次（8～28次），隨訪時(shí)采用美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)（ASES）評(píng)分、Constant－Murley評(píng)分以及視覺模擬評(píng)分法（VAS）不穩(wěn)定評(píng)分進(jìn)行功能評(píng)估。結(jié)果平均隨訪時(shí)間為48．3個(gè)月（37～61個(gè)月），術(shù)后患肩制動(dòng)2周后即在醫(yī)師指導(dǎo)下按計(jì)劃進(jìn)行肩關(guān)節(jié)功能康復(fù)及力量恢復(fù)訓(xùn)練，術(shù)后6個(gè)月三維CT顯示喙突平行轉(zhuǎn)位組骨塊均與肩胛頸愈合，而喙突內(nèi)旋90°轉(zhuǎn)位組有3例骨塊未與肩胛頸愈合，兩組喙突骨塊愈合率相比，差異有統(tǒng)計(jì)學(xué)意義（χ2＝4．258，P＜0．05）。喙突平行轉(zhuǎn)位組手術(shù)前對(duì)終末次隨訪比較，前屈上舉（152．5±22．6）°與（168．0±7．8）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．028，P ＜0．05），平均體側(cè)外旋（52．6±18．4）°與（44．9±15．0）°比較，差異無統(tǒng)計(jì)學(xué)意義（t＝1．486，P ＞0．05），ASES評(píng)分80．7±16．7與92．2±6．4比較，差異有統(tǒng)計(jì)學(xué)意義（t＝2．947，P ＜0．05），Constant－Murley評(píng)分78．6±10．1與91．6±13．2比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．584，P ＜0．05），VAS不穩(wěn)定評(píng)分平均6．0±1．4與4．3±1．6比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．664，P ＜0．05）；而喙突內(nèi)旋90°轉(zhuǎn)位組前屈上舉（148．5±19．2）°與（170．0±10．5）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．930，P ＜0．05）；平均體側(cè)外旋（55．8±16．9）°與（40．6±13．6）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝2．803，P ＜0．05）；ASES評(píng)分81．4±14．7與92．4±7．0比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－2．702，P ＜0．05），Constant－Murley評(píng)分80．2±12．6與92．8±5．1比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．708，P ＜0．05），VAS不穩(wěn)定評(píng)分平均6．4±1．5與4．2±2．1比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．410，P＜0．05）；至末次隨訪喙突平行轉(zhuǎn)位組與喙突內(nèi)旋90°轉(zhuǎn)位組相比，無論前屈上舉、平均體側(cè)外旋、ASES評(píng)分、Constant－Murley評(píng)分或VAS不穩(wěn)定評(píng)分，P值均＞0．05，差異無統(tǒng)計(jì)學(xué)意義。終末復(fù)查時(shí)X線片6例出現(xiàn)骨關(guān)節(jié)炎表現(xiàn)，其中喙突平行轉(zhuǎn)位組有1例，喙突內(nèi)旋90°轉(zhuǎn)位5例，兩者相比差異有統(tǒng)計(jì)學(xué)意義。結(jié)論對(duì)于重度骨缺損的肩關(guān)節(jié)復(fù)發(fā)性前脫位，肩關(guān)節(jié)鏡下或開放鉚釘重建修復(fù)Bankart損傷脫位復(fù)發(fā)率較高，風(fēng)險(xiǎn)大，微創(chuàng)治療難以徹底治愈，多采用Latarjet手術(shù)治療，目前有喙突平行轉(zhuǎn)位和喙突內(nèi)旋90°轉(zhuǎn)位兩種術(shù)式，均能為該種類型的肩關(guān)節(jié)復(fù)發(fā)性前脫位提供更好的靜力穩(wěn)定性，從而有效減少脫位的再發(fā)率；而喙突平行轉(zhuǎn)位較喙突內(nèi)旋90°轉(zhuǎn)位固定強(qiáng)度相對(duì)較高、接觸面積更大，愈合率相對(duì)較高，并且發(fā)生骨關(guān)節(jié)炎改變的幾率相對(duì)較低。

Latarjet； 骨缺損； 肩關(guān)節(jié)復(fù)發(fā)性前脫位； 喙突

肩關(guān)節(jié)脫位占全身關(guān)節(jié)脫位的40%以上［1］，其中絕大部分為前脫位，主要的病理機(jī)制是外傷引起前下方盂唇關(guān)節(jié)囊韌帶復(fù)合體的功能缺失，即Bankart損傷，如未修復(fù)可致復(fù)發(fā)性前脫位，部分病例同時(shí)伴有肩盂的撕脫骨折或骨性缺損，甚至形成倒梨形肩盂，軟組織性Bankart損傷和骨性缺損＜25%時(shí)，切開或關(guān)節(jié)鏡下Bankart重建術(shù)臨床效果優(yōu)良，再脫位率低［2］；但如肩盂骨缺損25%～30%形成倒梨形，和（或）伴嚙合型的肱骨頭后外上方壓縮骨折（Hill－Sach損傷），單純的Bankart重建術(shù)再脫位率可達(dá)67%［3］，Latarjet術(shù)式重建肩盂骨性結(jié)構(gòu)則能明顯減少再脫位率［4］，在Latarjet手術(shù)中，喙突轉(zhuǎn)位有平行轉(zhuǎn)位和內(nèi)旋90°轉(zhuǎn)位兩種［5］。2006年4月至2009年10月，我科對(duì)伴有重度骨缺損的肩關(guān)節(jié)復(fù)發(fā)性前脫位采用Latarjet手術(shù)治療。其中2006年4月至2007年12月采用喙突內(nèi)旋90°轉(zhuǎn)位術(shù)式，隨訪資料完整的共16例；2008年1月至2009年10月采用喙突平行轉(zhuǎn)位術(shù)式，隨訪資料完整的共21例。隨訪時(shí)間37～61個(gè)月。

臨床資料

一、一般資料

患者37例，其中男性23例，女性14例；平均年齡26．5歲（17～46歲）。左肩10例，右肩27例；優(yōu)勢(shì)側(cè)29例。初次肩關(guān)節(jié)前脫位的原因：運(yùn)動(dòng)損傷23例，日?；顒?dòng)12例，其他外傷2例。平均脫位次數(shù)13．5次（8～28次）。初次脫位至手術(shù)時(shí)間為9個(gè)月至21年，平均6．4年；末次脫位至手術(shù)時(shí)間為2～3．5個(gè)月，平均75d。術(shù)前體格檢查：均有恐懼試驗(yàn)（Apprehension sign）陽性，33例為單一前向不穩(wěn)定，其余4例伴下方不穩(wěn)定。術(shù)前拍攝肩關(guān)節(jié)正位、肩胛骨側(cè)位X線片，并對(duì)患側(cè)肩關(guān)節(jié)行三維CT檢查，通過對(duì)重建CT影像的處理，去掉肱骨頭影像并使肩盂轉(zhuǎn)向正對(duì)檢查者形成所謂“en face view”［67］，根據(jù)術(shù)中肩關(guān)節(jié)鏡鏡檢，其中 Hill－Sachs損傷34例（91．9% ），根據(jù) Calandra分型標(biāo)準(zhǔn)［8］：Ⅰ型8例、Ⅱ型16例、Ⅲ型10例；上盂唇前后位（superior labrum anterior and posterior，SLAP）損傷3例（8．1% ），根據(jù)Snyder等［9］的分型標(biāo)準(zhǔn)：Ⅰ型2例、Ⅲ型1例。

二、手術(shù)方法

患側(cè)臂叢神經(jīng)阻滯加全身麻醉下，取沙灘椅位，標(biāo)記肩關(guān)節(jié)骨性標(biāo)志。先行肩關(guān)節(jié)鏡鏡檢，證實(shí)肩盂骨性缺損的程度；處理Hill－Sachs損傷，其中2例Hill－Sachs損傷因骨缺損＞1／3，行取自體髂骨植骨；對(duì)I型SLAP損傷用刨刀給予清創(chuàng)；而1例Ⅲ型損傷因長(zhǎng)頭腱附麗點(diǎn)穩(wěn)定，僅給予清創(chuàng)處理。然后，采用三角肌胸大肌間隙入路，保護(hù)頭靜脈拉向外側(cè)，顯露喙突及附著于其上的喙肩韌帶、胸小肌腱和聯(lián)合腱，切斷胸小肌腱喙突止點(diǎn)，在肩峰處切斷喙肩韌帶，于喙鎖韌帶的錐狀韌帶前方截下喙突，約24～25mm，經(jīng)肩胛下肌中下1／3水平劈開顯露前關(guān)節(jié)囊并沿肩胛盂外側(cè)縱向切開，暴露肩胛盂，清除撕脫的盂唇小骨片和瘢痕組織，盡量保留殘留的盂唇、韌帶和關(guān)節(jié)囊組織，去除肩胛頸前下方的骨皮質(zhì)。喙突平行轉(zhuǎn)位時(shí)，喙突下方去皮質(zhì)后將其連同附于其上聯(lián)合腱穿過肩胛下肌水平裂隙，使喙突外側(cè)緣和關(guān)節(jié)面平整，用2枚3．5mm全螺紋皮質(zhì)骨螺釘將其固定于肩胛盂前下方；喙突內(nèi)旋90°轉(zhuǎn)位時(shí)，喙突內(nèi)側(cè)（胸小肌腱附著側(cè)）去皮質(zhì)后將其連同附于其上聯(lián)合腱穿過肩胛下肌水平裂隙，使喙突下緣和關(guān)節(jié)面平整，用2枚3．0mm中空螺釘將其固定于肩胛盂前下方。將肩關(guān)節(jié)置于外旋10°位仔細(xì)縫合喙突相連的喙肩韌帶殘端與關(guān)節(jié)囊，逐層關(guān)閉切口，放置引流管，體側(cè)外旋中立位吊帶制動(dòng)。

三、術(shù)后處理

術(shù)后24h拔出引流管，制動(dòng)2周后即開始在醫(yī)師指導(dǎo)下行被動(dòng)前屈和體側(cè)外旋活動(dòng)，6周后行肩關(guān)節(jié)主動(dòng)前屈上舉和外旋活動(dòng)，8周開始內(nèi)旋練習(xí)，并逐漸力量練習(xí)；所有患者術(shù)后定期拍攝肩關(guān)節(jié)正位、肩胛骨側(cè)位X線片及術(shù)后6個(gè)月肩關(guān)節(jié)三維CT掃描檢查。術(shù)后3周、6周、3個(gè)月、6個(gè)月、1年時(shí)門診隨訪，此后每年隨訪1次。隨訪時(shí)采用ASES評(píng)分、Constant－Murley評(píng)分和視覺模擬評(píng)分法（VAS）不穩(wěn)定評(píng)分進(jìn)行功能評(píng)估。

四、統(tǒng)計(jì)學(xué)分析方法

采用SPSS 19．0統(tǒng)計(jì)軟件包進(jìn)行數(shù)據(jù)分析。對(duì)患者手術(shù)前與后的肩關(guān)節(jié)前屈上舉、體側(cè)外旋的活動(dòng)度，ASES評(píng)分、Constant－Murley評(píng)分以及VAS不穩(wěn)定評(píng)分比較比較采用t檢驗(yàn)，數(shù)據(jù)以±s表示；兩組喙突骨塊愈合率比較采用軟件中的χ2檢驗(yàn)。以P＜0．05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

患者術(shù)后平均隨訪時(shí)間為48．3個(gè)月（37～61個(gè)月），術(shù)后患肩制動(dòng)2周后即在醫(yī)師指導(dǎo)下按計(jì)劃進(jìn)行肩關(guān)節(jié)功能康復(fù)及力量恢復(fù)訓(xùn)練，術(shù)后6個(gè)月時(shí)三維CT顯示喙突平行轉(zhuǎn)位組骨塊均與肩胛頸愈合，而喙突內(nèi)旋90°轉(zhuǎn)位組有3例骨塊未與肩胛頸愈合，兩組喙突骨塊愈合率相比，差異有統(tǒng)計(jì)學(xué)意義（χ2＝4．258，P ＜0．05）。喙突平行轉(zhuǎn)位組手術(shù)前與末次隨訪比較結(jié)果詳見表1，其中前屈上舉（152．5±22．6）°與（168．0±7．8）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．028，P ＜0．05），平均體側(cè)外旋（52．6±18．4）°與（44．9±15．0）°比較，差異無統(tǒng)計(jì)學(xué)意義（t ＝1．486，P ＞0．05），ASES評(píng)分80．7±16．7與92．2±6．4比較，差異有統(tǒng)計(jì)學(xué)意義（t＝2．947，P ＜0．05），Constant－Murley評(píng)分78．6±10．1與91．6±13．2比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．584，P ＜0．05），VAS不穩(wěn)定評(píng)分平均6．0±1．4與4．3±1．6比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．664，P ＜0．05）；而喙突內(nèi)旋90°轉(zhuǎn)位組（表2）前屈上舉（148．5±19．2）°與（170．0±10．5）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－3．930，P ＜0．05）；平均體側(cè)外旋（55．8±16．9）°與（40．6±13．6）°比較，差異有統(tǒng)計(jì)學(xué)意義（t＝2．803，P ＜0．05）；ASES評(píng)分81．4±14．7與92．4±7．0比較，差異有統(tǒng)計(jì)學(xué)意義（t＝－2．702，P ＜0．05），Constant－Murley評(píng)分80．2±12．6與92．8±5．1比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．708，P ＜0．05），VAS不穩(wěn)定評(píng)分平均6．4±1．5與4．2±2．1比較，差異有統(tǒng)計(jì)學(xué)意義（t＝3．410，P ＜0．05）；至末次隨訪喙突平行轉(zhuǎn)位組與喙突內(nèi)旋90°轉(zhuǎn)位組相比，無論前屈上舉、平均體側(cè)外旋、ASES評(píng)分、Constant－Murley評(píng)分或VAS不穩(wěn)定評(píng)分，P值均＞0．05，差異無統(tǒng)計(jì)學(xué)意義。終末復(fù)查X線片，按照Samilson和Prieto骨關(guān)節(jié)炎的分型［10］，6例出現(xiàn)輕至中度骨關(guān)節(jié)炎，其中喙突平行轉(zhuǎn)位組有1例，喙突內(nèi)旋90°轉(zhuǎn)位5例，兩者相比差異有統(tǒng)計(jì)學(xué)意義。喙突內(nèi)旋90°轉(zhuǎn)位組有1例術(shù)后殘留Apprehension sign陽性，2例在最大外展、外旋時(shí)有輕度疼痛；喙突平行轉(zhuǎn)位組有1例在最大外展、外旋時(shí)有輕度疼痛。

1．典型病例1：患者男性，37歲，26歲時(shí)發(fā)生初次脫位，后反復(fù)脫位28次。見圖1。

2．典型病例2：患者男性，27歲，16歲時(shí)發(fā)生初次脫位，后反復(fù)脫位19次。見圖2。

表1 喙突平行轉(zhuǎn)位組患者術(shù)前與末次隨訪的各項(xiàng)檢測(cè)結(jié)果（±s）

表1 喙突平行轉(zhuǎn)位組患者術(shù)前與末次隨訪的各項(xiàng)檢測(cè)結(jié)果（±s）

注：ASES為美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)；VAS為視覺模擬評(píng)分法

項(xiàng)目 前屈上舉 體側(cè)外旋 ASES Constant－Murle評(píng)分 VAS評(píng)分術(shù) 前 152．5°±22．6° 52．6°±18．4° 80．7±16．7 78．6±10．1 6．0±1．4末 次隨 訪 168．0°±7．8° 44．9°±15．0° 92．2±6．4 91．6±13．2 4．3±1．6

表2 喙突內(nèi)旋90°轉(zhuǎn)位組患者術(shù)前與末次隨訪的各項(xiàng)檢測(cè)結(jié)果（±s）

表2 喙突內(nèi)旋90°轉(zhuǎn)位組患者術(shù)前與末次隨訪的各項(xiàng)檢測(cè)結(jié)果（±s）

注：ASES為美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)；VAS為視覺模擬評(píng)分法

項(xiàng)目 前屈上舉 體側(cè)外旋 ASES Constant－Murle評(píng)分 VAS評(píng)分術(shù) 前 148．5°±19．2° 55．8°±16．9° 81．4±14．7 80．2±12．6 6．4±1．5末 次隨 訪 170．0°±10．5° 40．6°±13．6° 92．4±7．0 92．8±5．1 4．2±2．1

討 論

盂肱關(guān)節(jié)的穩(wěn)定性是肌肉、韌帶和骨結(jié)構(gòu)共同作用的結(jié)果，以維持肱骨頭和肩盂始終處于同一的旋轉(zhuǎn)中心。美國(guó)肩關(guān)節(jié)脫位的發(fā)生率為11．2／100 000，其中90%為前脫位［11］；肩關(guān)節(jié)初次前脫位后常見病變有前下關(guān)節(jié)囊、盂唇和盂肱韌帶等軟組織從肩盂緣撕脫即Bankart損傷，同時(shí)有關(guān)節(jié)囊的變薄，或伴不同程度的骨性損傷，如骨性Bankart損傷和Hill－Sachs損傷，反復(fù)脫位所致的磨損會(huì)進(jìn)一步改變盂肱關(guān)節(jié)的接觸面積和靜力穩(wěn)定裝置從而降低盂肱關(guān)節(jié)的穩(wěn)定性［2］。通過對(duì)每例肩關(guān)節(jié)急性前脫位的患者進(jìn)行MRI檢查，Widjaja等發(fā)現(xiàn)初次脫位后73%有Bankart損傷，67%有Hill－Sachs損傷［12］；Yiannakopoulos等發(fā)現(xiàn)肩關(guān)節(jié)反復(fù)前脫位后Bankart和前方盂唇韌帶骨膜袖狀撕脫（anterior labroligamentous periosteal sleeve avulsion，ALPSA）損傷高達(dá)97%而Hill－Sachs損傷高達(dá)93%，倒梨形肩盂占15%［13］。

圖1 喙突內(nèi)旋90°轉(zhuǎn)位Latarje術(shù)式 圖A為術(shù)前X線正位片；圖B為術(shù)前CT冠狀位；圖C為術(shù)前三維CT重建顯示肩盂有骨缺損和Hill－sachs損傷；圖D、E為喙突內(nèi)旋90°轉(zhuǎn)位兩枚螺釘固定，術(shù)后6個(gè)月X線正側(cè)位片；圖F為術(shù)后6個(gè)月三維CT顯示喙突骨塊已與肩胛盂愈合，關(guān)節(jié)面平整，肩盂形狀恢復(fù)良好；圖G～I(xiàn)為術(shù)后3年半隨訪肩功能恢復(fù)良好，Apprehension sign陰性，從事較重體力勞動(dòng)

Robinson等的一項(xiàng)前瞻性臨床研究表明15～35歲的患者發(fā)生肩關(guān)節(jié)前脫位后經(jīng)保守治療平均13個(gè)月后，56%再次脫位，而20歲左右的男性高達(dá)72%～86%［14］。切開Bankart重建術(shù)以恢復(fù)前方肩盂的解剖結(jié)構(gòu)，3%的復(fù)發(fā)率曾是金標(biāo)準(zhǔn)手術(shù)方式，隨著關(guān)節(jié)鏡技術(shù)和器械的發(fā)展，多數(shù)作者報(bào)道關(guān)節(jié)鏡下Bankart重建術(shù)獲得了優(yōu)良的效果［15－16］，甚至接近20%的肩盂骨缺損也能通過關(guān)節(jié)鏡僅重建軟組織獲得滿意的療效［17－18］。然而，越來越多的研究表明肩盂骨性結(jié)構(gòu)的完整性是手術(shù)修復(fù)是否能成功的一個(gè)最重要因素［19－21］，Burkhart等［3］的研究證實(shí)，倒梨形肩盂僅行軟組織Bankart重建術(shù)，失效率高達(dá)67%。因此，建議對(duì)倒梨形肩盂合并或伴有Engaging Hill－Sachs損傷的患者應(yīng)行骨性重建術(shù)。

Latarjet和Helfet于1954和1958年分別報(bào)道采用喙突移位阻滯術(shù)治療肩關(guān)節(jié)復(fù)發(fā)性前脫位，取得了較滿意的療效［11］。Latarjet手術(shù)的原理是移植局部的喙突骨塊使之成為關(guān)節(jié)外的平臺(tái)而達(dá)到關(guān)節(jié)面的延伸，其穩(wěn)定肩關(guān)節(jié)的作用有三：（1）骨塊增加了脫位前肱骨頭在肩盂上移動(dòng)的安全面積；（2）上臂外展外旋時(shí)，聯(lián)合腱可發(fā)揮動(dòng)力系帶的作用阻擋肱骨頭向前移動(dòng)；（3）轉(zhuǎn)位的喙突和聯(lián)合腱跨過肩胛下肌中下1／3能起到肌腱固定的效應(yīng)從而加固前下方關(guān)節(jié)囊的缺損［3］。本研究證實(shí)Latarjet手術(shù)對(duì)伴有重度骨缺損的肩關(guān)節(jié)復(fù)發(fā)性前脫位療效確切，能明顯增加肩關(guān)節(jié)的前方穩(wěn)定性，患者的前屈上舉等以及多種功能評(píng)分均明顯增加。傳統(tǒng)的Latarjet手術(shù)要切斷肩胛下肌近端止點(diǎn)纖維，導(dǎo)致肩胛下肌肌力下降和限制肱骨頭向前的作用降低，并且因重疊縫合肩胛下肌和內(nèi)旋固定引起肩關(guān)節(jié)外旋功能丟失明顯［22］。經(jīng)典的Latarjet手術(shù)在胸小肌腱止點(diǎn)和喙鎖韌帶附著點(diǎn)之間截骨，向外平行移位于肩盂前下緣，喙突骨塊的外緣與關(guān)節(jié)面平整；由de Beer改良的Latarjet手術(shù)喙突骨塊沿其長(zhǎng)軸內(nèi)旋90°轉(zhuǎn)位，使喙突下緣和關(guān)節(jié)面平整［5］。作者分期采用喙突內(nèi)旋90°轉(zhuǎn)位術(shù)式和采用喙突平行轉(zhuǎn)位術(shù)式，均通過水平劈開肩胛下肌并縱行切開肩關(guān)節(jié)囊，以盡量降低手術(shù)操作對(duì)肩胛下肌肌力的削弱，術(shù)畢縫合關(guān)節(jié)囊時(shí)將肩關(guān)節(jié)置于外旋10°從而減少外旋的丟失。喙突骨塊因其寬度大于厚度［1］，平行轉(zhuǎn)位時(shí)與肩盂有較大的接觸面積，能用2枚3．5mm皮質(zhì)骨螺絲釘進(jìn)行固定，從而提供更高的強(qiáng)度；相反，內(nèi)旋90°轉(zhuǎn)位喙突骨塊與肩盂之間接觸面積相對(duì)較小，只能用2枚3．0mm中空螺絲釘進(jìn)行固定。因此，喙突骨塊平行轉(zhuǎn)位時(shí)較內(nèi)旋90°轉(zhuǎn)位有更大的接觸面積和生物力學(xué)強(qiáng)度，從而提高骨塊愈合率。但內(nèi)旋90°轉(zhuǎn)位本身能提供更大的關(guān)節(jié)面安全范圍，有利于肩盂骨缺損較大的患者。本研究?jī)?nèi)旋90°轉(zhuǎn)位組3例不愈合均發(fā)生在該組的早期，骨塊未愈合降低了Latarjet手術(shù)所提供的穩(wěn)定機(jī)制，所以1例術(shù)后殘留Apprehension sign陽性，2例在最大外展、外旋時(shí)有輕度疼痛。為了增加骨塊的愈合率，作者取喙突基底的松質(zhì)骨植骨于喙突骨塊與肩盂接觸面的內(nèi)側(cè)，之后的病例6個(gè)月CT顯示骨塊均已愈合。從終末隨訪來看，喙突平行轉(zhuǎn)位組與喙突內(nèi)旋90°轉(zhuǎn)位組相比，無論前屈上舉、平均體側(cè)外旋、ASES評(píng)分、Constant－Murley評(píng)分或VAS不穩(wěn)定評(píng)分差異均無統(tǒng)計(jì)學(xué)意義。內(nèi)旋90°轉(zhuǎn)位組患者外旋丟失程度大于平行轉(zhuǎn)位組，原因可能在于患者和康復(fù)師早期擔(dān)心骨塊愈合，有一定的恐懼心理，不愿嚴(yán)格執(zhí)行術(shù)后康復(fù)計(jì)劃。

圖2 喙突平行轉(zhuǎn)位Latarje術(shù)式 圖A、B為術(shù)前X線正、側(cè)位片；圖C、D為術(shù)前CT平掃及三維CT重建顯示肩盂有骨缺損和Hill－sachs損傷；圖E、F為喙突平行轉(zhuǎn)位兩枚螺釘固定，術(shù)后6個(gè)月X線正側(cè)位片；圖G、H為術(shù)后6個(gè)月橫截面及三維CT顯示喙突骨塊已與肩胛盂愈合，關(guān)節(jié)面平整，肩盂形狀恢復(fù)良好；圖I～K為術(shù)后2年半隨訪肩功能恢復(fù)良好，Apprehension sign陰性，從事較重體力勞動(dòng)

術(shù)中關(guān)節(jié)面的平整度對(duì)術(shù)后關(guān)節(jié)炎的發(fā)生密切相關(guān)［20］，為此，作者在術(shù)中調(diào)整骨塊的弧度與關(guān)節(jié)面的弧度一致和平整后，先用2枚1．0mm克氏針臨時(shí)固定，再用螺絲釘最終固定，術(shù)后CT證實(shí)兩組喙突骨塊的弧度與關(guān)節(jié)面的弧度均較平滑，臺(tái)階小于3mm。終末隨訪時(shí)按照Samilson和Prieto骨關(guān)節(jié)炎的分型［10］，本研究?jī)H有6例患者終末復(fù)查時(shí)X線片出現(xiàn)骨關(guān)節(jié)炎表現(xiàn)，可能與術(shù)中精確對(duì)合喙突骨塊有關(guān)，也可能與隨訪年限過短有關(guān)。喙突平行轉(zhuǎn)位組與喙突內(nèi)旋90°轉(zhuǎn)位組相比，喙突平行轉(zhuǎn)位組因其固定強(qiáng)度相對(duì)更高、接觸面積更大，喙突骨塊全部愈合，骨關(guān)節(jié)炎在喙突平行轉(zhuǎn)位組僅發(fā)生1例，而喙突內(nèi)旋90°轉(zhuǎn)位組發(fā)生5例，其中3例不愈合病例均出現(xiàn)了輕至中度的骨關(guān)節(jié)炎表現(xiàn)。因此，喙突骨塊不愈合會(huì)導(dǎo)致喙突骨塊不穩(wěn)定，使盂肱關(guān)節(jié)出現(xiàn)非同心運(yùn)動(dòng)也是導(dǎo)致骨關(guān)節(jié)炎的重要原因。

Latarjet手術(shù)雖能增加肩盂關(guān)節(jié)面的安全范圍從而穩(wěn)定肩關(guān)節(jié)，但改變了肩關(guān)節(jié)的自然解剖，降低了肩胛下肌肌力，導(dǎo)致其不同程度的攣縮，會(huì)不同程度降低肩關(guān)節(jié)外旋的范圍以及后期可能出現(xiàn)骨關(guān)節(jié)炎［2］。因此，應(yīng)嚴(yán)格掌握其適應(yīng)證。盡管結(jié)果顯示喙突平行轉(zhuǎn)位較喙突內(nèi)旋90°轉(zhuǎn)位固定強(qiáng)度更高、接觸面積更大、愈合率更高且骨關(guān)節(jié)炎發(fā)生率較低；但喙突內(nèi)旋90°轉(zhuǎn)位則能提供更大的關(guān)節(jié)面安全范圍，通過在喙突骨塊與肩盂接觸面的內(nèi)側(cè)進(jìn)行植骨則有利于骨愈合，從而減少并發(fā)癥。由于本組資料樣本量尚較小，且為非隨機(jī)對(duì)照和回顧性的研究，這兩種轉(zhuǎn)位方式的選用原則尚需進(jìn)一步的研究。

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Comparison of two kinds of Latarjet procedures for recurrent anterior dislocation of the shoulder with severe glenoid bone defects：a 3－5year follow－up study

Xiang Ming，Yang Guoyong，Chen Hang，Hu Xiaochuan，Tang Haochen．Department of Upper Extremity，Sichuan Provincial Orthopadic Hospital，Chengdu 610041，China

Latarjet； Coracoid； Shoulder dislocation； Bony defect

Xiang Ming，Email：josceph＿xm＠sina．com

2013－06－23）

（本文編輯：史鳳穎）

10．3877／cma．j．issn．2095－5790．2014．01．007

610041 成都，四川省骨科醫(yī)院上肢科

向明，Email：josceph＿xm＠sina．com

【Abstract】ObjectiveShoulder dislocations，most of which are anterior dislocations，account for over 40%of joint dislocations．The main pathological mechanism is the dysfunction of the anteroinferior glenolabral articular ligamental complex，namely theBankart injury．Failure of the repair can cause the recurrent dislocation．Some cases are accompanied with the glenoidavulsion fracture or the bony defect，even with the inverted pear glenoid．Open or arthroscopic reconstruction can achieve excellent clinical results for the Bankart injury which bone defect is less than 25%．But if bony defect of glenoid is over 25%－30%or associtaed with Hill－Sachs injury，the re－dislocation rate is up to 67%after the simple Bankart reconstruction．The Latarjet procedure is able to reduce the recurrent dislocation significantly．This study is to retrospectively evaluate the three－to－five years＇follow－up results of the Latarjet coracoid bone block procedure for the recurrent anterior dislocation of the shoulder associated with the severe bony defects．MethodsThirty－seven patients （23men and 14 women）underwent the Latarjet procedure for the anterior glenohumeral instability between April 2006 and October 2009．All the shoulders had the severe osseous deficiency of the anterior glenoid rim，which was more than 25%of the glenoid width according to 3－dimensional CT scan and arthroscopic findings．The patients were associtated with Engaging Hill－Sachs lesion．21patients were treated by the parallel coracoid transposition bone block from January 2008to October 2009，and 16patients were performed with the intorted coracoid transposition method from April 2006to December 2007．Apprenhension sign was positive in all of the 37patients before operation．And the mean time of their dislocations was 13．5 （ranged from 8to 28times）．We evaluated the preoperative and postoperative pain，the daily living activities，the range of motion，stability of the shoulders，and function of the shoulder using the American Shoulder and Elbow Surgeons Assessment（ASES），the Constant－Murley Score and the VAS score．ResultsThe follow－up period ranged from 37to 61months （mean，48．3 months）．All the patients got bony union in the coracoid parallel transposition group while three got a nonunion in the intorted group according to the 3dimensional CT scan taken at 6months＇follow－up．For the parallel transposition group，most of the patients had a satisfactory pain relief and daily living activities postoperatively at the final follow－up．The forward elevation improved from （152．5±22．6）°preoperatively to （168．0±7．8）°postoperatively，the average external rotational limitation measured in the neutral position of the arm improved from （52．6±18．4）°to（44．9±15．0）°（t＝1．486，P ＞0．05），the ASES scores increased from 80．7±16．7to 92．2±6．4（t ＝2．947，P ＜0．05），the Constant－Murley scores increased from 78．6±10．1to 91．6±13．2（t＝－3．584，P ＜0．05），and the VAS scores increased from 6．0±1．4to 4．3±1．6（t ＝3．664，P ＜0．05）．However，for the intorted transposition group，the forward elevation improved from （148．5±19．2）°to（170．0±10．5）°（t ＝3．930，P ＜0．05），the mean external rotation improved from （55．8±16．9）°to （40．6±13．6）°（t ＝2．803，P ＜0．05），the ASES score increased from 81．4±14．7to 92．4±7．0（t ＝－2．702，P ＜0．05），the Constant－Murley score increased from 80．2±12．6to 92．8±5．1（t＝3．708，P ＜0．05），the VAS score increased from 6．4±1．5 to 4．2±2．1（t ＝3．410，P ＜0．05），and one patient had a residual positive Apprehension sign postoperatively，two had mild pain at the position of the maximal abduction or the external rotation．Only one got mild pain at this position in the parallel group．Secondary mild to moderate osteoarthritic changes of the glenohumeral joint were observed in six shoulders postoperatively in the final follow－up．Discussion Glenohumeral stability depends on the structure of the muscle，the ligament and the bone，which can maintain the rotation center of the humeral head and the glenoid．The incidence of shoulder dislocation in US is 11．2／10million，90%of which is areanterior dislocation．The recurrent dislocation will further change the glenohumeral joint contact area and the static stability，which reduces the stability of glenohumeral．Through the MRI examination for patients with the acute anterior shoulder dislocation，Widjaja and colleagues found that 73%of the initial dislocation were associated with Bankart injury and 67%with Hill－Sachs injury．Yiannakopoulos et al．demonstrated that the rates of Bankart and ALPSA injury were up to 97%after the repeated anterior dislocation，howerer，the rates of Hill－Sachsinjury and inverted pearglenoid were 93%and 15%，respectively．Robinson et al．reported a prospective clinical study of patients（aged from 15－35years old）after the conservative treatment forthe anterior shoulder dislocation，56%of which were re－dislocated．The instability rate of those 20－yearold males was as high as 72%－86% ．The open Bankart reconstruction could restore the anterior glenoid anatomy，and had been considered as the gold standard with the 3%recurrence rate．With the development of the arthroscopic techniqueand instruments，many authors have reported the arthroscopic Bankart reconstruction with excellent results，even 20%of the patients with the glenoid bone defect had satisfactory outcomes for the reconstruction of the arthroscopic soft tissue．However，a growing number of researches show that the structural integrity of the glenoid bone is one of the key factors for the successful surgical repair．Burkhart et al．demonstrated the rate of the failure repair was as high as 67%in the soft tissue Bankart reconstruction for the obpyriform glenoid．Therefore，the bony reconstruction was recommended for the obpyriform glenoid associated with the Engaging Hill－Sachs injury．Latarjet and Helfet reported the treatment of the recurrent anterior shoulder dislocation with the coracoid process transposition had achieved satisfactory results in 1954and 1958，respectively．The principle of latarjet procedure is to make the coracoid fragment become a platform to attain the extra－articular extension of the articular surface．Its role in stabilizing the shoulder are：1the fragment increases the security area of glenoid before the humeral head is dislocated；2the conjoined tendon acts to prevent the huemral head to move forward while the external rotation of the arm；3the anteroinferior capsule can be reinforced by the translocated coracoid process and the conjoined tendon strided across the lower 1／3position of the subscapularis tendon．This study demonstrated that the Latarjet procedure had good results to treat recurrent anterior dislocation associated with severe bone defects，and significantly increased the anterior stability and the flexion of the shoulder as well as a variety of functional scores．The traditional Latarjet procedure needs to cut off the proximal subscapularis tendon，which declines the muscle strength of subscapularis and reduces the restriction of the humeral head moving forward．The overlapping suture of subscapularis and the shoulder immobilization in internal rotation cause a significant loss of the external rotation of shoulder．Osteotomy in the classic Latarjet surgery is between the origins of the pectoralis minor and the coracoclavicular ligaments．The coracoid fragment is shifted laterally to anteroinferior rim of glenoid，and its lateral edge is surfaced．In the latarjet procedure modified by de Beer，the coracoid fragment is pronated 90°along its long axis，so that the lower edge of the coracoid processis is surfaced．The width of the coracoid fragment is greater than its thickness，so the coracoid fragment has a larger contact area with the glenoidin classic transposition，and can be fixed with two 3．5mm cortical screws with more stability．On the contrary，the fragment has a smaller contact area with the glenoid in the modified transposition，and can be fixed with only two 3．0mm cannulated screws．Therefore，the classic transposition has a better biomechanical advantage and improves the union of bones．However，the modified transposition provides a greater articular surface，and are advised for the patients with the massive bone defect．In this study，the first three patients from the intorted coracoid transposition group suffered the nonunion which reduced the stabilization offered by Latarjet procedure，therefore，Apprehension sign of one case was positive，and the mild pain existed while the maximum of abduction and external rotation in the remaining two cases．In order to decrease the risk of the nonunion，we performed the autograft between the glenoid and the fragment with the cancellous bone obtained from the base of the corocoid process．There was no significant statistical differences between the parallel group and the intorted group on the forward elevation，the external rotation in the neutral position of the arm，the ASES scores，the Constant－Murley scores，and the VAS instability scores．The loss of the external rotation was obviously greater than that in intorted group，for the rehabilitation physicians were unwilling to strictly carry out the postoperative rehabilitation program due to their anxiety about the bone union．The roughness of the articualr surface is closely related with the occurrence of the postoperative arthritis．So we adjusted the curvature of the fragment to make it consistent with articular surface．The fragment was first fixed with two 1．0mm K－wires for the temporary fixation，and then screws were used for the fixation．Postoperative CT scans confirmed that the glenoid surface was relatively smooth and the step was less than 3mm．According to the Samilson and Prieto osteoarthritisclassification，6patients had OA in X－ray films in the final follow－up of this study，which might be related with the intraoperative fragment reduction and the short follow－up period．Compared with the modified transposition，the classic procedure had more stability of fixation，so the bone heeled in all cases and OA only appeared in one case．Conclusions The Latarjet coracoid bone block procedure has proved effective with a lower redislocation rate for most of the patients with the complex recurrent anterior dislocation of the shoulder accompanied by the severe glenoid bony defect．The parallel coracoid transposition group with more contact area and more stable fixation strength had a higher union rate compared with the coracoid intorted group．

向明，楊國(guó)勇，陳杭，等．Latarjet兩種術(shù)式在治療肩關(guān)節(jié)復(fù)發(fā)性前脫位伴重度骨缺損中3～5年隨訪的比較研究［J／CD］．中華肩肘外科電子雜志，2014，2（1）：33－40．