朱以明 姜春巖

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評(píng)估Latarjet手術(shù)后移位喙突骨塊吸收情況的CT分型系統(tǒng)的一致性研究

朱以明 姜春巖

目的 提出一種基于CT的分型系統(tǒng)來(lái)評(píng)估Latarjet手術(shù)后移位喙突骨塊的吸收程度。應(yīng)用該分型系統(tǒng)研究Latarjet手術(shù)后患者最終隨訪時(shí)行CT檢查以了解喙突骨吸收現(xiàn)象的發(fā)生率及嚴(yán)重程度；并了解應(yīng)用該分型系統(tǒng)時(shí)檢查者之間的一致性以及檢查者自身的前后一致性。方法 選取2009年1月至2012年1月期間，63例接受切開(kāi)Latarjet手術(shù)治療的患者。所有患者術(shù)前診斷均為復(fù)發(fā)性肩關(guān)節(jié)前脫位。所有患者在術(shù)后12個(gè)月時(shí)均行CT檢查。4位與手術(shù)治療無(wú)關(guān)的獨(dú)立骨科醫(yī)師對(duì)患者術(shù)后12個(gè)月隨訪時(shí)CT影像進(jìn)行閱片，并采用我們提出的分型系統(tǒng)對(duì)移位喙突骨塊吸收程度進(jìn)行了評(píng)估。在初次評(píng)估后3個(gè)月，4位檢查者對(duì)上述影像進(jìn)行了再次評(píng)估。以ICCs系數(shù)評(píng)價(jià)各位檢查者之間檢查結(jié)果的一致性，以及每位檢查者前后兩次檢查結(jié)果的一致性。結(jié)果 在術(shù)后12個(gè)月時(shí)，移位喙突骨吸收的發(fā)生率為90.5%。其中骨吸收0級(jí)患者有6例，Ⅰ級(jí)患者26例，Ⅱ級(jí)患者25例，Ⅲ級(jí)患者6例。結(jié)論 切開(kāi)Latarjet手術(shù)后12個(gè)月時(shí)，移位喙突骨塊吸收的發(fā)生率很高。該分型系統(tǒng)有優(yōu)秀的檢查者之間一致性以及檢查者自身前后一致性。

復(fù)發(fā)性肩關(guān)節(jié)前脫位；Latarjet手術(shù)；骨吸收

1954年法國(guó)醫(yī)師Latarjet首先描述了采用喙突截骨移位的方法治療復(fù)發(fā)性肩關(guān)節(jié)前脫位。他所描述的手術(shù)技術(shù)的要點(diǎn)包括：(1)喙突截骨；(2)將帶有聯(lián)合腱的喙突骨塊穿過(guò)肩胛下肌腱后用螺釘固定于肩盂前緣。Patte與Walch在1980年對(duì)Latarjet技術(shù)做了一些改良，包括使用2枚螺釘固定喙突骨塊以及將關(guān)節(jié)囊和喙突上的喙肩韌帶殘端縫合以重建起止點(diǎn)。他們認(rèn)為L(zhǎng)atarjet手術(shù)穩(wěn)定肩關(guān)節(jié)作用來(lái)源于3方面：(1)移位的喙突骨塊可增加肩盂的寬度；(2)肩關(guān)節(jié)外展、外旋時(shí)固定在肩盂前下緣的聯(lián)合腱可起到動(dòng)力阻擋的作用；(3)將關(guān)節(jié)囊縫合至喙肩韌帶殘端上可重建前關(guān)節(jié)囊的止點(diǎn)從而起到穩(wěn)定作用。時(shí)至今日，在復(fù)發(fā)性肩關(guān)節(jié)前脫位的治療中，尤其是針對(duì)那些合并明顯肩盂前緣骨缺損的患者，這一術(shù)式仍是最常用的手術(shù)方法之一。另一方面，隨著對(duì)該手術(shù)的研究的不斷深入，人們發(fā)現(xiàn)該術(shù)式的一些常見(jiàn)合并癥明顯影響手術(shù)的療效。其中，移位喙突骨塊吸收的現(xiàn)象曾被多次報(bào)道。一些研究者認(rèn)為嚴(yán)重的喙突骨塊吸收可能導(dǎo)致患者出現(xiàn)復(fù)發(fā)脫位或肩關(guān)節(jié)疼痛等癥狀。但是，目前對(duì)手術(shù)后喙突骨塊吸收的研究仍十分有限。由于缺乏統(tǒng)一的研究方法、分型系統(tǒng)對(duì)其進(jìn)行標(biāo)準(zhǔn)化的描述，因而不同作者采用不同的研究方法所得的喙突骨吸收的發(fā)生率亦千差萬(wàn)別，更難以進(jìn)一步深入探究這一現(xiàn)象的成因和對(duì)臨床療效的影響。

本研究的目的在于提出一種專(zhuān)用于Latarjet手術(shù)后移植喙突骨塊吸收研究的CT掃描方法及分型系統(tǒng)。我們希望在這類(lèi)患者中應(yīng)用這一方法和分型系統(tǒng)，以調(diào)查不同程度的喙突骨吸收的發(fā)生率；并通過(guò)檢查者之間比較和檢查者個(gè)人前后可重復(fù)性分析來(lái)評(píng)估該方法的一致性。

對(duì) 象 與 方 法

一、入選和排除標(biāo)準(zhǔn)

入選標(biāo)準(zhǔn)：(1)患者診斷為創(chuàng)傷后復(fù)發(fā)性肩關(guān)節(jié)前脫位；(2)術(shù)前均行三維CT檢查，CT enface view顯示肩盂存在明顯骨缺損；(3)手術(shù)方式為切開(kāi)Latarjet術(shù)；(4)患者同意參加相關(guān)臨床研究并簽署知情同意書(shū)；(5)術(shù)后臨床隨訪超過(guò)2年，有完整的影像學(xué)評(píng)估資料(術(shù)后即刻CT與術(shù)后12個(gè)月CT)。排除標(biāo)準(zhǔn)：(1)存在肩關(guān)節(jié)多方向不穩(wěn)定；(2)既往患側(cè)肩關(guān)節(jié)有手術(shù)史；(3)術(shù)后12個(gè)月CT顯示移位喙突不愈合或內(nèi)固定失效，因而難以評(píng)估喙突骨吸收情況。

二、術(shù)前評(píng)估

入選患者在術(shù)前均提供了包括初次脫位年齡以及脫位次數(shù)等信息在內(nèi)的詳細(xì)病史。檢查者對(duì)患者進(jìn)行詳細(xì)的肩關(guān)節(jié)體格檢查，并填寫(xiě)ASES評(píng)分(American shoulder & elbow surgeons′ score)、Constant-Murley評(píng)分以及Rowe評(píng)分表。術(shù)前需行患側(cè)肩關(guān)節(jié)三維CT檢查。在肩關(guān)節(jié)三維重建CT上，依照Sugaya所描述的方法，將肱骨頭影像去除后，使肩盂正對(duì)檢查者，形成所謂enface view。在enface view上評(píng)估肩盂骨缺損的大小，如超過(guò)完整肩盂的25%，則選擇進(jìn)行切開(kāi)Latarjet術(shù)。

三、患者體位與手術(shù)入路

全部病例均在全身麻醉下接受手術(shù)?；颊咧糜谏碁┮挝?，患側(cè)肩關(guān)節(jié)置于手術(shù)臺(tái)邊緣之外且消毒鋪單后患側(cè)上肢仍能向各個(gè)方向自由運(yùn)動(dòng)。手術(shù)切口從喙突尖開(kāi)始直行向下，長(zhǎng)約5 cm。切開(kāi)后由三角肌-胸大肌間隙進(jìn)入。注意保護(hù)頭靜脈完整并將其拉向外側(cè)。在喙突上置入一把Hohmann骨撬以充分顯露喙突。

1.喙突準(zhǔn)備：使肩關(guān)節(jié)處于外展、外旋位，顯露喙肩韌帶。在喙突側(cè)保留約1 cm長(zhǎng)喙肩韌帶止點(diǎn)后切斷喙肩韌帶。切斷喙肩韌帶喙突側(cè)止點(diǎn)深方的喙肱韌帶止點(diǎn)。使肩關(guān)節(jié)處于內(nèi)收、內(nèi)旋位以顯露喙突內(nèi)側(cè)。將喙突內(nèi)側(cè)的胸小肌止點(diǎn)切斷。但避免沿聯(lián)合腱內(nèi)側(cè)向下松解，以防損傷肌皮神經(jīng)并影響喙突的血供。通過(guò)上述準(zhǔn)備，應(yīng)可充分顯露喙突的內(nèi)側(cè)、外側(cè)及下面。在喙突的弓背轉(zhuǎn)彎、緊貼喙鎖韌帶止點(diǎn)處，用彎骨刀自上向下截?cái)噜雇?。以微型擺鋸將截?cái)嗟泥雇坏南卤砻嫣幚砥秸⑷コ瞧べ|(zhì)以顯露深方松質(zhì)骨床。垂直于喙突上表面骨皮質(zhì)，使用2.7 mm電鉆，在喙突上鉆兩個(gè)骨孔。兩骨孔間應(yīng)留有足夠間隙。將喙突骨塊塞在胸大肌深方后進(jìn)行下一步操作。

2.顯露肩盂：將患肢置于體側(cè)外旋位，用自動(dòng)拉鉤拉開(kāi)三角肌-胸大肌間隙，充分顯露肩胛下肌。在肩胛下肌腱的中下1/3處水平劈開(kāi)肩胛下肌腱。首先用組織剪在肩胛下肌的中下1/3處沿肌纖維方向水平劈開(kāi)肩胛下肌。然后將組織剪沿垂直肌纖維方向打開(kāi)，從而分開(kāi)肌纖維。從組織剪分開(kāi)處向內(nèi)側(cè)在肩胛下肌和肩胛骨間塞入紗布，以使肩胛下肌和深方關(guān)節(jié)囊和肩胛骨間有足夠間隙以增加顯露。在劈開(kāi)的肩胛下肌裂隙內(nèi)側(cè)，肩胛骨體前面放置一把Batman骨撬，擋住內(nèi)側(cè)軟組織及重要的血管神經(jīng)結(jié)構(gòu)。緊貼肩盂在其下插入一把Hohmann骨撬，將下1/3肩胛下肌纖維擋向下方。在肩胛骨體前面盡可能靠上的位置鉆入1枚4 mm的Steinman針，并將其扳向上方從而將上2/3的肩胛下肌纖維擋向上方。這樣就可以將盂肱關(guān)節(jié)前方充分顯露了。在盂肱關(guān)節(jié)間隙處，縱行切開(kāi)約2 cm長(zhǎng)的前關(guān)節(jié)囊，將Fukuda撬插入肩盂和肱骨頭間，扳向外側(cè)從而將肱骨頭擋向外后方，充分顯露肩盂。

3.肩盂準(zhǔn)備和喙突固定：在緊貼肩盂前緣的肩胛骨前面做骨床準(zhǔn)備，其范圍為肩盂前緣大約5點(diǎn)鐘(右肩)位置(左肩則為7點(diǎn)鐘位置)開(kāi)始向近端大約2 cm長(zhǎng)的區(qū)域。切除這一區(qū)域內(nèi)的盂唇及骨膜組織，以骨刀將表面骨皮質(zhì)打掉露出滲血的松質(zhì)骨床面。在大約5點(diǎn)鐘位置的肩胛骨前面以2.7 mm骨鉆鉆孔作為固定喙突的下方螺釘孔。該骨孔應(yīng)距離肩盂關(guān)節(jié)面邊緣足夠的距離以使喙突骨塊固定后其外緣不至于高于肩盂關(guān)節(jié)面。鉆孔時(shí)鉆頭方向應(yīng)平行肩盂關(guān)節(jié)面，直至鉆透肩胛骨后側(cè)骨皮質(zhì)。

在喙突上預(yù)鉆的兩個(gè)骨塊中偏下方的一個(gè)內(nèi)擰入1枚4.0 mm半螺紋空心釘，長(zhǎng)度大約30 mm。將該螺釘擰入肩胛骨前面預(yù)鉆的骨孔，保證喙突長(zhǎng)軸處于平行于肩盂關(guān)節(jié)面的位置的前提下，擰緊該螺釘。固定后，喙突骨塊的外緣應(yīng)與肩盂關(guān)節(jié)面平齊，如果較關(guān)節(jié)面高度略低1～2 mm亦可以接受。用2.7 mm骨鉆通過(guò)喙突骨塊上預(yù)鉆的偏上方的骨孔在肩胛骨上鉆孔，直至鉆透肩胛骨的后側(cè)皮質(zhì)。用測(cè)深尺測(cè)量后，擰入另一枚4.0 mm半螺紋空心釘。如其測(cè)量長(zhǎng)度與下方已置入螺釘差距明顯，則可在擰緊上方螺釘后取出下方螺釘，再準(zhǔn)確測(cè)量后擰入合適長(zhǎng)度的螺釘。保持肩關(guān)節(jié)位于體側(cè)極度外旋位的前提下，將縱行切開(kāi)的前關(guān)節(jié)囊與喙突上保留的喙肩韌帶起點(diǎn)縫合，以重建前關(guān)節(jié)囊的止點(diǎn)。傷口內(nèi)留置引流管后逐層縫合。

四、康復(fù)計(jì)劃

術(shù)后肩關(guān)節(jié)應(yīng)使用頸腕吊帶制動(dòng)3周。此后在理療師指導(dǎo)下開(kāi)始患肢被動(dòng)活動(dòng)練習(xí)。術(shù)后6周時(shí)可摘掉吊帶以患肢做日常生活，但6周內(nèi)避免抗阻屈肘肌力練習(xí)。術(shù)后3個(gè)月開(kāi)始進(jìn)行終末牽拉練習(xí)。術(shù)后半年可恢復(fù)進(jìn)行接觸性的或過(guò)頭的體育項(xiàng)目。

圖1 喙突骨吸收0級(jí)，喙突骨塊無(wú)吸收，螺釘帽均深埋于喙突骨塊內(nèi) 圖2 喙突骨吸收Ⅰ級(jí)，喙突骨塊稍有吸收，僅有螺釘?shù)尼斆辈糠致队卩雇还菈K外，螺釘桿部完全埋于喙突骨塊內(nèi) 圖3 喙突骨吸收Ⅱ級(jí)，喙突骨塊明顯吸收，螺釘帽與部分螺釘桿裸露于喙突骨塊之外，但肩盂前方仍有喙突骨塊殘留 圖4 喙突骨吸收Ⅲ級(jí)，喙突骨塊完全吸收，肩盂前面無(wú)骨塊殘留，僅有完全暴露的螺釘桿部及螺釘尾帽

五、術(shù)后隨訪計(jì)劃

預(yù)約患者在術(shù)后的3周、6周、3個(gè)月、6個(gè)月、12個(gè)月時(shí)回醫(yī)院隨訪。此后每年隨訪1次。術(shù)后早期隨訪時(shí)，主要由臨床醫(yī)師檢查患者肩關(guān)節(jié)功能康復(fù)的情況并指導(dǎo)功能鍛煉。術(shù)后12個(gè)月時(shí)需行詳細(xì)體格檢查，征得患者的同意后行三維CT檢查以明確肩盂前緣折塊的位置和愈合情況。

六、影像學(xué)評(píng)估方法

術(shù)前行患側(cè)肩關(guān)節(jié)三維CT檢查，以評(píng)估肩盂骨缺損的情況。術(shù)后即刻行患側(cè)肩關(guān)節(jié)三維CT檢查，以評(píng)估喙突骨塊的位置及固定情況。術(shù)后12個(gè)月隨訪時(shí)再次行肩關(guān)節(jié)三維CT檢查，在橫斷位上評(píng)估喙突愈合情況及喙突骨吸收情況。以我們所提出的針對(duì)喙突骨吸收的專(zhuān)用分級(jí)系統(tǒng)對(duì)吸收情況進(jìn)行分級(jí)。

七、喙突骨塊術(shù)后骨吸收分型

0級(jí)：喙突骨塊無(wú)吸收，螺釘帽均深埋于喙突骨塊內(nèi)(圖1)；Ⅰ級(jí)：喙突骨塊稍有吸收，僅有螺釘?shù)尼斆辈糠致队卩雇还菈K外，螺釘桿部完全埋于喙突骨塊內(nèi)(圖2)；Ⅱ級(jí)：喙突骨塊明顯吸收，螺釘帽與部分螺釘桿裸露于喙突骨塊之外，但肩盂前方仍有喙突骨塊殘留(圖3)；Ⅲ級(jí)：喙突骨塊完全吸收，肩盂前面無(wú)骨塊殘留，僅有完全暴露的螺釘桿部及螺釘尾帽(圖4)。

本系統(tǒng)以喙突骨吸收后螺釘暴露情況作為分級(jí)標(biāo)準(zhǔn)。當(dāng)進(jìn)行分級(jí)時(shí)，檢查者需分別依據(jù)2枚固定喙突的空心釘中的偏頭側(cè)釘和偏足側(cè)釘?shù)谋┞肚闆r分別對(duì)其周?chē)雇还琴|(zhì)吸收情況進(jìn)行分級(jí)，并加以記錄。然后以其中吸收較為嚴(yán)重，螺釘暴露更明顯的結(jié)果作為喙突骨吸收的最終分級(jí)等級(jí)。

八、檢查者及可靠性研究方法

4位獨(dú)立檢查者參與了本分級(jí)系統(tǒng)的可靠性研究。這些檢查者均為完成了骨科及肩關(guān)節(jié)外科培訓(xùn)的臨床骨科醫(yī)師，從事肩關(guān)節(jié)外科平均6.5年(3～12年)。

在檢查者培訓(xùn)階段，將喙突骨吸收的專(zhuān)用分級(jí)系統(tǒng)說(shuō)明書(shū)分發(fā)給4位檢查者，使其熟悉該分級(jí)系統(tǒng)的應(yīng)用方法。

所有患者的CT圖像收集齊后，隱去患者信息，發(fā)給4位檢查者，由其依據(jù)喙突骨吸收的專(zhuān)用分級(jí)系統(tǒng)對(duì)喙突骨塊的骨吸收情況加以分級(jí)。每位檢查者瀏覽CT圖像時(shí)，患者均以隨機(jī)順序排列。1個(gè)月后，由4位檢查者以相同方法再次對(duì)患者喙突骨吸收情況進(jìn)行分級(jí)。最終患者喙突骨吸收情況以評(píng)估者中年資最高的醫(yī)師的分級(jí)結(jié)果為準(zhǔn)。

此外，我們還對(duì)比了年資最高醫(yī)師進(jìn)行分級(jí)工作時(shí)所記錄的偏頭側(cè)空心釘周?chē)菈K吸收分級(jí)以及偏足側(cè)空心釘周?chē)菈K吸收的分級(jí)結(jié)果，從而希望發(fā)現(xiàn)哪一部位的喙突骨塊的吸收程度更為嚴(yán)重。

九、統(tǒng)計(jì)學(xué)方法

本研究采用SPSS 16.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。以ICCs系數(shù)(intraclass correlation coefficients)來(lái)評(píng)價(jià)檢查者之間評(píng)價(jià)一致性以及每位檢查者前后兩次檢查結(jié)果的可重復(fù)性。如ICCs系數(shù)>0.75，則認(rèn)為評(píng)價(jià)方法的一致性?xún)?yōu)秀；如ICCs系數(shù)在0.40～0.75則認(rèn)為一致性中等；如ICCs系數(shù)<0.40則一致性差。

結(jié) 果

從2009年1月至2012年1月期間，共有81例復(fù)發(fā)性肩關(guān)節(jié)前脫位患者接受切開(kāi)Latarjet手術(shù)治療。其中65例在術(shù)前、術(shù)后即刻及術(shù)后12個(gè)月時(shí)均行CT檢查。在這65例患者中有1例因術(shù)后12個(gè)月CT顯示移位喙突骨塊未骨性愈合，另1例出現(xiàn)內(nèi)固定失效而被排除，剩余63例入選本次研究。

一、喙突骨吸收

術(shù)后12個(gè)月CT顯示喙突骨吸收的發(fā)生率較高，63例患者的骨吸收分級(jí)情況如下，0級(jí)：6例(9.5%)；Ⅰ級(jí)：26例(41.3%)；Ⅱ級(jí)：25例(39.7%)；Ⅲ級(jí)：6例(9.5%)。由此可見(jiàn)，在術(shù)后12個(gè)月時(shí)，喙突骨吸收的發(fā)生率為90.5%(57/63)。如仔細(xì)區(qū)分2枚空心釘周?chē)琴|(zhì)吸收情況的差別時(shí)我們發(fā)現(xiàn)，63例病例中34例2枚螺釘周?chē)琴|(zhì)吸收分級(jí)相同，另有29例病例偏頭側(cè)螺釘周?chē)琴|(zhì)吸收情況較偏足側(cè)螺釘更加嚴(yán)重。

二、分級(jí)系統(tǒng)的可靠性

統(tǒng)計(jì)分析顯示，本分級(jí)系統(tǒng)的檢查者之間一致性(ICCs,95% confidence Interval,0.856)和檢查者個(gè)人前后可重復(fù)性(ICCs,95% confidence Interval,0.946)均十分出色。

討 論

復(fù)發(fā)性肩關(guān)節(jié)前脫位是臨床常見(jiàn)疾患。多數(shù)情況下，采用關(guān)節(jié)鏡下盂肱下韌帶前盂唇復(fù)合體修復(fù)術(shù)(關(guān)節(jié)鏡下Bankart修復(fù)術(shù))進(jìn)行治療能取得良好的療效[1-11]。但是，對(duì)于那些脫位次數(shù)多、時(shí)間長(zhǎng)的患者，往往合并明顯肩盂骨質(zhì)缺損。這種情況下，鏡下Bankart修復(fù)術(shù)后再脫位率很高[12]。在合并明顯骨缺損或前關(guān)節(jié)囊質(zhì)量很差時(shí)Latarjet手術(shù)是治療復(fù)發(fā)性肩關(guān)節(jié)前脫位的有效方法，從目前的文獻(xiàn)報(bào)道來(lái)看，其術(shù)后復(fù)發(fā)率在0%～8%[13-18]。因此在治療這類(lèi)難治性的復(fù)發(fā)性肩關(guān)節(jié)前脫位的患者時(shí)，Latarjet手術(shù)仍是最為廣泛應(yīng)用的術(shù)式。

但是從我們的臨床隨訪看，雖然Latarjet手術(shù)后肩關(guān)節(jié)復(fù)發(fā)脫位率很低，但隨訪時(shí)的CT往往顯示移位的喙突骨塊存在不同程度的骨吸收的現(xiàn)象。檢索文獻(xiàn)我們發(fā)現(xiàn)，這一現(xiàn)象也被不同作者多次報(bào)道。但圍繞這一問(wèn)題，目前仍有許多爭(zhēng)議。

首先，對(duì)術(shù)后喙突骨吸收的發(fā)生率，文獻(xiàn)報(bào)道的結(jié)果大不相同。Allain等對(duì)56例患者(58個(gè)肩關(guān)節(jié))進(jìn)行了平均14.3年的隨訪，所有患者在隨訪時(shí)均拍攝了X光片，有15例患者進(jìn)行了CT檢查[13]。作者報(bào)道10例肩關(guān)節(jié)出現(xiàn)移位喙突骨塊的部分吸收，占所有病例的17%。Di Giacomo 等對(duì)Latarjet手術(shù)后移位喙突骨塊吸收的現(xiàn)象做了詳盡的研究。他們對(duì)16例病例進(jìn)行了兩次術(shù)后CT檢查[19]。第一次在術(shù)后3 d，另外一次在術(shù)后平均17.5個(gè)月隨訪時(shí)。他們發(fā)現(xiàn)所有的移位喙突骨塊均有不同程度的骨吸收。最嚴(yán)重的骨吸收發(fā)生在喙突的近端、內(nèi)側(cè)、淺部。此處有平均93.4%的骨量被吸收。喙突整體骨量被平均吸收59.5%。但是許多其他的有關(guān)Latarjet手術(shù)后的隨訪研究均未提到喙突骨吸收的情況[14-16,20-21]。究其原因，我們發(fā)現(xiàn)所有沒(méi)有提到喙突骨吸收情況的隨訪研究，其術(shù)后影像學(xué)評(píng)估方法仍為普通X線(xiàn)片，均未采用CT檢查。由此可見(jiàn)，X線(xiàn)片不能準(zhǔn)確的評(píng)估喙突骨吸收的情況，因此我們選擇CT檢查作為評(píng)估這一現(xiàn)象的研究方法。從我們的研究結(jié)果看，術(shù)后90.5%的患者存在不同程度的骨吸收，81%的患者存在Ⅰ級(jí)或Ⅱ級(jí)的骨吸收，9.5%的患者的喙突骨塊完全吸收。

其次，對(duì)于術(shù)后喙突骨吸收一旦發(fā)生對(duì)臨床療效可能造成的影響也有不同的意見(jiàn)。Allain等學(xué)者的隨訪研究顯示，移位喙突的骨吸收現(xiàn)象在術(shù)后平均14.3年隨訪時(shí)并未對(duì)患者的肩關(guān)節(jié)功能和穩(wěn)定性造成明顯的影響，但也認(rèn)為由于隨訪中發(fā)現(xiàn)喙突骨吸收的病例較少，因此難以對(duì)臨床療效的影響作出明確的判斷[13]。Di Giacomo 等所報(bào)道的病例系列中，在術(shù)后短期隨訪時(shí)，明顯的喙突骨吸收并未對(duì)患者的肩關(guān)節(jié)穩(wěn)定性、關(guān)節(jié)活動(dòng)度以及術(shù)后肩關(guān)節(jié)疼痛情況造成明顯影響[19]。但是另一方面，Cassagnaud等的研究則認(rèn)為，嚴(yán)重的喙突骨吸收會(huì)使患者出現(xiàn)肩關(guān)節(jié)疼痛癥狀并影響其肩關(guān)節(jié)功能[22]。Lafosse等報(bào)道了62例病例行Latarjet手術(shù)后的隨訪結(jié)果，其中3例出現(xiàn)了明顯的移位喙突的骨吸收，導(dǎo)致螺釘尾帽明顯突出，最終需手術(shù)取出螺釘[23]。Lunn等報(bào)道了46例行Latarjet手術(shù)后復(fù)發(fā)脫位的病例，其中13例移位的喙突骨塊有明顯的吸收，作者分析這是導(dǎo)致出現(xiàn)肩關(guān)節(jié)復(fù)發(fā)脫位的重要的風(fēng)險(xiǎn)因素[24]。分析這些既往的文獻(xiàn)報(bào)道，我們認(rèn)為喙突骨塊吸收的現(xiàn)象有可能導(dǎo)致患者術(shù)后出現(xiàn)復(fù)發(fā)脫位和關(guān)節(jié)疼痛等癥狀。之所以在文獻(xiàn)中有不同的意見(jiàn)，有可能與骨塊吸收的程度不同有關(guān)，只有那些嚴(yán)重的骨吸收才會(huì)使患者出現(xiàn)上述癥狀。這就使我們想到，單純描述是否出現(xiàn)術(shù)后喙突骨吸收并不足以闡明其對(duì)臨床療效的影響，有必要提出一種專(zhuān)用的分型系統(tǒng)，從而不僅闡明是否出現(xiàn)骨吸收而且說(shuō)明其吸收的程度。

檢索現(xiàn)有的文獻(xiàn)，我們發(fā)現(xiàn)目前尚無(wú)這樣的分型系統(tǒng)。Di Giacomo等對(duì)術(shù)后喙突骨吸收的現(xiàn)象應(yīng)用CT檢查做了詳細(xì)的研究。他們將喙突骨塊依其部位分成8個(gè)部分，分別描述各個(gè)部分在術(shù)后吸收的情況。這一方法雖然可精確描述術(shù)后骨吸收的程度和位置，但過(guò)于復(fù)雜，難以在臨床上推廣應(yīng)用。我們所提出的分型方法通過(guò)描述固定螺釘暴露的情況來(lái)決定骨吸收的程度，應(yīng)用起來(lái)比較簡(jiǎn)單，有很好的檢查者之間一致性和檢查者個(gè)人前后可重復(fù)性，由此可見(jiàn)其臨床應(yīng)用的可靠性較高。

如仔細(xì)區(qū)分不同部位喙突骨吸收的情況我們可以看到，在大多數(shù)患者中，偏頭側(cè)喙突骨質(zhì)吸收更為顯著，這一結(jié)果與Di Giacomo等既往的報(bào)道一致。我們推測(cè)這可能是由于該部分的喙突骨質(zhì)與聯(lián)合腱距離較遠(yuǎn)，更難以得到來(lái)自聯(lián)合腱及其周?chē)M織的血液供應(yīng)滋養(yǎng)。

下一步，我們希望將該分型系統(tǒng)應(yīng)用于更大規(guī)模的患者隨訪中，從而探究何種程度的喙突骨吸收會(huì)明顯影響患者的臨床療效；造成喙突骨吸收的可能的原因是什么，及其預(yù)防方法；關(guān)節(jié)鏡下喙突移位和切開(kāi)喙突移位在術(shù)后喙突骨吸收的發(fā)生率和嚴(yán)重程度方面是否有顯著性區(qū)別。

本研究的優(yōu)點(diǎn)在于首次提出了一種簡(jiǎn)單易用的分型方法來(lái)描述Latarjet術(shù)后移位喙突骨塊吸收的嚴(yán)重程度，并證實(shí)該分型方法具有較高的可靠性。研究的不足之處在于由于病例數(shù)量有限，因此尚難以明確不同程度喙突骨吸收的臨床意義。

結(jié)論：Latarjet手術(shù)后喙突骨吸收現(xiàn)象的發(fā)生率很高，且吸收的嚴(yán)重程度差異很大。應(yīng)用我們所提出的分型方法，可有效的評(píng)估骨吸收的嚴(yán)重程度。

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(本文編輯：李靜)

朱以明，姜春巖.評(píng)估Latarjet手術(shù)后移位喙突骨塊吸收情況的CT分型系統(tǒng)的一致性研究[J/CD].中華肩肘外科電子雜志,2015,3(1):35-42.

Study on the consistency of CT classification system evaluating coracoid fragment absorption after Latarjet operation

ZhuYiming,JiangChunyan.

DepartmentofSportsMedicine,BeijingJishuitanHospital,Beijing100035,China

JiangChunyan,Email:chunyanj@hotmail.com

Background In 1954,the method of coracoid osteotomy and transfer for the treatment of recurrent anterior shoulder instability was firstly described by French doctor Latarjet.Till today,Latarjet procedure is still one of the most commonly used procedures in dealing with anterior shoulder instability especially with significant bony defect at anterior glenoid rim.On the other hand,many studies are focused in this procedure and have found some complications that will influence outcome.Among the complications,the occurrence of coracoid absorption has been repeatedly reported.Due to the lack of unified research methods and classification system to standardize the occurrence rates of coracoid fragment absorption,it is difficult to further explore the causes of this phenomenon and the influence on clinical effect.The purpose of this study is to propose a CT scanning method and a classification system to evaluate the coracoid fragment absorption after Latarjet operation.We hope to adopt this method and the classification system for these patients to investigate the occurrence rates of different levels of coracoid fragment absorption,and evaluate its consistency by examining inter-observer and intra-observer reliability.Methods The inclusion and exclusion criteria of the study.The inclusion criteria of this study are as follows:(1)The patients are diagnosed as post traumatic recurrent anterior dislocation of shoulder;(2)Obvious bone defects of the glenoid are revealed in both preoperative three-dimensional CT and glenoid enface view;(3)The operative method is open Latarjet procedure;(4)The patients agree to participate in this clinical research and sign informed consents;(5)The postoperative clinical follow-up is over 2 years with complete imaging evaluation data (immediate CT examination after operation and CT scanning 1 year after surgery).The exclusion criteria of this study are as follows:(1)Multiple directional shoulder instability;(2)Previous operation history of the affected shoulder joint;(3)CT examination of 1 year after surgery reveals nonunion of coracoid fragment or failure of internal fixation,which is difficult to evaluate the absorption of coracoid fragment.The detailed medical history including the age of first time dislocation,numbers of dislocations,etc.was provided before surgery.The detailed physical examination of shoulder joint was conducted.ASES score (American Shoulder & Elbow Surgeons′ score),Constant-Murley score and Rowe score were evaluated for each patient.Preoperative 3D CT examination of the shoulder joint was needed for the affected shoulder,and the so-called enface view was reconstructed with the humeral head removed and the glenoid faced to the observer with the method described by Sugaya.The assessment of bone defect size on the glenoid was performed in enface view,and the open Latarjet operation would be selected if the size is over 25%.Operation method:Patient position and surgical incision.After successful general anesthesia,the patient was in the beach chair position with the affected shoulder placed out of the operating table border and mobilized freely in all directions.The incision was made downward from the coracoid tip and the coracoid was exposed through the deltoid and pectoralis major muscle interval.Coracoid process preparation:The shoulder was in abduction and external rotation to expose the coracoacromial ligament.The coracohumeral ligament,pectoralis minor and coracoacromial ligament were released from coracoid.The coracoid was osteotomized just anterior to coraco-clavicle ligament.Two holes were drilled on the coracoid with enough space between them and the coracoid was put deep behind the pectoralis major muscle for further operation.Exposure of the glenoid:The affected limb was in external rotation and the glenoid was fully exposed with the subscapularis tendon split and the anterior joint capsule opened vertically.Preparations of glenoid and fixation of coracoid:The bone bed of anterior glenoid rim and neck was prepared.One hole was drilled at 5 o′clock in front of scapula for fixation through the lower hole on the coracoid with a 4.0 mm half thread canulated screw.The fragment should not protrude over glenoid surface.The other hole on the scapula was drilled through the upper pre-drilled hole on the coracoid fragment and a 4.0mm half thread canulated screw was inserted.The coracoacromial ligament attached to coracoid fragment was sutured with anterior capsule with shoulder in extreme external rotation.The wound was closed in layers.Rehabilitation programme:The shoulder was immobilized with a sling for 3 weeks after operation.Passive exercises of the affected limb were carried out under the guidance of a physical therapist.Sling was removed 6 weeks later and the shoulder was allowed to take regular activities,but the resistant exercises of elbow flexion should be avoided within 6 weeks.Three months after operation,terminal stretch exercise was initiated.Contact sports or sports with hand above the head were resumed half a year after operation.Postoperative follow-up plan:Follow-ups were conducted in 3 weeks,6 weeks,3 months,6 months,and 1 year after operation.After that,the follow-ups were conducted 1 time a year which mainly composed of the assessment of functional rehabilitation and the guidance of exercises by clinicians.Detailed physical examination was carried out 1 year after operation,and the 3D CT examination was underwent with the consent of the patient to detect the position and healing of the fragment in front of the glenoid.Radiological evaluation methods:Preoperative 3D CT examination for the affected shoulder was carried out to assess the severity of glenoid bone defect.Immediate postoperative 3D CT examination for the affected shoulder was conducted to assess the position of coracoid fragment and its fixation.Postoperative 3D CT examination was conducted after one year of follow-up to assess the healing and absorption of coracoid fragment in the cross section.The classification of postoperative coracoid fragment absorption:Level 0:No coracoid fragment absorption and the screw heads are buried deep in the coracoid; Level Ⅰ:Slight coracoid fragment absorption.Only the screw heads are exposed out of the coracoid,and the screw shanks are totally buried in the coracoid; Level Ⅱ:Obvious coracoid fragment absorption,and the screw heads and part of screw shanks are exposed out of the coracoid,but there are still remaining coracoid fragment in front of the glenoid; Level Ⅲ:Total coracoid fragment absorption,no remaining fragment in front of the glenoid,the screws are fully exposed; The grading standards of this system are based on the screw exposure after coracoid bone absorption.While grading,the observer is required to respectively assess the exposure of the two screws and record each of the coracoid fragment absorption.The final classification of coracoid fragment absorption is determined by the screw exposure of more obvious.Observer and research method of reliability:Four independent observers,who completed the training of orthopedics and shoulder surgery,were involved in the research on reliability of the grading system.Instructions were distributed to familiarize them with the application method of this grading system.The final grade was determined by the senior doctor.Statistics method:The SPSS 16.0 software is adopted for statistical analysis in this study.The ICCs (intraclass correlation coefficients) is aimed at assessing the consistency between observers and the repeatability of two examination results from one individual observer.If the ICCs is greater than 0.75,the consistency of evaluation method is considered excellent; If the ICCs is between 0.40 and 0.75,the consistency is considered normal; If the ICCs is less than 0.4,the consistency is considered poor.Results From January 2009 to January 2012,a total of 81 patients with recurrent anterior shoulder dislocation

open Latarjet operation.Among them,65 patients underwent preoperative CT,immediate CT after operation and postoperative CT one year later.Of the 65 patients,1 patient was considered nonunion of the coracoid fragment in postoperative CT scan 1 year after surgery.Another patient was excluded due to the internal fixation failure.The remaining 63 patients were selected for this study.Coracoid bone absorption:The postoperative CT of one year after surgery revealed higher incidence of coracoid bone absorption,and the grading of 63 patients with bone absorption are as follows.Level 0∶6 patients (9.5%); Level 1∶26 patients (41.3%); Level 2∶25 patients (39.7%); Level 3∶6 patients (9.5%).Thus,1 year after surgery,the rate of coracoid bone absorption was 90.5% (57/63).Carefully distinguishing bone absorption around two canulated screws,we found that among the 63 cases,34 cases had the same grades of bone absorption around the two screws; and in another 29 cases,the absorption degree around the proximal screw was more serious than that around the distal screw.The reliability of the grading system:Statistical analysis indicated that in this grading system the consistency between observers (ICC,95% confidence Interval,0.856) and the repeatability of two results in individual observer (ICC,95% confidence Interval,0.946) were both very good.Conclusion One year after open Latarjet operation,the coracoid fragment absorption is of high incidence.The classification system we proposed has excellent inter-observer and intra-observer reliability.

Recurrent anterior shoulder dislocation;Latarjet operation;Bone absorption

10.3877/cma.j.issn.2095-5790.2015.01.008

國(guó)家自然基金青年科學(xué)基金項(xiàng)目資助課題(81201438)；北京市醫(yī)院管理局臨床醫(yī)學(xué)發(fā)展專(zhuān)項(xiàng)經(jīng)費(fèi)資助

100035北京積水潭醫(yī)院運(yùn)動(dòng)損傷科

姜春巖，Email:chunyanj@hotmail.com

2014-12-01)

(XMLX201511)