目的：研究 Latarj et手术治疗肩关节复发性前脱位伴重度骨缺损患者的疗效。方法结合三维CT扫描和肩关节镜对肩关节复发性前脱位的肩盂前缘骨缺损和肱骨头后外侧的 Hill-Sachs损伤的范围和程度进行评估,如肩盂呈倒梨形(骨缺损大于肩盂宽度的25%)合并或伴有Engaging Hill-Sachs 损伤,即通过三角肌胸大肌入路运用 Latarjet技术进行重建,治疗伴有重度骨缺损的肩关节复发性前脱位37例。其中2006年4月至2007年12月采用喙突内旋90°转位术式,随访资料完整的共16例；2008年1月至2009年10月采用喙突平行转位术式,随访资料完整的共21例。男性23例,女性14例,平均年龄26.5岁(17~46岁)。术前 Apprehension sign 均为阳性,平均脱位次数13.5次(8~28次),随访时采用美国肩与肘协会评分系统(ASES)评分、Constant-Murley评分以及视觉模拟评分法(VAS)不稳定评分进行功能评估。结果平均随访时间为48.3个月(37~61个月),术后患肩制动2周后即在医师指导下按计划进行肩关节功能康复及力量恢复训练,术后6个月三维CT显示喙突平行转位组骨块均与肩胛颈愈合,而喙突内旋90°转位组有3例骨块未与肩胛颈愈合,两组喙突骨块愈合率相比,差异有统计学意义(χ2=4.258,P <0.05)。喙突平行转位组手术前对终末次随访比较,前屈上举(152.5±22.6)°与(168.0±7.8)°比较,差异有统计学意义(t=3.028, P<0.05),平均体侧外旋(52.6±18.4)°与(44.9±15.0)°比较,差异无统计学意义(t=1.486,P >0.05),ASES评分80.7±16.7与92.2±6.4比较,差异有统计学意义(t=2.947,P<0.05),Constant-Murley评分78.6±10.1与91.6±13.2比较,差异有统计学意义(t=3.584,P<0.05),VAS不稳定评分平均6.0±1.4与4.3±1.6比较,差异有统计学意义(t=3.664,P <0.05)；而喙突内旋90°转位组前屈上举(148.5±19.2)°与(170.0±10.5)°比较,差异有统计学意义(t=3.930,P<0.05)；平均体侧外旋(55.8±16.9)°与(40.6±13.6)°比较,差异有统计学意义(t=2.803,P <0.05)；ASES 评分81.4±14.7与92.4±7.0比较,差异有统计学意义(t=2.702,P <0.05),Constant-Murley 评分80.2±12.6与92.8±5.1比较,差异有统计学意义(t=3.708,P<0.05),VAS不稳定评分平均6.4±1.5与4.2±2.1比较,差异有统计学意义(t=3.410,P <0.05)；至末次随访喙突平行转位组与喙突内旋90°转位组相比,无论前屈上举、平均体侧外旋、ASES 评分、Constant-Murley 评分或 VAS 不稳定评分,P值均>0.05,差异无统计学意义。终末复查时 X线片6例出现骨关节炎表现,其中喙突平行转位组有1例,喙突内旋90°转位5例,两者相比差异有统计学意义。结论对于重度骨缺损的肩关节复发性前脱位,肩关节镜下或开放铆钉重建修复 Bankart 损伤脱位复发率较高,风险大,微创治疗难以彻底治愈,多采用 Latarj et手术治疗,目前有喙突平行转位和喙突内旋90°转位两种术式,均能为该种类型的肩关节复发性前脱位提供更好的静力稳定性,从而有效减少脱位的再发率；而喙突平行转位较喙突内旋90°转位固定强度相对较高、接触面积更大,愈合率相对较高,并且发生骨关节炎改变的几率相对较低。
目的：研究 Latarj et手術治療肩關節複髮性前脫位伴重度骨缺損患者的療效。方法結閤三維CT掃描和肩關節鏡對肩關節複髮性前脫位的肩盂前緣骨缺損和肱骨頭後外側的 Hill-Sachs損傷的範圍和程度進行評估,如肩盂呈倒梨形(骨缺損大于肩盂寬度的25%)閤併或伴有Engaging Hill-Sachs 損傷,即通過三角肌胸大肌入路運用 Latarjet技術進行重建,治療伴有重度骨缺損的肩關節複髮性前脫位37例。其中2006年4月至2007年12月採用喙突內鏇90°轉位術式,隨訪資料完整的共16例；2008年1月至2009年10月採用喙突平行轉位術式,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)。術前 Apprehension sign 均為暘性,平均脫位次數13.5次(8~28次),隨訪時採用美國肩與肘協會評分繫統(ASES)評分、Constant-Murley評分以及視覺模擬評分法(VAS)不穩定評分進行功能評估。結果平均隨訪時間為48.3箇月(37~61箇月),術後患肩製動2週後即在醫師指導下按計劃進行肩關節功能康複及力量恢複訓練,術後6箇月三維CT顯示喙突平行轉位組骨塊均與肩胛頸愈閤,而喙突內鏇90°轉位組有3例骨塊未與肩胛頸愈閤,兩組喙突骨塊愈閤率相比,差異有統計學意義(χ2=4.258,P <0.05)。喙突平行轉位組手術前對終末次隨訪比較,前屈上舉(152.5±22.6)°與(168.0±7.8)°比較,差異有統計學意義(t=3.028, P<0.05),平均體側外鏇(52.6±18.4)°與(44.9±15.0)°比較,差異無統計學意義(t=1.486,P >0.05),ASES評分80.7±16.7與92.2±6.4比較,差異有統計學意義(t=2.947,P<0.05),Constant-Murley評分78.6±10.1與91.6±13.2比較,差異有統計學意義(t=3.584,P<0.05),VAS不穩定評分平均6.0±1.4與4.3±1.6比較,差異有統計學意義(t=3.664,P <0.05)；而喙突內鏇90°轉位組前屈上舉(148.5±19.2)°與(170.0±10.5)°比較,差異有統計學意義(t=3.930,P<0.05)；平均體側外鏇(55.8±16.9)°與(40.6±13.6)°比較,差異有統計學意義(t=2.803,P <0.05)；ASES 評分81.4±14.7與92.4±7.0比較,差異有統計學意義(t=2.702,P <0.05),Constant-Murley 評分80.2±12.6與92.8±5.1比較,差異有統計學意義(t=3.708,P<0.05),VAS不穩定評分平均6.4±1.5與4.2±2.1比較,差異有統計學意義(t=3.410,P <0.05)；至末次隨訪喙突平行轉位組與喙突內鏇90°轉位組相比,無論前屈上舉、平均體側外鏇、ASES 評分、Constant-Murley 評分或 VAS 不穩定評分,P值均>0.05,差異無統計學意義。終末複查時 X線片6例齣現骨關節炎錶現,其中喙突平行轉位組有1例,喙突內鏇90°轉位5例,兩者相比差異有統計學意義。結論對于重度骨缺損的肩關節複髮性前脫位,肩關節鏡下或開放鉚釘重建脩複 Bankart 損傷脫位複髮率較高,風險大,微創治療難以徹底治愈,多採用 Latarj et手術治療,目前有喙突平行轉位和喙突內鏇90°轉位兩種術式,均能為該種類型的肩關節複髮性前脫位提供更好的靜力穩定性,從而有效減少脫位的再髮率；而喙突平行轉位較喙突內鏇90°轉位固定彊度相對較高、接觸麵積更大,愈閤率相對較高,併且髮生骨關節炎改變的幾率相對較低。
목적：연구 Latarj et수술치료견관절복발성전탈위반중도골결손환자적료효。방법결합삼유CT소묘화견관절경대견관절복발성전탈위적견우전연골결손화굉골두후외측적 Hill-Sachs손상적범위화정도진행평고,여견우정도리형(골결손대우견우관도적25%)합병혹반유Engaging Hill-Sachs 손상,즉통과삼각기흉대기입로운용 Latarjet기술진행중건,치료반유중도골결손적견관절복발성전탈위37례。기중2006년4월지2007년12월채용훼돌내선90°전위술식,수방자료완정적공16례；2008년1월지2009년10월채용훼돌평행전위술식,수방자료완정적공21례。남성23례,녀성14례,평균년령26.5세(17~46세)。술전 Apprehension sign 균위양성,평균탈위차수13.5차(8~28차),수방시채용미국견여주협회평분계통(ASES)평분、Constant-Murley평분이급시각모의평분법(VAS)불은정평분진행공능평고。결과평균수방시간위48.3개월(37~61개월),술후환견제동2주후즉재의사지도하안계화진행견관절공능강복급역량회복훈련,술후6개월삼유CT현시훼돌평행전위조골괴균여견갑경유합,이훼돌내선90°전위조유3례골괴미여견갑경유합,량조훼돌골괴유합솔상비,차이유통계학의의(χ2=4.258,P <0.05)。훼돌평행전위조수술전대종말차수방비교,전굴상거(152.5±22.6)°여(168.0±7.8)°비교,차이유통계학의의(t=3.028, P<0.05),평균체측외선(52.6±18.4)°여(44.9±15.0)°비교,차이무통계학의의(t=1.486,P >0.05),ASES평분80.7±16.7여92.2±6.4비교,차이유통계학의의(t=2.947,P<0.05),Constant-Murley평분78.6±10.1여91.6±13.2비교,차이유통계학의의(t=3.584,P<0.05),VAS불은정평분평균6.0±1.4여4.3±1.6비교,차이유통계학의의(t=3.664,P <0.05)；이훼돌내선90°전위조전굴상거(148.5±19.2)°여(170.0±10.5)°비교,차이유통계학의의(t=3.930,P<0.05)；평균체측외선(55.8±16.9)°여(40.6±13.6)°비교,차이유통계학의의(t=2.803,P <0.05)；ASES 평분81.4±14.7여92.4±7.0비교,차이유통계학의의(t=2.702,P <0.05),Constant-Murley 평분80.2±12.6여92.8±5.1비교,차이유통계학의의(t=3.708,P<0.05),VAS불은정평분평균6.4±1.5여4.2±2.1비교,차이유통계학의의(t=3.410,P <0.05)；지말차수방훼돌평행전위조여훼돌내선90°전위조상비,무론전굴상거、평균체측외선、ASES 평분、Constant-Murley 평분혹 VAS 불은정평분,P치균>0.05,차이무통계학의의。종말복사시 X선편6례출현골관절염표현,기중훼돌평행전위조유1례,훼돌내선90°전위5례,량자상비차이유통계학의의。결론대우중도골결손적견관절복발성전탈위,견관절경하혹개방류정중건수복 Bankart 손상탈위복발솔교고,풍험대,미창치료난이철저치유,다채용 Latarj et수술치료,목전유훼돌평행전위화훼돌내선90°전위량충술식,균능위해충류형적견관절복발성전탈위제공경호적정력은정성,종이유효감소탈위적재발솔；이훼돌평행전위교훼돌내선90°전위고정강도상대교고、접촉면적경대,유합솔상대교고,병차발생골관절염개변적궤솔상대교저。
Objective Shoulder 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 inj ury.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 Latarj et 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 Latarj et coracoid bone block procedure for the recurrent anterior dislocation of the shoulder associated with the severe bony defects.Methods Thirty-seven patients (23 men 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.21 patients were treated by the parallel coracoid transposition bone block from January 2008 to October 2009,and 16 patients were performed with the intorted coracoid transposition method from April 2006 to December 2007. Apprenhension sign was positive in all of the 37 patients before operation.And the mean time of their dislocations was 13.5 (ranged from 8 to 28 times).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.Results The follow-up period ranged from 37 to 61 months (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 3 dimensional CT scan taken at 6 months'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 ± 16.7 to 92.2 ± 6.4 (t =2.947,P <0.05 ),the Constant-Murley scores increased from 78.6±10.1 to 91.6±13.2(t= 3.584,P <0.05),and the VAS scores increased from 6.0±1.4 to 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±14.7 to 92.4±7.0(t= 2.702,P<0.05), the Constant-Murley score increased from 80.2±12.6 to 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 inj ury were up to 9 7% 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 15-35 years old)after the conservative treatment for the anterior shoulder dislocation,5 6% of which were re-dislocated.The instability rate of those 20-year-old 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 1954 and 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:1 the fragment increases the security area of glenoid before the humeral head is dislocated;2 the conjoined tendon acts to prevent the huemral head to move forward while the external rotation of the arm;3 the anteroinferior capsule can be reinforced by the translocated coracoid process and the conjoined tendon strided across the lower 1/3 position of the subscapularis tendon.This study demonstrated that the Latarj et 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 Latarj et 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 latarj et 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 3.5 mm 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 3.0 mm 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 Latarj et 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 adj usted 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 osteoarthritis classification,6 patients 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 Latarj et 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.
