中华肩肘外科电子杂志
中華肩肘外科電子雜誌
중화견주외과전자잡지
Chinese Journal of Shoulder and Elbow (Electronic Edition)
2014年
2期
91-96
,共6页
Latarjet%骨缺损%肩关节%脱位%喙突%癫痫
Latarjet%骨缺損%肩關節%脫位%喙突%癲癇
Latarjet%골결손%견관절%탈위%훼돌%전간
Latarjet%Bony defect%Shoulder joint%Dislocation%Coracoid%Epilepsy
目的研究 Latarjet 手术治疗癫痫患者肩关节复发性前脱位伴有重度骨缺损的短期疗效。方法2006年4月至2009年10月,对多例患者结合三维 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,当肩盂呈倒梨形(骨缺损>肩盂宽度的25%),合并或伴有 Engaging Hill-Sachs 损伤,即运用 Latarjet 手术进行治疗,并对其中的7例癫痫患者作回顾性分析。其中男性4例,女性3例,年龄20~49岁,平均27.5岁。术前均有 Apprehension sign 阳性,平均脱位17.5次(13~28次),随访时采用 ASES 评分、Constant-Murley 评分以及 Rowe 评分进行功能评估。结果本组患者随访36~60个月,平均46.3个月,术后制动2周后即在医生指导下按计划进行肩关节功能康复和力量恢复训练,术后6个月时三维 CT 显示喙突转位骨块均与肩胛颈愈合。术前与终末次随访相比较：前屈上举(150.5±20.9)°与(169.0±13.5)°比较,差异无统计学意义(t =-1.967,P >0.05),平均体侧外旋为(54.2±11.2)°与(40.2±6.8)°比较,差异有统计学意义(t =2.827,P <0.05),ASES 评分81.1±15.7与92.3±6.7比较,差异无统计学意义(t =-1.736,P >0.05),Constant-Murley 评分为79.4±11.4与92.2±4.2比较,差异有统计学意义(t =-2.788,P <0.05),Rowe 评分平均为42±1.5与76±1.8比较,差异有统计学意义(t =-38.392,P <0.05)；终末次随访时 X 线片显示有2例患者出现早期骨关节炎表现。结论癫痫患者继发复发性肩关节前脱位伴有重度骨缺损治疗比较棘手,肩关节镜下或切开锚钉重建修复Bankart 损伤术后脱位复发率较高,风险较大,在控制癫痫后选择 Latarjet 重建手术能提供较好的静力稳定性,从而有效减少脱位的复发率。
目的研究 Latarjet 手術治療癲癇患者肩關節複髮性前脫位伴有重度骨缺損的短期療效。方法2006年4月至2009年10月,對多例患者結閤三維 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,噹肩盂呈倒梨形(骨缺損>肩盂寬度的25%),閤併或伴有 Engaging Hill-Sachs 損傷,即運用 Latarjet 手術進行治療,併對其中的7例癲癇患者作迴顧性分析。其中男性4例,女性3例,年齡20~49歲,平均27.5歲。術前均有 Apprehension sign 暘性,平均脫位17.5次(13~28次),隨訪時採用 ASES 評分、Constant-Murley 評分以及 Rowe 評分進行功能評估。結果本組患者隨訪36~60箇月,平均46.3箇月,術後製動2週後即在醫生指導下按計劃進行肩關節功能康複和力量恢複訓練,術後6箇月時三維 CT 顯示喙突轉位骨塊均與肩胛頸愈閤。術前與終末次隨訪相比較：前屈上舉(150.5±20.9)°與(169.0±13.5)°比較,差異無統計學意義(t =-1.967,P >0.05),平均體側外鏇為(54.2±11.2)°與(40.2±6.8)°比較,差異有統計學意義(t =2.827,P <0.05),ASES 評分81.1±15.7與92.3±6.7比較,差異無統計學意義(t =-1.736,P >0.05),Constant-Murley 評分為79.4±11.4與92.2±4.2比較,差異有統計學意義(t =-2.788,P <0.05),Rowe 評分平均為42±1.5與76±1.8比較,差異有統計學意義(t =-38.392,P <0.05)；終末次隨訪時 X 線片顯示有2例患者齣現早期骨關節炎錶現。結論癲癇患者繼髮複髮性肩關節前脫位伴有重度骨缺損治療比較棘手,肩關節鏡下或切開錨釘重建脩複Bankart 損傷術後脫位複髮率較高,風險較大,在控製癲癇後選擇 Latarjet 重建手術能提供較好的靜力穩定性,從而有效減少脫位的複髮率。
목적연구 Latarjet 수술치료전간환자견관절복발성전탈위반유중도골결손적단기료효。방법2006년4월지2009년10월,대다례환자결합삼유 CT 소묘화견관절경대견관절복발성전탈위적견우전연골결손화굉골두후외측적 Hill-Sachs 손상적범위화정도진행평고,당견우정도리형(골결손>견우관도적25%),합병혹반유 Engaging Hill-Sachs 손상,즉운용 Latarjet 수술진행치료,병대기중적7례전간환자작회고성분석。기중남성4례,녀성3례,년령20~49세,평균27.5세。술전균유 Apprehension sign 양성,평균탈위17.5차(13~28차),수방시채용 ASES 평분、Constant-Murley 평분이급 Rowe 평분진행공능평고。결과본조환자수방36~60개월,평균46.3개월,술후제동2주후즉재의생지도하안계화진행견관절공능강복화역량회복훈련,술후6개월시삼유 CT 현시훼돌전위골괴균여견갑경유합。술전여종말차수방상비교：전굴상거(150.5±20.9)°여(169.0±13.5)°비교,차이무통계학의의(t =-1.967,P >0.05),평균체측외선위(54.2±11.2)°여(40.2±6.8)°비교,차이유통계학의의(t =2.827,P <0.05),ASES 평분81.1±15.7여92.3±6.7비교,차이무통계학의의(t =-1.736,P >0.05),Constant-Murley 평분위79.4±11.4여92.2±4.2비교,차이유통계학의의(t =-2.788,P <0.05),Rowe 평분평균위42±1.5여76±1.8비교,차이유통계학의의(t =-38.392,P <0.05)；종말차수방시 X 선편현시유2례환자출현조기골관절염표현。결론전간환자계발복발성견관절전탈위반유중도골결손치료비교극수,견관절경하혹절개묘정중건수복Bankart 손상술후탈위복발솔교고,풍험교대,재공제전간후선택 Latarjet 중건수술능제공교호적정력은정성,종이유효감소탈위적복발솔。
Background Shoulder instability affects the young population and causes serious labor loss.High-energy injuries can cause fractures around the shoulder girdle,such as coracoid fractures.Individuals with an epileptic seizure disorder and anterior glenohumeral instability frequently have severe anteroinferior glenoid osseous deficiency and a posterior humeral head defect.The risk of a subsequent osseous deficiency among recurrent unstable shoulders in patients with seizure disorders is very high.Therefore,this is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure,such as coracoid osteotomy and transfer to the anterior glenoid rim (the Latarjet procedure),to address glenoid osseous deficiency. The aim of this study is to assess the effects of Latarjet procedure on the radiological and clinical results in cases with severe glenoid osseous deficiency accompanied with epileptic seizure disorders and recurrent anterior dislocation of shoulder.Methods The study included 7 patients with severe glenoid osseous deficiency accompanied with epileptic seizure disorders and recurrent anterior dislocation.The cases were reviewed at a mean post-operative follow-up duration was 46.3 months (range from 36 to 60 months)from 2006 to 2009.The average age of the patients was 27.5 years old (range:20 to 49 years old),including 4 males and 3 females.The average time between the first-time dislocation and operation was 4 years (range:2.5 to 9 years).In addition to conventional anteroposterior and axillary radiographs,all patients underwent computed tomography (CT)as part of our routine protocol.Three-dimensional reformatting of these images enabled assessment of the degree of glenoid and humeral head bone loss and the post-operative bone healing.All scans were examined by a single observer. Further information specifically relating to previous shoulder injuries and seizures was obtained from patients.Symptoms previously described in association with shoulder dislocation,including anterior shoulder pain,weakness,and restricted shoulder motion,were specifically sought.Functional assessment was obtained using the parameters of three types of functional assessment systems (the American Shoulder and Elbow Surgeons Assessment (ASES),the Constant-Murley Score and the Rowe Score).All patients underwent elective anterior shoulder stabilization (a standard Bristow-Latarjet procedure)performed by the same senior surgeon.The fragment was secured with two lag screws through the graft to obtain rotational control of the fragment to the glenoid rim.Then a special rehabilitation protocol and power recovery exercise was administered in all patients 2 weeks after surgery.All patients were followed with radiographic and functional evaluations.Results On the basis of preoperative CT scans and the arthroscopic appearances,all shoulders showed a severe glenoid-rim defect and Hill-Sachs lesions pre-operatively.Osteo-arthritic changes of the glenohumeral joint were seen in two shoulders (28.6%)pre-operatively and in four shoulders (57.1%)post-operatively.And the mean dislocation time was 1 7.5(range:13 to 28 times).These patients shared the common features of recurrent anterior instability in association with epileptic seizures and a severe osseous deficiency that was detectable on preoperative CT scans and was confirmed at surgery.The post-operative radiographic evaluations showed that all bone grafts healed without evidence of secondary displacement according to the three dimensional CT scan.The coracoid transposition bone and scapular neck was healed.Comparing the pre-operation condition with the final follow-up,forward elevation improved from 1 50.5±20.9 preoperatively to 1 69.0±13.5 postoperatively,while the average external rotational limitation measured in the neutral position of the arm decreased from 54.2±1 1.2 to 42.2 ±6.8(t =2.827,P <0.05).ASES score improved from 81.1 ± 1 5.7 to 92.3 ± 6.7 (t = 1.736,P > 0.05 ), Constant-Murley score from 79.4 ± 1 1.4 to 92.2 ± 4.2 (t = -2.788,P < 0.05 ).The mean Rowe score was 76 (range,45 to 100)at the final follow-up.Re-dislocation during a seizure occurred in two shoulders (28.6%).And three patients had mild pain at the position of maximal abduction or external rotation.Secondary osteoarthritic changes of the glenohumeral joint were seen in two shoulders postoperatively.None of the patients had immediate postoperative complications.None had developed recurrent glenohumeral instability after surgery and only one person still had a passive apprehension sign at the time of the latest follow-up,ranging between thirty-six and sixty months postoperatively. On routine radiographs after surgery,there was no evidence of fixation failure or graft resorption in the shoulders.No one underwent revision surgery.Overall,most of the patients had satisfactory pain relief and daily living activities postoperatively at the time of the latest follow-up.Conclusions The anterior dislocation of the shoulder in the epileptic patients is really uncommon.The treatment of the secondary recurrent anterior dislocations of the shoulder associated with severe osseous deficiency is quite difficult,due to the unacceptably high rate of re-dislocation after the open or arthroscopic reconstruction surgery of the Bankart lesion.Our study assessed the effects of Latarjet procedure on the radiological and clinical results in seven cases with severe glenoid osseous deficiency accompanied with epileptic seizure disorders and recurrent anterior dislocation of shoulder.The results suggested that when treating patients with an epileptic seizure disorder and recurrent anterior glenohumeral instability,effective control of the epileptic seizures is one of the most important methods to reduce the incidence of post-operative recurrent dislocation,because a compliant patient was very important for a successful clinical outcome.The Latarjet procedure can provide a satisfied reconstruction of shoulder stability,but the possibility of re-dislocation and osteoarthritis should be also noticed.We recommend a high index of suspicion when treating patients with a seizure disorder who have anterior shoulder instability,and we recommend making a preoperative CT scan,if there is a strong likelihood that a coracoid transfer will be used at surgery.This enables the diagnosis of a coracoid fracture nonunion to be made prior to surgery and helps to determine whether there is sufficient bone to allow a Latarjet procedure to be performed.However,it needs further investment to choose an appropriate surgery procedure for the untreated epileptic patients.
