CAJ | 학술논문

目的：提出一种基于 CT 的分型系统来评估 Latarjet 手术后移位喙突骨块的吸收程度。应用该分型系统研究 Latarjet 手术后患者最终随访时行 CT 检查以了解喙突骨吸收现象的发生率及严重程度；并了解应用该分型系统时检查者之间的一致性以及检查者自身的前后一致性。方法选取2009年1月至2012年1月期间,63例接受切开 Latarjet 手术治疗的患者。所有患者术前诊断均为复发性肩关节前脱位。所有患者在术后12个月时均行 CT 检查。4位与手术治疗无关的独立骨科医师对患者术后12个月随访时 CT 影像进行阅片,并采用我们提出的分型系统对移位喙突骨块吸收程度进行了评估。在初次评估后3个月,4位检查者对上述影像进行了再次评估。以 ICCs 系数评价各位检查者之间检查结果的一致性,以及每位检查者前后两次检查结果的一致性。结果在术后12个月时,移位喙突骨吸收的发生率为90.5%。其中骨吸收0级患者有6例,Ⅰ级患者26例,Ⅱ级患者25例,Ⅲ级患者6例。结论切开 Latarjet 手术后12个月时,移位喙突骨块吸收的发生率很高。该分型系统有优秀的检查者之间一致性以及检查者自身前后一致性。
목적：제출일충기우 CT 적분형계통래평고 Latarjet 수술후이위훼돌골괴적흡수정도。응용해분형계통연구 Latarjet 수술후환자최종수방시행 CT 검사이료해훼돌골흡수현상적발생솔급엄중정도；병료해응용해분형계통시검사자지간적일치성이급검사자자신적전후일치성。방법선취2009년1월지2012년1월기간,63례접수절개 Latarjet 수술치료적환자。소유환자술전진단균위복발성견관절전탈위。소유환자재술후12개월시균행 CT 검사。4위여수술치료무관적독립골과의사대환자술후12개월수방시 CT 영상진행열편,병채용아문제출적분형계통대이위훼돌골괴흡수정도진행료평고。재초차평고후3개월,4위검사자대상술영상진행료재차평고。이 ICCs 계수평개각위검사자지간검사결과적일치성,이급매위검사자전후량차검사결과적일치성。결과재술후12개월시,이위훼돌골흡수적발생솔위90.5%。기중골흡수0급환자유6례,Ⅰ급환자26례,Ⅱ급환자25례,Ⅲ급환자6례。결론절개 Latarjet 수술후12개월시,이위훼돌골괴흡수적발생솔흔고。해분형계통유우수적검사자지간일치성이급검사자자신전후일치성。
Background In 1 954,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 1 6.0 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 received 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.