摘要
目的：探讨肩关节镜下Bankart损伤重建术治疗复发性肩关节前脱位的临床疗效。方法自2010年6月至2014年4月随访60例应用肩关节镜下Bankart损伤重建术治疗的复发性肩关节前脱位患者,随访10~38个月,平均26.6个月；年龄15~45岁,平均29岁。60例患者均为前方单方向性不稳定,术前平均脱位次数为6.5次(2~17次)。手术中采用缝合锚进行Bankart损伤重建术。随访时采用 ASES评分和Constant-Murley评分进行功能评估。结果60例患者手术前及终末随访时 ASES平均评分为(83.5±3.2)分与(97.1±2.1)分(t=4.79,P>0.01),肩关节平均前屈上举角度为(163.8±6.0)°与(185.4±3.9)°(t =4.87,P >0.01),外展角度为(90±1.1)°与(135.4±9.9)°(t=6.40,P>0.01),外旋角度为(57.6±4.3)°与(86.5±5.2)°(t=5.43,P >0.01)；术前及终末随访时Constant-Murley平均评分为(77.6±3.5)分与(97.2±3.2)分(t=5.06,P >0.01)。终末随访时所有病例均未发生术后再脱位,术后残存恐惧试验阳性4例(6.7%)。所有患者均恢复术前工作,52例(8 6.7%)恢复到第一次脱位前的运动水平。结论肩关节镜下微创行 Bankart 损伤重建手术是治疗复发性肩关节前脱位的有效方法之一,术前病例选择、术中关节镜下操作技术及术后功能康复锻炼是手术成功的关键。
Background Recurrent dislocation of shoulder joint(or traumatic shoulder instability)initiates from the first shoulder dislocation,compromising the ligaments for stability of the shoulder.When the labrum is torn from the glenoid,the stable function of these ligaments is lost.The progression of traumatic shoulder instability and the type and degree of injuries in glenoid labrum and surrounding ligaments are inextricably linked.Bankart injury is the most common cause of recurrent anterior shoulder dislocation,and the rehabilitation and reconstruction of stable structure in anterior shoulder is critical for the treatment of recurrent anterior dislocation of the shoulder joint.With the development and popularization of the arthroscopic technique,shoulder arthroscopic surgery in the treatment of recurrent anterior dislocation of the shoulder joint has been adopted by increasing surgeons.From June 2010 to April 2014,60 patients of recurrent anterior shoulder dislocation were treated arthroscopically with metallic suture anchor Bankart repair to explore its clinical efficacy.Methods Clinical data:From June of 2010 to April of 2014,sixty patients in our hospital were treated with arthroscopic reconstruction for Bankart injury of recurrent anterior dislocation of the shoulder.The patients were followed up for 10~38 months and the mean time was 26.6 months.Their ages ranged from 15 to 45 years with an average of 29 years.Each of 60 cases had a unidirectional instability of anterior shoulder,and the average number of dislocation before surgery was 6.5times(2-17times).Suture anchor was applied for reconstruction of Bankart injury.ASES score and Constant-Murley score were adopted for the functional assessment during follow-ups. The postoperative recovery time of shoulder function was 6 weeks without redislocation in each case.Complete rotator cuff tear,subacromial impingement syndrome,etc.were excluded from this group of patients.Imaging examination:X-ray films of anteroposterior view,lateral view and supraspinatus outlet view,CT scanning,MRI and CT three-dimensional reconstruction with humeral head removed were done preoperatively.No obvious bone defect was shown on preoperative X-ray films,no definite bony Bankart injury was revealed on CT three-dimensional reconstruction,and all MRI showed hyperintense between anterior labrum and glenoid rim with 3cases of glenoid labrum disappeared.Operative methods:After successful general anesthesia,the patient was placed in lateral position.Every 3000 ml saline for flushing purpose was added with 1ml of 0.1%epinephrine,and the pressure of adjustable water pump was maintained at 60 mmHg.The bony markers and surgical portals were marked before operation.Posterior portal/arthroscopic portal:2cm below the posterior corner of acromion.Anterosuperior portal:in the lateral side of coracoid process and between the long head of the biceps tendon and upper margin of the subscapularis tendon inside the joint.Antroinferior portal:2~3cm below the anterosuperior portal and close to the upper margin of the subscapularis tendon inside the joint as much as possible.Two arthroscopic working cannulas were positioned as working channels.The arthroscopy was put in through the posterior portal to explore the shoulder joint in order.The labrum-shoulder joint capsule-ligament complex was found detached and shifted from the glenoid labrum and the anterior joint capsule and ligaments were aneuros in all cases of this group.The injury sites were often located in the range of 1~5o′clock.7patients were with articular cartilage lesion of humeral head and 5patients were with glenohumeral cartilage degeneration.Radiofrequency ablation and cartilage-plasty were adopted for surface cleaning of articular cartilage injury and degeneration.The shoulder joint soft tissue detacher was used in the front of the damaged glenoid to dissect the adhesive labrum-shoulder joint capsule-ligament complex to the direction of scapular neck.The fibrous tissue was rasped off at the damage of labrum with glenoid file,exposing the fresh bone.The locator was put at the glenoid rim of 2,3,4,5o′clock position through the antroinferior working cannula.Employed the bone mallet to percuss the locator with in an angle of 45°with glenoid to make a pilot hole on the fresh bony surface of glenoid.The inner core was removed and the metal suture anchor was put in the center of locator and screwed in the glenoid.The labrum-shoulder joint capsule-ligament complex was sutured with suture penetrator device with the knot tied to complete the fixation.After finishing the fixation,the repair effect was rechecked with probe and the wound margin was cleaned by radiofrequency ablation.Postoperative management:Postoperative examination of shoulder joint includes radiographs,and the shoulder joint is fixed with abduction orthosis for 6weeks with active movement prohibited.The patient is advised to exercise elbow,wrist and hand,and be given local physical therapy,pain relief and icing.Protective rehabilitation,including pendulum training and pulley device training,is allowed 6weeks later.Rehabilitation for muscle strength begins3 months later,consisting of increased joint range of motion,resistance training of muscle and endurance training.After 6months motor function recovery is initiated to strengthen the exercises of muscles around the shoulder joint,proprioception,etc.,and non-contact sports activities can be engaged,including special training of restoration movement function,weight lifting,dumbbell training,etc.Immediate postoperative physical therapy and rehabilitation is performed under the guidance of rehabilitation physicians and therapists.Physical therapy mainly contains early cold compress to relieve pain and disperse swelling,ultrashort wave therapy to improve local blood circulation and promotion of soreness subsiding and tissue healing.Rehabilitation can improve circulation,promote joint capsule-labrum complex healing,strengthen muscle,increase joint stability,and prevent joint stiffness,swelling and other complications.Results Outpatient follow-upswere carried out 3week,6week,3month,6month and 1year after operation and henceforth once each year.The mean ASES score before operation and at the final follow-ups,the angle of anteflexion,abduction and external rotation,and the mean Constant-Murley score at the final followups of 60 patients were processed by paired t-test and a value of P <0.05 was considered statistically significant.No postoperative redislocation occurred in all patients during the final follow-up.Postoperative residual Crank test was positive in 4patients(6.7%).All patients restored preoperative work with 52patients(86.7%)restored to the sports level before the first dislocation.Discussion Arthroscopic Bankart repair is one of the effective methods for treatment of recurrent anterior dislocation of the shoulder,the proper case selection,and arthroscopic technique during operation and strict postoperative functional rehabilitation are the keys to successful operation.
出处
《中华肩肘外科电子杂志》
2014年第4期219-224,共6页
Chinese Journal of Shoulder and Elbow(Electronic Edition)
基金
云南省医学学科带头人项目(D-201207)
云南省创新团队项目(2014HC018)
