Sachs Raymond A, Lin David, Stone Mary Lou, Paxton Elizabeth, Kuney Mary
Southern California Permanente Medical Group, San Diego, CA, USA.
J Bone Joint Surg Am. 2007 Aug;89(8):1665-74. doi: 10.2106/JBJS.F.00261.
Some surgeons believe that they can identify patients who are at high risk for shoulder redislocation and that these patients are best served by immediate surgical stabilization. This natural history study was performed to examine the validity of this concept and to determine whether it is possible to predict the need for future surgery at the time of the index injury and examination.
One hundred and thirty-one patients were followed for an average of four years after their first shoulder dislocation. An extensive history was recorded and a thorough physical examination was performed on each patient. Final evaluation consisted of a physical examination, radiographic evaluation, and determination of three outcome measurements.
Twenty-nine (22%) of the 131 patients requested surgery during the follow-up period. There were twenty Bankart repairs and nine rotator cuff repairs. Forty-three patients (33%) had at least one recurrent dislocation. Thirty-nine of these patients were in the group of ninety patients under the age of forty years. Thirty-seven of these thirty-nine patients either participated in contact or collision sports or used the arm at or above chest level in their occupation. Eighteen (49%) of these thirty-seven patients had surgery. Only two of the more sedentary patients had redislocation, and none had surgery. Four (10%) of the forty-one patients over the age of forty had a redislocation, but none required a Bankart repair. However, eight (20%) of the forty-one patients required a rotator cuff repair. Eighty-eight (67%) of the 131 patients never had a redislocation. Their outcome scores were high and equivalent to those of the cohort of patients who had had a successful Bankart repair of an unstable shoulder. Patients who had redislocation but chose to cope with the instability rather than have surgery had lower outcome scores. Twenty-two (51%) of the forty-three patients who had recurrent instability had only one redislocation during the entire follow-up period, whereas some patients had as many as twelve complete redislocations.
Younger patients involved in contact or collision sports or who require overhead occupational use of the arm are more likely to have a redislocation of the shoulder than are their less active peers or older persons. However, even in the highest-risk groups, only approximately half of patients with shoulder redislocation requested surgery within the follow-up period. Early surgery based on the presumption of future dislocations, unhappiness, and disability cannot be justified.
一些外科医生认为他们能够识别出肩关节再脱位风险高的患者，并且这些患者最好通过立即进行手术稳定治疗。本自然史研究旨在检验这一概念的有效性，并确定在初次受伤和检查时是否有可能预测未来手术的必要性。
131例患者在首次肩关节脱位后平均随访4年。记录每位患者详尽的病史并进行全面的体格检查。最终评估包括体格检查、影像学评估以及三项结果测量的判定。
131例患者中有29例（22%）在随访期间要求手术。其中20例行Bankart修复术，9例行肩袖修复术。43例患者（33%）至少有一次复发性脱位。这43例患者中有39例在90例40岁以下的患者组中。这39例患者中有37例参与接触性或碰撞性运动，或在工作中手臂举过胸部水平或更高。这37例患者中有18例（49%）接受了手术。只有2例活动较少的患者发生了再脱位，且均未接受手术。41例40岁以上的患者中有4例（10%）发生了再脱位，但均不需要进行Bankart修复术。然而，41例患者中有8例（20%）需要进行肩袖修复术。131例患者中有88例（67%）从未发生过再脱位。他们的结果评分很高，与成功进行Bankart修复术治疗不稳定肩关节的患者队列相当。发生再脱位但选择应对不稳定而非进行手术的患者结果评分较低。43例有复发性不稳定的患者中有22例（51%）在整个随访期间仅发生过一次再脱位，而有些患者多达12次完全脱位。
与活动较少的同龄人或老年人相比，参与接触性或碰撞性运动或工作中需要手臂举过头顶的年轻患者更有可能发生肩关节再脱位。然而，即使在风险最高的组中，随访期间只有约一半的肩关节再脱位患者要求手术。基于未来脱位、不适和残疾的推测而进行早期手术是不合理的。
