Abid A, Kany J, Accadbled F, Darodes P, Knorr G, Sales de Gauzy J, Cahuzac J-P
Unité d'orthopédie pédiatrique, hôpital des Enfants, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France.
Rev Chir Orthop Reparatrice Appar Mot. 2008 Nov;94(7):643-8. doi: 10.1016/j.rco.2008.01.003. Epub 2008 Apr 1.
Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer.
From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer.
Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees .
A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation.
Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.
在25%的臂丛神经产瘫（C5、C6 +/- C7）患儿中观察到内旋时肩部回缩。这会导致影响盂肱关节的早期骨与关节畸形。僵硬的内旋需要手术松解，可能涉及关节囊和韧带、肌肉或两者。内松解可与肌肉转移相结合以改善主动外旋。我们报告关节镜下前路关节囊松解联合背阔肌转移的结果。
1999年至2006年，我们科室治疗了14例因臂丛神经产瘫继发肩部内旋僵硬的患儿。所有患儿术后6个月肱二头肌功能均恢复。术前通过磁共振成像分析盂肱关节发育不良情况。术前和术后，在手臂沿身体及肘部屈曲90度时测量被动外旋（RE）。使用马利特评分（手背试验）测量内旋。在患儿玩耍时测量联合主动外展前推。手术平均年龄为3岁6个月。8例患儿接受了关节镜下内松解。所有患儿均联合背阔肌转移。
在本科室治疗的14例患儿中，6例未进行关节松解，其中2例是因为缺乏合适的电极，4例是因为患儿存在盂肱关节后脱位，无法插入观察通道。另外8例患儿接受了关节镜下前路松解。这8例患儿平均随访3年。被动外旋得到改善，平均增加60度，被动内旋未恢复。外展前推动作也得到改善，平均增加90度。
内旋僵硬的肩部可能在生命的头两年出现。已经提出了几种内松解技术。被动外旋逐渐受限的原因仍是一个有争议的话题。是由于内旋肌的回缩，还是关节囊 - 韧带的回缩，或者两者皆有？1992年，哈里曼等人证明了关节囊和喙肱韧带在限制外旋中的作用。因此，我们选择在2岁以下（早期）采用仅限于关节囊和韧带的关节镜方法进行松解。我们被动外旋的结果与其他人报告的结果相当。然而，这种技术能保留内旋的活动度。
仅限于关节囊和韧带的关节镜下前路松解是一种有效、微创的技术。保留内旋肌可保持肩部内旋并降低前向不稳定的风险。
