Seebauer Ludwig, Goebel Michael
Zentrum für Orthopädie, Unfallchirurgie und Sportmedizin, Klinikum Bogenhausen, Kliniken München GmbH, München, Germany.
Oper Orthop Traumatol. 2008 Dec;20(6):500-10. doi: 10.1007/s00064-008-1506-5.
Restoration of a stable, pain-free and functional shoulder in chronic glenoid defects following anterior or posterior shoulder dislocations.
Anterior glenoid defect: all recurrent or persistent shoulder instabilities in association with chronic glenoid lesions. Posterior glenoid defect: all recurrent or persistent postreposition shoulder instabilities with chronic osseous glenoid defects.
Brachial plexus injury. Poor glenoid bone stock.
Anterior glenoid defect: exposition of the glenoid through a deltopectoral approach. Glenoid reconstruction by autologous iliac crest graft or coracoid transfer, in cases with progressive joint destruction in combination with shoulder arthroplasty. Posterior glenoid defect: exposition of the glenoid through a modified Brodsky approach from posterolateral. Exposure of the posterior capsule between infraspinatus and teres minor muscles, medial capsulotomy, glenoid reconstruction with auto- or allograft, normally by screw osteosynthesis. Treatment of the often accompanying anterior humeral head defect (reverse Hill-Sachs defect) by transposition of the lesser tubercle (modified from McLaughlin), defect coverage by auto- or allograft, or hemiarthroplasty through an anterior approach. In cases of persisting instability reconstruction of the glenoid defect with autologous graft and, if necessary, by shoulder arthroplasty.
To preserve reconstructed anatomy, a Gilchrist sling is required in anterior reconstructions for 4-6 weeks. For postoperative treatment of posterior defects a thorax abduction splint is recommended for 6 weeks. Active-assisted reduced range of motion exercise is provided under physiotherapeutic guidance according to the individual pathology.
Clinical results following open surgery of chronic glenoid lesions in shoulder instability differ from the treatment results in acute fractures because of the often accompanying large rotator cuff tears, bad bone quality and frequently large defect size. In the hands of experienced shoulder surgeons, however, favorable results can be achieved with modern implants, leading to decisive improvement in patients' quality of life.
恢复前或后肩关节脱位后慢性关节盂缺损患者稳定、无痛且功能良好的肩部。
前关节盂缺损：所有与慢性关节盂病变相关的复发性或持续性肩关节不稳。后关节盂缺损：所有伴有慢性关节盂骨质缺损的复位后复发性或持续性肩关节不稳。
臂丛神经损伤。关节盂骨量不佳。
前关节盂缺损：通过三角肌胸大肌入路暴露关节盂。对于伴有进行性关节破坏且需行肩关节置换术的病例，采用自体髂嵴植骨或喙突转移进行关节盂重建。后关节盂缺损：通过改良的后外侧Brodsky入路暴露关节盂。在冈下肌和小圆肌之间暴露后关节囊，行内侧关节囊切开术，采用自体或异体移植进行关节盂重建，通常用螺钉内固定。对于常伴随的肱骨头前方缺损（反向Hill-Sachs缺损），采用小转子转位（改良自McLaughlin法）、自体或异体移植覆盖缺损，或通过前入路行半肩关节置换术进行治疗。对于持续存在不稳的病例，用自体移植物重建关节盂缺损，必要时行肩关节置换术。
为保持重建后的解剖结构，前侧重建术后需使用Gilchrist吊带4 - 6周。后侧缺损术后建议使用胸外展夹板6周。根据个体病情，在物理治疗师指导下进行主动辅助下的有限度活动范围锻炼。
由于常伴有巨大的肩袖撕裂、骨质不佳和缺损较大，肩关节不稳患者慢性关节盂病变开放手术后的临床结果与急性骨折的治疗结果不同。然而，在经验丰富的肩部外科医生手中，使用现代植入物可取得良好效果，从而显著改善患者生活质量。
