Elhassan Bassem, Ozbaydar Mehmet, Diller David, Higgins Lawrence D, Warner Jon J P
Massachusetts General Hospital, Boston, Massachusetts, USA.
J Bone Joint Surg Am. 2009 Feb;91(2):419-24. doi: 10.2106/JBJS.H.00318.
Soft-tissue resurfacing of the glenoid, with arthroplasty of the humeral head, has been proposed as a viable treatment option for younger patients with symptomatic osteoarthritis of the shoulder. The purpose of this study was to evaluate our results with soft-tissue resurfacing of the glenoid in patients with glenohumeral arthritis who were less than fifty years of age, as we were concerned that this type of procedure was leading to poor outcomes.
Between 2000 and 2006, thirteen patients with an average age of thirty-four years underwent soft-tissue resurfacing of the glenoid and humeral head arthroplasty. Achilles tendon allograft was used in eleven patients; fascia lata autograft, in one; and anterior shoulder joint capsule, in one. Three patients had resurfacing of the humeral head with a stemless resurfacing implant, and ten patients had a hemiarthroplasty. The patients were followed for a minimum of two years or until failure, and the duration of follow-up averaged forty-eight months. The results were graded with a visual analog pain scale, the subjective shoulder value, and the Constant and Murley score. Radiographic review was performed in order to determine the degree of joint space loss and glenoid erosion.
Ten of the thirteen patients required a revision total shoulder arthroplasty at a mean of fourteen months (range, six to thirty-four months) postoperatively. The principal reasons for revision were persistent pain and a decreased range of motion. Radiographic evaluation at the time of the revision surgery demonstrated loss of joint space and glenoid erosion in all cases. At the revision surgery, the allograft was found to be absent, and thick scar tissue, which may have been a graft remnant, was found at the perimeter of the glenoid. Of the three patients who did not have a revision arthroplasty, one had good function, pain relief, and an improved range of motion; however, the postoperative course of the other two was complicated by infection. One of them had a salvage with early irrigation and débridement as well as intravenous antibiotics, whereas the other underwent resection arthroplasty because of persistent infection.
Soft-tissue resurfacing of the glenoid with an Achilles tendon allograft combined with humeral head arthroplasty is not a reliable method of treatment of glenohumeral arthritis in an active patient younger than fifty years of age, as the clinical outcome is poor. Moreover, we found no evidence that the graft acts as a durable bearing surface.
对于有症状的肩关节骨关节炎的年轻患者，有人提出采用盂肱关节软组织重建术联合肱骨头置换术作为一种可行的治疗选择。本研究的目的是评估我们对年龄小于50岁的盂肱关节炎患者采用盂肱关节软组织重建术的结果，因为我们担心这种手术方式会导致不良后果。
2000年至2006年期间，13例平均年龄为34岁的患者接受了盂肱关节软组织重建术和肱骨头置换术。11例患者使用了跟腱同种异体移植物；1例使用了阔筋膜自体移植物；1例使用了肩关节前关节囊。3例患者使用无柄表面置换植入物进行肱骨头表面置换，10例患者进行了半关节置换术。对患者进行了至少两年的随访或直至失败，随访时间平均为48个月。结果采用视觉模拟疼痛量表、主观肩关节评分和Constant和Murley评分进行分级。进行了影像学检查以确定关节间隙丢失和盂肱关节侵蚀的程度。
13例患者中有10例在术后平均14个月（范围为6至第34个月）需要进行翻修全肩关节置换术。翻修的主要原因是持续疼痛和活动范围减小。翻修手术时的影像学评估显示所有病例均有关节间隙丢失和盂肱关节侵蚀。在翻修手术中，发现同种异体移植物缺失，在盂肱关节周边发现了可能是移植物残余的厚瘢痕组织。在未进行翻修关节置换术的3例患者中，1例功能良好、疼痛缓解且活动范围改善；然而，另外2例患者的术后病程因感染而复杂化。其中1例通过早期冲洗清创以及静脉使用抗生素得以挽救，而另1例因持续感染接受了关节切除成形术。
对于年龄小于50岁的活跃患者，采用跟腱同种异体移植物进行盂肱关节软组织重建术联合肱骨头置换术并非治疗盂肱关节炎的可靠方法，因为临床结果较差。此外，我们没有发现证据表明移植物可作为持久的承重表面。
