Orthopedic and Traumatological Surgery Department, hôpital d'instruction des Armées-Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France.
Orthop Traumatol Surg Res. 2009 Apr;95(2):100-7. doi: 10.1016/j.otsr.2008.09.008. Epub 2009 Mar 21.
Posterior shoulder instability is a rare condition, representing only 4% of all shoulder-joint instabilities. Numerous surgical techniques are used to treat it when conservative functional treatment proves to be insufficient. This retrospective study relates to 8 patients, presenting recurrent posterior shoulder instability, all treated with a posterior iliac bone-block procedure. The results were assessed both clinically and with contemporary imaging techniques.
A unique identical surgical technique was used in all these cases including a posterior deltoid head detachment, an infraspinatus muscle dissociation and a bone-block positioning intended to extend and enlarge the glenoid cavity rather than to act as an actual block. Seven of these 8 cases were posttraumatic (including 2 with a concomitant congenital hyperlaxity past history) and the non-traumatic 1 was secondary to an epileptic seizure episode. All the patients had a typical posterior shoulder instability clinical presentation in the form of recurrent true dislocation incidents. In 6 cases, imaging revealed lesions of the humeral head or the glenoid cavity. These lesions were displacement-related anterior impaction defects of the humeral head (McLaughlin lesion) and/or a fracture (or erosion) of the posterior glenoid rim. Mean postoperative follow-up was 34 months.
No cases of postoperative suprascapular nerve deficit were observed. All patients recovered normal joint range of motion in abduction and anterior elevation; in 3 patients, however, external rotation ended up being limited by an average 20 compared to the opposite side. The mean Constant score was 96.25 points and the mean Duplay score 90. Only 4 patients were able to return to their preoperative sports activity level. Three required an additional procedure, 2 for hardware removal and 1 for posterior deltoid repair, which all lead to an uneventful evolution. Imaging at follow-up (X-ray or CT) did not show any instance of bone-block pseudoarthrosis or osteolysis nor did it exhibit glenohumeral early degenerative changes. In all, at a mean 3 years' follow-up, the present series showed satisfactory results in 80% of cases. A literature review found comparable results for bone-block stabilization procedures. No recurrences of instability are reported with this technique, the main difficulty of which residing in the correct positioning of the bone-block. The stabilizing efficacy and low subsequent arthritic changes of the iliac posterior bone-block graft procedure seem thus confirmed by these encouraging results.
The iliac posterior shoulder bone-block is effective in managing instances of involuntary posterior shoulder instability. A review of the literature confirmed these satisfactory results in terms of non-recurrence, pain relief and function recovery with this technique; the main difficulties of this technique remains in the correct positioning of the bone-block and the proper orientation of the fixation screws.
肩后不稳定是一种罕见的疾病，仅占所有肩关节不稳定的 4%。当保守功能治疗无效时，有许多手术技术用于治疗。本回顾性研究涉及 8 例复发性肩后不稳定的患者，均采用髂后骨块术治疗。使用临床和现代影像学技术对结果进行评估。
在所有这些病例中都使用了独特的相同手术技术，包括后三角肌头分离、冈下肌分离和骨块定位，旨在扩大和扩大关节盂，而不是作为实际的阻挡物。这 8 例中有 7 例为创伤性（包括 2 例伴有先天性过度松弛病史），1 例非创伤性为癫痫发作引起。所有患者均表现出典型的肩后不稳定临床表现，表现为反复真性脱位事件。在 6 例中，影像学显示肱骨头或关节盂有损伤。这些损伤是肱骨头相关的前向撞击缺陷（McLaughlin 病变）和/或后关节盂缘骨折（或侵蚀）。平均术后随访 34 个月。
术后未观察到肩胛上神经缺损。所有患者的外展和前举的关节活动范围均恢复正常；然而，在 3 例患者中，外旋平均受限 20°，与对侧相比。Constant 评分平均为 96.25 分，Duplay 评分平均为 90 分。只有 4 例患者能够恢复术前的运动水平。有 3 例需要进行额外的手术，2 例用于去除内固定，1 例用于修复后三角肌，所有这些都导致了无并发症的演变。随访时的影像学（X 线或 CT）未显示骨块假关节或骨溶解的任何迹象，也未显示早期退行性关节盂肱关节炎改变。总的来说，在平均 3 年的随访中，本系列 80%的病例结果令人满意。文献回顾发现，骨块稳定术的结果相似。该技术未报告不稳定复发，其主要困难在于骨块的正确定位。这些令人鼓舞的结果证实，髂后骨块移植术在管理非自愿性肩后不稳定方面是有效的。
