Hart R, Okál F, Komzák M
Ortopedicko-traumatologické oddělení Nemocnice Znojm.
Acta Chir Orthop Traumatol Cech. 2010 Oct;77(5):402-10.
The aim of this presentation is to inform the medical community about causal therapy (transhumeral head plasty or massive osteochondral allograft transplantation) for large Hill-Sachs lesions which frequently cause failure of anterior stabilisation following ventral shoulder dislocations.
Seven men with an average age of 26 years (19 to 33 years) undergoing surgery in 2006 and 2007 were evaluated. The minimum follow-up was 18 months (41 to 18 months). Impressions on more than 30 % of the articular surface, or those whose critical size was larger than one-eighth of the humeral diameter (on CT scan) were taken as indications for surgery. Four patients had had previous surgery for anterior instability and three had a primary procedure. Four men underwent acute surgery and three had elective operations.Trans- humeral head plasty was used in five and massive osteochondral allograft in two patients.
In the patients with large lesions in the anterior aspect of the shoulder joint, transhumeral head plasty involving repair of the ventral structures from the anterior approach was indicatedúúú in those with an isolated posterior bony defect, a massive osteochondral allograft was transplanted through the posterior approach. The Constant-Murley score was used to assess clinical status before (not in acute conditions) and after surgery.
All patients reported improved clinical status. The average Constant-Murley score at final follow-up was 95.9 points (83-100 points). In the patients not having an acute procedure in whom pre-operative Constant-Murley scores were obtained, the average improvement was by 22.7 points (8 - 37 points). No general surgical complications were recorded. All patients reported subjective satisfaction and willingness to undergo surgery under the same conditions again.
A Hill-Sachs lesion is a frequent injury to the humeral head resulting from anterior shoulder dislocation. To distinguish between major and minor defects in terms of clinical significance is essential for the choice of appropriate shoulder treatment. Up to now large lesions have mostly been managed by non-causal techniques affecting shoulder biomechanics. Transhumeral head plasty or transplantation of a massive osteochondral allograft, on the other hand, offers a causal treatment. However, these two methods have rarely been mentioned in the international literature, and usually only as case reports.
Transhumeral head plasty and transplantation of a massive osteochondral allograft offer a causal therapy for the management of Hill-Sachs lesions that does not alter shoulder biomechanics. They are not associated with a higher percentage of post-operative complications. Neither technique is more demanding than non-causal procedures. Operations carried out as primary and not as "salvage" procedures restored the function of the shoulder joint to normal. After secondary surgery, occasional shoulder pain may persist as well as its restricted range of motion.
本报告的目的是向医学界介绍针对大型Hill-Sachs损伤的病因治疗（经肱骨头部成形术或大块骨软骨异体移植），这种损伤常导致肩关节前脱位后前路稳定手术失败。
对2006年和2007年接受手术的7名平均年龄26岁（19至33岁）的男性进行了评估。最短随访时间为18个月（41至18个月）。关节面超过30%有损伤，或其关键尺寸大于肱骨直径的八分之一（CT扫描）的情况被视为手术指征。4例患者曾因前方不稳定接受过手术，3例为初次手术。4名男性接受了急诊手术，3例为择期手术。5例采用经肱骨头部成形术，2例采用大块骨软骨异体移植。
对于肩关节前方有大损伤的患者，若采用经前方入路修复前方结构的经肱骨头部成形术；对于有孤立后方骨缺损的患者，则通过后方入路移植大块骨软骨异体移植。采用Constant-Murley评分评估手术前（非急性情况）和手术后的临床状况。
所有患者均报告临床状况有所改善。末次随访时Constant-Murley评分平均为95.9分（83 - 100分）。在术前获得Constant-Murley评分的非急诊手术患者中，平均改善了22.7分（8 - 37分）。未记录到一般外科并发症。所有患者均表示主观满意，并愿意在相同情况下再次接受手术。
Hill-Sachs损伤是肩关节前脱位导致的肱骨头常见损伤。从临床意义上区分大、小缺损对于选择合适的肩部治疗方法至关重要。到目前为止，大型损伤大多采用影响肩部生物力学的非病因技术处理。另一方面，经肱骨头部成形术或大块骨软骨异体移植提供了一种病因治疗方法。然而，这两种方法在国际文献中很少被提及，通常仅作为病例报告。
经肱骨头部成形术和大块骨软骨异体移植为Hill-Sachs损伤的治疗提供了一种不改变肩部生物力学的病因治疗方法。它们与较高比例的术后并发症无关。这两种技术都不比非病因手术要求更高。作为初次手术而非“挽救”手术进行的操作可使肩关节功能恢复正常。二次手术后，偶尔可能会持续存在肩部疼痛及其活动范围受限的情况。
