Lenoir Hubert, Dagneaux Louis, Canovas François, Waitzenegger Thomas, Pham Thuy Trang, Chammas Michel
Centre Ostéo-Articulaire des Cèdres, Echirolles, France.
Hip, Knee and Foot Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France.
J Shoulder Elbow Surg. 2017 Feb;26(2):323-330. doi: 10.1016/j.jse.2016.07.020. Epub 2016 Sep 30.
Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress.
Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA.
When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve.
During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies.
全肩关节置换术后神经损伤相对常见。这些损伤大多是由于牵拉所致。我们旨在确定在反式全肩关节置换术（RTSA）过程中影响神经张力的手臂操作和步骤。
在5具尸体的10个肩部上，通过使用张力计对臂丛神经的每条神经进行测量，测量在不同手臂位置以及RTSA的不同手术步骤期间肩部的神经张力。
当我们在无假体情况下研究肩部位置时，相对于中立位，内旋会增加桡神经和腋神经的张力，外旋会增加肌皮神经、正中神经和尺神经的张力。伸展与所有神经的张力增加相关。外展与桡神经的张力增加相关。我们确定了RTSA期间的2个高风险步骤：肱骨暴露，尤其是当肩部处于更伸展位置时，以及肩胛盂暴露。所使用的聚乙烯肱骨头假体的厚度与除尺神经外的所有神经的神经张力增加有关。
在肱骨准备过程中，外科医生必须小心限制肩部伸展。在肩胛盂暴露时必须小心。应避免过度旋转和使用过大的植入物，以尽量减少牵张性神经病变。
