S. W. Mayer, Department of Orthopedic Surgery, Children's Hospital Colorado, Aurora, CO, USA A. P. Kraszewski, A. Kontaxis, Motion Analysis Laboratory, Hospital for Special Surgery, New York, NY, USA A. Skelton, Musculoskeletal Research Center, Children's Hospital Colorado, Aurora, CO, USA R. Warren, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.
Clin Orthop Relat Res. 2018 Jul;476(7):1526-1536. doi: 10.1097/01.blo.0000534681.21276.14.
Surgical treatment for shoulder instability generally involves labral repair with a capsular plication or imbrication. Good results are reported in both open and arthroscopic procedures, but there is no consensus on the amount or location of capsular plication that is needed to achieve stability and anatomic anterior, posterior, and inferior translation of the joint.
QUESTIONS/PURPOSES: (1) What are the separate and combined effects of increasing plication magnitude and sequential additive plications in the anterior, posterior, and inferior locations of the joint capsule on glenohumeral joint translation in the anterior, posterior, and inferior directions? (2) What plication location and magnitude restores anterior, posterior, and inferior translation to a baseline level?
Fourteen cadaveric shoulders were dissected down to the glenohumeral capsule and underwent instrumented biomechanical testing. Each shoulder was loaded with 22 N in anterior, posterior, and inferior directions at 60° abduction and neutral rotation and flexion and the resulting translation were recorded. Testing was done over baseline (native), stretched (mechanically stretched capsule to imitate a lax capsule), and 5-mm, 10-mm, and 15-mm plication conditions. Individually, for each of the 5-, 10-, and 15-mm increments, plications were done in a fixed sequential order starting with anterior plication at the 3 o'clock position (Sequence I), then adding posterior plication at the 9 o'clock position (Sequence II), and then adding inferior plication at the 6 o'clock position (Sequence III). Each individual sequence was tested by placing 44 N (10 pounds) of manual force on the humerus directed in an anterior, posterior, and inferior direction to simulate clinical load and shift testing. The effect of plication magnitude and sequence on translation was tested with generalized estimating equation models. Translational differences between conditions were tested with paired t-tests.
Translational laxity was highest with creation of the lax condition, as expected. Increasing plication magnitude had a significant effect on all three directions of translation. Plication location sequence had a significant effect on anterior and posterior translation. An interaction effect between plication magnitude and sequence was significant in anterior and posterior translation. Laxity in all directions was most restricted with 15-mm plication in anterior, posterior, and inferior locations. For anterior translational laxity, at 10-mm and 15-mm plication, there was a progressive decrease in translation magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: 0.29 mm, plus inferior, -0.12 mm; and for 15-mm anterior only: -0.53 mm, plus posterior: -1.00 mm, plus inferior: -1.66 mm). For posterior translational laxity, 10-mm and 15-mm plication also showed progressive decrease in magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: -0.25 mm, plus inferior: -1.94; and for 15-mm anterior only: 0.14 mm, plus posterior: -1.54 mm, plus inferior: -3.66). For inferior translational laxity, tightening was observed only with magnitude of plication (anterior only at 5 mm: 0.31 mm, at 10 mm: -1.39, at 15 mm: -3.61) but not with additional plication points (adding posterior and inferior sequences). To restore laxity closest to baseline, 10-mm AP/inferior plication best restored anterior translation, 15-mm anterior plication best restored posterior translation, and 5 mm posterior with or without inferior plication best restored inferior translation.
Our results suggest that (1) a 10-mm plication in the anterior and posterior or anterior, posterior, and inferior positions may restore anterior translation closest to baseline; (2) 10-mm anterior and posterior or 15-mm anterior plications may restore posterior translation closest to baseline; and (3) 5-mm anterior and posterior or anterior, posterior, and inferior plications may restore inferior translation closest to baseline. Future studies using arthroscopic techniques for plication or open techniques via a true surgical approach might further characterize the effect of plication on glenohumeral translation.
This study found that specific combinations of plication magnitude and location can be used to restore glenohumeral translation from a lax capsular state to a native state. This information can be used to guide surgical technique based on an individual patient's degree and direction of capsular laxity. In vivo testing of glenohumeral translation before and after capsular plication will be needed to validate these cadaveric results.
肩部不稳定的手术治疗通常包括盂唇修复，伴或不伴关节囊紧缩缝合。开放和关节镜手术都有良好的效果，但对于实现稳定性和关节前、后和下向平移所需的关节囊紧缩缝合的量和位置，尚未达成共识。
问题/目的：（1）在关节囊的前、后和下部位分别增加紧缩缝合的幅度和连续附加紧缩缝合对盂肱关节前、后和下向平移的单独和联合影响是什么？（2）哪种紧缩缝合位置和幅度可以将前、后和下向平移恢复到基线水平？
对 14 个尸体肩部进行解剖，直至肩胛盂肱关节囊，并进行仪器生物力学测试。每个肩部在 60°外展和中立旋转及屈曲位下，在前、后和下方向施加 22N 的负荷，并记录相应的平移量。测试采用基线（原生）、拉伸（机械拉伸关节囊以模拟松弛关节囊）以及 5mm、10mm 和 15mm 紧缩缝合条件。对于每个 5mm、10mm 和 15mm 的增量，以固定的顺序进行单独的紧缩缝合，从 3 点钟位置的前紧缩缝合（序列 I）开始，然后在 9 点钟位置添加后紧缩缝合（序列 II），最后在 6 点钟位置添加下紧缩缝合（序列 III）。通过将 44N（10 磅）的手动力施加在肱骨上，模拟临床负荷和移位测试，对每个单独的序列进行测试。使用广义估计方程模型测试紧缩缝合幅度和顺序对平移的影响。通过配对 t 检验测试条件之间的平移差异。
如预期的那样，创建松弛条件会导致最大的平移松弛。增加紧缩缝合幅度对所有三个平移方向都有显著影响。紧缩缝合位置序列对前向和后向平移有显著影响。紧缩缝合幅度和序列之间的相互作用效应对前向和后向平移有显著影响。在前、后和下三个方向，15mm 的紧缩缝合对松弛限制最大。在前向平移的松弛度方面，在 10mm 和 15mm 的紧缩缝合中，平移幅度逐渐减小（10mm 前紧缩缝合仅：0.46mm，加后：0.29mm，加下：-0.12mm；而 15mm 前紧缩缝合仅：-0.53mm，加后：-1.00mm，加下：-1.66mm）。在后向平移的松弛度方面，10mm 和 15mm 的紧缩缝合也显示出幅度逐渐减小（10mm 前紧缩缝合仅：0.46mm，加后：-0.25mm，加下：-1.94mm；而 15mm 前紧缩缝合仅：0.14mm，加后：-1.54mm，加下：-3.66mm）。在下向平移的松弛度方面，仅通过紧缩缝合幅度观察到收紧（前紧缩缝合仅 5mm：0.31mm，10mm：-1.39mm，15mm：-3.61mm），而不是通过附加的紧缩缝合点（增加后和下序列）。为了使松弛度最接近基线，10mm 的前、下紧缩缝合最能恢复前向平移，15mm 的前紧缩缝合最能恢复后向平移，而前、后或后、下紧缩缝合最能恢复下向平移。
我们的结果表明：（1）在关节囊的前、后或前、后、下三个位置进行 10mm 的紧缩缝合可能会使前向平移最接近基线；（2）10mm 的前、后或 15mm 的前紧缩缝合可能会使后向平移最接近基线；（3）5mm 的前、后或前、后、下紧缩缝合可能会使下向平移最接近基线。使用关节镜技术进行紧缩缝合或通过真正的手术方法进行开放技术的进一步研究可能会进一步描述紧缩缝合对盂肱关节平移的影响。
本研究发现，特定的紧缩缝合幅度和位置组合可用于将从松弛关节囊状态恢复到原生状态的盂肱关节平移。这些信息可以用于根据患者的关节囊松弛程度和方向来指导手术技术。需要对活体的盂肱关节平移进行术前和术后的关节镜测试，以验证这些尸体结果。
