Abrams Jeffrey S
University Medical Center at Princeton, Princeton, New Jersey.
JBJS Essent Surg Tech. 2019 Mar 27;9(1):e11. doi: 10.2106/JBJS.ST.17.00072. eCollection 2019 Mar 26.
Surgical repair of the unstable shoulder begins with reattachment of the detached capsulolabral complex. The degree of damage to the glenohumeral articulation can be variable and is often related to the degree of trauma, duration of dislocation, and the number of instability events. There have been many surgical procedures proposed for the treatment of shoulder instability in the athlete, ranging from soft-tissue repair to coracoid transfer or the addition of a bone graft. The arthroscope provides an opportunity to visualize and repair the injured structures, returning the shoulder to maximal range of motion and permitting functional improvement. Indications for arthroscopic anterior stabilization include a first-time dislocation, patients with apprehension following dislocation, and recurrent dislocation and subluxation prior to creating advanced bone loss. If there is advanced bone loss, an augmented repair or a procedure other than arthroscopic stabilization has been recommended. Mobilization of the anterior capsule and fixation to recreate the proper anterior tension will limit translation and potential recurrence of instability. The steps of the arthroscopic anterior stabilization include:Perform examination under anesthesia to identify the directions and degree of humeral translation relative to the glenoid.Position the patient with the shoulder 30° abducted and 20° flexed.Create proper portals, including a posterior viewing portal, dual anterior portals, and accessory portals for suture anchor placement.Perform a diagnostic arthroscopy to determine the damaged structures and how they relate to shoulder positions that may invite future dislocations.Perform capsule and labrum mobilization to permit anatomic relocation of the injured ligament.Place a series of suture anchors along the anterior and inferior glenoid margin.Utilize suture hooks to retrieve the sutures placed through the capsule to advance the capsule superiorly to the glenoid margin.Assess glenoid deficiency and place an autograft anterior to the damaged glenoid rim in selected cases.Tenodese the posterior capsule and infraspinatus to a large Hill-Sachs lesion on the posterosuperior aspect of the humeral head in selected cases.Repair additional labral structures superiorly and posteriorly if they contribute to glenohumeral instability. The anticipated outcome is a return to sport and high-demand activities. Bracing is available, but the internal repair is the most reliable technique to protect the glenohumeral articulation. Additional techniques can be implemented when added trauma has resulted in severe bone loss of the glenoid, humeral head, or anterior capsular structures. A return to high-risk activities can be anticipated in 4 to 7 months.
不稳定肩关节的手术修复始于重新附着分离的关节囊盂唇复合体。肱盂关节的损伤程度可能各不相同，且通常与创伤程度、脱位持续时间以及不稳定事件的次数有关。针对运动员肩部不稳定的治疗，已经提出了许多手术方法，从软组织修复到喙突转移或添加骨移植。关节镜提供了一个可视化和修复受损结构的机会，使肩部恢复最大活动范围并促进功能改善。关节镜下前路稳定术的适应证包括首次脱位、脱位后有恐惧的患者以及在出现严重骨质流失之前的复发性脱位和半脱位。如果存在严重骨质流失，建议进行增强修复或采用关节镜稳定术以外的手术。松解前关节囊并固定以重建适当的前张力，将限制移位和不稳定的潜在复发。关节镜下前路稳定术的步骤包括：
在麻醉下进行检查，以确定肱骨相对于肩胛盂的移位方向和程度。
将患者肩部外展30°、屈曲20°进行体位摆放。
创建合适的切口，包括后方观察切口、两个前方切口以及用于放置缝合锚的辅助切口。
进行诊断性关节镜检查，以确定受损结构以及它们与可能导致未来脱位的肩部位置的关系。
进行关节囊和盂唇松解，以使受损韧带进行解剖复位。
沿肩胛盂前下方边缘放置一系列缝合锚。
使用缝合钩取回穿过关节囊放置的缝线，将关节囊向上推进至肩胛盂边缘。
评估肩胛盂缺损情况，在选定病例中，在受损肩胛盂边缘前方放置自体移植物。
在选定病例中，将后关节囊和冈下肌固定于肱骨头后上方的大型希尔-萨克斯损伤处。
如果其他盂唇结构导致肱盂不稳定，则在上方和后方修复这些结构。预期结果是恢复运动和进行高要求活动。可以使用支具，但内部修复是保护肱盂关节最可靠的技术。当额外的创伤导致肩胛盂、肱骨头或前关节囊结构严重骨质流失时，可以采用其他技术。预计4至7个月后可恢复高风险活动。
