Department of Shoulder Surgery, Concordia Hospital for Special Surgery, Rome, Italy.
Steadman Philippon Research Institute), Vail, Colorado, U.S.A.
Arthroscopy. 2020 Jan;36(1):56-67. doi: 10.1016/j.arthro.2019.07.020.
The purpose of this study is (1) to test the proposed treatment algorithm, the Glenoid Track Instability Management Score (GTIMS), which incorporates the glenoid track concept into the instability severity index score (ISIS), and (2) to compare treatment decision-making using either GTIMS versus ISIS in 2 cohorts of patients with operatively treated anterior instability.
A multicenter, retrospective review of two consecutive groups consisting of 72 and 189 patients treated according to ISIS and GTIMS, respectively, was conducted. Inclusion criteria for all patients were ≥2 confirmed traumatic anterior shoulder instability events and a physical examination demonstrating a positive anterior apprehension and relocation test. The GTIMS was graded for all 189 patients in the cohort, which uses 3-dimensional computed tomography as the sole radiographic parameter to assess on-track (0 points) versus off-track (4 points) Hill-Sachs lesions. This method differs from ISIS, which uses multiple plain radiographs for the 4-point imaging portion of the score. Outcomes scores were compared within the GTIMS and ISIS groups, as well as between them for overall comparisons based on the Western Ontario Shoulder Instability Index (WOSI), the Single Assessment Numerical Evaluation (SANE) score, and the mean rates of recurrent instability.
A total of 261 consecutive patients from 2009 to 2014 who presented with recurrent anterior shoulder instability were treated according to either ISIS (n = 72/261, 27.6%) or GTIMS (n = 189/261, 72.4%). At a mean follow-up time of 33.2 months (range 24-49 months), the overall cohort mean ISIS of 2.9 ± 2.2 (range 0-9) was significantly higher than the mean GTIMS of 1.9 ± 1.9 (range = 0-9, P < .001). Of the 72 ISIS treated patients, 50 (69.4%) had an ISIS score of ≥ 4 and underwent a Latarjet, and the 22 patients (30.6%) with an ISIS score of < 4 underwent an arthroscopic Bankart repair. Based on GTIMS in the 189-patient cohort, using the same cutoff of 4 to indicate the need for a Latarjet, 162 patients were treated with arthroscopic Bankart repair (85.7%) and 27 with Latarjet (14.3%). The overall outcomes improved for patients treated with a Latarjet in both groups (GTIMS WOSI from 1099 [47.7% normal] to 395 [81.3% normal]; GTIMS SANE from 48 to 81; ISIS WOSI from 1050 [50% normal] to 345 [83.4% normal]; ISIS SANE from 50 to 84; P < .01). Similar positive outcomes were seen in patients treated with arthroscopic Bankart repair (GTIMS WOSI from 1062 [49.2% normal] to 402 [80.6% normal]; GTIMS SANE from 49 to 82; ISIS WOSI from 1080 [51.8% normal] to 490 [76.7% normal]; ISIS SANE from 48 to 77; P < .01). Of note, the patients with arthroscopically indicated ISIS had significantly worse outcomes scores than those treated arthroscopically according to GTIMS (P < .01). Of the 189 patients graded with GTIMS, there would have been 33 more Latarjet procedures recommended based on ISIS score. Thus the distribution of procedures based on ISIS versus GTIMS was significantly different (χ = 45.950; P < .001), indicating a higher rate of recommending Latarjets when using ISIS versus GTIMS.
When ISIS scoring and plain radiograph parameters only are used, this predicted a 2-fold increase in recommending a Latarjet versus GTIMS scoring criteria, which uses advanced imaging and the on- and off-track principle to more conservatively delineate anterior instability treatment with promising postoperative patient outcomes. Overall, there were minimal differences in outcomes between GTIMS and ISIS Latarjet patients; however, better outcomes were seen in patients indicated for arthroscopic Bankart repair according to GTIMS and on-off track computed tomography scanning indications.
II, Prospective Cohort Study.
本研究旨在（1）测试拟议的治疗算法，即 Glenoid Track Instability Management Score（GTIMS），该算法将盂肱关节窝轨迹的概念纳入到不稳定严重指数评分（ISIS）中；（2）通过比较分别使用 GTIMS 和 ISIS 对接受手术治疗的前向不稳定的两批患者进行治疗决策。
对分别符合 ISIS 和 GTIMS 标准的连续两批共 72 例和 189 例患者进行了多中心回顾性分析。所有患者的纳入标准均为至少有 2 次经证实的创伤性前向肩不稳定事件，且体格检查显示有阳性前向惊吓和复位试验。189 例患者的 GTIMS 分级全部完成，该方法仅使用三维 CT 作为评估矢状面 Hill-Sachs 病变的轨道（0 分）与非轨道（4 分）的唯一影像学参数。这种方法与 ISIS 不同，后者使用多张普通 X 线片评估评分的 4 分影像学部分。比较了 GTIMS 和 ISIS 组内以及组间的结果评分，根据 Western Ontario Shoulder Instability Index（WOSI）、Single Assessment Numerical Evaluation（SANE）评分和复发性不稳定的平均发生率进行了总体比较。
2009 年至 2014 年间，261 例复发性前向肩不稳定患者连续就诊，分别根据 ISIS（n=72/261，27.6%）或 GTIMS（n=189/261，72.4%）进行治疗。平均随访时间为 33.2 个月（范围 24-49 个月），总体患者的平均 ISIS 为 2.9±2.2（范围 0-9），显著高于平均 GTIMS 为 1.9±1.9（范围 0-9，P<.001）。在 72 例 ISIS 治疗患者中，50 例（69.4%）的 ISIS 评分≥4 分，行 Latarjet 手术，22 例（30.6%）的 ISIS 评分<4 分，行关节镜 Bankart 修复术。根据 GTIMS 在 189 例患者队列中的结果，使用相同的 4 分作为需要 Latarjet 手术的界限，162 例患者行关节镜 Bankart 修复术（85.7%），27 例行 Latarjet 手术（14.3%）。两组中接受 Latarjet 手术的患者总体结局均有所改善（GTIMS WOSI 从 1099（47.7%正常）到 395（81.3%正常）；GTIMS SANE 从 48 到 81；ISIS WOSI 从 1050（50%正常）到 345（83.4%正常）；ISIS SANE 从 50 到 84；P<.01）。接受关节镜 Bankart 修复术的患者也出现了类似的积极结局（GTIMS WOSI 从 1062（49.2%正常）到 402（80.6%正常）；GTIMS SANE 从 49 到 82；ISIS WOSI 从 1080（51.8%正常）到 490（76.7%正常）；ISIS SANE 从 48 到 77；P<.01）。值得注意的是，根据 GTIMS 进行关节镜检查的患者的结局评分明显低于根据 ISIS 进行关节镜检查的患者（P<.01）。在根据 GTIMS 分级的 189 例患者中，根据 ISIS 评分建议进行 Latarjet 手术的患者将增加 33 例。因此，根据 ISIS 与 GTIMS 的手术推荐分布存在显著差异（χ²=45.950；P<.001），这表明在使用 ISIS 与 GTIMS 评分标准时，推荐 Latarjet 手术的比率更高。
当仅使用 ISIS 评分和普通 X 线片参数时，与 GTIMS 评分标准相比，建议行 Latarjet 手术的比率增加了 2 倍，而 GTIMS 评分标准使用了先进的影像学技术和轨道内外的原理，更保守地划定了前向不稳定的治疗范围，术后患者预后良好。总体而言，GTIMS 和 ISIS Latarjet 患者的结局差异较小；然而，根据 GTIMS 和关节镜内外轨迹 CT 扫描的适应证，行关节镜 Bankart 修复术的患者的结局更好。
II，前瞻性队列研究。
