Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
Clin Orthop Relat Res. 2021 Sep 1;479(9):1995-2005. doi: 10.1097/CORR.0000000000001757.
Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery.
QUESTIONS/PURPOSES: In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up?
Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care.
In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned.
In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures.
Level IV, therapeutic study.
对于伴有病理性肩胛盂后倾和发育不良的创伤后肩关节不稳定患者，如何解决这一问题是肩部外科领域尚未解决的难题。
问题/目的：在一项初步研究中，我们对一组因肩胛盂后倾≥ 15°和肩胛盂下后区发育不良而导致创伤后肩关节不稳定的患者，采用无植入物 J 形髂嵴骨移植物进行后开放楔形截骨和肩胛盂后凹重建，研究了以下几个问题：（1）有多少比例的患者存在持续的恐惧？（2）患者报告的肩部评分有何改善？（3）短期随访时的影像学结果如何？
2016 年至 2018 年，我们对 7 例创伤后肩关节不稳定的患者进行了治疗。当创伤后肩关节不稳定的症状对至少 6 个月的物理治疗无反应，且与肩胛盂后倾≥ 15°和肩胛盂下后区发育不良有关时，我们会进行这种干预。所有 7 例患者均在至少 2 年时进行了随访检查。手术时的中位（范围）年龄为 27 岁（16 至 45 岁），中位随访时间为 2.3 年（2 至 3 年）。通过后向恐惧和/或后向弹响试验评估恐惧。获得患者报告的肩部评分，包括通过图表回顾获得的主观肩部值（评分 100%表示正常肩部；最小临床重要差异[MCID]为 12%）和 Constant 疼痛评分（无疼痛为 15 分；MCID 为 1.5 分）。影像学测量包括肩关节炎和肱骨头后脱位、骨移植物融合、肩胛盂后倾和肩胛盂后凹深度的矫正以及肩胛盂表面积的增加。所有终点均由未参与患者治疗的人员进行评估。
在 7 例患者中有 4 例存在后向恐惧，但是均无再脱位报告。术前主观肩部值（中位数[范围]40%[30%至 80%]）和 Constant 疼痛评分（中位数 7 分[3 至 13 分]）在末次随访时得到改善（中位主观肩部值 90%[70%至 100%]；p = 0.02；中位 Constant 疼痛评分 15 分[10 至 15 分]；p = 0.03）。4 例患者（均为 Walch B1 型肩胛盂）术前存在后肩胛盂软骨侵蚀，直至最终随访检查时未见进展。肱骨头后脱位指数中位数（范围）从术前的 69%（54%至 85%）降至术后的 55%（46%至 67%）（p = 0.02），在术前肱骨头后脱位＞65%的 2 例患者中，肱骨头已复位至中心位。CT 图像显示所有无植入物 J 形髂嵴骨移植物均已融合。术前平均肩胛盂后倾从 16°（15°至 25°）矫正至术后的 0°（-5°至 6°）（p = 0.02），术前平均肩胛盂后凹深度从 0.3 mm（-0.7 至 1.6）矫正至术后的 1.2 mm（1.1 至 3.1）（p = 0.02），术前平均肩胛盂表面积增加了 20%（p = 0.02）。术中及术后均未发生并发症，也未进行或计划进行再次手术。
在由经验丰富的肩部外科医生进行的这项小回顾性系列研究中，后 J 形骨移植物手术能够重建后肩胛盂形态，矫正肩胛盂后倾，并改善与病理性肩胛盂后倾和发育不良相关的创伤后肩关节不稳定，尽管 7 例患者中有 4 例存在持续的后向恐惧。尽管本小系列中没有患者发生并发症，但该手术的规模和复杂性使得更多患者发生并发症的可能性增加；未来的研究需要描述这些并发症的频率和严重程度，我们建议仅由经验丰富的肩部外科医生进行该手术。这 7 例患者的早期结果证明了进一步研究该手术适应证的合理性，但需要更长时间的随访，以继续评估与传统手术技术（如后开放楔形截骨术或单纯后骨块术）相比，重建后肩胛盂后凹、矫正病理性肩胛盂后倾和增加肩胛盂表面积是否具有优势。
IV 级，治疗性研究。
