University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A.
The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado.
Arthroscopy. 2022 May;38(5):1396-1397. doi: 10.1016/j.arthro.2022.03.009.
Treatment of recurrent anterior shoulder instability has gained significant interest in recent years and involves evaluation of both glenoid and humeral sided bone loss. Decision making is more complex in patients with significant humeral or glenoid bone defects or in those who underwent previous instability surgery. Appropriate assessment of the glenoid track is necessary as "off track" lesions typically require treatments beyond arthroscopic labral repair alone. In those with significant humeral or glenoid sided bone loss, the authors recommend three-dimensional computed tomography in addition to magnetic resonance imaging for accurate evaluation. The Glenoid Track Instability Management Score is a useful guide to help direct treatment by using the glenoid track as well as other known risk factors for recurrence. In circumstances with significant glenoid bone loss, typically over 20%, a coracoid transfer such as the Latarjet is recommended. In patients that previously failed a coracoid transfer, the authors recommend a distal tibia allograft; however, distal clavicle and iliac crest autograft have also been reported to have high success rates. In those with large Hill-Sachs lesions, remplissage or bone grafting are recommended. An estimation of the postoperative glenoid track after glenoid bone augmentation is required for appropriate Hill-Sachs lesion treatment. The authors typically recommend against revision instability surgical treatment with arthroscopic repair alone.
近年来，复发性肩关节前不稳定的治疗引起了广泛关注，包括对肩胛盂和肱骨侧骨丢失的评估。对于存在明显肱骨或肩胛盂骨缺损的患者，或曾接受过不稳定手术的患者，决策更为复杂。需要对肩胛盂轨迹进行适当评估，因为“脱位”病变通常需要除关节镜盂唇修复外的治疗。对于存在明显肱骨或肩胛盂侧骨丢失的患者，作者建议除磁共振成像外，还应进行三维计算机断层扫描，以进行准确评估。肩胛盂轨迹不稳定管理评分是一种有用的指南，可通过使用肩胛盂轨迹以及其他已知的复发危险因素来指导治疗。在肩胛盂骨丢失明显的情况下，通常超过 20%，建议行喙突转移术，如 Latarjet 术。对于先前喙突转移术失败的患者，作者建议采用胫骨远端同种异体移植物；然而，也有报道称，锁骨远端和髂嵴自体移植物的成功率也很高。对于大的 Hill-Sachs 病变，建议行填充或植骨。需要对肩胛盂骨增强术后的肩胛盂轨迹进行估计，以进行适当的 Hill-Sachs 病变治疗。作者通常不建议单独行关节镜修复的复发性不稳定手术治疗。
