Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rua Mário Ribeiro 117/2° andar, GáveaRio de Janeiro, RJ, 22430-160, Brazil.
Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil.
Eur J Orthop Surg Traumatol. 2023 Apr;33(3):571-580. doi: 10.1007/s00590-022-03389-7. Epub 2022 Sep 12.
The standard treatment of anterior glenaoid fractures carrying > 20% of the glenoid fossa is open reduction and internal fixation (ORIF). In the herein study, we report our outcomes in a retrospective cohort of anterior and anteroinferior glenoid rim fractures using an accelerated postoperative rehabilitation protocol. A secondary aim is to describe the surgical steps for ORIF of anterior and anteroinferior glenoid rim fractures using the anterior axillary approach, describing the tricks, pearls, and pitfalls of this surgical technique.
A retrospective cohort of skeletally mature patients treated for an anterior glenoid rim fracture carrying > 20% of the glenoid fossa during a 10-year period were operated on using a vertical axillary incision, osteosynthesis with 2.0-mm cortical screws, and labral repair with small diameter metallic anchors and non-absorbable sutures. Rehabilitation began on the first postoperative day, including passive external rotation exercises and active-assisted flexion, adduction, and abduction exercises as tolerated. The exercises are performed with the patient sitting or lying down. Phase 1 is continued for 6-10 weeks until the patient regains painless, normal, or near-normal ROM. Usually by 10 weeks, the fracture and labrum are healed, so phase 2 rehabilitation begins with strengthening and ROM exercises. Radiologic and clinical outcomes, including active range of motion (ROM), glenohumeral stability, and visual analogue scale (VAS) were measured.
About 33 patients (35 fractures) had complete medical records and pre- and post-operative imaging exams available for further analysis regarding the surgical protocol, with a mean of 4.8 years. The mean DASH questionnaire was 3.75 ± 9.0 and the mean CM score was 62.5 ± 0.1. Active flexion and internal rotation were recovered in all patients, while external rotation presented an average loss of 8° (p = 0.12) and abduction of 5° (p = 0.33). The mean VAS was 1.1 ± 0.8. No patient reported major or disabling symptoms, or great difficulty or inability to perform daily or recreational activities. No patient presented residual instability of the glenohumeral joint.
In this retrospective cohort, ORIF using a vertical axillary incision, osteosynthesis with 2.0-mm screws, and labral repair with small diameter metallic anchors and non-absorbable sutures was a safe approach, with a minimal risk of complications and residual instability. The accelerated postoperative rehabilitation protocol, allowing immediate passive external rotation of the operated shoulder, resulted in a non-significant loss of ROM compared to the contralateral side. Therefore, we recommend this management strategy for anterior glenoid rim fractures in patients with unstable shoulder joint after traumatic glenohumeral dislocation.
Therapeutic Study (Surgical technique and Retrospective cohort).
对于前盂肱关节窝超过 20%的前盂唇骨折，标准治疗方法是切开复位内固定（ORIF）。在此研究中，我们报告了采用加速术后康复方案治疗前盂唇和前下盂唇缘骨折的回顾性队列的结果。次要目的是描述采用前腋入路治疗前盂唇和前下盂唇缘骨折的 ORIF 手术步骤，描述该手术技术的技巧、要点和陷阱。
对 10 年内接受治疗的前盂唇缘骨折（前盂唇窝超过 20%）的骨骼成熟患者进行回顾性队列研究，采用垂直腋入路进行手术，使用 2.0 毫米皮质螺钉进行骨固定，并使用小直径金属锚钉和不可吸收缝线进行盂唇修复。术后第一天开始康复，包括被动外旋运动和主动辅助的前屈、内收和外展运动，根据耐受情况进行。运动在患者坐或躺下时进行。第 1 阶段持续 6-10 周，直到患者恢复无痛、正常或接近正常的活动范围。通常在 10 周时，骨折和盂唇已经愈合，因此开始第 2 阶段的康复，包括强化和活动范围锻炼。测量放射学和临床结果，包括主动活动范围（ROM）、盂肱关节稳定性和视觉模拟量表（VAS）。
约 33 名患者（35 处骨折）有完整的病历和术前及术后影像学检查可供进一步分析手术方案，平均随访 4.8 年。平均 DASH 问卷评分为 3.75±9.0，CM 评分为 62.5±0.1。所有患者均恢复了主动屈曲和内旋，而外旋平均损失 8°（p=0.12），外展平均损失 5°（p=0.33）。平均 VAS 为 1.1±0.8。无患者报告有重大或致残症状，或有较大困难或无法进行日常或娱乐活动。无患者出现盂肱关节残余不稳定。
在本回顾性队列中，采用垂直腋入路、使用 2.0 毫米螺钉进行骨固定以及使用小直径金属锚钉和不可吸收缝线进行盂唇修复的 ORIF 是一种安全的方法，并发症和残余不稳定的风险极小。加速的术后康复方案允许立即被动外旋手术侧肩部，与对侧相比，ROM 无显著损失。因此，我们建议对创伤性盂肱关节脱位后不稳定的肩部患者采用这种前盂唇缘骨折的管理策略。
证据水平 IV：治疗性研究（手术技术和回顾性队列）。
