Villefort Christina, Stern Christoph, Gerber Christian, Wyss Sabine, Ernstbrunner Lukas, Wieser Karl
Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
JSES Int. 2022 Dec 21;7(2):211-217. doi: 10.1016/j.jseint.2022.12.008. eCollection 2023 Mar.
There is little consensus on the best treatment after failed conservative management of recurrent posterior shoulder instability. The purpose of this study was to analyze our clinical and radiological mid-term to long-term results of an open, posterior bone block procedure for the treatment of recurrent posterior shoulder instability.
From 1999 to 2015, 14 patients were included in the study and available for clinical and radiographic follow-up (FU). FU included a standardized physical examination, assessment of the Constant-Murley-Score, subjective shoulder value, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability Index. Conventional radiographs and a computed tomography (CT)-scan were performed preoperatively and at latest FU. Glenohumeral arthropathy was classified as per Samilson and Prieto. The CT scans were used to evaluate the structure of the graft (resorption, union), graft positioning, glenoid version, centering of the humeral head, and glenoid erosion and morphology.
The median age at the time of surgery was 26 years (range 16-41 years) and the median FU period was 9 years (range 4-20 years). The rate of reported dynamic postoperative subluxation and instability was 46% (n = 6) and the rate of dynamic posterior instability during clinical testing at FU was 31% (n = 4). The tested instability rate in the traumatic group was 14% (n = 1) compared to the atraumatic group with 50% (n = 3) during clinical FU. The mean Constant-Murley-Score increased from preoperatively (77 ± 11 points) to postoperatively (83 ± 14 points, = .158). The last FU showed an American Shoulder and Elbow Surgeons score of 85 ± 12; the Western Ontario Shoulder Instability Index score was 715 ± 475 points. The mean subjective shoulder value increased from 58% ± 19 preoperatively to 73% ± 17 at final FU ( = .005). Degenerative changes increased by at least one grade in 67% of the patients. Mean preoperative glenoid retroversion (CT) was 7.5° ± 6°. The position of the graft was optimal in 86% (n = 12). In 62% of the cases, a major resorption of the graft (Zhu grade II) was observed.
The rate of tested recurrent instability at last FU was as high as 31% (n = 4, atraumatic [n = 3] vs. traumatic [n = 1]) after a median FU of 9 years. Given the moderate improvement of clinical outcome scores, shoulder stability and the increase of degenerative joint changes by at least one grade (Samilson/Prieto) in 67% of patients, a posterior bone block procedure is not a uniformly satisfying treatment option for recurrent posterior shoulder subluxation, especially in cases of atraumatic posterior instability.
对于复发性后肩部不稳定保守治疗失败后的最佳治疗方法，目前尚无定论。本研究的目的是分析我们采用开放性后路骨块手术治疗复发性后肩部不稳定的临床和影像学中期至长期结果。
1999年至2015年，14例患者纳入本研究并可进行临床和影像学随访（FU）。随访包括标准化体格检查、Constant-Murley评分、主观肩关节评分、美国肩肘外科医师评分以及西 Ontario 肩部不稳定指数评估。术前及最后一次随访时均拍摄了传统X线片及计算机断层扫描（CT）。根据Samilson和Prieto对盂肱关节病进行分类。CT扫描用于评估移植物的结构（吸收、愈合情况）、移植物位置、肩胛盂形态、肱骨头中心位置以及肩胛盂侵蚀情况和形态。
手术时的中位年龄为26岁（范围16 - 41岁），中位随访期为9年（范围4 - 20年）。术后报告的动态半脱位和不稳定发生率为46%（n = 6），随访时临床检查中动态后向不稳定发生率为31%（n = 4）。创伤组临床随访期间测试的不稳定发生率为14%（n = 1），而非创伤组为50%（n = 3）。Constant-Murley评分均值从术前的（77 ± 11分）提高到术后的（83 ± 14分，P = 0.158）。最后一次随访时美国肩肘外科医师评分为85 ± 12；西 Ontario 肩部不稳定指数评分为715 ± 475分。主观肩关节评分均值从术前的58% ± 19提高到最终随访时的73% ± 17（P = 0.005）。67%的患者退变改变至少增加了一级。术前肩胛盂平均后倾（CT）为7.5° ± 6°。86%（n = 12）的移植物位置最佳。62%的病例观察到移植物有明显吸收（朱Ⅱ级）。
中位随访9年后，最后一次随访时测试的复发性不稳定发生率高达31%（n = 4，非创伤性[n = 3]对比创伤性[n = 1]）。鉴于临床结果评分改善一般、肩部稳定性情况以及67%的患者退变关节改变至少增加一级（Samilson/Prieto），后路骨块手术并非复发性后肩部半脱位的一致令人满意的治疗选择，尤其是在非创伤性后向不稳定的病例中。
