Hoyt Benjamin W, Tisherman Robert T, Popchak Adam J, Dickens Jonathan F
USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, U.S.A.
Department of Orthopaedic Surgery, Captain James A Lovell Federal Health Care Center, North Chicago, IL, U.S.A.
Curr Rev Musculoskelet Med. 2024 Nov;17(11):465-475. doi: 10.1007/s12178-024-09921-y. Epub 2024 Aug 19.
The management options for anterior shoulder instability with minimal bone loss or with critical bone loss are well established. However, there is less clear evidence to guide management for patients with subcritical bone loss, the spectrum of pathology where soft tissue repair alone is prone to higher rates of failures. In this range of bone loss, likely around 13.5% to 20%, the goal of surgery is to restore function and stability while limiting morbidity. As with many procedures in the shoulder, this decision should be tailored to patient anatomy, functional goals, and risk factors. This article provides a review of our current understanding of subcritical bone loss and treatment strategies as well as innovations in management.
While surgeons have largely understood that restoration of anatomy is important to optimize outcomes after stabilization surgery, there is increasing evidence that reconstructing bony anatomy and addressing both osseous and soft tissue structures yields better results than either alone. Even in the setting of subcritical bone loss, there is likely a benefit to combined osseous augmentation with soft tissue management. Additionally, there is new evidence to support management of even on-track humeral lesions when the distance to dislocation is sufficiently small, particularly for athletes. Surgeons must balance bony and soft tissue restoration to achieve optimal outcomes for anterior instability with subcritical bone loss. There are still significant limitations in the literature and several emerging techniques for management will require further study to prove their long-term efficacy. Beyond surgery, there should be a focus on a collaborative treatment strategy with the surgeon, patient, and therapists to achieve high-level function and minimize recurrence.
对于骨量丢失极少或存在严重骨量丢失的前肩不稳，其治疗选择已得到充分确立。然而，对于骨量丢失处于临界以下的患者，目前尚无明确的证据来指导治疗，在此病理范围内，单纯软组织修复的失败率往往较高。在这个骨量丢失范围内，可能约为13.5%至20%，手术的目标是在限制并发症的同时恢复功能和稳定性。与肩部的许多手术一样，这一决策应根据患者的解剖结构、功能目标和风险因素进行个体化制定。本文综述了我们目前对临界以下骨量丢失的认识、治疗策略以及管理方面的创新。
虽然外科医生大多已认识到解剖结构的恢复对于稳定手术后优化疗效很重要，但越来越多的证据表明，重建骨解剖结构并同时处理骨与软组织结构比单独处理任何一方能产生更好的结果。即使在临界以下骨量丢失的情况下，联合骨增强与软组织处理可能也有益处。此外，有新证据支持当肱骨头病变距脱位距离足够小时，即使病变处于进展期也可进行处理，尤其是对于运动员。外科医生必须在骨与软组织修复之间取得平衡，以实现临界以下骨量丢失的前肩不稳的最佳治疗效果。文献中仍存在显著局限性，几种新兴的治疗技术需要进一步研究以证明其长期疗效。除手术外，应注重外科医生、患者和治疗师之间的协作治疗策略，以实现高水平功能并减少复发。
