Gleyze P, Habermeyer P
Service Chirurgie Orthopédique, Clinique du Diaconat, Colmar.
Rev Chir Orthop Reparatrice Appar Mot. 1996;82(4):288-98.
The authors present a prospective and mono-operator study of 91 gleno-humeral arthroscopies for post-traumatic antero-inferior instability of the shoulder. The aim of the study was to obtain a dynamic understanding of the relationship between the anatomic lesions to allow the integration of all the described lesions into literature and to produce a natural history of lesions in antero-inferior shoulder instability.
91 endoscopies for post-traumatic instability of the shoulder were performed by the same surgeon. Revision chart comprised 67 purely descriptive items. For the purpose of the study, the patients were divided into 4 groups of dislocation (first dislocation: 9 cases, 1 to 2 recurrences: 12 cases; 3 to 5 recurrences: 23 cases; more than 5 recurrences: 32 cases) and 1 group of subluxation (15 cases).
The statistical evaluation of each individual data item gathered value allowed the selection of the most significant lesions and to regroup them into "lesions families", relations to the same physiopathological mechanism (traumatic or degenerative). The correlation between each lesion in terms of evolution, age and number of recurrences was studied.
The first and most constant lesion is the periosteal avulsion of the antero-inferior labrum ("single lesion": healing potential of +/- 30 per cent, in ectopic position in +/- 90 per cent). With recurrences, the avulsion of the gleno-humeral ligament adds this "single lesion" ("double lesion". Healing potential of +/- 50 per cent, in ectopic position in +/- 90 per cent). Continuing the recurrence, we also noted a degenerative and plastic deformation under the level of the glenoid rim ("triple lesion": infra-glenoid degenerescence) then over the glenoid rim ("quadruple lesion": supra glenoid degenerescence). The age factor and duration of evolution were not negligible and one must associate the "labro-ligament complex" studies with the avulsion lesions of the long head of the biceps (SLAP lesions) in which the frequency varies from 15 per cent to 30 per cent and which was consistently present in patients above 35 years of age.
The authors believe that recurrences give rise to a progressive worsening of the lesions by the sum of the separate lesions. They propose a physiopathological classification in 4 stages where each lesions has its own healing potential, which explains the apparent large variation in endoscopic aspects of antero-inferior shoulder instability.
This classification should permit a precise therapeutic strategy in post-traumatic anterior instability, according to the most recent techniques of endoscopic reattachment of the labro-ligament complex.
作者开展了一项前瞻性单术者研究，对91例因创伤后肩关节前下不稳而行盂肱关节镜检查的病例进行研究。本研究的目的是动态了解解剖损伤之间的关系，以便将所有描述的损伤整合到文献中，并得出肩关节前下不稳损伤的自然病程。
同一位外科医生对91例创伤后肩关节不稳患者进行了关节镜检查。修订后的图表包含67个纯描述性项目。为进行本研究，将患者分为4组脱位病例（首次脱位：9例；1至2次复发：12例；3至5次复发：23例；超过5次复发：32例）和1组半脱位病例（15例）。
对收集到的每个单独数据项进行统计评估，从而选出最显著的损伤，并将它们重新归类为“损伤家族”，即与相同生理病理机制（创伤性或退行性）相关的损伤。研究了各损伤在进展、年龄和复发次数方面的相关性。
首先也是最常见的损伤是前下盂唇的骨膜撕脱（“单一损伤”：愈合潜力约为30%，异位发生率约为90%）。随着复发次数增加，盂肱韧带撕脱叠加了这种“单一损伤”（“双重损伤”。愈合潜力约为50%，异位发生率约为90%）。继续复发时，我们还注意到在关节盂边缘水平以下出现退行性和塑性变形（“三重损伤”：关节盂下退变），然后在关节盂边缘上方出现（“四重损伤”：关节盂上退变）。年龄因素和病程不可忽视，而且必须将“盂唇 - 韧带复合体”研究与肱二头肌长头撕脱损伤（SLAP损伤）联系起来，其发生率在15%至30%之间，且在35岁以上患者中始终存在。
作者认为，复发会因单独损伤的累加导致损伤逐渐加重。他们提出了一个分为4个阶段的生理病理分类，其中每个损伤都有其自身的愈合潜力，这解释了肩关节前下不稳在内镜下表现出的明显巨大差异。
根据盂唇 - 韧带复合体内镜下重新附着的最新技术，这种分类应能为创伤后前向不稳制定精确的治疗策略。
