评估Latarjet手术后移位喙突骨块吸收情况的CT分型系统的一致性研究

朱以明 姜春岩



评估Latarjet手术后移位喙突骨块吸收情况的CT分型系统的一致性研究

朱以明 姜春岩

目的 提出一种基于CT的分型系统来评估Latarjet手术后移位喙突骨块的吸收程度。应用该分型系统研究Latarjet手术后患者最终随访时行CT检查以了解喙突骨吸收现象的发生率及严重程度；并了解应用该分型系统时检查者之间的一致性以及检查者自身的前后一致性。方法 选取2009年1月至2012年1月期间，63例接受切开Latarjet手术治疗的患者。所有患者术前诊断均为复发性肩关节前脱位。所有患者在术后12个月时均行CT检查。4位与手术治疗无关的独立骨科医师对患者术后12个月随访时CT影像进行阅片，并采用我们提出的分型系统对移位喙突骨块吸收程度进行了评估。在初次评估后3个月，4位检查者对上述影像进行了再次评估。以ICCs系数评价各位检查者之间检查结果的一致性，以及每位检查者前后两次检查结果的一致性。结果 在术后12个月时，移位喙突骨吸收的发生率为90.5%。其中骨吸收0级患者有6例，Ⅰ级患者26例，Ⅱ级患者25例，Ⅲ级患者6例。结论 切开Latarjet手术后12个月时，移位喙突骨块吸收的发生率很高。该分型系统有优秀的检查者之间一致性以及检查者自身前后一致性。

复发性肩关节前脱位；Latarjet手术；骨吸收

1954年法国医师Latarjet首先描述了采用喙突截骨移位的方法治疗复发性肩关节前脱位。他所描述的手术技术的要点包括：(1)喙突截骨；(2)将带有联合腱的喙突骨块穿过肩胛下肌腱后用螺钉固定于肩盂前缘。Patte与Walch在1980年对Latarjet技术做了一些改良，包括使用2枚螺钉固定喙突骨块以及将关节囊和喙突上的喙肩韧带残端缝合以重建起止点。他们认为Latarjet手术稳定肩关节作用来源于3方面：(1)移位的喙突骨块可增加肩盂的宽度；(2)肩关节外展、外旋时固定在肩盂前下缘的联合腱可起到动力阻挡的作用；(3)将关节囊缝合至喙肩韧带残端上可重建前关节囊的止点从而起到稳定作用。时至今日，在复发性肩关节前脱位的治疗中，尤其是针对那些合并明显肩盂前缘骨缺损的患者，这一术式仍是最常用的手术方法之一。另一方面，随着对该手术的研究的不断深入，人们发现该术式的一些常见合并症明显影响手术的疗效。其中，移位喙突骨块吸收的现象曾被多次报道。一些研究者认为严重的喙突骨块吸收可能导致患者出现复发脱位或肩关节疼痛等症状。但是，目前对手术后喙突骨块吸收的研究仍十分有限。由于缺乏统一的研究方法、分型系统对其进行标准化的描述，因而不同作者采用不同的研究方法所得的喙突骨吸收的发生率亦千差万别，更难以进一步深入探究这一现象的成因和对临床疗效的影响。

本研究的目的在于提出一种专用于Latarjet手术后移植喙突骨块吸收研究的CT扫描方法及分型系统。我们希望在这类患者中应用这一方法和分型系统，以调查不同程度的喙突骨吸收的发生率；并通过检查者之间比较和检查者个人前后可重复性分析来评估该方法的一致性。

对 象 与 方 法

一、入选和排除标准

入选标准：(1)患者诊断为创伤后复发性肩关节前脱位；(2)术前均行三维CT检查，CT enface view显示肩盂存在明显骨缺损；(3)手术方式为切开Latarjet术；(4)患者同意参加相关临床研究并签署知情同意书；(5)术后临床随访超过2年，有完整的影像学评估资料(术后即刻CT与术后12个月CT)。排除标准：(1)存在肩关节多方向不稳定；(2)既往患侧肩关节有手术史；(3)术后12个月CT显示移位喙突不愈合或内固定失效，因而难以评估喙突骨吸收情况。

二、术前评估

入选患者在术前均提供了包括初次脱位年龄以及脱位次数等信息在内的详细病史。检查者对患者进行详细的肩关节体格检查，并填写ASES评分(American shoulder & elbow surgeons′ score)、Constant-Murley评分以及Rowe评分表。术前需行患侧肩关节三维CT检查。在肩关节三维重建CT上，依照Sugaya所描述的方法，将肱骨头影像去除后，使肩盂正对检查者，形成所谓enface view。在enface view上评估肩盂骨缺损的大小，如超过完整肩盂的25%，则选择进行切开Latarjet术。

三、患者体位与手术入路

全部病例均在全身麻醉下接受手术。患者置于沙滩椅位，患侧肩关节置于手术台边缘之外且消毒铺单后患侧上肢仍能向各个方向自由运动。手术切口从喙突尖开始直行向下，长约5 cm。切开后由三角肌-胸大肌间隙进入。注意保护头静脉完整并将其拉向外侧。在喙突上置入一把Hohmann骨撬以充分显露喙突。

1.喙突准备：使肩关节处于外展、外旋位，显露喙肩韧带。在喙突侧保留约1 cm长喙肩韧带止点后切断喙肩韧带。切断喙肩韧带喙突侧止点深方的喙肱韧带止点。使肩关节处于内收、内旋位以显露喙突内侧。将喙突内侧的胸小肌止点切断。但避免沿联合腱内侧向下松解，以防损伤肌皮神经并影响喙突的血供。通过上述准备，应可充分显露喙突的内侧、外侧及下面。在喙突的弓背转弯、紧贴喙锁韧带止点处，用弯骨刀自上向下截断喙突。以微型摆锯将截断的喙突的下表面处理平整并去除骨皮质以显露深方松质骨床。垂直于喙突上表面骨皮质，使用2.7 mm电钻，在喙突上钻两个骨孔。两骨孔间应留有足够间隙。将喙突骨块塞在胸大肌深方后进行下一步操作。

2.显露肩盂：将患肢置于体侧外旋位，用自动拉钩拉开三角肌-胸大肌间隙，充分显露肩胛下肌。在肩胛下肌腱的中下1/3处水平劈开肩胛下肌腱。首先用组织剪在肩胛下肌的中下1/3处沿肌纤维方向水平劈开肩胛下肌。然后将组织剪沿垂直肌纤维方向打开，从而分开肌纤维。从组织剪分开处向内侧在肩胛下肌和肩胛骨间塞入纱布，以使肩胛下肌和深方关节囊和肩胛骨间有足够间隙以增加显露。在劈开的肩胛下肌裂隙内侧，肩胛骨体前面放置一把Batman骨撬，挡住内侧软组织及重要的血管神经结构。紧贴肩盂在其下插入一把Hohmann骨撬，将下1/3肩胛下肌纤维挡向下方。在肩胛骨体前面尽可能靠上的位置钻入1枚4 mm的Steinman针，并将其扳向上方从而将上2/3的肩胛下肌纤维挡向上方。这样就可以将盂肱关节前方充分显露了。在盂肱关节间隙处，纵行切开约2 cm长的前关节囊，将Fukuda撬插入肩盂和肱骨头间，扳向外侧从而将肱骨头挡向外后方，充分显露肩盂。

3.肩盂准备和喙突固定：在紧贴肩盂前缘的肩胛骨前面做骨床准备，其范围为肩盂前缘大约5点钟(右肩)位置(左肩则为7点钟位置)开始向近端大约2 cm长的区域。切除这一区域内的盂唇及骨膜组织，以骨刀将表面骨皮质打掉露出渗血的松质骨床面。在大约5点钟位置的肩胛骨前面以2.7 mm骨钻钻孔作为固定喙突的下方螺钉孔。该骨孔应距离肩盂关节面边缘足够的距离以使喙突骨块固定后其外缘不至于高于肩盂关节面。钻孔时钻头方向应平行肩盂关节面，直至钻透肩胛骨后侧骨皮质。

在喙突上预钻的两个骨块中偏下方的一个内拧入1枚4.0 mm半螺纹空心钉，长度大约30 mm。将该螺钉拧入肩胛骨前面预钻的骨孔，保证喙突长轴处于平行于肩盂关节面的位置的前提下，拧紧该螺钉。固定后，喙突骨块的外缘应与肩盂关节面平齐，如果较关节面高度略低1～2 mm亦可以接受。用2.7 mm骨钻通过喙突骨块上预钻的偏上方的骨孔在肩胛骨上钻孔，直至钻透肩胛骨的后侧皮质。用测深尺测量后，拧入另一枚4.0 mm半螺纹空心钉。如其测量长度与下方已置入螺钉差距明显，则可在拧紧上方螺钉后取出下方螺钉，再准确测量后拧入合适长度的螺钉。保持肩关节位于体侧极度外旋位的前提下，将纵行切开的前关节囊与喙突上保留的喙肩韧带起点缝合，以重建前关节囊的止点。伤口内留置引流管后逐层缝合。

四、康复计划

术后肩关节应使用颈腕吊带制动3周。此后在理疗师指导下开始患肢被动活动练习。术后6周时可摘掉吊带以患肢做日常生活，但6周内避免抗阻屈肘肌力练习。术后3个月开始进行终末牵拉练习。术后半年可恢复进行接触性的或过头的体育项目。

图1 喙突骨吸收0级，喙突骨块无吸收，螺钉帽均深埋于喙突骨块内 图2 喙突骨吸收Ⅰ级，喙突骨块稍有吸收，仅有螺钉的钉帽部分露于喙突骨块外，螺钉杆部完全埋于喙突骨块内 图3 喙突骨吸收Ⅱ级，喙突骨块明显吸收，螺钉帽与部分螺钉杆裸露于喙突骨块之外，但肩盂前方仍有喙突骨块残留 图4 喙突骨吸收Ⅲ级，喙突骨块完全吸收，肩盂前面无骨块残留，仅有完全暴露的螺钉杆部及螺钉尾帽

五、术后随访计划

预约患者在术后的3周、6周、3个月、6个月、12个月时回医院随访。此后每年随访1次。术后早期随访时，主要由临床医师检查患者肩关节功能康复的情况并指导功能锻炼。术后12个月时需行详细体格检查，征得患者的同意后行三维CT检查以明确肩盂前缘折块的位置和愈合情况。

六、影像学评估方法

术前行患侧肩关节三维CT检查，以评估肩盂骨缺损的情况。术后即刻行患侧肩关节三维CT检查，以评估喙突骨块的位置及固定情况。术后12个月随访时再次行肩关节三维CT检查，在横断位上评估喙突愈合情况及喙突骨吸收情况。以我们所提出的针对喙突骨吸收的专用分级系统对吸收情况进行分级。

七、喙突骨块术后骨吸收分型

0级：喙突骨块无吸收，螺钉帽均深埋于喙突骨块内(图1)；Ⅰ级：喙突骨块稍有吸收，仅有螺钉的钉帽部分露于喙突骨块外，螺钉杆部完全埋于喙突骨块内(图2)；Ⅱ级：喙突骨块明显吸收，螺钉帽与部分螺钉杆裸露于喙突骨块之外，但肩盂前方仍有喙突骨块残留(图3)；Ⅲ级：喙突骨块完全吸收，肩盂前面无骨块残留，仅有完全暴露的螺钉杆部及螺钉尾帽(图4)。

本系统以喙突骨吸收后螺钉暴露情况作为分级标准。当进行分级时，检查者需分别依据2枚固定喙突的空心钉中的偏头侧钉和偏足侧钉的暴露情况分别对其周围喙突骨质吸收情况进行分级，并加以记录。然后以其中吸收较为严重，螺钉暴露更明显的结果作为喙突骨吸收的最终分级等级。

八、检查者及可靠性研究方法

4位独立检查者参与了本分级系统的可靠性研究。这些检查者均为完成了骨科及肩关节外科培训的临床骨科医师，从事肩关节外科平均6.5年(3～12年)。

在检查者培训阶段，将喙突骨吸收的专用分级系统说明书分发给4位检查者，使其熟悉该分级系统的应用方法。

所有患者的CT图像收集齐后，隐去患者信息，发给4位检查者，由其依据喙突骨吸收的专用分级系统对喙突骨块的骨吸收情况加以分级。每位检查者浏览CT图像时，患者均以随机顺序排列。1个月后，由4位检查者以相同方法再次对患者喙突骨吸收情况进行分级。最终患者喙突骨吸收情况以评估者中年资最高的医师的分级结果为准。

此外，我们还对比了年资最高医师进行分级工作时所记录的偏头侧空心钉周围骨块吸收分级以及偏足侧空心钉周围骨块吸收的分级结果，从而希望发现哪一部位的喙突骨块的吸收程度更为严重。

九、统计学方法

本研究采用SPSS 16.0软件进行统计学分析。以ICCs系数(intraclass correlation coefficients)来评价检查者之间评价一致性以及每位检查者前后两次检查结果的可重复性。如ICCs系数>0.75，则认为评价方法的一致性优秀；如ICCs系数在0.40～0.75则认为一致性中等；如ICCs系数<0.40则一致性差。

结 果

从2009年1月至2012年1月期间，共有81例复发性肩关节前脱位患者接受切开Latarjet手术治疗。其中65例在术前、术后即刻及术后12个月时均行CT检查。在这65例患者中有1例因术后12个月CT显示移位喙突骨块未骨性愈合，另1例出现内固定失效而被排除，剩余63例入选本次研究。

一、喙突骨吸收

术后12个月CT显示喙突骨吸收的发生率较高，63例患者的骨吸收分级情况如下，0级：6例(9.5%)；Ⅰ级：26例(41.3%)；Ⅱ级：25例(39.7%)；Ⅲ级：6例(9.5%)。由此可见，在术后12个月时，喙突骨吸收的发生率为90.5%(57/63)。如仔细区分2枚空心钉周围骨质吸收情况的差别时我们发现，63例病例中34例2枚螺钉周围骨质吸收分级相同，另有29例病例偏头侧螺钉周围骨质吸收情况较偏足侧螺钉更加严重。

二、分级系统的可靠性

统计分析显示，本分级系统的检查者之间一致性(ICCs,95% confidence Interval,0.856)和检查者个人前后可重复性(ICCs,95% confidence Interval,0.946)均十分出色。

讨 论

复发性肩关节前脱位是临床常见疾患。多数情况下，采用关节镜下盂肱下韧带前盂唇复合体修复术(关节镜下Bankart修复术)进行治疗能取得良好的疗效[1-11]。但是，对于那些脱位次数多、时间长的患者，往往合并明显肩盂骨质缺损。这种情况下，镜下Bankart修复术后再脱位率很高[12]。在合并明显骨缺损或前关节囊质量很差时Latarjet手术是治疗复发性肩关节前脱位的有效方法，从目前的文献报道来看，其术后复发率在0%～8%[13-18]。因此在治疗这类难治性的复发性肩关节前脱位的患者时，Latarjet手术仍是最为广泛应用的术式。

但是从我们的临床随访看，虽然Latarjet手术后肩关节复发脱位率很低，但随访时的CT往往显示移位的喙突骨块存在不同程度的骨吸收的现象。检索文献我们发现，这一现象也被不同作者多次报道。但围绕这一问题，目前仍有许多争议。

首先，对术后喙突骨吸收的发生率，文献报道的结果大不相同。Allain等对56例患者(58个肩关节)进行了平均14.3年的随访，所有患者在随访时均拍摄了X光片，有15例患者进行了CT检查[13]。作者报道10例肩关节出现移位喙突骨块的部分吸收，占所有病例的17%。Di Giacomo 等对Latarjet手术后移位喙突骨块吸收的现象做了详尽的研究。他们对16例病例进行了两次术后CT检查[19]。第一次在术后3 d，另外一次在术后平均17.5个月随访时。他们发现所有的移位喙突骨块均有不同程度的骨吸收。最严重的骨吸收发生在喙突的近端、内侧、浅部。此处有平均93.4%的骨量被吸收。喙突整体骨量被平均吸收59.5%。但是许多其他的有关Latarjet手术后的随访研究均未提到喙突骨吸收的情况[14-16,20-21]。究其原因，我们发现所有没有提到喙突骨吸收情况的随访研究，其术后影像学评估方法仍为普通X线片，均未采用CT检查。由此可见，X线片不能准确的评估喙突骨吸收的情况，因此我们选择CT检查作为评估这一现象的研究方法。从我们的研究结果看，术后90.5%的患者存在不同程度的骨吸收，81%的患者存在Ⅰ级或Ⅱ级的骨吸收，9.5%的患者的喙突骨块完全吸收。

其次，对于术后喙突骨吸收一旦发生对临床疗效可能造成的影响也有不同的意见。Allain等学者的随访研究显示，移位喙突的骨吸收现象在术后平均14.3年随访时并未对患者的肩关节功能和稳定性造成明显的影响，但也认为由于随访中发现喙突骨吸收的病例较少，因此难以对临床疗效的影响作出明确的判断[13]。Di Giacomo 等所报道的病例系列中，在术后短期随访时，明显的喙突骨吸收并未对患者的肩关节稳定性、关节活动度以及术后肩关节疼痛情况造成明显影响[19]。但是另一方面，Cassagnaud等的研究则认为，严重的喙突骨吸收会使患者出现肩关节疼痛症状并影响其肩关节功能[22]。Lafosse等报道了62例病例行Latarjet手术后的随访结果，其中3例出现了明显的移位喙突的骨吸收，导致螺钉尾帽明显突出，最终需手术取出螺钉[23]。Lunn等报道了46例行Latarjet手术后复发脱位的病例，其中13例移位的喙突骨块有明显的吸收，作者分析这是导致出现肩关节复发脱位的重要的风险因素[24]。分析这些既往的文献报道，我们认为喙突骨块吸收的现象有可能导致患者术后出现复发脱位和关节疼痛等症状。之所以在文献中有不同的意见，有可能与骨块吸收的程度不同有关，只有那些严重的骨吸收才会使患者出现上述症状。这就使我们想到，单纯描述是否出现术后喙突骨吸收并不足以阐明其对临床疗效的影响，有必要提出一种专用的分型系统，从而不仅阐明是否出现骨吸收而且说明其吸收的程度。

检索现有的文献，我们发现目前尚无这样的分型系统。Di Giacomo等对术后喙突骨吸收的现象应用CT检查做了详细的研究。他们将喙突骨块依其部位分成8个部分，分别描述各个部分在术后吸收的情况。这一方法虽然可精确描述术后骨吸收的程度和位置，但过于复杂，难以在临床上推广应用。我们所提出的分型方法通过描述固定螺钉暴露的情况来决定骨吸收的程度，应用起来比较简单，有很好的检查者之间一致性和检查者个人前后可重复性，由此可见其临床应用的可靠性较高。

如仔细区分不同部位喙突骨吸收的情况我们可以看到，在大多数患者中，偏头侧喙突骨质吸收更为显著，这一结果与Di Giacomo等既往的报道一致。我们推测这可能是由于该部分的喙突骨质与联合腱距离较远，更难以得到来自联合腱及其周围组织的血液供应滋养。

下一步，我们希望将该分型系统应用于更大规模的患者随访中，从而探究何种程度的喙突骨吸收会明显影响患者的临床疗效；造成喙突骨吸收的可能的原因是什么，及其预防方法；关节镜下喙突移位和切开喙突移位在术后喙突骨吸收的发生率和严重程度方面是否有显著性区别。

本研究的优点在于首次提出了一种简单易用的分型方法来描述Latarjet术后移位喙突骨块吸收的严重程度，并证实该分型方法具有较高的可靠性。研究的不足之处在于由于病例数量有限，因此尚难以明确不同程度喙突骨吸收的临床意义。

结论：Latarjet手术后喙突骨吸收现象的发生率很高，且吸收的严重程度差异很大。应用我们所提出的分型方法，可有效的评估骨吸收的严重程度。

[1] Chen L,Xu Z,Peng J,et al.Effectiveness and safety of arthroscopic versus open Bankart repair for recurrent anterior shoulder dislocation:a meta-analysis of clinical trial data[J].Arch Orthop Trauma Surg,2015,135(4):529-538.

[2] Harris JD,Gupta AK,Mall NA,et al.Long-term outcomes after Bankart shoulder stabilization[J].Arthroscopy,2013,29(5):920-933.

[3] Sommaire C,Penz C,Clavert P,et al.Recurrence after arthroscopic Bankart repair:Is quantitative radiological analysis of bone loss of any predictive value?[J].Orthop Traumatol Surg Res,2012,98(5):514-519.

[4] Ahmed I,Ashton F,Robinson CM.Arthroscopic bankart repair and capsular shift for recurrent anterior shoulder instability:functional outcomes and identification of risk factors for recurrence[J].J Bone Joint Surg Am,2012,94(14):1308-1315.

[5] Castagna A,Markopoulos N,Conti M,et al.Arthroscopic bankart suture-anchor repair:radiological and clinical outcome at minimum 10 years of follow-up[J].Am J Sports Med,2010,38(10):2012-2016.

[6] Robinson CM,Jenkins PJ,White TO,et al.Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder.A randomized,double-blind trial[J].J Bone Joint Surg Am,2008,90(4):708-721.

[7] Tan CK,Guisasola I,Machani B,et al.Arthroscopic stabilization of the shoulder:a prospective randomized study of absorbable versus nonabsorbable suture anchors[J].Arthroscopy,2006,22(7):716-720.

[8] Ide J,Maeda S,Takagi K.Arthroscopic bankart repair using suture anchors in athletes:patient selection and postoperative sports activity[J].Am J Sports Med,2004,32(8):1899-1905.

[9] Kim SH,Ha KI,Cho YB,et al.Arthroscopic anterior stabilization of the shoulder:two to six-year follow-up[J].J Bone Joint Surg Am,2003,85-A(8):1511-1518.

[10] Burkhart SS,De Beer JF.Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs:significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion[J].Arthroscopy,2000,16(7):677-694.

[11] 李彦林，王国梁，何川，等.关节镜下治疗创伤复发性Bankart损伤疗效分析[J/CD].中华肩肘外科电子杂志，2014，2(4)：219-224.

[12] 张尧，何耀华.盂肱关节骨性缺损对肩关节前向稳定性的影响[J/CD].中华肩肘外科电子杂志，2014，2(1)：50-54.

[13] Allain J,Goutallier D,Glorion C.Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder[J].J Bone Joint Surg Am,1998,80(6):841-852.

[14] Burkhart SS,De Beer JF,Barth JR,et al.Results of modified Latarjet Reconstruction in patients with anteroinferior instability and significant bone loss[J].Arthroscopy,2007,23(10):1033-1041.

[15] Mizuno N,Denard PJ,Raiss P,et al.Long-term results of the Latarjet procedure for anterior instability of the shoulder[J].J Shoulder Elbow Surg,2014,23(11):1691-1699.

[16] Schmid SL,Farshad M,Catanzaro S,et al.The latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair:a retrospective case series of forty-nine consecutive patients[J].J Bone Joint Surg Am,2012,94(11):e75.

[17] 向明，杨国勇，陈杭，等.Latarjet两种术式治疗肩关节复发性前脱位伴重度骨缺损3～5年随访的比较研究[J/CD].中华肩肘外科电子杂志，2014，2(1)：33-40.

[18] 杨国勇，向明，陈杭，等.Latarjet 手术治疗癫痫患者复发性肩关节前脱位伴重度骨缺损的短期疗效分析[J/CD].中华肩肘外科电子杂志，2014，2(2)：91-96.

[19] Di Giacomo G,Costantini A,De Gasperis N,et al.Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability:a computed tomography scan study of twenty-six patients[J].J Shoulder Elbow Surg,2011,20(6):989-995.

[20] Hovelius L,Sandström B,Sundgren K,et al.One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years:study I--clinical results[J].J Shoulder Elbow Surg,2004,13(5):509-516.

[21] Shah AA,Butler RB,Romanowski J,et al.Short-term complications of the Latarjet procedure[J].J Bone Joint Surg Am,2012,94(6):495-501.

[22] Cassagnaud X,Maynou C,Mestdagh H.Clinical and computed tomography results of 106 Latarjet-Patte procedures at mean 7.5 year follow-up[J].Rev Chir Orthop Reparatrice Appar Mot,2003,89(8):683-692.

[23] Lafosse L,Boyle S.Arthroscopic Latarjet procedure [J].J Shoulder Elbow Surg,2010.19(2 Suppl):2-12.

[24] Lunn JV,Castellano-Rosa J,Walch G.Recurrent anterior dislocation after the Latarjet procedure:outcome after revision using a modified Eden-Hybinette operation[J].J Shoulder Elbow Surg,2008,17(5):744-750.

(本文编辑：李静)

朱以明，姜春岩.评估Latarjet手术后移位喙突骨块吸收情况的CT分型系统的一致性研究[J/CD].中华肩肘外科电子杂志,2015,3(1):35-42.

Study on the consistency of CT classification system evaluating coracoid fragment absorption after Latarjet operation

ZhuYiming,JiangChunyan.

DepartmentofSportsMedicine,BeijingJishuitanHospital,Beijing100035,China

JiangChunyan,Email:chunyanj@hotmail.com

Background In 1954,the method of coracoid osteotomy and transfer for the treatment of recurrent anterior shoulder instability was firstly described by French doctor Latarjet.Till today,Latarjet procedure is still one of the most commonly used procedures in dealing with anterior shoulder instability especially with significant bony defect at anterior glenoid rim.On the other hand,many studies are focused in this procedure and have found some complications that will influence outcome.Among the complications,the occurrence of coracoid absorption has been repeatedly reported.Due to the lack of unified research methods and classification system to standardize the occurrence rates of coracoid fragment absorption,it is difficult to further explore the causes of this phenomenon and the influence on clinical effect.The purpose of this study is to propose a CT scanning method and a classification system to evaluate the coracoid fragment absorption after Latarjet operation.We hope to adopt this method and the classification system for these patients to investigate the occurrence rates of different levels of coracoid fragment absorption,and evaluate its consistency by examining inter-observer and intra-observer reliability.Methods The inclusion and exclusion criteria of the study.The inclusion criteria of this study are as follows:(1)The patients are diagnosed as post traumatic recurrent anterior dislocation of shoulder;(2)Obvious bone defects of the glenoid are revealed in both preoperative three-dimensional CT and glenoid enface view;(3)The operative method is open Latarjet procedure;(4)The patients agree to participate in this clinical research and sign informed consents;(5)The postoperative clinical follow-up is over 2 years with complete imaging evaluation data (immediate CT examination after operation and CT scanning 1 year after surgery).The exclusion criteria of this study are as follows:(1)Multiple directional shoulder instability;(2)Previous operation history of the affected shoulder joint;(3)CT examination of 1 year after surgery reveals nonunion of coracoid fragment or failure of internal fixation,which is difficult to evaluate the absorption of coracoid fragment.The detailed medical history including the age of first time dislocation,numbers of dislocations,etc.was provided before surgery.The detailed physical examination of shoulder joint was conducted.ASES score (American Shoulder & Elbow Surgeons′ score),Constant-Murley score and Rowe score were evaluated for each patient.Preoperative 3D CT examination of the shoulder joint was needed for the affected shoulder,and the so-called enface view was reconstructed with the humeral head removed and the glenoid faced to the observer with the method described by Sugaya.The assessment of bone defect size on the glenoid was performed in enface view,and the open Latarjet operation would be selected if the size is over 25%.Operation method:Patient position and surgical incision.After successful general anesthesia,the patient was in the beach chair position with the affected shoulder placed out of the operating table border and mobilized freely in all directions.The incision was made downward from the coracoid tip and the coracoid was exposed through the deltoid and pectoralis major muscle interval.Coracoid process preparation:The shoulder was in abduction and external rotation to expose the coracoacromial ligament.The coracohumeral ligament,pectoralis minor and coracoacromial ligament were released from coracoid.The coracoid was osteotomized just anterior to coraco-clavicle ligament.Two holes were drilled on the coracoid with enough space between them and the coracoid was put deep behind the pectoralis major muscle for further operation.Exposure of the glenoid:The affected limb was in external rotation and the glenoid was fully exposed with the subscapularis tendon split and the anterior joint capsule opened vertically.Preparations of glenoid and fixation of coracoid:The bone bed of anterior glenoid rim and neck was prepared.One hole was drilled at 5 o′clock in front of scapula for fixation through the lower hole on the coracoid with a 4.0 mm half thread canulated screw.The fragment should not protrude over glenoid surface.The other hole on the scapula was drilled through the upper pre-drilled hole on the coracoid fragment and a 4.0mm half thread canulated screw was inserted.The coracoacromial ligament attached to coracoid fragment was sutured with anterior capsule with shoulder in extreme external rotation.The wound was closed in layers.Rehabilitation programme:The shoulder was immobilized with a sling for 3 weeks after operation.Passive exercises of the affected limb were carried out under the guidance of a physical therapist.Sling was removed 6 weeks later and the shoulder was allowed to take regular activities,but the resistant exercises of elbow flexion should be avoided within 6 weeks.Three months after operation,terminal stretch exercise was initiated.Contact sports or sports with hand above the head were resumed half a year after operation.Postoperative follow-up plan:Follow-ups were conducted in 3 weeks,6 weeks,3 months,6 months,and 1 year after operation.After that,the follow-ups were conducted 1 time a year which mainly composed of the assessment of functional rehabilitation and the guidance of exercises by clinicians.Detailed physical examination was carried out 1 year after operation,and the 3D CT examination was underwent with the consent of the patient to detect the position and healing of the fragment in front of the glenoid.Radiological evaluation methods:Preoperative 3D CT examination for the affected shoulder was carried out to assess the severity of glenoid bone defect.Immediate postoperative 3D CT examination for the affected shoulder was conducted to assess the position of coracoid fragment and its fixation.Postoperative 3D CT examination was conducted after one year of follow-up to assess the healing and absorption of coracoid fragment in the cross section.The classification of postoperative coracoid fragment absorption:Level 0:No coracoid fragment absorption and the screw heads are buried deep in the coracoid; Level Ⅰ:Slight coracoid fragment absorption.Only the screw heads are exposed out of the coracoid,and the screw shanks are totally buried in the coracoid; Level Ⅱ:Obvious coracoid fragment absorption,and the screw heads and part of screw shanks are exposed out of the coracoid,but there are still remaining coracoid fragment in front of the glenoid; Level Ⅲ:Total coracoid fragment absorption,no remaining fragment in front of the glenoid,the screws are fully exposed; The grading standards of this system are based on the screw exposure after coracoid bone absorption.While grading,the observer is required to respectively assess the exposure of the two screws and record each of the coracoid fragment absorption.The final classification of coracoid fragment absorption is determined by the screw exposure of more obvious.Observer and research method of reliability:Four independent observers,who completed the training of orthopedics and shoulder surgery,were involved in the research on reliability of the grading system.Instructions were distributed to familiarize them with the application method of this grading system.The final grade was determined by the senior doctor.Statistics method:The SPSS 16.0 software is adopted for statistical analysis in this study.The ICCs (intraclass correlation coefficients) is aimed at assessing the consistency between observers and the repeatability of two examination results from one individual observer.If the ICCs is greater than 0.75,the consistency of evaluation method is considered excellent; If the ICCs is between 0.40 and 0.75,the consistency is considered normal; If the ICCs is less than 0.4,the consistency is considered poor.Results From January 2009 to January 2012,a total of 81 patients with recurrent anterior shoulder dislocation

open Latarjet operation.Among them,65 patients underwent preoperative CT,immediate CT after operation and postoperative CT one year later.Of the 65 patients,1 patient was considered nonunion of the coracoid fragment in postoperative CT scan 1 year after surgery.Another patient was excluded due to the internal fixation failure.The remaining 63 patients were selected for this study.Coracoid bone absorption:The postoperative CT of one year after surgery revealed higher incidence of coracoid bone absorption,and the grading of 63 patients with bone absorption are as follows.Level 0∶6 patients (9.5%); Level 1∶26 patients (41.3%); Level 2∶25 patients (39.7%); Level 3∶6 patients (9.5%).Thus,1 year after surgery,the rate of coracoid bone absorption was 90.5% (57/63).Carefully distinguishing bone absorption around two canulated screws,we found that among the 63 cases,34 cases had the same grades of bone absorption around the two screws; and in another 29 cases,the absorption degree around the proximal screw was more serious than that around the distal screw.The reliability of the grading system:Statistical analysis indicated that in this grading system the consistency between observers (ICC,95% confidence Interval,0.856) and the repeatability of two results in individual observer (ICC,95% confidence Interval,0.946) were both very good.Conclusion One year after open Latarjet operation,the coracoid fragment absorption is of high incidence.The classification system we proposed has excellent inter-observer and intra-observer reliability.

Recurrent anterior shoulder dislocation;Latarjet operation;Bone absorption

10.3877/cma.j.issn.2095-5790.2015.01.008

国家自然基金青年科学基金项目资助课题(81201438)；北京市医院管理局临床医学发展专项经费资助

100035北京积水潭医院运动损伤科

姜春岩，Email:chunyanj@hotmail.com

2014-12-01)

(XMLX201511)