Bankart損傷的診療進(jìn)展培訓(xùn)課件

1、Anatomy加強(qiáng)了由岡上肌前束和肩胛下肌上部分所形成的旋轉(zhuǎn)間隙一起維持盂肱關(guān)節(jié)上方穩(wěn)定性中起重要作用盂上結(jié)節(jié)小結(jié)節(jié)嵴，覆蓋肱二頭肌長(zhǎng)頭腱前方，肩袖間隙的一部分下盂肱韌帶前束、后束及腋袋組成盂肱下韌帶復(fù)合體腋袋Anatomy加強(qiáng)了由岡上肌前束和肩胛下肌上部分所形成的旋轉(zhuǎn)Anatomy肩關(guān)節(jié)最重要的靜力穩(wěn)定結(jié)構(gòu)Anatomy肩關(guān)節(jié)最重要的靜力穩(wěn)定結(jié)構(gòu)Anatomy盂肱韌帶的穩(wěn)定作用與體位有很大關(guān)系外展0外展45 后束+腋袋外展大于45Anatomy盂肱韌帶的穩(wěn)定作用與體位有很大關(guān)系外展0外展Bankart lesion定義：盂肱關(guān)節(jié)的前下部結(jié)構(gòu)包括盂肱關(guān)節(jié)囊的前下部、盂肱下韌帶的前束或前下部盂唇

2、自肩盂邊緣處撕脫，或伴肩胛盂骨折。Bankart lesion定義：盂肱關(guān)節(jié)的前下部結(jié)構(gòu)包括盂ClassificationFibrous Bankart lesion：關(guān)節(jié)囊破裂，盂肱韌帶連同附著的關(guān)節(jié)盂唇從關(guān)節(jié)盂上撕脫。肩關(guān)節(jié)前脫位時(shí)最常見(jiàn)的是下盂肱韌帶-盂唇復(fù)合體損傷，即經(jīng)典的Bankart損傷，占創(chuàng)傷性肩關(guān)節(jié)前脫位的85%。ClassificationFibrous Bankart ClassificationBony Bankart lesion:下盂肱韌帶盂唇復(fù)合體損傷同時(shí)伴有關(guān)節(jié)盂前下方的撕脫性骨折。Itoi等認(rèn)為前下盂唇骨性缺損的寬度盂長(zhǎng)度的21%會(huì)引起不穩(wěn)1。1Itoi,et

3、al.The effect of a glenoid defect on anterior stability of the shoulder after Bankart repair:a cadaveric study.J Bone Joint Surg AM.2000 Jan;82(1):35-46.ClassificationBony Bankart lesEpidemiology肩關(guān)節(jié)脫位約占人體脫位的50%，多發(fā)生于年輕人，人群發(fā)生率約2%，運(yùn)動(dòng)員中發(fā)生率約7%。脫位后復(fù)發(fā)率高，尤其是年輕人，20歲以下患者初次脫位后再脫位的復(fù)發(fā)率超過(guò)90%2。復(fù)發(fā)性肩關(guān)節(jié)脫位患者Bankart損傷的

4、發(fā)生率為53%-100%3-6。2Boyd HB,Hunt HL. Recurrent dislocation of the shoulder,the staple capsulorrhaphy.J Bone Joint Surg(Am),1965,47:1514-1520.3Engebretsen L,Craig EvV.Radiologic features of shoulder instability.Clin Orthop Relat Res,1933,(291):29-44.4Norlin R.Intaarticular pathology in acute,first-time

5、anterior shoulder dislocation:an arhroseopie study.Arthroscopy,1993,9:546-549.5Taylor DC,Arciero RA.Pathologic changes associated with shoulder dislocations:arthroscopic and physical examination fingdings in first-time traumatic anterior dislocations.Am J Sports Med,1997,25:306-311.6Hintermann B,Gac

6、hter A. Arthroscopic findings after shoulder dislocation.Am J Sports Med,1995,23:545-551.Epidemiology肩關(guān)節(jié)脫位約占人體脫位的50%，多發(fā)DiagnosisHistoryPhysical Examination Imaging DiagnosisArthroscopeDiagnosisHistoryPhysical ExaminationExaminationMethodSignificanceShift and load將肱骨頭推入關(guān)節(jié)盂，向前/后推移向前/后運(yùn)動(dòng)提示該方向不穩(wěn)定Sulcus

7、test坐位，肩部中立位，固定肩胛骨后向下?tīng)坷獠考绶逑鲁霈F(xiàn)橫溝2cm提示下方不穩(wěn)Anterior apprehension肩外展90、肘屈曲90，隨后外旋恐懼提示向前不穩(wěn)Augment test以上同時(shí)向前推肱骨頭進(jìn)一步引發(fā)恐懼或疼痛提示前方不穩(wěn)Relocation test肩外展90，最大外旋，向后推肱骨頭疼痛或恐懼緩解，或外旋增加提示向前不穩(wěn)Physical ExaminationExaminatioAnterior apprehensionAnterior apprehensionImaging DiagosisX-rayAP viewTrue APScapular LateralAx

8、illaryWest Point ViewApical-oblique viewStryker notch viewImaging DiagosisX-rayX-rayAP viewX-rayAP viewX-rayTrue APX-rayTrue APX-rayScapular LateralX-rayScapular LateralX-rayX-rayX-ray改良腋位X-ray改良腋位X-rayX-rayX-rayApical-oblique viewX-rayApical-oblique viewX-rayStryker notch viewX-rayStryker notch vie

9、wImaging DiagnosisCTImaging DiagnosisCTImaging DiagnosisMRI：對(duì)于韌帶、盂唇及軟組織診斷明顯優(yōu)于X線及CT。Imaging DiagnosisMRI：對(duì)于韌帶、盂唇及軟Arthroscope病史及普通體檢不能明確診斷麻醉下體檢PositiveNegative提示可能存在肩關(guān)節(jié)不穩(wěn)定，可繼續(xù)行肩關(guān)節(jié)鏡檢查及治療不需進(jìn)行肩關(guān)節(jié)鏡檢查7Robert H.Cofeild. Diagnosis of shoulder instability by examination Uder Anesthesia.Clin Orthop,1993,(291)

10、:45-53.Arthroscope病史及普通體檢不能明確診斷麻醉下體檢PDifferential DiagnosisBankart最早提出肩關(guān)節(jié)不穩(wěn)定（SI）是指肱骨頭不能保持在肩盂的中心位置，主要由創(chuàng)傷或非創(chuàng)傷引起的肱骨頭的脫位、半脫位。分前方、后方、多向。Differential DiagnosisBankart最A(yù)ntertior Shoulder InstabilityPathological Mechansim： Skeletal injury Labrum injury Joint capsule injury Rotator cuff injury Antertior Shou

11、lder InstabilitySkeletal injuryHill-Sachs損傷：肱骨頭后上的骨或軟骨缺損，由肩前下脫位時(shí)，肱骨頭的后外側(cè)與前下盂撞擊引起8。復(fù)發(fā)性肩關(guān)節(jié)脫位患者的發(fā)生率31-80% 9 。8Bost FC, Inman VT: J Bone Joint Surg 24:595,1942.9Danzig LA,Greenway G,Resnick D.The Hill-Sachs lesions:an experimental study.Am J Sports Med,1980,8:328-332.Skeletal injuryHill-Sachs損傷：肱骨Labrum

12、 injuryRowe提出盂唇損傷類型10 ： 盂唇從盂緣分離 盂唇實(shí)質(zhì)部撕裂 嚴(yán)重磨損直至消失10 Rowe CR,Patel D,Southmayd WW.The Bankart procedure:a longterm end-result study.J Bone Joint Surg Am,1978,60:1-16.Labrum injuryRowe提出盂唇損傷類型10 ALPSA損傷Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion于1993年由Neviaser提出并命名，前下盂唇連同相應(yīng)局部骨膜套袖狀撕脫11。1

13、1Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion:a cause of anterior instability of the shoulder.Arthroscopy,1993,9:17-21.ALPSA損傷Anterior LabroligamentoGLAD損傷Gleno-Labral Artic ular Disruption于1993年由Neviaser提出，為單純前下盂唇的關(guān)節(jié)內(nèi)損傷，不伴骨膜損傷，盂肱下韌帶的止點(diǎn)常完整12。12Neviaser TJ. The GLAD le

14、sion:another cause of anterior shoulder pain.Arthroscopy,1993,9:22-23.GLAD損傷Gleno-Labral Artic ular Perthes損傷1906年，德國(guó)醫(yī)生Perthes提出，是指肩關(guān)節(jié)前下盂唇及相應(yīng)區(qū)域盂骨膜自肩胛盂的剝離，盂唇及骨膜的聯(lián)系完整13。13Perthes G. Ueber operationnen bel der habituell schulterluxation Deutsch Z Chir,1906.85:199-277.Perthes損傷1906年，德國(guó)醫(yī)生Perthes提出，是SLAP損

15、傷Superior Labrum injury from Anterior to Posterior肩關(guān)節(jié)從前到后的上盂唇損傷，伴或不伴肱二頭肌腱損傷。SLAP損傷Superior Labrum injury fHAGL損傷HAGL損傷（humeral avulsion of inferior glenohumeral ligament）于1995年由Wolf等提出14。是指肩關(guān)節(jié)盂肱下韌帶肱骨頭止點(diǎn)處的撕脫性損傷。文獻(xiàn)報(bào)道，HAGL損傷的發(fā)生率為9%-39%14,15。14Wolf EM,Cheng JC,Dickson K.Humeral avulsion of glenohumeral

16、ligaments as a cause of anterior shoulder instablility.Arthroscopy,1995,11:600-607.15Bokor DJ,Conboy VB,Olson C.Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament:a review of 41 cases.J Bone Joint Surg(Br),1999,81:93-96.HAGL損傷HAGL損傷（humeral avulsion Lab

17、rum injuryBankart損傷Perthes損傷ALPSA損傷GLAD損傷HAGL損傷Labrum injuryBankart損傷Rotator cuff injury肩關(guān)節(jié)脫位病例中：肩袖損傷的概率為30%，其中16%為肩袖全撕裂，14%為肩袖部分撕裂。而且隨年齡增長(zhǎng)，肩袖撕裂發(fā)生率增加16。16Hintermann B,Gachter A. Arthroscopic findings after shoulder dislocation.Am J Sports Med,1995,23:545-551Rotator cuff injury肩關(guān)節(jié)脫位病例中：肩袖Treatment保守治

18、療：對(duì)于年輕、運(yùn)動(dòng)員、創(chuàng)傷后的復(fù)發(fā)性肩關(guān)節(jié)脫位保守治療效果不好，相反對(duì)老年、非運(yùn)動(dòng)員、非創(chuàng)傷后的復(fù)發(fā)性肩關(guān)節(jié)脫位保守治療有一定療效17-20。17Burkhead WZ Jr,Rockwood CA Jr. Treament of instability of the shoulder with an exercise program.J Bone Joint Surg Am,1992,74:890-896.18Hovelius L, Eriksson K,Fredin H,Hagberg G,Hussenius A,Lind B,Thorling J,Weckstrom J. Recuren

19、ces after initial dislocation of the shoulder.Results of a prospective study of treament.J Bone Joint Surg AM,1983,65:343-349.19Rowe CR,Zarins B. Recurrent transient subluxation of the shoulder.J Bone Joint Surg Am,1982,63:863-87220Simont WT,Cofield RH. Prognosis in anterior shoulder dislocation of

20、the shoulder.Am J Sports Med,1984,12:19-24.Treatment保守治療：對(duì)于年輕、運(yùn)動(dòng)員、創(chuàng)傷后的復(fù)發(fā)性Treatment經(jīng)保守治療無(wú)效時(shí)，切開(kāi)手術(shù)是對(duì)于復(fù)發(fā)性肩關(guān)節(jié)前方不穩(wěn)定的有效治療方法。近年來(lái)文獻(xiàn)報(bào)道顯示關(guān)節(jié)鏡下手術(shù)的效果已可與切開(kāi)手術(shù)相媲美21、22。21Kim SH,Ha KI,Cho YB, et al.Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up. J Bone Joint Surg Am,2003,85:1511-1518.2

21、2Potzl W,Kitt K,Hackenberg L, et al.Results of suture anchor repair of anteroinferior shoulder instability: a prospective clinical study of 85 shoulders. J Shoulder Elbow Surg,2003,12:322-326.Treatment經(jīng)保守治療無(wú)效時(shí)，切開(kāi)手術(shù)是對(duì)于復(fù)發(fā)性肩關(guān)Treatment切開(kāi)手術(shù) 非解剖型手術(shù)： Bristow-Latarjet：將喙突移位至肩胛頸 解剖型手術(shù) Bankart修補(bǔ)術(shù)關(guān)節(jié)鏡下治療Treatme

22、nt切開(kāi)手術(shù)Bristow-Latarjet Operation相對(duì)指征-盂肱韌帶肱骨撕裂及關(guān)節(jié)囊撕裂 -關(guān)節(jié)鏡手術(shù)或切開(kāi)手術(shù)失敗 -關(guān)節(jié)鏡下熱縮成形術(shù)失敗絕對(duì)指征-肩胛盂骨缺損（倒梨形） -關(guān)節(jié)囊缺損 -關(guān)節(jié)鏡下無(wú)法修復(fù)的肩袖缺損，尤其是肩胛下肌的缺損 -初次手術(shù)所致的肩胛下肌慢性損傷 -巨大的Hill-Sachs損傷23王蕾，莊澄宇，張偉濱，等. 切開(kāi)修補(bǔ)關(guān)節(jié)囊盂唇治療肩關(guān)節(jié)前方不穩(wěn)定J.中華創(chuàng)傷骨科雜志，2006,12(8):1101-1104.Bristow-Latarjet Operation相對(duì)指征Bristow-Latarjet Operation松解喙突尖時(shí)應(yīng)注意保護(hù)肌皮神經(jīng)，

23、它于喙突尖下幾厘米處穿過(guò)喙肱肌。Bristow-Latarjet Operation松解喙突Bristow-Latarjet Operation附著于喙突的肌肉喙突尖肩胛下肌如果關(guān)節(jié)囊及盂唇從關(guān)節(jié)盂前緣剝脫，可用縫線或鉚釘將其縫合于新的骨床Bristow-Latarjet Operation附著于喙改良的Bristow-Latarjet Operation翻起前關(guān)節(jié)盂唇的上、下瓣，轉(zhuǎn)為點(diǎn)應(yīng)于關(guān)節(jié)盂下方是非常重要的。在將喙突尖及其附著的肌肉穿過(guò)肩胛下肌的水平裂隙固定于肩胛頸之前，先間斷縫合關(guān)節(jié)囊不要去除肩胛頸的皮質(zhì)骨，但要去除所有軟組織并使其表面粗糙。改良的Bristow-Latarjet Op

24、eration翻改良的Bristow-Latarjet Operation喙突截骨后附著有肱二頭肌短頭、喙肱肌的骨塊關(guān)節(jié)盂缺損部關(guān)節(jié)盂喙突關(guān)節(jié)盂改良的Bristow-Latarjet Operation喙改良的Bristow-Latarjet Operation改良的Bristow-Latarjet OperationBankart修補(bǔ)術(shù)6、8、10點(diǎn)位置（左肩）2、4、6點(diǎn)位置（右肩）Bankart修補(bǔ)術(shù)6、8、10點(diǎn)位置（左肩）Arthroscope1982年Johnson首次施肩關(guān)節(jié)鏡下Bankart修復(fù)術(shù)24。經(jīng)關(guān)節(jié)盂修復(fù)可吸收螺釘縫合鉚釘24Detrisac DA,Johnson L

25、L. Arthroscopic shoulder capsulorrhaphy using metal staples.Orthop Clin North Am,1993,24:71-88.Arthroscope1982年Johnson首次施肩關(guān)節(jié)鏡Arthroscope帶線錨釘無(wú)線錨釘壓住Arthroscope帶線錨釘無(wú)線錨釘壓住Treatment Options開(kāi)放性手術(shù)VS關(guān)節(jié)鏡治療Treatment Options開(kāi)放性手術(shù)VS關(guān)節(jié)鏡治療開(kāi)放性手術(shù)VS關(guān)節(jié)鏡治療爭(zhēng)論無(wú)隨機(jī)化研究先前的研究 開(kāi)放性手術(shù)VS經(jīng)關(guān)節(jié)盂手術(shù) 開(kāi)放性手術(shù)VS可吸收釘開(kāi)放性手術(shù)VS關(guān)節(jié)鏡治療爭(zhēng)論開(kāi)放性手術(shù)學(xué)者復(fù)發(fā)率期刊Magnuso