原发性前位脱位后6周内肩关节再脱位:危险因素和治疗结果

C. Robinson, M. Kelly, A. Wakefield
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引用次数: 95

摘要

背景:前位脱位后,肩关节不稳定可能伴随着软组织或骨性约束的破坏,导致早期再脱位。本研究的目的是阐明首次外伤性前脱位后6周内发生这种并发症的危险因素,并评估立即手术稳定治疗的结果。方法:对538例首次肩关节前脱位患者进行了一项为期三年的前瞻性观察队列研究。在专门的肩部诊所重新评估肩部功能,并通过额外的x线片评估可疑的早期再脱位。所有经医学证实的急性脱位患者均在麻醉下进行重复闭合复位治疗。不稳定复位患者行手术治疗。在脱位后的第一年对结果进行功能和影像学评估。结果:538例患者中17例(3.2%)在原脱位后一周内发生早期再脱位。早期脱位风险增加的患者包括那些因高能损伤而导致原发脱位的患者(相对风险= 13.7),那些有神经功能缺陷的患者(相对风险= 2.0),那些在脱位的同时发生大的肩袖撕裂的患者(相对风险= 29.8),那些原发脱位与盂缘骨折相关的患者(相对风险= 7.0),肩胛盂缘和大结节同时骨折的患者(相对风险= 33.5)。手术重建后,损伤一年后的结果在功能、一般健康和影像学表现方面都是有利的。一年内没有患者出现再脱位或不稳定症状。结论:所有在首次脱位复位后一周内出现明显疼痛、明显肩部畸形或活动受限的患者都应通过重复x线片评估以排除再脱位。发生这种并发症的患者通常有:(1)由于大的肩袖撕裂导致软组织包膜严重破坏,或(2)由于孤立性关节盂缘骨折或关节盂缘和大结节同时骨折导致正常骨约束脱位破坏。对于脱位与这些并存的疾病相关且有明显不稳定迹象的患者,早期手术稳定是合理的。
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Redislocation of the Shoulder During the First Six Weeks After a Primary Anterior Dislocation: Risk Factors and Results of Treatment
Background: After an anterior dislocation, shoulder instability may occur with disruption of the soft-tissue or osseous restraints, leading to early redislocation. The aim of the present study was to clarify the risk factors for this complication within the first six weeks after a first-time anterior traumatic dislocation and to assess the outcome of treatment with immediate operative stabilization.Methods: A three-year, prospective, observational cohort study of 538 consecutive patients with a first-time anterior dislocation of the shoulder was carried out. Reassessment of shoulder function was performed at a dedicated shoulder clinic, and suspected early redislocations were assessed with additional radiographs. All medically fit patients with a confirmed acute redislocation were treated with repeat closed reduction under anesthesia. Patients with unstable reductions were treated operatively. Functional and radiographic assessment of outcome was carried out during the first year after dislocation.Results: Seventeen (3.2%) of the 538 patients sustained an early redislocation within the first week after the original dislocation. Patients at increased risk of early redislocation included those who sustained the original dislocation as the result of a high-energy injury (relative risk = 13.7), those who had a neurological deficit (relative risk = 2.0), those in whom a large rotator cuff tear occurred in conjunction with the dislocation (relative risk = 29.8), those in whom the original dislocation was associated with a fracture of the glenoid rim (relative risk = 7.0), and those who had a fracture of both the glenoid rim and the greater tuberosity (relative risk = 33.5). Following operative reconstruction, the outcome at one year after the injury was favorable in terms of function, general health, and radiographic findings. None of the patients had a redislocation or symptoms of instability at one year.Conclusion: All patients who have substantial pain, a visible shoulder deformity, or restriction of movement at one week after reduction of a first-time dislocation should be evaluated with repeat radiographs to exclude a redislocation. Patients in whom this complication develops usually have either (1) severe disruption of the soft-tissue envelope due to a large rotator cuff tear or (2) disruption of the normal osseous restraints to dislocation due to either an isolated fracture of the glenoid rim or fractures of both the glenoid rim and the greater tuberosity. Early operative stabilization is justified for patients in whom the dislocation is associated with these coexisting conditions and who have evidence of gross instability.
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