探讨关节镜下自体髂骨移植治疗复发性肩关节前脱位合并严重骨缺损的临床疗效及影像学结果。

对2016年1月至2018年12月在佛山市中医院运动医学科收治的复发性肩关节前脱位合并严重骨缺损行全镜下自体髂骨移植重建肩关节盂的患者病例资料进行回顾性研究，随访资料完整的共30例，其中男性23例、女性7例；左侧11例、右侧19例；平均年龄49.45岁（17~77岁）。术前脱位次数7~104次。所有病例均取自体髂骨移植行肩关节镜下肩盂重建术，术后通过三维CT扫描和重建评估移植骨块的位置。随访时肩关节功能和稳定性采用美国肩肘外科协会（American shoulder and elbow surgeons,ASES）评分、Constant-Murley评分、Rowe评分和关节主动活动度进行评估。

所有患者术后均获得随访，术后随访时间6~28个月，平均随访（17.67 ±10.17）个月，所有患者均未发生切口感染、关节腔积血及再脱位等临床并发症，其中1例患者术后出现髂骨取骨侧髂棘撕脱骨折。术前及末次随访时平均前屈上举（146.13±43.43）°和（163.23±13.21）°，平均内旋至T7和T8，平均体侧外旋为（53.91±8.60）°和（58.91±3.63）°，平均外展90°外旋（87.32±5.54）°和（88.12±6.12）°，术前和末次随访时前屈上举、体侧外旋差异具有统计学意义（P<0.05），而平均内旋和外展90°外旋差异无统计学意义（P>0.05）；术前及末次随访时平均ASES评分为（71.32±18.12）分和（93.45±7.87）分（P<0.05），Constant-Murley评分为（82.54±15.31）分和（92.52±7.67）分（P<0.05），Rowe评分为（39.56±6.75）分和（94.23±7.23）分（P<0.05）。最后随访时三维CT上按4:30为骨块中心评估：良好26例、过高2例、过低2例；CT横断位按与关节盂相平评估：良好28例、偏内1例、偏外1例，所有患者均能返回运动，无脱位和不稳感。

关节镜下自体髂骨移植重建肩关节盂是治疗合并严重骨缺损的复发性肩关节前脱位的有效方法，镜下髂骨移植操作简便、安全，是复发性肩关节脱位的终极解决方案。

Shoulder joint is the largest and most flexible joint of upper limb. The humeral head is large, and the glenoid is small. The joint is prone to instability, while it has a large range of motion.The most common case is anterior shoulder instability, and its incidence rate is up to 2%. In traumatic anterior shoulder instability, Bankart injury is the most common pathological change, which accounts for 4%-70% in anterior shoulder dislocation.Small bone defect generally has little effect on the stability of shoulder joint. However, with the increasing number of dislocations, the area of ??bone defect increases, and the risk of joint instability is growing. It is reported that the recurrence rate is up to 67% after arthroscopic Bankart repair surgery for the treatment of shoulder dislocation with giant bone defect. Therefore,the domestic and foreign experts believe that osseousreconstruction is necessary when the bone defect is greater than 20%-25% of the long axis of glenoid.The bone graft reconstruction is recommended when the case is combined with Hill-sachs injury. However, the current methods of bone reconstruction are still inconclusive.The previous method for the treatment of anterior glenoid bone defect was Latarjet procedure. However, this surgery requires the removal and transfer of coracoid process to glenoid for bone reconstruction. It destroys the anatomical structure around shoulder joint and has great influence on shoulder function. Another method is anterior glenoid bone grafting. This procedure is simple with minimal trauma, and it does not destroy the original structure of shoulder joint. Currently, the absorption of bone graft and the recovery of patient after anterior glenoid bone grafting are rarely reported. Objective To explore the clinical efficacy and radiological result of arthroscopic glenoid reconstructionwithautogenous iliac bone graft for the treatment of recurrent anterior shoulder dislocation with severe bone defect.

From January 2016 to December 2018, the patients with recurrent anterior shoulder dislocation with severe bone defect were treated by total arthroscopic glenoid reconstruction with autogenous iliac bone graftin our hospital, and the data was retrospectivelyanalyzed. A total of 30 patients (23 males and 7 females) received complete follow up, including 11 left shoulders and 19 right shoulders.The average age was 49.45 years (17-77 years) .The number of dislocations before operation was 7-104 times.All patients underwent arthroscopicglenoid reconstruction with autologous iliac bone graft.The positions of bone graft were evaluated by CT scan and three-dimensional reconstruction after operation.The function and stability of shoulder joint were evaluated by ASES, Constant-Murley, Rowe and VAS scoring systems, and active range of motion was applied in theassessment of shoulder function and stability during follow up.

All patients were followed up for 6-28 months with an average of (17.67±10.17) months.No complication such as incision infection, hemorrhage, redislocation, etc. occurred. During the preoperative and last followups: the average ranges of anteflexionwere (146.13±43.43) °and (163.23±13.21) °; the average ranges of internal rotation werein level T7 and T8; the average ranges of external rotation were (53.91±8.60) °and (58.91±3.63) °; the average ranges of external rotation in 90°abduction were (87.32±5.54) °and (88.12±6.12) °. There were significant differencesbetween the preoperative and last followupsinanteflexion andexternal rotation (P<0.05) , while there wasno significant differencebetween the preoperative and last followups in internal rotation and external rotationin 90° abduction (P>0.05) .The ASES scores during the preoperative and last follow-upswere (71.32±18.12) points and (93.45±7.87) points, respectively (P<0.05) .The Constant-Murley scores during the preoperative and last follow-ups were (82.54±15.31) points and (92.52±7.67) points, respectively (P<0.05) . The Rowe scores during the preoperative and last follow-ups were (39.56±6.75) points and (94.23±7.23) points, respectively (P<0.05) . There were statistical differences between the scores during the preoperative and last follow-ups (P<0.05) . With 4:30 as the center of fragment in three-dimensional CT reconstruction during the last follow up, there were 26 casesof good position, 2 cases of higher position and 2 cases of lower position. With the assessment conducted with the cross-sectional CT scan aligned to the level of glenoid, there were 28 cases of good position, 1 case of medial position and 1 case of lateral position.All patients returned to activity without dislocation or instability.

The arthroscopic glenoid reconstruction with autogenous iliac bone graft is an effective method for the treatment of recurrent anterior shoulder dislocation with severe bone defect. The operation of arthroscopic iliac bone graft is simple and safe, which is the ultimate solution for recurrent anterior shoulder dislocation.