骨科医生“木匠化”，看传统“榫卯结构”在现代骨科手术中的应用

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前言：

      古代中国建筑中“榫卯结构”可提供良好的稳定性。利用“榫卯结构”有效固定喙突截骨骨块至肩胛盂，作为复发性肩关节前方不稳Latarjet手术的改良方法，取得了良好效果。

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参考文献：Lin L, Zhang M, Song Q, Cheng X, Shao Z, Yan H, Cui G. Cuistow: Chinese Unique Inlay Bristow: A Novel Arthroscopic Surgical Procedure for Treatment of Recurrent Anterior Shoulder Instability with a Minimum 3-Year Follow-Up. J Bone Joint Surg Am. 2021 Jan 6;103(1):15-22. 

对复发性肩关节前方不稳，Latarjet手术（注：喙突截骨，将喙突骨块经劈肩胛下肌固定至肩胛盂，保留肱二头肌长头肌腱连接）作为一种广泛使用的术式，尽管疗效确切，但仍存在喙突截骨固定后不愈合的问题。

为了解决上述问题，北医三院从中国传统建筑“榫卯结构”中得到启发，通过对回喙突与关节盂塑形形成“嵌入式”结构，促进骨愈合。该结果发表在2021.01 JBJS期刊上。

Background

Latarjet术后骨不连发生率仍然很高。本研究目的是研究一种新颖的关节镜下喙突移位术后的骨愈合和临床疗效。 

（The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure. ）

Methods

63例患者行关节镜下“嵌入式”喙突移位手术并联合Bankart修补，最终纳了51例符合纳入标准的患者。这项技术的关键点是将喙突修整后用金属螺钉将其固定在肩胛盂颈部的一个深5-10mm深的凹槽内。术后使用计算机断层扫描（CT）成像评估骨移植愈合情况可和位置准确性。记录临床检查结果、运动恢复和功能评分（美国肩肘外科医师[ASES]评分和Rowe评分） 。

（Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded. ）

图1：榫卯结构

图2：喙突骨块的修整与关节盂凹槽

图3：患者基线资料

Results

平均随访时间（和标准差）为41.5±7.7个月（范围36-48个月）。术后CT扫描显示在矢状面中，喙突移植物的位置为4:10（从3:50至5:00）（以右肩为基准）。角度为16.4±9.5，其中51颗螺钉中有4颗（7.8％）角度过偏（a> 25°）（注：α角为横断面上，螺钉轴线与关节盂前后缘连线的夹角）。从轴向上看，移植物位置平齐的有33例（64.7％），内侧为11例（21.6％），重叠的为7例（13.7％），偏于外侧或内侧均无。术后1年，49例（96.1％）患者喙突移植物愈合，不愈合2例。对47例患者进行了CT扫描，其中9例患者显示0级骨溶解（注：指螺钉头埋于骨内），21例患者显示1级骨溶解（注：指螺钉头露出骨面，螺杆未露出），17例显示2级骨溶解（注：指螺杆露出骨面）。在最近一次随访时，Rowe评分（35.5±8.3到95.7±7.2）和ASES评分（从71.2±9.7到91.5±4.4）显着增加，并且87.0％的患者能够重返运动。所有患者未观察到关节炎发生。 

（The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The a angle was 16.4 ± 9.5, with 4 (7.8%) of 51 screws being overangulated (a > 25). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient.）

图4：病例示例及随访。A/B：术后6月；C/D：术后12月；E/F：术后40月

图5：骨溶解。A：0级，螺钉埋入骨面；B：1级，螺钉头露出：C：2级，螺杆露出。

图6：功能评估。

Conclusion

经过长于3年的随访，关节镜下“嵌入式”喙突移位手术获得了较高的移植物愈合率，良好的功能恢复和较好的运动恢复率。

（After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports.）

仅做学术交流使用，谢绝转载，侵权联系后删除

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