國人喙突的解剖特點(diǎn)及在Latarjet術(shù)的應(yīng)用

連建強(qiáng) 董樂樂 魏海濤 張文龍 賈建新

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·論著·

國人喙突的解剖特點(diǎn)及在Latarjet術(shù)的應(yīng)用

連建強(qiáng)1董樂樂1魏海濤1張文龍1賈建新2

目的 通過尸體解剖研究喙突及其韌帶附著點(diǎn)的特點(diǎn)，了解在行Latarjet術(shù)時(shí)，國人喙突的截骨量、喙突解剖與體長的關(guān)系。方法 解剖15具30肩男性防腐成人尸體，測量喙突長度，喙突尖寬度、高度，喙突尖到中點(diǎn)距離，喙突中點(diǎn)寬度、高度，喙突尖到胸小肌前界、后界距離，胸小肌喙突止點(diǎn)寬度，喙突尖到喙肩韌帶前界、后界距離，喙肩韌帶喙突止點(diǎn)寬度，喙突尖到斜方韌帶與錐狀韌帶最大距離(安全區(qū)域)，然后進(jìn)行統(tǒng)計(jì)學(xué)處理。結(jié)果 (1)喙突平均長度(42.10±2.3) mm，喙突中點(diǎn)平均寬度(15.29±1.70) mm，中點(diǎn)平均高度(11.61±1.98) mm，“安全區(qū)域”平均距離(23.93±2.32) mm；(2)內(nèi)踝尖到同側(cè)眉弓距離的線性回歸方程Y=-16.747+4.971喙突尖到斜方韌帶與錐狀韌帶的最大距離-3.469喙突中點(diǎn)高度-0.536喙突尖高度；(3)胸小肌止點(diǎn)變異率為23.33%，變異可為單側(cè)或雙側(cè)，無規(guī)律性。結(jié)論 (1)行Latarjet術(shù)時(shí)，國人喙突截骨量應(yīng)小于西方文獻(xiàn)報(bào)道量；剝離喙突上胸小肌止點(diǎn)時(shí)，應(yīng)關(guān)注其解剖變異；(2)患者身高與喙突可截骨量成正比，與喙突高度成反比，故身高越高，越不宜行Latarjet改良手術(shù)。

肩關(guān)節(jié)；喙突；解剖學(xué)；關(guān)節(jié)鏡

肩關(guān)節(jié)前方不穩(wěn)定是常見的肩關(guān)節(jié)運(yùn)動(dòng)損傷，肩關(guān)節(jié)鏡下關(guān)節(jié)囊盂唇修復(fù)術(shù)仍是肩關(guān)節(jié)前方不穩(wěn)定的常用手術(shù)方式，但文獻(xiàn)報(bào)道其復(fù)發(fā)率較高，尤其是肩盂前緣嚴(yán)重骨質(zhì)缺損的患者[1]。對于這一類患者，關(guān)節(jié)鏡下Latarjet手術(shù)可獲得良好的效果[2]。Latarjet手術(shù)喙突截骨時(shí)，不同的人種，喙突截骨量大小不同，最新美國一篇文獻(xiàn)報(bào)道其平均截骨量28.5 mm[3]，巴西的一篇文獻(xiàn)報(bào)道為26.4 mm[4]。查閱國內(nèi)文獻(xiàn)，僅發(fā)現(xiàn)一篇關(guān)于國人喙突的解剖研究[5]，但此文獻(xiàn)研究對象為干燥肩胛骨標(biāo)本，對臨床關(guān)節(jié)鏡下喙突截骨指導(dǎo)有限。本文通過防腐尸體解剖主要研究：(1)喙突上附著韌帶止點(diǎn)的解剖特點(diǎn)；(2)Latarjet手術(shù)時(shí)，國人喙突的截骨量；(3)喙突解剖與體長的關(guān)系。

材 料 與 方 法

15具30肩防腐成人尸體標(biāo)本，全部為男性，取肩關(guān)節(jié)倒“7”型切口，切口跨過喙突尖，切除局部皮膚、皮下組織，并切斷部分三角肌充分顯露喙突、鎖骨外段及肩峰。仔細(xì)解剖喙突上附著的聯(lián)合腱、喙肩韌帶止點(diǎn)、胸小肌止點(diǎn)及喙鎖韌帶的前界，并用標(biāo)記筆標(biāo)記。用精度為0.02 mm的游標(biāo)卡尺，由課題組任意2名成員完成， 每人分別兩次測量喙突長度:(1)喙突尖的寬度。(2)喙突尖的高度。(3)喙突尖中點(diǎn)距離。(4)喙突中點(diǎn)寬度。(5)喙突中點(diǎn)高度。(6)喙突尖到胸小肌前界(A)，喙突尖到胸小肌后界(B)，胸小肌喙突止點(diǎn)寬度(C)，喙突尖到喙肩韌帶前界(D)，喙突尖到喙肩韌帶后界(E)，喙肩韌帶喙突止點(diǎn)寬度(F)，喙突尖到斜方韌帶與錐狀韌帶的最大距離(G，安全區(qū)域)，見圖1～5，取其平均值，如果任意兩次測量數(shù)值差別較大，則由第三人重新測量，測量者互盲。

圖1 左肩關(guān)節(jié)喙突的解剖結(jié)構(gòu) CAL：喙肩韌帶，CT：聯(lián)合腱，CP：喙突尖，PMI：胸小肌，TL：錐狀韌帶

圖2 左肩關(guān)節(jié)喙突的解剖結(jié)構(gòu) CAL：喙肩韌帶，CT：聯(lián)合腱， PMI：胸小肌，TL：錐狀韌帶，A：喙突尖到胸小肌前界，B：喙突尖到胸小肌后界，D：喙突尖到喙肩韌帶前界，E：喙突尖到喙肩韌帶后界，G：喙突尖到斜方韌帶與錐狀韌帶的最大距離(安全區(qū)域)，兩＊之間：胸小肌喙突止點(diǎn)寬度(C)，兩●之間：喙肩韌帶喙突止點(diǎn)寬度(F)

圖3 左喙突外側(cè)面觀模式圖 1：喙突長度，3：喙突高度，4：喙突尖中點(diǎn)距離， 6：中點(diǎn)高度

圖4 左喙突上面觀模式圖 2：喙突尖的寬度，5：喙突尖中點(diǎn)距離，CAL：喙肩韌帶，PMI：胸小肌，TL：錐狀韌帶，CL：斜方韌帶，A：喙突尖到胸小肌前界，B：喙突尖到胸小肌后界， G：喙突尖到斜方韌帶與錐狀韌帶的最大距離(安全區(qū)域)

圖5 左肩關(guān)節(jié)喙突的解剖結(jié)構(gòu) G：喙突尖到斜方韌帶與錐狀韌帶的最大距離(安全區(qū)域)

本實(shí)驗(yàn)中，因?yàn)殄F狀韌帶喙突止點(diǎn)前于斜方韌帶，故“安全區(qū)域”是指喙突尖到喙鎖韌帶的錐狀韌帶的前界(即“喙突肘部”)的距離。并且測量每具尸體內(nèi)踝尖到同側(cè)眉弓的距離。所得數(shù)據(jù)采用SPSS 13.0軟件分析，分別求證均數(shù)、標(biāo)準(zhǔn)差、極大值、極小值、99%有效區(qū)間，及體長與上述測量值的相關(guān)性。

表1 喙突骨性結(jié)構(gòu)及其韌帶止點(diǎn)的解剖測量

結(jié) 果

喙突解剖數(shù)據(jù)見表1。喙突的平均長度(42.10±2.3) mm，喙突尖平均寬度(13.61±2.00) mm、平均高度(9.10±1.75) mm，喙突尖到中點(diǎn)的平均距離(24.75±7.23) mm，喙突中點(diǎn)的平均寬度(15.29±1.70) mm，中點(diǎn)平均高度(11.61±1.98) mm，喙突尖到胸小肌前界平均距離(8.53±1.78) mm，喙突尖到胸小肌后界平均距離(19.67±1.89) mm，胸小肌喙突止點(diǎn)平均寬度(12.76±1.62) mm，喙突尖到喙肩韌帶前界平均距離(9.67±2.96) mm，喙突尖到喙肩韌帶后界平均距離(18.75±5.46) mm，喙肩韌帶喙突止點(diǎn)平均寬度(13.93±4.82) mm，喙突尖到斜方韌帶與錐狀韌帶的最大距離的平均距離(23.93±2.32) mm。

多元線性回歸方程如：Y(內(nèi)踝尖到同側(cè)眉弓的距離)=-16.747+4.971左側(cè)喙突尖到斜方韌帶與錐狀韌帶的最大距離-3.469喙突中點(diǎn)高度-0.536喙突尖的高度。

討 論

1954年，Latarjet[6]報(bào)道了Latarjet術(shù)式，該術(shù)式將喙突由基底部截?cái)?，穿過沿肌纖維走行縱劈的肩胛下肌，移位固定至肩盂前緣2點(diǎn)到6點(diǎn)的位置。同年，Helfet[7]指出喙突截骨量為尖部以近10 mm。May[8]提出喙突截骨量為喙突尖到喙肱韌帶起始部。Mead主張截骨量為喙突尖以近10～30 mm。Freehill等[9]指出截骨量約為25 mm，截骨塊附帶部分喙鎖韌帶。Burkhart等[10]提出截骨點(diǎn)為喙突“肘部”，但未明確“肘部”的準(zhǔn)確概念。目前，大部分肩肘外科專家行喙突截骨時(shí)，嚴(yán)格遵從“安全區(qū)域”原則，“安全區(qū)域”是指喙突尖到喙鎖韌帶的錐狀韌帶的前界(即“喙突肘部”)的距離。最近美國一篇文章報(bào)道：“安全區(qū)域”平均距離為28.5 mm[3]，巴西一篇文獻(xiàn)報(bào)道為26.4 mm[4]。本實(shí)驗(yàn)結(jié)果：“安全區(qū)域”為(23.93±2.32) mm，與國外兩篇報(bào)道數(shù)據(jù)相比較小，但這一點(diǎn)與姜春巖教授的報(bào)道相符[1]。

2010年由Beer等[11]改良的Latarjet手術(shù)，建議喙突截骨塊沿其長軸內(nèi)旋90°轉(zhuǎn)位，再移植到關(guān)節(jié)盂前下方，使喙突下緣和關(guān)節(jié)面平齊。2013年Boons等[12]指出傳統(tǒng)術(shù)式與改良術(shù)式在肩關(guān)節(jié)的活動(dòng)度、僵硬程度無明顯差別，改良術(shù)式可增加肱骨頭在關(guān)節(jié)內(nèi)向前滑動(dòng)的范圍，但還需進(jìn)一步研究，哪一種術(shù)式占絕對優(yōu)勢。2012年Giles等[13]指出改良術(shù)式骨塊固定穩(wěn)定性明顯差于傳統(tǒng)術(shù)式，但與關(guān)節(jié)盂前緣密切結(jié)合，可能會(huì)產(chǎn)生良好的遠(yuǎn)期療效。就目前國外文獻(xiàn)報(bào)道，還沒有明確指出Latarjet術(shù)式的選擇受喙突寬高比的影響。國內(nèi)向明等[2]教授也報(bào)道了傳統(tǒng)Latarjet手術(shù)與改良術(shù)式的比較研究，他認(rèn)為喙突骨塊寬度大于厚度，平行轉(zhuǎn)位時(shí)與肩盂的接觸面積較大，能用兩枚3.5 mm皮質(zhì)骨螺絲釘固定，可提供更高的強(qiáng)度；相反內(nèi)旋90°轉(zhuǎn)位喙突骨塊與肩盂的接觸面積較小，只能用兩枚3.0 mm中空螺絲釘固定，因此，喙突骨塊平行轉(zhuǎn)位時(shí)較內(nèi)旋90°轉(zhuǎn)位有更大的接觸面積和生物力學(xué)強(qiáng)度，從而提高骨塊愈合率。但內(nèi)旋90°轉(zhuǎn)位可提供更大的關(guān)節(jié)面安全范圍，有利于肩盂骨缺損較大的患者[2]。

本實(shí)驗(yàn)研究發(fā)現(xiàn)喙突寬度大于高度，這與向明教授的觀點(diǎn)一致。多元線性回歸方程指出內(nèi)踝尖到同側(cè)眉弓的距離與“安全區(qū)域”成正比，與喙突尖高度、喙突中點(diǎn)高度成反比，這一點(diǎn)說明患者的身高越高，“安全區(qū)域”越大，喙突截骨量越大，但喙突高度越小，越不宜行Latarjet改良手術(shù)。Terra等[4]還指出喙突尖到胸小肌止點(diǎn)后界每增加10 mm，“安全區(qū)域”增大8.5 mm，但本實(shí)驗(yàn)未發(fā)現(xiàn)喙突尖到胸小肌后界距離與“安全區(qū)域”有相關(guān)性。

國外文獻(xiàn)報(bào)道：胸小肌止點(diǎn)變異率為15%，胸小肌異常附著點(diǎn)引起的功能障礙時(shí)，需要將其移位致喙突[14]。2000年張?jiān)龇降萚15]報(bào)道：胸小肌止點(diǎn)變異率為19.38%，變異者均為雙側(cè)對稱一致的，并將其分為單腱型及雙腱型，雙腱型又分為兩亞型。同年，孟文件等[16]報(bào)道胸小肌止點(diǎn)跨過喙突止于關(guān)節(jié)囊內(nèi)層一病例，本實(shí)驗(yàn)可見胸小肌止點(diǎn)跨過喙突尖止于上關(guān)節(jié)囊4側(cè)(圖6)，胸小肌小部分止于喙突而大部分止于上關(guān)節(jié)囊3側(cè)，胸小肌止點(diǎn)總變異率為23.33%，且變異者可雙側(cè)不對稱，無規(guī)律性。這一解剖變異提示肩肘外科醫(yī)生臨床行Latarjet手術(shù)時(shí)，剝離喙突上胸小肌止點(diǎn)時(shí)，還需進(jìn)一步關(guān)注其解剖變異，以免造成上關(guān)節(jié)囊松弛，導(dǎo)致醫(yī)源性關(guān)節(jié)疾病。

圖6 左肩關(guān)節(jié)胸小肌喙突止點(diǎn)變異解剖結(jié)構(gòu) CAL：喙肩韌帶，CT：聯(lián)合腱，CP：喙突尖，PMI：胸小肌，TL：錐狀韌帶，“”：胸小肌止點(diǎn)入關(guān)節(jié)囊點(diǎn)，“”胸小肌止點(diǎn)喙突壓跡

不足之處：本實(shí)驗(yàn)測量三維結(jié)構(gòu)標(biāo)本，建立一個(gè)標(biāo)準(zhǔn)的測量點(diǎn)較困難，為了減小此誤差，由任意兩名熟悉測量的成員完成測量，每人分別兩次測量同一部位，取其平均值，若兩人數(shù)值差距較大時(shí)，由第三人重新測量。另外，本實(shí)驗(yàn)數(shù)據(jù)基于尸體解剖，受試者一般資料不全，且均為成年男性，實(shí)驗(yàn)數(shù)據(jù)存在偏倚。下一步計(jì)劃增加樣本量，使實(shí)驗(yàn)數(shù)據(jù)更具代表性。

[1] 姜春巖,吳關(guān),魯誼,等.關(guān)節(jié)鏡下喙突移位術(shù):手術(shù)技術(shù)與早期隨訪探討[J].中國運(yùn)動(dòng)醫(yī)學(xué)雜志,2014,33(4):297-302, 311.

[2] 向明,楊國勇,陳杭,等.Latarjet兩種術(shù)式治療肩關(guān)節(jié)復(fù)發(fā)性前脫位伴重度骨缺損3～5年隨訪的比較研究[J/CD].中華肩肘外科電子雜志,2014,2(1):33-40.

[3] Dolan CM, Hariri S, Hart ND, et al. An anatomic study of the coracoid process as it relates to bone transfer procedures[J]. J Shoulder Elbow Surg, 2011, 20(3): 497-501.

[4] Terra BB, Ejnisman B, De Figueiredo EA, et al. Anatomic study of the coracoid process: safety margin and practical implications[J]. Arthroscopy, 2013, 29(1): 25-30.

[5] 馮沃君,楊會(huì)營,王軍.喙突的解剖學(xué)測量及其臨床意義[J].中醫(yī)外治雜志,2011,20(5):7-8.

[6] Latarjet M. Treatment of recurrent dislocation of the shoulder[J]. Lyon Chir,1954,49(8):994-997.

[7] Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder[J]. J Bone Joint Surg Br, 1958, 40B(2): 198-202.

[8] May VR. A modified Bristow operation for anterior recurrent dislocation of the shoulder[J]. J Bone Joint Surg Am, 1970, 52(5): 1010-1016.

[9] Freehill MT, Srikumaran U, Archer KR, et al. The latarjet coracoid process transfer procedure: alterations in the neurovascular structures[J]. J Shoulder Elbow Surg, 2013, 22(5): 695-700.

[10] 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.

[11] De Beer JF, Roberts C. Glenoid bone defects--open latarjet with congruent arc modification[J]. Orthop Clin North Am, 2010, 41(3): 407-415.

[12] Boons HW, Giles JW, Elkinson I, et al. Classic versus congruent coracoid positioning during the Latarjet procedure: an in vitro biomechanical comparison[J]. Arthroscopy, 2013, 29(2): 309-316.

[13] Giles JW, Puskas G, Welsh M, et al. Do the traditional and modified latarjet techniques produce equivalent Reconstruction stability and strength?[J]. Am J Sports Med, 2012, 40(12): 2801-2807.

[14] Rockwood CA.肩關(guān)節(jié)外科學(xué)[M].北京:人民軍醫(yī)出版社,2012:51.

[15] 張?jiān)龇?杜建春,張巖,等.胸小肌止點(diǎn)變異的解剖學(xué)研究[J].中華創(chuàng)傷骨科雜志,2004,6(9):1080.

[16] 孟文件,常寶林,劉漢鋒,等.雙側(cè)胸小肌止點(diǎn)變異1例[J].中國臨床解剖學(xué)雜志,2000,18(1):67.

(本文編輯：李靜)

連建強(qiáng),董樂樂,魏海濤,等.國人喙突的解剖特點(diǎn)及在Latarjet術(shù)的應(yīng)用[J/CD]. 中華肩肘外科電子雜志,2015,3(4):233-237.

The anatomical features of coracoid of Chinese population as well as their applications in Latarjet operation

LianJianqiang1,DongLele1,WeiHaitao1,ZhangWenlong1,JiaJianxin2.

1TheSecondEndemicArea,DepartmentofOrthopedics,theFirstAffiliatedHospitalofBaotouMedicalCollege,Baotou014010,China;2DepartmentofAnatomy,BaotouMedicalCollege,Baotou014010,China

Correspondingauthor：DongLele,Email:dong_le_le@126.com

Background Anterior shoulder instability is a common sport injury of shoulder joint, and bankart repair under shoulder arthroscopy is still common operation method for anterior shoulder instability. However, some literatures report this operation method has high recurrence rate, in particular for the patients with serious bony defect at anteior glenoid rim. For the treatment of such patients, arthroscopic Latarjet operation can achieve satisfactory effects. In Latarjet coracoid osteotomy, different races vary in coracoid osteotomy quantity. Recently, an American literature reported that the average coracoid osteotomy quantity is 28.5 mm, and a Brazilian literature reported it as 26.4 mm. By referring to domestic literatures, we only found one literature regarding the anatomic study on coracoid of Chinese population. However, the research object of this literature is dry scapula specimen, so that this literature has limited instructions on clinical arthroscopic coracoid osteotomy. Through autopsy of Formalined cadaver, this article mainly studies the following:(1) The anatomical features of ligament end point attached on coracoid;(2) In Latarjet operation, the osteotomy quantity of coracoid of Chinese population;(3) The relation between coracoid anatomy and body length.Methods For 15 Formalined male cadaver specimens with 30 shoulders (all male cadaver specimens), take inversed "7" form incision on shoulder joint, with incision crossing coracoid tip, remove local skin and subcutaneous tissues, and cut off partial deltoid, sufficiently exposed coracoid, outer segment of clavicular and acromion. Carefully dissect the conjoint tendon attached on coracoid, the coracoacromial ligament end point, musculus pectoralis minor end point and the anterior hyaloid of coracoclavicular ligament, and use a marker pen to mark these positions;By using vernier caliper with accuracy of 0.02 mm, any two members of research group are assigned to complete this operation. Each member respectively measure the following data twice: coracoid length:(1)width of coracoid tip;(2)height of coracoid tip ;(3) distance from center point of coracoid tip;(4)width of coracoid center point ;(5)height of center point;(6)Coracoid tip to musculus pectoralis minor anterior (A), coracoid tip to musculus pectoralis minor posterior (B), width of musculus pectoralis minor coracoid end point (C), coracoid tip to coracoacromial ligament posterior (D), coracoid tip to coracoacromial ligament posterior (E), width of coracoacromial ligament coracoid end point (F), maximum distance from coracoid tip to trapezoid ligament and conoid ligament (G, safety zone), take the mean value, if there is major difference between values measured at any two times, it is necessary to assign a third person to make measurement again, with measurers being mutually blind. In this test, since the conoid ligament coracoid end point is anterior to trapezoid ligament, the "safety zone" refer to the distance from the coracoid tip to the anterior of the conoid ligament of coracoclavicular ligament (namely "coracoid elbow"). In addition, measure the distance from medial malleolus tip to superciliary arch in each corpse. Use SPSS 13.0 software to analyze the obtained data; respectively verify the correlations among mean, standard deviation, maximum value, minimum value, 99% effective bargaining section and body length with said measured values.Results The average length of coracoid is (42.10±2.3) mm, the average edge line of coracoid tip is (13.61±2.00) mm, average height is (9.10±1.75), the mean distance from coracoid tip to center point is (24.75±7.23) mm, the mean width of coracoid center point is (15.29±1.70) mm, the average height of center point is (11.61±1.98) mm, the mean distance from coracoid tip to musculus pectoralis minor anterior is (8.53±1.78) mm, the mean distance from coracoid tip to musculus pectoralis minor posterior is (19.67±1.89) mm, the mean width of musculus pectoralis minor coracoid end point is (12.76±1.62) mm, the mean distance from coracoid tip to coracoacromial ligament anterior is (9.67±2.96) mm, the mean distance from coracoid tip to coracoacromial ligament posterior is (18.75±5.46) mm, the mean width of coracoacromial ligament coracoid end point is (13.93±4.82) mm, and the mean distance of the maximum distance from coracoid tip to trapezoid ligament and conoid ligament is (23.93±2.32) mm. Multivariate equation of linear regression: Y (distance from medial malleolar tip to superciliary arch on same side)=-16.747+4.971 the maximum distance of left side coracoid tip to trapezoid ligament and conoid ligament -3.469 coracoid center point height -0.536 Height of coracoid tip.Conclusions (1)In Latarjet operation, the coracoid osteotomy quantity of Chinese population shall be less than the quantity reported by western literatures; In the stripping the musculus pectoralis minor end point on coracoid, it is necessary to pay close attention to its anatomic variation;(2) The body height of the patients is proportional to the osteotomy quantity of coracoid and is inversely proportional to the height of coracoid. Therefore, the higher the body height is, Latarjet procedure is even not suitable.

Shoulder;Coracoid;Anatomy;Arthroscopy;Latarjet

10.3877/cma.j.issn.2095-5790.2015.04.007

014010包頭醫(yī)學(xué)院第一附屬醫(yī)院骨科二病區(qū)1；014040包頭醫(yī)學(xué)院解剖教研室2

董樂樂,Email:dong_le_le@126.com

2015-05-04)