| BackgroundShoulder instability refers to the instability of the glenohumeral joint in one or more directions,and with the joint diseases of the joint dislocation.Traumatic glenohumeral joint dislocation or subluxation often lead to joint instability in the front of the shoulder,especially young athletes or people with epilepsy,The front shoulder joint instability is the most common,about 98%,in the unstable cases,87%of patients with glenoid cavity defects of bone.The study showed that the "en-face" 3D-CT showed that the bone defect was greater than 21%,or was greater than 25%to 30%,and the osteotomy of the shoulder should be performed.A young patient with an ISIS score greater than 4,or ISIS score greater than 6,should be treated with glenoid osteotomy.At present,the shoulder instability in the front of joint with glenoid bone defect treatment are mainly coracoid shift reconstruction(Bristow,Lartajet technique,etc.)and structural bone graft reconstruction(iliac transplantation,fibula transplantation,femoral head transplant,etc.).Hovelius found that Bristow’s overall satisfaction was 95%,and the reposition rate was 20%.There were also reports that the failure rate was 15.4%in 26 years after Bristow.126 patients were followed up in 41 months,and the redislocation rate was 1.6%.However,for Latarjet surgery,56 patients were followed up for 14.3 years,and the optimal rate was 88%,In more than 2000 patients,the failure rate was 1%,62 patients were followed up for 6.4 years with a failure rate of 1.6%.Some scholars have put forward that when bone defect of normal shoulder joint is 15%to 30%,shoulder forward stability significantly worse in Latarjet procedure after Bristow operation,when bone defect is more than 50%,suggested that large pieces of bone graft reconstruction of glenoid cavity structure.Clinical observation showed that there were fewer cases of large bone defect in the glenoid cavity,so the indication of Latarjet was wider and wider in the incision or arthroscopy.Since 1954,the Latarjet surgery in the treatment of recurrent anterior dislocation of shoulder joint is put forward by French doctor Latarjet.After more than half a century of development,the Latarjet procedure with several improvements,which involves the coracoid bone cutting,and fixing.mainly in 2009,De Beer and Roberts reported coracoid "inward turning 90°" modified Latarjet surgery and reconstruction of the glenoid cavity by Zhang Hongxin professor in 2017,such as the coronoid process of "standing”fixed reconstruction glenoid cavity.Although Latarjet has been modified several times,its core idea is invariable,namely,the osteotomy of coracoid process and the reconstruction of the glenoid cavity.Therefore,it is very important to evaluate the size,position and shape of the glenoid bone defect.Nearly a decade of foreign literatures,Europa,mongoloid race,nigel’s three big race,dry scapula 478,body 82,patients with 161 people,because of racial differences,the research method is not unified,the same variable results is more different,therefore these conclusions limited clinical doctors,work guidance in our country.For example,Latarjet suggests that the coracoid osteotomy is located in the basal part of the coracoid process and protects the coracoclavicular ligament.In 1958,Helfet advocated that the osteotomy was 10mm from the tip of tip,and May suggested that the osteotomy line was located at the leading edge of the coracoclavicular ligament,such as Lafosse,the osteotomy line was recommended to be 20-25mm,and Burkhart et al described the osteotomy point at the turning point of the coracoid process.To sum up,the consistent view of the above literature is to protect the coracoclavicular ligaments,the "safe distance" osteotomy,that is,the tip of the beak to the anterior border of the coracoclavicular ligament.However,as for the definition of "safe distance",different scholars also put forward different opinions.For example,Dolan et al.reported that "safe distance" was 28.5mm,and Terra et al proposed a"safe distance" of 26.4mm.Domestic literatures,reports about the Latarjet technique is more,but have focused on clinical experience,large sample of coracoid correlation studies of bone cutting is not reported,the basis of the collected only two Chinese coracoid anatomical study,but which is not base on clinical Latarjet technique applied anatomy study,failed to help the chinese people Latarjet coracoid researchThe first phase of this study(30 samples)found that the "safe distance" of Chinese male coracoid process was less than that of westerners,i.e.23.93 ± 2.32mm.The body length was positively correlated with the "safe distance" and negatively correlated with the diameter of the coracoid process.Pectoralis minor muscle with coracoid attachment point mutation rate was 23.33%,the attachment point comes across the coracoid tip and joins the shoulder capsule on four cases,a small part of pectoralis minor muscle attached the coracoid tip,most parts of it attached the capsular in three cases,the mutation is higher than foreign coverage of the pectoralis minor muscle mutation rate,that is 15%,is higher than that of domestic professor Zhang zeng fang reported such as pectoralis minor muscle check point mutation rate was 19.38%.The first study also reported that the pectoralis minor attachments of the coracoid had no symmetry and no regularity,which was different from the the previous reports,that the pectoralis minor points were symmetrical.Based on the research status of home and abroad,and early experiments showed that this study to increase sample size and anatomical variables into women,further explore the coracoid process of the Chinese people in the Latarjet technique applied anatomy study,fill the gap of domestic related research.The first part of the study found that the coronoid process of the Chinese "safe distance" is 23.41 ± 1.92mm,but in the experiments,the author found anatomic variation of some specimens coracoid are more great and difference with reported values is larger,if the osteotomy in accordance with the reported values,will damage the coracoclavicular ligament,how do we assess each patient anatomical characteristic of the coronoid process before the operation?The literature reports that there are more preoperative evaluation methods and more mature techniques for the study and quantitative study of the joint glenoid defect,but there is less research on the application of coracoid process in Latarjet.In 2003,Griffith first pointed out the defect of the glenoid defect,the anterior dislocation of the shoulder joint was often combined with the anterior inferior margin of the glenoid and the anterior border of the bony Bankart injury.Saito et al further illustrate this point in 2005,namely the scapula relative to the trunk coronary about 20° inclination,glenoid cavity relative to the scapula plane front tilt 1 8.4±6.7°,so the glenoid cavity relative to the trunk coronary pour about 38°,The defects of bone in glenoid cavity clockface at 3:01 by biomechanical analysis,namely in the front of the glenoid cavity,but relative to the surface of the trunk coronary,is located at 4:17,namely the glenoid cavity beneath the former.In 2017,Bockmann pointed out that the bone defect Angle(glenoid cavity after the farthest point B,inscribed circle centre point O,connecting the BO to defect edge point A,defect in the flange on the point C,<BAC for bone defect Angle)is about 90 °,the bone defect line is located in the front of the glenoid cavity,and multiple defects in parallel line,and the defect quantity size.Yamamoto et al also reported the results of the study.In summary,the glenoid defect of the glenoid cavity is often located in front of the glenoid cavity.At present,the quantitative research method of glenoid defect is the main imaging evaluation technique.The sensitivity of the diagnostic sensitivity was about 66%and the specificity was 100%.For example,if the anterior inferior margin of hardening line is less than 5mm,it can be diagnosed as the anterior border injury of the shoulder joint.The conclusion was also confirmed by Jankauskas.Bishop said 3D-CT is the most reliable indicator of preoperative evaluation of glenoid cavity defect,2D-CT,MRI effect is the worst in 2013,3D-CT evaluation technology of Chuang "glenoid cavity index",the defect ratio of Barchilon,Griffith "defect quantity",and Sugaya "defects" area ratio,and scholars have pointed out the normal glenoid cavity width ratio is about 0.7.2D-CT evaluation technique classic represents the Pico technique proposed by Baudi.MRI imaging technology is not only the gold standard for evaluation of soft tissue injury,but also in evaluation of glenoid cavity bone defects has obvious advantages,especially popular with the young patients,because nuclear magnetic water imaging not only avoid the damage of X rays,and also more mature technology.In the case of shoulder joint instability,the evaluation method of glenoid defect in the joint was studied in addition to the imaging assessment technique.For example,in 2013,Owens et al proposed to calculate the width of the glenoid cavity by using the glenoid cavity height,thus further evaluating the lack of the glenoid bone.In 2015,Giles et al reported that the width of the male joint was equal to 2/3 of the glenoid height+ 5mm.Femoral glenoid width=2/3 of glenoid height+3mm.In 2015,Joshua W also proposed that the glenoid cavity width=0.7glenoid height +8mm.Based on the analysis,first,glenoid ca-vity defects of bone imaging evaluation technology mature,second,glenoid cavity variable correlation,third,the application of coronoid process of anatomical study and preoperative assessment technology lag behind.It is assumed that there is a correlation between the anatomic variable of the glenoid and the anatomic variable of the coracoid process,so that the anatomic features of the coracoid process can be inferred from the glenoid variable before the operation.In 2012,Karin L et al reported that the front and rear diameter of the coracoid process was 35.4%of the glenoid width.The diameter of the female coracoid process was 34.4%of the width of the glenoid cavity.In 2017,domestic literatures report that the outer diameter of the coracoid process is 55%±6%of the width of the joint,and the related equation y=1.080x +10.950,x:the larger the outer diameter of the coracoid process,y:the greater the width of the glenoid cavity.That means the larger the diameter of the coracoid process,the width of the glenoid cavity.However,two literatures only completed the study of the correlation between the glenoid and coracoid processes from the anatomical point of view,and did not combine the technical points of Latarjet.This study combined with shoulder joint unstable cases in front of the glenoid cavity bone defect site,size,and the Latarjet coracoid bone cutting parts and the main technical points of the bone cutting way,explore the Chinese glenoid cavity,coracoid process,and the correlation among the variables,to provide theoretical basis for clinical work.Part 1 Anterior shoulder instability:applied anatomical study of the coracoid with Latarjet in ChineseObjective to study the anatomical characteristics of Chinese coracoid process.During the operation of Latarjet,the osteotomy of the Chinese coracoid process.The relationship between the anatomic characteristics of the coracoid process and the body length,and the mutation rate of the coracoid process of the pectoralis minor.Methods 14 anticorrosive male corpse,10 corpse with anticorrosive women(30%formalin soaked),1 fresh frozen male corpse,age 32-71 years,with an average age of 54.4 years,body length is 128-170 cm,mean 145.2cm.All the observation indicators were completed by two trained doctors.The same observation index was used by each doctor to measure two times with the same standard vernier caliper,and the accuracy of the vernier caliper was 0.02mm.Observation indexes;coracoid anatomic morphology,pectoralis minor.Measurements:coracoid length,tip width,tip height,distance from tip to midpoint,midpoint width,midpoint height,distance from tip to anterior pectoralis minor,distance from tip to posterior pectoralis minor,pectoralis minor insertion AP width,coracoid tip to anterior coracoacromial ligament,coracoid tip to posterior coracoacromial ligament,coracoacromial ligament insertion AP width,coracoid tip to anterior coracoclavicular trapezoid ligament(safety margin).All the data were processed by SPSS 22.0,and the detection]evel of p was less than 0.05,which was considered statistically significant.Results the coronoid process is located in the top of cervical base of the glenoid,forward and laterally across the glenoid cavity sagittal and form a hook structure,and there is a 30° angle with the scapula plane.Divided into one top,two sides(upper and lower sides),two edges(inner and outer edges),a base,the former side not the plane,there are pectoralis minor attachment point,coracoacromial ligament nodules,coracoclavicular ligament attachment point nodules,back side is a curved surface,the medial edge approximate curve,the lateral edge as a straight line,the base and glenoid cavity are a integration.The coracoacromial ligament and the pectoralis minor tendon are fused to the coracoid tip behind 8-9mm,and the pectoralis minor tendon can be seen passing through the coracoid to the shoulder cuff or the joint capsule.Mutation rate of pectoralis minor muscle attachment in the coracoid was 18.00%,the mutation no regularity,a small parts of pectoralis minor muscle tendon attached the coracoid,most ended into the capsule,which was five cases,pectoralis minor muscle came across the coracoid and fused upper shoulder sleeve,4 cases.3 body symmetry,2 bodies on the right side alone,1 bodies left alone.Single factor variance analysis:there was a statistical difference in height between men and women(P=0.041),and there was no statistical difference between male and female coracoid process(P>0.05).There was no statistical difference between the left and right sides(P>0.05).Independent samples t-test:male and female,left and right side sample,the average length of coracoid of 42.66 ±2.60mm,the average width of 13.31 ± 1.76mm,the average height of 9.63 ±2.84mm,the average distance of coracoid tip to the midpoint is 24.86 ±6.79mm,the average width of coracoid midpoint of 14.89 ±1.55mm,the average height of midpoint of 11.82 ±1.69mm,distance from tip to anterior pectoralis minor of 8.18 ±1.88mm,distance from tip to posterior pectoralis minor of 19.79 ± 1.89mm,pectoralis minor insertion AP width of 12.15 ±1.54mm,coracoid tip to anterior coracoacromial ligament of 9,39 ±2.41mm,coracoid tip to posterior coracoacromial ligament of 18.43 ±4.64mm,coracoacromial ligament insertion AP width of 13.76 ±4.67mm,coracoid tip to anterior coracoclavicular trapezoid ligament(safety margin)of 23.41 ±1.92mm.Linear regression analysis(coracoid osseous anatomy and body length):Y1 =12.846+0.195X,Y2 =4.953+0.056X,Y3=3.349+0.088X,Y4=5.901+0.061X,Y5=9.005+0.019X,Y6=9.472+0.094X(Y1:coracoid length(mm),Y2:coracoid tip width(mm),Y3,coracoid height(mm),Y4:coracoid midpoint width(mm),Y5:coracoid height of the midpoint(mm),Y6:coracoid tip to anterior coracoclavicular trapezoid ligament(safety margin)(mm),X:length(cm)).Conclusion Chinese anatomical configuration of coracoid process has its inherent characteristics.compared with westerners,Chinese coracoid is smaller,the safety of the coronoid process osteotomy was 23.41 ± 1.92mm,the anatomy of the index of coronoid process does not vary with gender and side,but the anatomy of the coronoid process variables changes as the patient’s height,but the midpoint of the coracoid height change is not obvious,the higher the coronoid process,the longer,the bigger of the coracoid top,but coracoid middle height has no obvious change.It is more noteworthy that there is a higher mutation rate,18.0%,and no regularity.To sum up,the performer preoperative preparation,must be specific cases of specific analysis,especially the evaluation of coronoid process data such as size,shape,avoid by all means in accordance with the western authors scripted,lest cause iatrogenic injury.The innovation point of this study:first,the first study of Chinese Latarjet was reported by autopsy,with an average safety margin of 23.93±2.32mm,which was significantly shorter than that of western patients.Second,the first use the same research methods,by increasing the sample size,with the female coracoid mutation,and report male pectoralis minort mutation rate is 23.33%,the update is 18.00%,and points out that update muscle mutation no regularity,symmetry.Third,the first case study that the Chinese height was positively correlated with the anatomic variables of the coracoid process,but the correlation between the height of the coracoid process and the height was small.Part 2 Anterior shoulder instability:applied anatomical and correlative study with Latarjet in ChineseObjective The study is based on the main techniques of the Latarjet,by measuring the scapula glenoid height,height of anterior border of the glenoid,glenoid cavity width,as well as the distance of medial-lateral diameter and anteroposterior diameter of coracoid in the point after 1 cm to the coracoid top,the distance of medial-lateral diameter and anteroposterior diameter of coracoid in the base of coracoid(coracoid vertical segment),and statistical analysis of the glenoid and coracoid correlation between the amount of mutation,for clinical preoperative assessment lay a theoretical foundation.Methods From 118 cases in group 48 cases in the scapula samples,including fresh frozen corpse of 1,all specimens appearance structure complete,no fracture,deformity and pathological change,will not affect the measurement data.All of the specimens were left of 29,19 in the right,gender unknown and age unknown.All specimens are marked on the top of glenoid,the highest tubercle and the lowest nodular tubercle,and the two points are defined as the glenoid height,marking a.The anterior margin of the glenoid cavity is the starting point,then parallel to the glenoid cavity height as a straight line,as b.It is perpendicular to the height of the glenoid cavity,and the maximum distance of the diameter of the glenoid cavity is defined as the width of the glenoid,as c.To measure the length of the coracoid process,that is,the distance between the tip of the coracoid and the vertical part of the coracoid,as d.the distance of anteroposterior diameter and medial-lateral diameter of coracoid in the point after 1 cm to the coracoid tip,as e and f.the distance of anteroposterior diameter and medial-lateral diameter of coracoid in the base of coracoid(coracoid vertical segment),as g and h.All the observation indicators were completed by two trained doctors.The same observation index was used by each doctor to measure two times with the same standard vernier caliper,and the accuracy of the vernier caliper was 0.02mm.All the data were processed by SPSS22.0,and the detection level of p was less than 0.05,which was considered statistically significant.Results Glenoid relative to the scapula plane forward about 20 °inclination,glenoid cavity under two-thirds of approximate circle,glenoid cavity front upper one-third intersection for is incisure.The supraglenoid tubercle and infraglenoid tubercle are located on the long axis of the glenoid cavity.Coracoid process is a complex anatomic structure,coracoid located at the top of the glenoid cavity cervical basal,forward and laterally across the glenoid cavity sagittal,and form a hook structure,with the scapula plane into about 30°.The coracoid process consists of upper column and lower column,divided into one pointed,two sides(upper and lower sides),two edges(inner and outer edges),a base,the former side not the plane,there are pectoralis minor attachment point,coracoacromial ligament nodules,coracoclavicular ligament attachment point nodules,back side is a curved surface,the medial edge approximate curve,the lateral edge as a straight line,the base and glenoid cavity are a integration.Independent samples t-test:The glenoid cavity height a:33.80±2.81mm,glenoid cavity front incisure height b:24.27±2.70mm,width of the glenoid cavity c:18.94±2.71mm,the length of the coracoid d:20.91±2.93mm,the distance of anteroposterior diameter and medial-lateral diameter of coracoid in the point after 1 cm to the coracoid tip,e:8.57±1.97mm,f:13.50 ± 2.14mm,the distance of anteroposterior diameter and medial-lateral diameter of coracoid in the base of coracoid(coracoid vertical segment),g:11.14±2.57mm,h:14.98± 2.58mm.The correlation between the glenoid variable and coracoid mutation was analyzed,and the correlation between the height of glenoid a and length of the coracoid process d,anteroposterior diameter e and medial-lateral diameter g of coracoid the was low degree(0.3<r<0.5).It was positively correlated with h(r=0.542).There was no correlation with the medial-lateral diameter f of coracoid in the base of coracoid(r=0.249).The height b of the anterior border of the glenoid cavity was correlated with the length d of the coracoid process and medial-lateral diameter h(0.3<r<0.5).There was no correlation(r<0.3)between anteroposterior diameters of the coracoid process e,medial-lateral diameter f,and medial-lateral diameter g of coracoid base.The width c of the glenoid cavity was positively correlated with the length d of the coracoid process,the distance of anteroposterior diameter and medial-lateral diameter of coracoid in the point after 1 cm to the coracoid tip,g and h(0.3<r<0.5).There was no correlation with anteroposterior diameters e,medial-lateral diameter f of-the coracoid process(r<0.3)(correlation coefficient:r,P=0.05).Linear regression analysis(articular variable and beak mutation):d=6.045+0.440a,e=0.859+0.228a,f=7.057+0.191a,g=1.909+0.386a,h=-2.372+0.499a;d =10.646+0.423b,e=6.274+0.095b,f=8.2 1 6+0.218b,g=5.887+0.217b,h=3.028+0.473b;d=11.494+0.497c,e = 8.979-0.021c,f =11.060+ 0.129 c,g=5.699+ 0.287c,h = 6.085+ 0.444c(a:glenoid cavity height,b:glenoid cavity height of front incisure,c:glenoid cavity width,d:coracoid length,e:the distance of anteroposterior diameter of coracoid in the point after 1 cm to the coracoid tip,f:the distance of medial-lateral diameter of coracoid in the point after 1 cm to the coracoid tip,g:the distance of anteroposterior diameter of coracoid in the base of coracoid(coracoid vertical segment),h:the distance of medial-lateral diameter of coracoid in the base of coracoid(coracoid vertical segment),unit:mm).Conclusion Clinically,Latarjet technique and the improvement of surgical treatment of chinese shoulder joint instability ahead,through the glenoid cavity height,glenoid cavity front incisure height,width of glenoid cavity assessment of anatomical configuration is feasible,but because of the coronoid process is a three dimensional irregular bones,and glenoid is a certain variables and coronoid process variables may be unrelated,so use of glenoid cavity univariate assessment coracoid the three-dimensional structure of possible error is bigger,the iatrogenic damage.In this study,it is suggested that the correlation between the glenoid variable and the coracoid mutation amount,and the targeted evaluation of the three dimensional structural variables can greatly improve the accuracy of the anatomic evaluation.The innovation of this study:the first combination of Latarjet and its improved operations core idea,as coracoid osteotomy and glenoid reconstruction,we design glenoid variables(a:glenoid cavity height,b:glenoid cavity height of front incisure,c:glenoid cavity width),and coracoid variables(d:coracoid length,e:the distance of anteroposterior diameter of coracoid in the point after 1 cm to the coracoid tip,f:the distance of medial-lateral diameter of coracoid in the point after 1 cm to the coracoid tip,g:the distance of anteroposterior diameter of coracoid in the base of coracoid(coracoid vertical segment),h:the distance of medial-lateral diameter of coracoid in the base of coracoid(coracoid vertical segment)),to reduce the subjective randomness measurement point selection.Second,first study glenoid cavity through anatomy method of three variables with coracoid correlation and linear regression equation,and put forward the coronoid process and glenoid cavity not all variables corresponding to the variables related to coracoid a variable might not changes over glenoid cavity variables.Third,according to the anatomical morphology of the coracoid process,this study shows that the coracoid process is irregular bone,and the non-traditional rule is long square. |
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