橈骨小頭置換治療MasonⅢ型橈骨小頭骨折的臨床療效觀察

趙加松 扶世杰 汪國友 沈驊睿 曾勝強(qiáng) 郝琦

橈骨小頭置換治療MasonⅢ型橈骨小頭骨折的臨床療效觀察

趙加松 扶世杰 汪國友 沈驊睿 曾勝強(qiáng) 郝琦

目的探討采用橈骨小頭置換治療MasonⅢ型橈骨小頭骨折早期臨床療效。方法對2010年3月至2013年3月我院收治的9例MasonⅢ型橈骨小頭骨折患者予以橈骨小頭置換,采用Broberg和Morrey的肘關(guān)節(jié)功能評分標(biāo)準(zhǔn),評價術(shù)后早期療效。結(jié)果患者全部得到隨訪,術(shù)后隨訪6～36個月,平均19.6個月,優(yōu)5例、良3例、中1例,本組病例隨訪時均未發(fā)現(xiàn)肘關(guān)節(jié)感染、強(qiáng)直或脫位,慢性肘關(guān)節(jié)炎及肘、前臂和腕部長期慢性疼痛等并發(fā)癥。結(jié)論橈骨小頭置換治療MasonⅢ型橈骨小頭骨折早期臨床療效良好,遠(yuǎn)期療效有待進(jìn)一步評價。

橈骨小頭;骨折,粉碎性;置換;治療,臨床研究性

橈骨小頭骨折是肘部常見骨折,為關(guān)節(jié)內(nèi)骨折,約占肘部骨折的17%～19%,約有1/3合并關(guān)節(jié)其他部位損傷[1],其中伴隨肱骨小頭損傷約1%,隨著損傷的加重,其發(fā)生率可達(dá)24%。隨著對橈骨小頭在肘關(guān)節(jié)及前臂穩(wěn)定性的作用認(rèn)識的逐漸深入,在治療方法的認(rèn)識上也逐步明確。MasonⅢ型橈骨小頭骨折治療方法較多,常見的有橈骨小頭切除術(shù)、切開復(fù)位“T”型或“L”微型鋼板等治療方法,然而,常出現(xiàn)肘關(guān)節(jié)不穩(wěn)、慢性長期疼痛、早期內(nèi)固定失敗,骨不連和前臂旋轉(zhuǎn)功能障礙等并發(fā)癥。1941年Speed行橈骨小頭置換術(shù)治療橈骨小頭粉碎性骨折后,多種假體應(yīng)運(yùn)而生,橈骨小頭置換對橈骨小頭粉碎性骨折也是一種較為合適的選擇,它能快速恢復(fù)肘關(guān)節(jié)的穩(wěn)定結(jié)構(gòu)避免長期固定引起關(guān)節(jié)功能障礙、內(nèi)固定失效及骨折不愈合帶來的風(fēng)險[2-3],逐漸成為研究熱點。對2010年3月至2013年3月我院收治9例MasonⅢ型橈骨小頭骨折患者,予以行橈骨小頭置換,恢復(fù)其肘關(guān)節(jié)功能,保持關(guān)節(jié)的活動度及穩(wěn)定性,臨床療效較好,現(xiàn)報道如下:

資料與方法

一、一般資料

2010年3月至2013年3月我院收治9例MasonⅢ型橈骨小頭骨折患者,男性3例、女性6例,年齡24～36歲,平均29.4歲,左側(cè)4例、右側(cè)5例,其中合并內(nèi)側(cè)副韌帶損傷和骨間膜損傷7例、合并尺骨近端骨折2例,急性損傷7例、陳舊性損傷2例。骨折分型參照橈骨小頭骨折Mason分型分類[4],Ⅰ型:橈骨頭或頸骨折,無或微小移位;Ⅱ型:橈骨頭或頸骨折,脫位>2 mm;Ⅲ型:橈骨頭和橈骨頸嚴(yán)重的粉碎性骨折;伴發(fā)肘關(guān)節(jié)脫位及前臂骨間膜損傷的Ⅲ型骨折可稱為Mason JohnstonⅣ型。本組9例均為Ⅲ型。

二、手術(shù)方法

在臂叢或全身麻醉成功后,患肢上臂上止血帶,常規(guī)消毒鋪巾,取肘關(guān)節(jié)Kocher入路切口,長約6～8 cm,逐層切開,于尺側(cè)腕伸肌及肘后肌之間的間隙分離,顯露外側(cè)肘關(guān)節(jié)囊,在顯露過程中應(yīng)保持前臂旋前,以保護(hù)骨間后側(cè)神經(jīng)。在靠近肱二頭肌結(jié)節(jié)處切斷橈骨頸,修整橈骨近側(cè)骨髓腔,用專用髓腔銼打磨,以便假體的植入,平整切除橈骨近端關(guān)節(jié)面,使得橈骨與假體頸之間能完全吻合。用假體作為試模,假體近端的凹面朝向外側(cè),使之與正常橈骨小頭解剖一致,防止脫位。安裝到位后復(fù)位,檢查復(fù)位后穩(wěn)定情況,屈伸有無脫位。如果檢查合適后,沖洗傷口,放入合適假體(采用美國瑞特公司生產(chǎn)的生物型Swanson鈦金屬橈骨小頭假體置換治療),方向是近端關(guān)節(jié)面朝向外側(cè),復(fù)位,再次檢查關(guān)節(jié)穩(wěn)定性,被動活動肘關(guān)節(jié)和前臂時,人工橈骨頭和周圍骨結(jié)構(gòu)或軟組織之間不發(fā)生撞擊,肱骨小頭和假體之間要有良好的接觸,使假體能夠很好的覆蓋在橈骨近端,一般要使假體和肱骨小頭軟骨面之間保持2 mm的間距。肘關(guān)節(jié)不穩(wěn)定的情況下需修復(fù)內(nèi)側(cè)副韌帶,還要修復(fù)關(guān)節(jié)囊、環(huán)狀韌帶以及外側(cè)副韌帶復(fù)合體。沖洗傷口,安放引流管,逐層縫合,術(shù)畢。

三、術(shù)后處理

術(shù)后3 d常規(guī)使用抗生素預(yù)防感染。術(shù)后48 h拔除引流管,局部冰敷。術(shù)后3～5 d即開始被動屈伸活動功能鍛煉,術(shù)后14 d開始主動功能鍛煉,旋轉(zhuǎn)活動必須在屈肘90°的情況下方能進(jìn)行。術(shù)后常規(guī)給予非甾體抗炎藥預(yù)防骨化性肌炎。

四、療效評價標(biāo)準(zhǔn)

根據(jù)患者肘關(guān)節(jié)的活動度、肌力、穩(wěn)定度和疼痛情況,按照Broberg和Morrey的肘關(guān)節(jié)功能評分標(biāo)準(zhǔn)[5]進(jìn)行評分。具體方法:肘關(guān)節(jié)屈伸滿分27分(0.2×肘關(guān)節(jié)屈伸弧),旋前評分滿分6分(0.1×旋前角度),旋后評分滿分7分(0.1×旋后角度)。此處屈伸弧定義為135°,旋前弧為60°,旋后弧為70°。其他評分有力量:正常20分,輕度無力13分,重度無力5分,嚴(yán)重?zé)o力0分;穩(wěn)定性:正常5分,輕度不穩(wěn)活動無受限4分,中度不穩(wěn)部分活動受限2分,嚴(yán)重不穩(wěn)日?；顒邮芟?分;疼痛:無疼痛35分,活動時輕度疼痛無需服用止痛藥28分,活動產(chǎn)生中度疼痛15分,嚴(yán)重疼痛0分。滿分為100分,95～100分為優(yōu),80～94分為良,60～79分為可,0～5分為差。

結(jié) 果

根據(jù)Broberg和Morrey的肘關(guān)節(jié)功能評分標(biāo)準(zhǔn)評定,術(shù)后隨訪6～36個月,平均19.6個月,優(yōu)5例、良3例、中1例,本組病例隨訪時均未發(fā)現(xiàn)肘關(guān)節(jié)感染、強(qiáng)直或脫位,慢性肘關(guān)節(jié)炎及肘、前臂和腕部長期慢性疼痛等并發(fā)癥。

典型病例:患者男性,34歲,為左橈骨小頭陳舊性骨折,傷后3個月出現(xiàn)左肘關(guān)節(jié)疼痛,關(guān)節(jié)活動受限,屈曲約120°,伸直約5°,前臂旋前約70°,旋后約45°。術(shù)后1個月屈曲約135°,伸直約0°,前臂旋前約85°,旋后約70°(圖1～4)。

討 論

肘關(guān)節(jié)的穩(wěn)定系統(tǒng)包括結(jié)構(gòu)性穩(wěn)定系統(tǒng)(或稱靜力穩(wěn)定系統(tǒng))和動力穩(wěn)定系統(tǒng)。Heim將結(jié)構(gòu)性穩(wěn)定系統(tǒng)歸結(jié)為肘關(guān)節(jié)的穩(wěn)定環(huán),由4個柱組成:內(nèi)側(cè)柱、外側(cè)柱、前柱和后柱。前柱包括冠狀突、肱肌、前關(guān)節(jié)囊;后柱包括鷹嘴突、三頭肌、后關(guān)節(jié)囊;內(nèi)側(cè)柱由尺側(cè)副韌帶、冠狀突、內(nèi)髁或內(nèi)上髁組成;外側(cè)柱由橈骨頭、肱骨小頭和橈側(cè)副韌帶組成。如部分破壞時,肘關(guān)節(jié)穩(wěn)定性即下降[6]。

目前,對橈骨小頭生物力學(xué)和解剖學(xué)的研究表明[7],橈骨小頭對肘關(guān)節(jié)外側(cè)柱穩(wěn)定性起著重要的作用,在穩(wěn)定肘關(guān)節(jié)的生物力學(xué)功能中占有極為重要的地位,尤其當(dāng)肘關(guān)節(jié)內(nèi)側(cè)副韌帶和骨間膜損傷時,是肘關(guān)節(jié)抵抗外翻應(yīng)力的重要結(jié)構(gòu),并在Essex-Lopresti損傷時防止橈骨近端移位[8]。既往對無法重建的MasonⅢ、Ⅳ型橈骨小頭粉碎性骨折,常采用橈骨小頭切除術(shù),術(shù)后可能會出現(xiàn)一系列如肘關(guān)節(jié)不穩(wěn)、慢性長期疼痛、外翻強(qiáng)直畸形、異位骨化、創(chuàng)傷性關(guān)節(jié)炎、下尺橈關(guān)節(jié)紊亂、腕尺側(cè)撞擊征等并發(fā)癥。現(xiàn)在已很少選擇此術(shù)式。Businger等[9]采用On-table重建技術(shù)治療橈骨小頭MasonⅢ型骨折取得了良好的臨床效果。該技術(shù)主要是術(shù)中將所有橈骨小頭碎骨塊取出,放于手術(shù)臺上直視下進(jìn)行精確復(fù)位,盡量做到解剖復(fù)位,保證關(guān)節(jié)面平整光滑,有利于骨折的愈合及肘關(guān)節(jié)功能的恢復(fù)。復(fù)位后可通過埋頭螺釘或0.8 mm細(xì)克氏針行臨時固定,將所有骨折塊固定為一個整體,構(gòu)建大體框架[10]。后將橈骨小頭用事先預(yù)彎好的微型鋼板固定于橈骨上,鋼板置于后外側(cè)“安全區(qū)”(橈骨小頭頭頸外側(cè)約110°的區(qū)域有一弧形“非關(guān)節(jié)面”,此處不參與關(guān)節(jié)構(gòu)成)[11],注意橈骨的旋轉(zhuǎn)功能不能受限,術(shù)中鋼板放置的位置是否恰當(dāng)是手術(shù)成功的關(guān)鍵。本手術(shù)操作要求較高,骨折塊較小,復(fù)位骨折不能反復(fù)操作,以免造成更嚴(yán)重的骨折,從而影響其穩(wěn)定性及復(fù)位效果。也正因為骨折塊多,固定有限,術(shù)后常需功能位石膏托固定,短期內(nèi)不能功能鍛煉,不利于關(guān)節(jié)功能恢復(fù)。劉麟等[12]對55例MasonⅢ型橈骨小頭骨折患者采取切開復(fù)位內(nèi)固定術(shù),術(shù)后采用Broberg和Morrey的肘關(guān)節(jié)功能評分標(biāo)準(zhǔn)評定療效,優(yōu)良率為85.5%。Cai等[13]對9例復(fù)雜MasonⅢ型橈骨小頭骨折患者采取切開復(fù)位微型鋼板內(nèi)固定治療,隨訪結(jié)果顯示優(yōu)良率僅為22%。在切開復(fù)位組中,23例患者中有1例發(fā)生骨不連,2例發(fā)生較嚴(yán)重的異位骨化,3例發(fā)生內(nèi)固定失敗,嚴(yán)重影響關(guān)節(jié)功能,優(yōu)良率僅65.2%。作者認(rèn)為,對于不穩(wěn)定、粉碎性橈骨小頭骨折,內(nèi)固定失效概率較高,應(yīng)慎重考慮。

圖1～4 手術(shù)前后正側(cè)位X線片。圖1橈骨小頭骨折,關(guān)節(jié)面塌陷,關(guān)節(jié)間隙增大;圖2橈骨小頭置換術(shù)后,假體位置準(zhǔn)確,無松動,關(guān)節(jié)間隙可;圖3橈骨小頭骨折,骨折線波及關(guān)節(jié)面;圖4橈骨小頭置換術(shù)后假體位置準(zhǔn)確,關(guān)節(jié)間隙正常

對于橈骨小頭置換治療橈骨小頭MasonⅢ型骨折,解決了橈骨小頭切除后的諸多并發(fā)癥,恢復(fù)了橈骨頭、頸解剖上的完整性,肘關(guān)節(jié)在生物力學(xué)上的平衡,加上術(shù)后早期主、被動功能鍛煉,往往能取得良好的治療效果。本組病例隨訪時均未發(fā)現(xiàn)肘關(guān)節(jié)感染、強(qiáng)直或脫位,慢性肘關(guān)節(jié)炎及肘、前臂和腕部長期慢性疼痛等并發(fā)癥。另外,術(shù)中經(jīng)常發(fā)現(xiàn)術(shù)前影像學(xué)檢查以為是簡單的骨折,術(shù)中卻很粉碎,給復(fù)位帶來困難,影響術(shù)后療效,有研究表明[14]:對于骨塊多于3塊者,切開復(fù)位失效率較高,常需要延期行橈骨頭切除術(shù)或橈骨小頭置換術(shù)。這不但增加了患者治療費(fèi)用和手術(shù)次數(shù),而且也在一定程度上相應(yīng)的影響臨床療效。目前多數(shù)認(rèn)同的適應(yīng)證:(1)MasonⅣ型骨折;(2)MasonⅢ型骨折難以作內(nèi)固定者;(3)橈骨小頭骨折合并尺骨上端骨折,尤其合并肘內(nèi)側(cè)副韌帶損傷導(dǎo)致的肘關(guān)節(jié)不穩(wěn);(4)陳舊性骨折或經(jīng)橈骨頭切除后出現(xiàn)明顯前述并發(fā)癥患者;(5)肘關(guān)節(jié)其他疾病影響功能者,如類風(fēng)濕性關(guān)節(jié)炎、腫瘤及先天性畸形等[15]。術(shù)中應(yīng)注意:(1)橈骨頸截骨的高度,根據(jù)假體試模做出正確判斷,避免過度截骨;(2)假體與肱骨小頭關(guān)節(jié)面的間隙以2 mm左右為佳,避免被動活動肘關(guān)節(jié)時發(fā)生撞擊;(3)如果伴有尺側(cè)副韌帶損傷的,應(yīng)予以修復(fù),恢復(fù)關(guān)節(jié)穩(wěn)定性;(4)有橈骨小頭置換適應(yīng)證的患者應(yīng)盡早一期置換,避免多次手術(shù)導(dǎo)致瘢痕攣縮影響關(guān)節(jié)功能及增加異位骨化風(fēng)險。目前橈骨小頭置換治療橈骨小頭粉碎性骨折的臨床報道較少,與切開復(fù)位內(nèi)固定的治療方法存在爭議,王思成等[16]采用前瞻性隨機(jī)對照分析45例不穩(wěn)定性粉碎性橈骨小頭骨折病例,予以橈骨小頭置換和切開復(fù)位內(nèi)固定治療,比較兩組Broberg和Morrey的肘關(guān)節(jié)功能評分和并發(fā)癥發(fā)生率,結(jié)果假體置換組Broberg和Morrey的肘關(guān)節(jié)功能評分平均90.1分,并發(fā)癥發(fā)生率13.6%,切開復(fù)位組Broberg和Morrey的肘關(guān)節(jié)功能評分平均76.8分,并發(fā)癥發(fā)生率47.9%,兩組比較差異有統(tǒng)計學(xué)意義(P<0.01)。與切開復(fù)位內(nèi)固定治療相比較,橈骨小頭置換治療不穩(wěn)定性粉碎性骨折可獲得更好的關(guān)節(jié)功能和更低的并發(fā)癥發(fā)生率。劉鵬程等[17]搜集MasonⅢ型橈骨頭骨折假體置換及切開復(fù)位內(nèi)固定的對照研究并加以系統(tǒng)評價。用Revmen 5.1統(tǒng)計學(xué)軟件進(jìn)行異質(zhì)性分析及Meta分析。假體置換組與切開復(fù)位內(nèi)固定組相比,均有明顯優(yōu)勢?，F(xiàn)有的有限證據(jù)表明,通過優(yōu)良率、肘關(guān)節(jié)功能評分及并發(fā)癥評價證實,人工假體置換治療MasonⅢ型橈骨小頭骨折較切開復(fù)位內(nèi)固定具有更大優(yōu)勢,且差異具有統(tǒng)計學(xué)意義。

當(dāng)然,橈骨小頭置換術(shù)治療橈骨小頭MasonⅢ型骨折,也存在假體松動、磨損及組織相容性等問題,這些仍需要長期臨床隨訪及大樣本的臨床研究,但我們相信,隨著科學(xué)技術(shù)的發(fā)展,假體設(shè)計及手術(shù)技術(shù)的改進(jìn),橈骨小頭置換的臨床療效也會更好。

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The preliminary clinical efficacy of treatment for Mason type-Ⅲradial head fractures with radial head arthroplasty

Zhao Jiasong,Fu Shijie,Wang Guoyou,Shen Huarui,Zeng Shengqiang,Hao Qi.Department of Orthopedics,Hospital of Traditional Chinese Medicine,Luzhou Medicine College,Luzhou 646000,China

BackgroundComminuted radial head fractures were difficult to treat with open reduction and internal fixation.Radial head arthroplasty was a favourable technique for the treatment of complex radial head fractures.The purpose of this study was to evaluate the early clinical efficacy of radial head arthroplasty for the treatment of Mason type-Ⅲradial head fractures.MethodsWe retrospectively reviewed 9 patients who suffered from Mason type-Ⅲradial head fractures requiring radial head arthroplasty between March 2010 and March 2013.In these nine patients,There were 6 female and 3 male with mean age 29.4(24-36 years),7 patients combined with medial collateral ligament injury and interosseous membrane damage,two patients combined fractures of the proximal ulna.According to Mason classification,Fractures of the radial head had been classified as follow,typeⅠ:radial head or neck fracture,with no or minimal displacement;TypeⅡ:radial head or neck fracture,fracture displacement>2 mm;TypeⅢ:Severe comminuted radial head and radial neck fractures;Type IV:If the patients associated with dislocation of the elbow and forearm interosseous membrane damage,the typeⅢfractures may be referred to Mason Johnston type IV.All of the nine patients were Mason Johnston typeⅢ.Surgical technique as follows:After the success of the brachial plexus or general anesthesia,a tourniquet was tied up to the ipsilateral arm,then the routine disinfection and draping were performed.We used the Kocher approach to open the skin and subcutaneous tissue,the incision was about 6～8 cm,Then,through the interval between the anconeus and the extensor carpiulnaris(ECU)to expose the lateral capsule of the elbow.During the operation,the forearm pronation should be kept to protect the posterior interosseous nerve.Identified the head fracture,and we removed all fragments of the unreconstructable head.A cutting guide was used in order to achieve a good resection,which must be perpendicular to the axis of the radius.Theparts of the broken head were reassembled on the table to ensure that the whole head had been resected and to choose the size of the prosthetic head.After resection of the radial head,the radial shaft was prepared.Then the trial stem was introduced and left temporarily in place.The positioning and height of the prosthesis are essential for the success of the implantation.The head had to reach the limit between the trochlear notch and the radial notch of the ulna.X-rays were performed to check proper choice of the elements sizes,the positioning of the neck and the height of the prosthesis.The proximal concave of the trial prosthesis is toward lateral side,so that the direction of the trial prosthesis was unanimous with the normal anatomy of the radial head.After installation of the trial prosthesis,reset the elbow joint,then checked the stability.If the size and the position were appropriate,the trial prosthesis was removed and the wound was irrigated.After removal of trial elements,the suitable Swanson prosthesis was inserted.Direction was toward the outside of the proximal articular surface,reset,check the joint stability again,passive elbow and forearm,and make sure there were no collision occured between the artificial radial head and surrounding soft tissue or bone structure,the contact between the humeral head and prosthesis must be good,so that the prosthesis can be well covered in the proximal radius,The height of the implant must keep 2 mm spacing between the prosthesis and the humeral head cartilage surface.If an anterior capsule tearing or annular ligament and lateral collateral ligament complex injury were present,the surgeon repaired it at this time.Then washed the wound,placed drainage tube,sutured the incision.Antibiotics were routinely used to prevent infection after surgery.The drainage tube would be removed within 48 hours,ice compress was used to release local edema.Passive range of motion exercise was peformed 3～5 days after surgery,active motion of the elbow joint was allowed 14 days after surgery,rotational activities must be carried out under conditions of 90 degrees of elbow flexion.The non-steroidal anti-inflammatory drugs were given to prevent myositis ossificans postoperatively.Functional outcomes were assessed by the Broberg and Morrey elbow function grading standards.ResultsAll of the 9 patients were performed 6-36 months follow-up,The mean follow-up time was 19.6 months.Five patients had an excellent result;3,a good result;and 1,a fair result,according to the Broberg and Morrey elbow functional grading standards.During the follow-up,we did not find any postoperative complications,such as elbow dislocation,infection,stiffness,or chronic arthritis and elbow,chronic pain of forearm and wrist.DiscussionTreatment of comminuted fractures of the radial head was controversial,and considerable effort has been made to restore optimal function of the elbows,either by surgical repair or prosthetic replacement.Radial head arthroplasty was an acceptable option when treating Mason type-Ⅲradial head fractures,and the early clinical curative effect was good.But a larger group of patients and a longer follow-up period will be required in order to estimate the long-term curative effect.However,none of the patients who underwent this procedure showed any complications during follow-up.

Radial head arthroplasty;Radial head prosthesis;Comminuted radial head fractures

Fu Shijie,Email:Fu-fsj@sina.com

2014-06-13)

(本文編輯:李靜)

10.3877/cma.j.issn.2095-5790.2014.04.006

四川省科技廳基金(2010HH0054)

646000 瀘州醫(yī)學(xué)院附屬中醫(yī)醫(yī)院骨關(guān)節(jié)科

扶世杰,Email:Fu-fsj@sina.com

趙加松,扶世杰,汪國友,等.橈骨小頭置換治療MasonⅢ型橈骨小頭骨折的臨床療效觀察[J/CD].中華肩肘外科電子雜志,2014,2(4):235-239.