自體掌長肌移植重建喙鎖韌帶結(jié)合帶線錨釘固定治療肩鎖關(guān)節(jié)脫位的療效

羅吉偉 余斌 魏寬海 覃承訶 胡巖君

自體掌長肌移植重建喙鎖韌帶結(jié)合帶線錨釘固定治療肩鎖關(guān)節(jié)脫位的療效

羅吉偉 余斌 魏寬海 覃承訶 胡巖君

目的觀察自體掌長肌移植重建喙鎖韌帶結(jié)合帶線錨釘固定治療肩鎖關(guān)節(jié)脫位的治療效果。方法自2011年5月至2012年5月，收治Rockwood分型Ⅲ度以上的肩鎖關(guān)節(jié)脫位患者30例，以自體掌長肌移植重建喙鎖韌帶，強(qiáng)生帶線錨釘固定維持鎖骨于復(fù)位狀態(tài)，觀察療效，包括X線片檢查復(fù)位效果及Rockwood肩關(guān)節(jié)功能評(píng)分。結(jié)果術(shù)后對(duì)30例患者進(jìn)行隨訪，平均隨訪16個(gè)月，術(shù)后12個(gè)月的患肢肩關(guān)節(jié) Rockwood評(píng)分，優(yōu) 25例（83．33%），良 4例（13．33%），可 1例（3．33%），差0例（0%），優(yōu)良率96．7%。結(jié)論自體掌長肌移植重建喙鎖韌帶結(jié)合帶線錨釘固定治療肩鎖關(guān)節(jié)脫位效果優(yōu)良，可成為治療肩鎖關(guān)節(jié)脫位的一種較好的選擇。

肩鎖關(guān)節(jié)脫位； 掌長??； 重建； 帶線錨釘

肩鎖關(guān)節(jié)脫位臨床上較為多見，是否選擇手術(shù)治療，應(yīng)根據(jù)患者損傷的類型、程度、癥狀、年齡、職業(yè)、運(yùn)動(dòng)要求等因素綜合判定。肩鎖關(guān)節(jié)脫位按Rockwood分型分為6型（度），一般認(rèn)為癥狀明顯的Ⅲ度以上損傷是重要的手術(shù)指征［1－2］。肩鎖關(guān)節(jié)脫位的手術(shù)治療關(guān)鍵在于復(fù)位后，選擇合適方法對(duì)肩鎖關(guān)節(jié)或喙鎖之間進(jìn)行固定，內(nèi)固定的選擇較多，如克氏針張力帶、鎖骨鉤鋼板或解剖鋼板固定肩鎖關(guān)節(jié)；空心螺釘、鋼絲、帶線錨釘固定喙鎖［3－8］。在選擇這些固定手術(shù)時(shí)，可結(jié)合肩鎖關(guān)節(jié)的清理、鎖骨遠(yuǎn)端的切除或喙鎖韌帶的縫合或重建等［6－7］。這些術(shù)式大部分獲得較好的效果，但也有內(nèi)固定失效、移位以及內(nèi)固定取出后再脫位等問題發(fā)生。鑒于喙鎖韌帶對(duì)于肩鎖關(guān)節(jié)穩(wěn)定性的重要意義，近年來學(xué)者們對(duì)喙鎖韌帶修復(fù)重建逐漸予以重視，修復(fù)方法包括直接縫合、局部韌帶移位、自體肌腱移植、異體肌腱移植等。我們在臨床中選擇了一種損傷小、技術(shù)簡便的自體掌長肌移植重建喙鎖韌帶，結(jié)合帶線錨釘復(fù)位固定治療肩鎖關(guān)節(jié)脫位，取得滿意療效。

資料與方法

一、一般資料

2011年5月至2012年5月，本院共收治30例Rockwood分型Ⅲ、Ⅳ或Ⅴ型肩鎖關(guān)節(jié)脫位的患者，其中Ⅲ型18例，Ⅳ型1例，Ⅴ型11例；男性23例，女性7例；右側(cè)20例，左側(cè)10例；年齡17～55歲（平均31歲）。所有患者均為單純的肩鎖關(guān)節(jié)脫位，無合并骨折與神經(jīng)血管損傷者；其中交通傷28例，擊打傷2例。所有患者均為新鮮損傷，就診時(shí)均有肩鎖關(guān)節(jié)疼痛、畸形、活動(dòng)受限及浮動(dòng)感等體征，且既往無肩鎖關(guān)節(jié)脫位史。均行術(shù)前X線片或MRI確診為肩鎖關(guān)節(jié)完全性脫位。平均手術(shù)時(shí)間為傷后8．2d（3～20d）。

二、手術(shù)方法

采用氣管插管全身麻醉，沙灘椅臥位，患肩墊高，頭部轉(zhuǎn)向健側(cè)。沿著喙突向上，做4cm的縱行切口，切開皮膚、皮下組織，顯露肩鎖關(guān)節(jié)、喙突、鎖骨中遠(yuǎn)段，在復(fù)位前將關(guān)節(jié)內(nèi)碎裂軟骨盤及軟組織清除干凈，根據(jù)局部損傷情況，必要時(shí)可行鎖骨遠(yuǎn)端部分切除術(shù)（切除5mm左右）。在證實(shí)喙鎖韌帶斷裂無法縫合后，則暫時(shí)止血覆蓋傷口。（1）掌長肌切?。和瑐?cè)上肢，腕正中捫及掌長肌，在腕部做1～1．5cm的縱行切口，暴露并向近端沿皮下分離掌長肌，在分離至上臂近端預(yù)定切斷肌腱的位置，做另1cm的縱行切口，切斷抽出掌長肌。根據(jù)長度，可將肌腱對(duì)折2～3折備用。（2）喙鎖韌帶重建：鎖骨中遠(yuǎn)端韌帶殘跡處做2骨道，為防止骨折，兩骨道間距不少于1cm。在喙突中部兩側(cè)各置入一枚直徑5．0mm的帶線錨釘，將備用的掌長肌，自喙突下方繞過，兩端與錨釘縫線一起分別穿出鎖骨上的骨道，在鎖骨上方行肌腱縫合與縫線打結(jié)。在收緊打結(jié)時(shí)，注意鎖骨上方加壓，使肩鎖關(guān)節(jié)充分復(fù)位。透視證實(shí)肩鎖關(guān)節(jié)復(fù)位滿意后，沖洗縫合傷口。

三、術(shù)后處理

術(shù)后頸腕吊帶懸吊患肢2周，傷口疼痛緩解后即指導(dǎo)患者做肩關(guān)節(jié)被動(dòng)功能鍛煉，6周內(nèi)關(guān)節(jié)被動(dòng)活動(dòng)只限于外展、屈曲90°以內(nèi)，允許內(nèi)外旋，6周以后可以逐漸開始全關(guān)節(jié)范圍的主動(dòng)活動(dòng)。術(shù)后1周、1個(gè)月、3個(gè)月、6個(gè)月和12個(gè)月時(shí)門診復(fù)查X線片，并評(píng)定肩關(guān)節(jié)功能。

四、療效評(píng)定

記錄患者的平均手術(shù)時(shí)間及術(shù)中出血量。療效根據(jù)術(shù)后肩關(guān)節(jié)X線正位片檢查關(guān)節(jié)復(fù)位情況，肩關(guān)節(jié)功能根據(jù)Rockwood評(píng)分法［1］進(jìn)行評(píng)定，該評(píng)分系統(tǒng)包括：（1）疼痛：無3分，輕微2分，中度1分，嚴(yán)重0分；（2）活動(dòng)范圍：正常3分，輕微受限（＜25%）2分，中度受限（25%～50%）1分，重度受限（＞50%）0分；（3）肌力：正常3分，輕微減弱（＜25%）2分，中度減弱（25%～50%）1分，嚴(yán)重減弱（＞50%）0分；（4）日?；顒?dòng)受限：無3分，輕微2分，中度1分，嚴(yán)重0分；（5）主觀結(jié)果：優(yōu)3分，良2分，可1分，差0分?？偡?3～15分為優(yōu)，10～12分為良，7～9分為可，7分以下為差。

結(jié) 果

本組患者平均手術(shù)時(shí)間為65min（40～90min）、術(shù)中平均出血量70ml（50～100ml）。術(shù)后隨訪12～22個(gè)月，平均16個(gè)月。所有患者術(shù)后外觀均獲得改善，無局部隆起、腫脹等。根據(jù)Rockwood評(píng)分法，術(shù)后關(guān)節(jié)功能優(yōu)25例，良4例，可1例，差0例，優(yōu)良率96．7%。所有病例無感染，2例術(shù)后3個(gè)月的X線片出現(xiàn)肩鎖關(guān)節(jié)向上半脫位，但外觀無異常，該2例患者至術(shù)后1年復(fù)查X線片，關(guān)節(jié)脫位無繼續(xù)加重。

討 論

肩鎖關(guān)節(jié)脫位臨床上并不少見，治療的方法較多，手術(shù)適應(yīng)證存在爭議［1，7］。喙鎖韌帶對(duì)于維持肩鎖關(guān)節(jié)的穩(wěn)定性有重要意義。Rockwood分型Ⅲ度以上的損傷喙鎖韌帶均已斷裂，保守治療患者可能會(huì)遺留不同程度的外觀異常、疼痛、上肢肌力減弱，且保守治療需要較長時(shí)間的外固定，可能導(dǎo)致關(guān)節(jié)僵硬。因此對(duì)于年輕及對(duì)上肢活動(dòng)能力有一定要求的Ⅲ度以上患者，手術(shù)治療是較好的選擇。目前治療肩鎖關(guān)節(jié)脫位的手術(shù)方法較多，固定肩鎖關(guān)節(jié)的方法有鎖骨鉤鋼板、解剖鋼板和克氏針張力帶等。將鎖骨與喙突固定的方法有螺釘、帶線錨釘、Endobutton、鋼絲捆綁等。據(jù)文獻(xiàn)報(bào)道［8］，這些方法大都能取得較好的臨床效果，但也有較多的并發(fā)癥。如內(nèi)固定的松動(dòng)、移位、斷裂、撞擊等。為了減少內(nèi)固定的并發(fā)癥，需要在局部軟組織瘢痕愈合后，盡早取出內(nèi)固定。而內(nèi)固定取出后，關(guān)節(jié)發(fā)生再脫位的報(bào)道也并不少見。因此，一期縫合或重建喙鎖韌帶，并非單純使其瘢痕愈合，而重要的是能夠獲得更好的生物力學(xué)穩(wěn)定性。

圖1 男性，43歲，摔傷致右側(cè)肩鎖關(guān)節(jié)脫位 圖A為術(shù)前X線片示肩鎖關(guān)節(jié)脫位；圖B為術(shù)后X線片示肩鎖關(guān)節(jié)復(fù)位情況

喙鎖韌帶斷裂后較難縫合。重建喙鎖韌帶的經(jīng)典術(shù)式，如喙肩韌帶移位，由于對(duì)局部軟組織造成進(jìn)一步損傷，且較難做到解剖點(diǎn)重建，存在應(yīng)用的局限性［78］。異體肌腱移植可以做到解剖附麗點(diǎn)重建，但有感染、排斥、不愈合的風(fēng)險(xiǎn)。應(yīng)用自體掌長肌移植重建喙鎖韌帶，其優(yōu)點(diǎn)：（1）肌腱切取方便、微創(chuàng)，手術(shù)時(shí)只需要消毒同側(cè)上肢即可；（2）作為喙鎖韌帶的移植物，該肌腱大小、長度較為合適；（3）與喙肩韌帶移位等術(shù)式相比，掌長肌移植可較好的選擇附麗點(diǎn)，使韌帶接近解剖位置重建；（4）相對(duì)于異體肌腱，自體肌腱移植沒有排斥風(fēng)險(xiǎn)，可較好地愈合，感染風(fēng)險(xiǎn)小；（5）供區(qū)的功能損失可以忽略不計(jì)。其缺點(diǎn)：（1）部分患者掌長肌缺如，或特別細(xì)小；（2）術(shù)前需要留意查體。

帶線錨釘?shù)氖褂脼殛P(guān)節(jié)提供相對(duì)的穩(wěn)定性和活動(dòng)度，這樣可防止剪切力過大，導(dǎo)致重建的韌帶愈合前松弛，同時(shí)也為關(guān)節(jié)盤和其他軟組織的愈合提供時(shí)間。與單獨(dú)的韌帶重建或縫合相比，結(jié)合應(yīng)用帶線錨釘內(nèi)固定，術(shù)后只需要行簡單的懸吊固定，且可以早期進(jìn)行功能鍛煉，避免關(guān)節(jié)僵硬。應(yīng)用帶線錨釘作為內(nèi)固定材料的優(yōu)點(diǎn)：（1）使用方便，術(shù)野不需大面積暴露，內(nèi)固定占用空間小；（2）縫線提供的是非剛性固定，保留了肩鎖關(guān)節(jié)微動(dòng)的生理狀態(tài)。由于帶線錨釘不是剛性固定，術(shù)中收緊打結(jié)時(shí)，需要控制好鎖骨的位置，移植肌腱的張力。本組所有病例術(shù)后的X線片都顯示肩鎖關(guān)節(jié)復(fù)位良好，但有2例術(shù)后3個(gè)月出現(xiàn)鎖骨向上的半脫位。這可能是術(shù)中肌腱移植物與錨釘縫線的張力控制欠佳，縫線未充分拉緊，鎖骨的穩(wěn)定性依靠肌腱維持，經(jīng)過功能鍛煉，移植物在充分愈合前受到牽拉，出現(xiàn)了遲發(fā)型松弛。

該組病例聯(lián)合帶線錨釘與自體掌長肌移植治療Ⅲ度以上的肩鎖關(guān)節(jié)脫位，可以使兩種術(shù)式的優(yōu)點(diǎn)結(jié)合起來，最大限度地減少了兩種術(shù)式的不足，提高了成功率，經(jīng)臨床隨訪證明為一種有效的手術(shù)方法，而且方法簡便、創(chuàng)傷較小，可早期恢復(fù)正常的功能。本組病例樣本量較少，后期需要大量病例的積累和觀察。

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Transplantation of autogenous palmaris longus tendon combined with suture anchor fixation in the treatment of aromioclavicular dislocations

Luo Jiwei，Yu Bin，Wei Kuanhai，Qin Chenghe，Hu Yanjun．Department of Orthopedic and Traumatology，the First Affiliated Hospital of Southern Medical University，Guangzhou 510515，China

BackgroundClinically，acromioclavicular dislocation is a common disease．Whether surgical treatment should be taken or not depends on the type and degree of the injury，as well as the symptoms，ages，occupation，exercise requirements，and other factors of patients．Acromioclavicular dislocation can be classified as six types（degrees）according to Rockwood．The injury with obvious symptoms aboveⅢ degree is generally considered as an important operation indication．The key point in the surgical treatment of acromioclavicular dislocation is to select appropriate methods for the acromioclavicular joint fixation after reduction．There are many choices of the internal fixation to fix the acromioclavicular joint，such as the Kirschner wire and tension band，the clavicular hook plate or anatomical plate for the coracoclavicular joint fixation，and the cannulated screws，steel wires or suture anchors for the coracoclavicular fixation．The selection of these fixations can be combined with debridement of the acromioclavicular joint，the distal clavicle resection，or stitching and reconstruction of the coracoclavicular ligament．Most of these surgical procedures have obtained better results．However，the internal fixation failure，displacement or dislocation after the fixation removal sometimes happened．Considering that the coracoclavicular ligament plays an important role for the acromioclavicular joint stability，researchers has gradually paid more attentions to the reconstruction of the coracoclavicular ligament recently．The repair methods include the direct suture，the partial ligament displacement，the autologous tendon graft，and the tendon graft transplantation．We chose a simple，less traumatic method for the acromioclavicular dislocations，which is autogenous palmaris longus muscle transplant combined with the suture anchor fixation，and achieved satisfactory results．Methods（1）General information：A total of 30cases aged from 17to 55years （mean 31years）with acromioclavicular dislocations of Rockwood typeⅢ，ⅣorⅤ were collected in our study，including 18 cases of typeⅢ，1case of typeⅣand 11cases of typeⅤ．Among all the 30cases，23are males and 7 are females，and 20cases with the right sides and 10cases with the left sides．All patients suffered anacromioclavicular dislocation without fracture and neurovascular injury，28cases of which got injured due to the traffic accident and 2cases owing to hitting．All patients had fresh injuries，and as well as the symptoms of acromioclavicular joint pain，deformity，limited mobility and floating feelings when treated．Preoperative X－rays or MRIs were performed to make the diagnosis that all the patients had a complete acromioclavicular dislocation．The mean time of the operation was 8．2d（3－20d）after injury．（2）Surgical methods：General anesthesia was performed using tracheal cannula．Patients lied on the beach chairs in a supine position and turned their head to the healthy side，and the suffering shoulder was blocked up．Make 4cm longitudinal incision along the coracoid，cut the skin and the subcutaneous tissue，reveal the acromioclavicular joint，the coracoid and mid－distal of the collarbone，remove the intra－articular cartilage fracture fragments and soft tissues before reduction and resect the partial distal clavicle if necessary according to the injury （excision of about 5mm）．Stop bleeding and cover the wound temporarily after the confirmation of the inability to suture the coracoclavicular ligament rupture．（1）The palmaris longus muscle cut：touch the palmaris longus at the center of the wrist in the ipsilateral upper extremity，and make a longitudinal incision from 1to 1．5cm at the wrist，and then the palmaris longus is exposed and separated proximally along the subcutaneous．Make another 1cm longitudinal incision on the predetermined cutting position of the tendon of the proximal muscles in the upper arm，and cut and extract the palmaris longus．The tendon can be folded 2－3folds back according to its length．（2）The coracoclavicular ligament reconstruction：make two bone tunnels at the ligament remnants of the distal clavicle，and ensure that the distance of these two bone tunnels is at least 1cm to prevent fractures．Screw a suture anchor with diameters of 5．0mm on both sides of the coronoid process．Make the prepared palmaris longus bypass the beneath of the coracoid process，pierce the two ends of the palmaris longus together with suture anchors along the bone tunnel of the clavicle，and carry out the tendon suture and suture knot above the clavicle．When tightening the knot，pay attention to the exert pressure above the clavicle to make a full reset of the acromioclavicular joint．After the satisfactory reduction of acromioclavicular joint through X－ray fluoroscopy，wash and suture the wound．The mean operative time was 65min （40－90min），and the mean intraoperative blood loss was 70ml（50－100ml）．（3）Postoperative treatment：After the operation，hang the limb using the neck wrist strap for two weeks．Guide patients to do the shoulder passive functional exercise after the relief of the wound pain．Begin active functional exercise at 6weeks after the operation．The patients should be reviewed with both X－ray and functional evaluation at one week，one month，3months，6months and 12months postoperatively．（4）Efficacy assessment：Record the average operative time and the blood loss of patients．Make the efficacy assessment according to the X－ray examination of the joint reset condition and the Rockwood shoulder function assessment score．ResultsThe patients in this study were followed up for 12to 22months （mean 16months）．The appearances of all patients were improved without the local uplift and swelling．According to the Rockwood shoulder score，25cases got excellent function and 4good，1basically qualified．None case had poor result．The excellent and good rate was 96．7% ．All patients had no infection．The cromioclavicular joint subluxation without abnormal appearance occurred in two cases observed through X－ray 3months after the operation，and two patients had no exacerbated dislocation according to the X－ray examination at 1year after the operation．Conclusions The acromioclavicular joint dislocation is common in the clinic．There are many treatment methods for the acromioclavicular joint dislocation．The coracoclavicular ligament is important to maintain the acromioclavicular stability．Coracoclavicular ligaments are broken in the over Rockwood typeⅢ degree injuries．The patients may have varying degrees of abnormal appearance，pain，upper limb muscle weakness，external fixation after the conservative treatment．And the conservative treatment requires a long time，which may lead to joint stiffness．So surgical treatment is a better choice for the young and those with overⅢdegree injuries who have higher requirements of the upper limb activity．Currently，there are many surgical methods for the acromioclavicular joint dislocations．Acromioclavicular joint fixation methods are clavicular hook plate，anatomical plate，tension band and so on．The clavicle and coracoid fixation methods are screw，anchors with wire，Endobutton and wire bundling．According to reports，most of these methods can achieve better clinical results，but there are more complications，such as the internal fixation loosening，displacement，fracture，impact and so on．In order to reduce the fixation complications，the internal fixation need to be removed as soon as possible after the local soft tissue scar healed．And after the fixation removal，the reports of re－dislocation of the joint are not uncommon．Therefore，the primary suture or coracoclavicular ligament reconstruction，rather than making a scar to heal，is theoretically able to get a better biomechanical stability．The treatment of aromioclavicular dislocations with autogenous palmaris longus muscle transplant combined with fixation by the suture anchor has its advantages：（1）It is convenient and minimally invasive to cut off the palmaris longus，and surgery is only needed to disinfect the ipsilateral upper extremity；（2）As the coracoclavicular ligament graft，the tendon size and length are more appropriate；（3）Compared with the other surgical methods，the palmaris longus muscle transplantation is a better choice for the reattachment point so close to the anatomical location of the ligament reconstruction；（4）With respect to the tendon allograft，the autologous tendon graft does not have better healing and less risk of infection；（5）The functional loss for the supply area is negligible．Disadvantages：（1）The palmaris longus of some patients is agenesis or special small；（2）It is need to pay attention to do the preoperative examination．The suture anchor provides the relative stability and activity of the joint，which prevents excessive shear forces to cause the relaxation of ligament reconstruction before healing，and also provides time for the articular disk and other soft tissue to heal．Compared with the separate ligament reconstruction or suture，the combination with the application of the suture anchor fixation requires only a simple suspension after surgery，as well as make the patients do early functional exercise to avoid joint stiffness．Applications with wire anchors as the fixation material has some advantages：（1）It is easy to use，and did not need a lot of exposure of the operative field and a small fixed space；（2）The suture provides a non－rigid fixation which retains the fretting physiological state of the acromioclavicular joint．The treatment of the over Ⅲacromioclavicular joint dislocation for the group of patients with suture anchors and autologous palmaris longus transplantation，can combine advantages of the two surgery，minimize the lack of two surgical procedures，and improve the success rate．It has been proved to be an effective surgical method by the clinical follow－up．Moreover，its application is easy，and it has less trama and help joints early return to the normal function．The samples of patients in this study are not much，we need to accumulate a large number of cases and observation in the future．

Aromioclavicular dislocations； Palmaris longus muscle； Reconstruction； Suture anchor

Yu Bin，Email：yubinol＠163．com

2013－07－29）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．01．006

510515 廣州，南方醫(yī)科大學(xué)南方醫(yī)院創(chuàng)傷骨科

余斌，Email：yubinol＠163．com

羅吉偉，余斌，魏寬海，等．自體掌長肌移植重建喙鎖韌帶結(jié)合帶線錨釘固定治療肩鎖關(guān)節(jié)脫位的療效觀察［J／CD］．中華肩肘外科電子雜志，2014，2（1）：28－32．