肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療RockwoodⅢ型肩鎖關(guān)節(jié)脫位的療效研究

李奉龍 姜春巖

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肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療RockwoodⅢ型肩鎖關(guān)節(jié)脫位的療效研究

李奉龍 姜春巖

目的 分析采用肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的臨床療效。方法 回顧性研究2013年2月至2014年1月連續(xù)收治并獲得隨訪的21例Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者的資料。其中男性17例，女性4例。平均年齡42.8歲，平均受傷到手術(shù)時(shí)間11.1 d。所有患者均于肩關(guān)節(jié)鏡下應(yīng)用同種異體肌腱重建喙鎖韌帶并高強(qiáng)度縫線捆扎固定喙鎖間隙治療肩鎖關(guān)節(jié)脫位。術(shù)后定期隨訪，記錄患側(cè)肩關(guān)節(jié)活動(dòng)范圍，并采用疼痛視覺模擬評(píng)分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)評(píng)分及UCLA(university of California Los Angeles)評(píng)分評(píng)價(jià)患者肩關(guān)節(jié)功能狀況；同時(shí)拍攝肩關(guān)節(jié)正位、側(cè)位及腋位X線片，評(píng)估是否有肩鎖關(guān)節(jié)復(fù)位丟失。結(jié)果 21例患者術(shù)后平均隨訪(14.6±3.9)個(gè)月。末次隨訪時(shí)肩關(guān)節(jié)平均前屈上舉為173.9°±10.3°，體側(cè)外旋為59.5°±14.3°，內(nèi)旋為第12胸椎體水平，平均UCLA評(píng)分為(34.1±2.5)分，平均ASES評(píng)分為(95.5±4.7)分，平均VAS評(píng)分(0.3±0.6)分。末次隨訪拍攝肩關(guān)節(jié)X線片未發(fā)現(xiàn)肩鎖關(guān)節(jié)復(fù)位丟失。結(jié)論 采用肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的臨床療效滿意，患者術(shù)后可獲得良好的肩關(guān)節(jié)功能。

肩關(guān)節(jié)；關(guān)節(jié)鏡；脫位；手術(shù)

肩鎖關(guān)節(jié)脫位是肩關(guān)節(jié)外科的常見疾病[1],對(duì)于Rockwood Ⅰ型、Ⅱ型損傷程度較輕的肩鎖關(guān)節(jié)脫位患者，可通過保守治療取得滿意效果；對(duì)于Rockwood Ⅳ型、Ⅴ型、Ⅵ型等重度肩鎖關(guān)節(jié)脫位患者則需要進(jìn)行手術(shù)治療，而對(duì)于Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者，目前治療仍存爭(zhēng)議[2-5]。隨著關(guān)節(jié)鏡微創(chuàng)技術(shù)的發(fā)展，肩關(guān)節(jié)鏡下韌帶重建手術(shù)被逐漸廣泛地應(yīng)用于治療肩鎖關(guān)節(jié)脫位。肩關(guān)節(jié)鏡手術(shù)理論上具備微創(chuàng)、術(shù)后恢復(fù)快等優(yōu)勢(shì)，但目前國(guó)內(nèi)單純針對(duì)RockwoodⅢ型肩鎖關(guān)節(jié)脫位的關(guān)節(jié)鏡手術(shù)治療報(bào)道仍較為少見。本文通過回顧性研究，分析近年來(lái)我院采用肩關(guān)節(jié)鏡下異體肌腱移植、喙鎖韌帶重建術(shù)治療高運(yùn)動(dòng)水平需求的Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者的臨床療效。

對(duì) 象 與 方 法

一、一般資料

入選標(biāo)準(zhǔn)：(1)高運(yùn)動(dòng)水平要求的Rockwood Ⅲ型損傷患者；(2)于我院行肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)的患者；(3)新鮮損傷(手術(shù)距離受傷時(shí)間不超過3周)；(4)不合并血管神經(jīng)損傷；(5)術(shù)后隨訪時(shí)間≥12個(gè)月。排除標(biāo)準(zhǔn)：(1)陳舊性損傷(受傷至手術(shù)時(shí)間>3周)；(2)雙側(cè)損傷；(3) 患側(cè)肩關(guān)節(jié)既往手術(shù)史；(4)合并肩部其他部位骨折；(5)喙突基底骨折行鎖骨鉤鋼板固定治療的患者。2013年2月至2014年1月期間，連續(xù)于我院接受肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療的Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者共27例，最終有21例(77.8%)獲得了隨訪。其中男性17例，女性4例。平均年齡42.8歲，平均受傷到手術(shù)時(shí)間11.1 d。

二、手術(shù)方法

手術(shù)在全身麻醉下進(jìn)行，采取沙灘椅體位。術(shù)中建立關(guān)節(jié)鏡入路通道，包括后方主通道、外側(cè)通道、前外側(cè)通道和前內(nèi)側(cè)通道，其中，前內(nèi)側(cè)通道位于喙突與鎖骨中間。鎖骨遠(yuǎn)端上方喙鎖韌帶止點(diǎn)附近取3 cm小切口，用于固定。首先建立后方主通道，探查盂肱關(guān)節(jié)內(nèi)，觀察是否合并關(guān)節(jié)內(nèi)損傷。將鏡頭移至肩峰下間隙，建立外側(cè)通道，然后鏡頭移到肩峰下外側(cè)通道，進(jìn)行肩峰下清掃。同時(shí)建立前外側(cè)通道，清掃滑膜，顯露喙突，探查喙鎖韌帶損傷情況。于喙突上方建立前內(nèi)側(cè)通道，清理喙突周圍的軟組織，注意保護(hù)喙鎖韌帶殘端。由于臂叢血管神經(jīng)于喙突內(nèi)側(cè)走行，所以此步操作需謹(jǐn)慎，注意保護(hù)周圍的血管和神經(jīng)。于鎖骨遠(yuǎn)端插入硬膜外針頭，定位肩鎖關(guān)節(jié)。然后清掃鎖骨下方軟組織，并注意保護(hù)喙鎖韌帶鎖骨側(cè)止點(diǎn)。于鎖骨上方喙鎖韌帶止點(diǎn)處使用3.5 mm鉆頭建立2個(gè)鎖骨骨髓道。通過引導(dǎo)線將異體腘繩肌腱和4根高強(qiáng)度縫合線從喙突下方、喙肩韌帶止點(diǎn)后方穿過，兩端向上拉起并通過鎖骨骨隧道，在關(guān)節(jié)鏡直視下復(fù)位肩鎖關(guān)節(jié)，并在鎖骨上方依次將高強(qiáng)度縫合線及異體肌腱打結(jié)固定，構(gòu)成喙鎖懸吊結(jié)構(gòu)來(lái)固定遠(yuǎn)端鎖骨。

三、康復(fù)方法

術(shù)后采用肩關(guān)節(jié)吊帶制動(dòng)6周。手、腕、肘的被動(dòng)功能鍛煉在術(shù)后患者疼痛允許情況下盡早進(jìn)行。術(shù)后6周摘除吊帶，開始肩關(guān)節(jié)被動(dòng)及主動(dòng)活動(dòng)度練習(xí)，根據(jù)患者具體康復(fù)狀況逐步恢復(fù)日常非負(fù)重生活活動(dòng)。術(shù)后3個(gè)月開始肌肉力量練習(xí)。

四、術(shù)后隨訪及評(píng)價(jià)方法

患者分別在術(shù)后3周、6周、3個(gè)月、6個(gè)月、12個(gè)月以及末次隨訪時(shí)拍攝肩關(guān)節(jié)正位、側(cè)位及腋位X線片，評(píng)估是否有肩鎖關(guān)節(jié)復(fù)位丟失。末次隨訪時(shí)，通過查體記錄患者肩關(guān)節(jié)前屈上舉、體側(cè)外旋及內(nèi)旋的活動(dòng)度，有無(wú)肩鎖關(guān)節(jié)壓痛；采用疼痛視覺模擬評(píng)分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)評(píng)分及UCLA(university of California Los Angeles)評(píng)分評(píng)價(jià)患者肩關(guān)節(jié)功能狀況。

結(jié) 果

21例患者術(shù)后平均隨訪(14.6±3.9)個(gè)月(12～19個(gè)月)。末次隨訪時(shí)肩關(guān)節(jié)平均前屈上舉為173.9°±10.3°，體側(cè)外旋為59.5°±14.3°，內(nèi)旋為第12胸椎體水平，平均UCLA評(píng)分為(34.1±2.5)分(28～35分)，平均ASES評(píng)分為(95.5±4.7)分(82～100分)，平均VAS評(píng)分(0.3±0.6)分(0～3分)。末次隨訪拍攝肩關(guān)節(jié)X線片未發(fā)現(xiàn)肩鎖關(guān)節(jié)復(fù)位丟失。

所有患者術(shù)后未出現(xiàn)感染、神經(jīng)血管損傷；術(shù)后無(wú)患者發(fā)生喙突或鎖骨骨折。

討 論

一、肩鎖關(guān)節(jié)脫位的手術(shù)指證

有關(guān)肩鎖關(guān)節(jié)脫位的治療，目前較為統(tǒng)一的觀點(diǎn)認(rèn)為，Rockwood Ⅰ型或Ⅱ型損傷一般采用保守治療，而對(duì)于損傷嚴(yán)重的Rockwood Ⅳ、Ⅴ型肩鎖關(guān)節(jié)脫位則建議積極進(jìn)行手術(shù)治療[2-5]。對(duì)于Rockwood Ⅲ型損傷的治療，目前仍存在爭(zhēng)議。部分研究表明對(duì)于Rockwood Ⅲ型損傷，手術(shù)治療與保守治療可得到相似的療效[2]。盡管如此，對(duì)于一些對(duì)運(yùn)動(dòng)水平要求較高或從事重體力勞動(dòng)的Rockwood Ⅲ型損傷患者，由于其肩胛鎖骨同步運(yùn)動(dòng)受損，在高強(qiáng)度運(yùn)動(dòng)或工作時(shí)可能導(dǎo)致疼痛或活動(dòng)受限[7-9]。Wojtys等[5]通過對(duì)22例保守治療的Rockwood Ⅲ型損傷患者平均2.6年的隨訪發(fā)現(xiàn)，保守治療后患側(cè)的力量及耐力與健側(cè)水平相當(dāng)，但活動(dòng)量增大時(shí)會(huì)出現(xiàn)明顯不適。Gstettner等[10]報(bào)道了24例采用鉤鋼板技術(shù)治療Rockwood Ⅲ型損傷的病例，術(shù)后平均34個(gè)月隨訪，肩關(guān)節(jié)功能評(píng)分顯著優(yōu)于保守治療組(17例)。因此，我們認(rèn)為對(duì)于高運(yùn)動(dòng)水平要求或從事重體力勞動(dòng)的Rockwood Ⅲ型損傷患者可考慮進(jìn)行手術(shù)治療。

二、肩鎖關(guān)節(jié)脫位的手術(shù)方法

早期肩鎖關(guān)節(jié)脫位的手術(shù)治療以剛性固定為主，主要包括經(jīng)肩鎖關(guān)節(jié)穿針固定、喙鎖間隙螺釘固定、鉤鋼板固定等。由于鎖骨與喙突及肩峰鎖骨端之間存在一定角度的活動(dòng)度[11]，隨著時(shí)間進(jìn)展，會(huì)出現(xiàn)內(nèi)固定物金屬疲勞甚至折斷的情況，亦有可能在鎖骨遠(yuǎn)端、喙突、肩峰的應(yīng)力集中區(qū)域發(fā)生骨溶解甚至骨折，術(shù)后并發(fā)癥發(fā)生率較高，而且常需進(jìn)行二次手術(shù)取出內(nèi)固定物。與之相比，采用高強(qiáng)度縫線加自體或異體肌腱等進(jìn)行肩鎖關(guān)節(jié)彈性重建的手術(shù)方式逐漸被廣泛接受。隨著關(guān)節(jié)鏡微創(chuàng)技術(shù)的發(fā)展，肩關(guān)節(jié)鏡下韌帶重建手術(shù)被逐漸廣泛地應(yīng)用于治療肩鎖關(guān)節(jié)脫位，重建方式主要包括喙鎖間隙彈性固定(如紐扣鋼板、縫線等)、單純異體肌腱移植或肌腱移植聯(lián)合喙鎖間隙固定。Salzmann等[12]采用紐扣鋼板技術(shù)固定喙鎖間隙治療肩鎖關(guān)節(jié)脫位，術(shù)后兩年隨訪肩關(guān)節(jié)功能評(píng)分明顯改善，但其病例系列中有35%患者術(shù)后出現(xiàn)復(fù)位失效，原因可能與紐扣鋼板局部應(yīng)力集中所致喙突和鎖骨骨溶解而導(dǎo)致固定失效有關(guān)；另外，單純采用內(nèi)固定材料重建喙鎖間隙，無(wú)法確保喙鎖韌帶的愈合狀況，增加了術(shù)后復(fù)位失效的風(fēng)險(xiǎn)。Carofino等[13]采用單純肌腱移植重建喙鎖韌帶，并應(yīng)用擠壓螺釘將移植肌腱固定于鎖骨骨隧道，術(shù)后隨訪平均ASES評(píng)分92分，但復(fù)位失效率仍較高，達(dá)17.6%。單純應(yīng)用肌腱移植重建喙鎖韌帶，術(shù)后早期肌腱未愈合，缺乏固定強(qiáng)度，難以維持復(fù)位，易發(fā)生失效。本研究中采用肌腱移植聯(lián)合高強(qiáng)度縫線固定技術(shù)以喙鎖懸吊方式重建喙鎖韌帶，其優(yōu)勢(shì)在于術(shù)后早期，縫線固定可維持牢固復(fù)位，為移植肌腱的愈合提供了穩(wěn)定的生物力學(xué)環(huán)境；而移植肌腱的愈合及爬行替代重構(gòu)則對(duì)術(shù)后遠(yuǎn)期維持復(fù)位起到主要作用。另外，我們采用的喙鎖懸吊技術(shù)方法簡(jiǎn)單，且不需要使用特殊的內(nèi)固定材料，降低了手術(shù)的時(shí)間和成本，同時(shí)因不需要在喙突基底處鉆孔，從而避免了醫(yī)源性喙突骨折的風(fēng)險(xiǎn)。

本研究有一定的局限性：(1)本研究為回顧性研究，且樣本量較小，隨訪時(shí)間較短，應(yīng)進(jìn)一步延長(zhǎng)隨訪時(shí)間以明確其遠(yuǎn)期療效；(2)應(yīng)設(shè)計(jì)對(duì)照組進(jìn)一步明確對(duì)于高運(yùn)動(dòng)水平需求的Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者手術(shù)治療的必要性。

總之，采用肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療高運(yùn)動(dòng)水平需求的Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者的臨床療效滿意，患者術(shù)后可獲得良好的肩關(guān)節(jié)功能。

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(本文編輯：李靜)

李奉龍，姜春巖.肩關(guān)節(jié)鏡下喙鎖韌帶重建術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的療效研究[J/CD].中華肩肘外科電子雜志,2015,3(1):14-17.

Arthroscopic coracoclavicular ligament reconstruction for Rockwood type Ⅲ acromioclavicular joint dislocations

LiFenglong,JiangChunyan.

DepartmentofSportsMedicine,BeijingJishuitanHospital,Beijing100035,China

JiangChunyan,Email:chunyanj@hotmail.com

Background Dislocation of the acromioclavicular joint is a common injury of shoulder girdle.For the dislocation of acromioclavicular joint of Rockwood type Ⅰ and type Ⅱ,patient can obtain satisfactory result from conservative treatment; For the severe dislocation such as Rockwood type Ⅳ and type Ⅴ,operative treatment should be a good choice.However,for the patients of Rockwood type Ⅲ dislocation,the treatment is still controversial.With the development of minimally invasive technique,arthroscopic ligament reconstruction is gradually widely used in the treatment of acromioclavicular joint dislocation.Shoulder arthroscopic operation has the advantage of minimally invasive,quick recovery after operation,but at present the arthroscopic operation therapy for type Ⅲ acromioclavicular joint dislocation is still comparatively rare domestically.The purpose of this study was to evaluate the clinical outcomes of the arthroscopic coracoclavicular ligament reconstruction for the treatment of Rockwood type Ⅲ AC joint dislocations through a retrospective study.Methods (1)General data：Iinclusion criteria:patients of type Ⅲ dislocation with a high level require of sports;patients who

arthroscopic reconstruction of the coracoclavicular ligament injury in our hospital;fresh injury (no more than 3 weeks);not complicated with vessel and nerve injury;the postoperative follow-up time is greater than or equal to 12 months.Exclusion criteria:chronic injury (more than 3 weeks between injury and operation);bilateral injury;the ipsilateral shoulder operation history;fracture with other parts of shoulder;patients with fracture of the coracoid base treated with clavicular hook plate.From February 2013 to January 2014,21 consecutive patients with type Ⅲ AC joint dislocations who were treated with arthroscopic coracoclavicular ligament reconstruction were retrospectively reviewed after the final follow-up.There were 17 men and 4 women with a mean age of 42.8 years.The mean time from injury to surgery was 11.1 days.(2) Operative method：The operations were performed under general anesthesia.Patients were in beach chair position.The posterior portal was viewing portal,routine gleno-humeral joint examination was performed first.Then the scope was put into subacromial space,the anterior lateral portal was established.Subacromial decompression was done and the coracoid and coracoclavicle ligament was exposed and examined.The anterior medial portal was between coracoid and clavicle.it was created under direct vision.The remnant attached on coracoid should be carefully protected.The brachial plexus and vessel were very near the medial side of coracoid and should be well protected.An epidural needle was inserted into acromioclavicular joint.Then the soft tissue below the clavicle was removed and coracoclavicular ligament remnant on the clavicle was protected.Two bone tunnels in the clavicle were drilled by 3.5 mm drill bit at the insertion site of coracoclavicular ligament.The allogenic gracilis tendon and 4 strand high tensile sutures were pulled through under coracoid.The two ends of tendon and sutures were pulled through the two bone tunnels on clavicle.Arthroscopic assisted reduction of acromial clavicular joint dislocation was performed and the tendon and sutures were tied rigidly.(3) Rehabilitation protocol：The shoulder was immobilized in a sling for 6 weeks.Exercise of the hand,wrist and elbow was started as early as pain could be tolerated.The sling was removed after 6 weeks,and passive and active activity of shoulder was started.Non-weight bearing activities were gradually started according to patient's tolerance.Muscle strengthening exercises began at 3 months postoperatively.(4) Postoperative follow-up and evaluation：All patients were routinely followed up after the surgery.The VAS score,ASES score and UCLA score were employed to evaluate the postoperative shoulder function.The postoperative radiographs of the affected shoulder were taken for each patient to evaluate the loss of reduction of the AC joint.Results The mean follow-up time was 14.6±3.9 months (range:12 to 19 months).At the last follow-up,the average range of motion of patients were 173.9°±10.3°for forward elevation,59.5°±14.3°for external rotation and T12 level for internal rotation.The average VAS pain score results,ASES score results and UCLA score results were 0.3±0.6 (0-3),95.5±4.7 (82-100) and 34.1±2.5 (28-35).No loss of reduction was noted through the postoperative radiographs.Conclusion Although the treatment of the type-Ⅲ AC joint dislocation remains controversial through literatures,surgical intervention is still recommended for the patients with high level of sport activity.Good clinical results and shoulder functions could be expected after arthroscopic coracoclavicular ligament reconstruction for Rockwood type Ⅲ AC joint dislocations.

Shoulder;Arthroscopy;Dislocation;Surgery

10.3877/cma.j.issn.2095-5790.2015.01.004

北京市新世紀(jì)百千萬(wàn)人才工程培養(yǎng)經(jīng)費(fèi)；北京市自然科學(xué)基金資助項(xiàng)目(7142074)

100035北京積水潭醫(yī)院運(yùn)動(dòng)損傷科

姜春巖，Email:chunyanj@hotmail.com

2014-12-03)