應(yīng)用Endobutton帶袢鋼板技術(shù)治療RockwoodⅢ型肩鎖關(guān)節(jié)脫位

宋哲 張堃 朱養(yǎng)均 李忠 莊巖 魏巍 楊娜

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應(yīng)用Endobutton帶袢鋼板技術(shù)治療RockwoodⅢ型肩鎖關(guān)節(jié)脫位

宋哲 張堃 朱養(yǎng)均 李忠 莊巖 魏巍 楊娜

目的 探討應(yīng)用Endobutton帶袢鋼板技術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的手術(shù)方法及療效。方法 回顧性分析2010年6月至2013年6月收治的Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者21例，其中男性14例、女性7例；年齡19～52歲，平均31.2歲。21例患者均Ⅰ期接受手術(shù)治療，通過X線片觀察術(shù)后肩鎖關(guān)節(jié)脫位修復(fù)情況以及內(nèi)固定牢固程度，并定期按Constant評(píng)分和Karlsson療效評(píng)價(jià)標(biāo)準(zhǔn)對(duì)肩鎖關(guān)節(jié)功能進(jìn)行評(píng)估。結(jié)果 21例患者均獲得16.2(12～36)個(gè)月隨訪。隨訪結(jié)果如下，Constant評(píng)分：平均92.4(70～100)分；Karlsson療效評(píng)價(jià)標(biāo)準(zhǔn)：優(yōu)16例(76.2%)、良4例(19.0%)、差1例(4.7%)，優(yōu)良率達(dá)95.2%。結(jié)論 應(yīng)用Endobutton帶袢鋼板技術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位具有臨床效果好、手術(shù)創(chuàng)傷小、并發(fā)癥少、不需二次手術(shù)等優(yōu)點(diǎn)。

肩鎖關(guān)節(jié)；脫位；Endobutton技術(shù)

肩鎖關(guān)節(jié)脫位是一種常見的損傷，經(jīng)常發(fā)生于重體力勞動(dòng)者和年輕運(yùn)動(dòng)員，多為摔傷時(shí)肩部著地引起。Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位通常需要手術(shù)治療[1]，目前文獻(xiàn)報(bào)道的手術(shù)方法有很多種，但沒有一種公認(rèn)的有效和理想的手術(shù)方法[2]。自2010年6月至 2013年 6月，我院使用Endobutton帶袢鋼板內(nèi)固定技術(shù)治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位患者21例，隨訪12～36個(gè)月，并進(jìn)行肩關(guān)節(jié)功能及影像學(xué)評(píng)估，臨床療效滿意，現(xiàn)報(bào)道如下。

對(duì) 象 與 方 法

一、一般資料

肩鎖關(guān)節(jié)脫位患者21例，男性14例，女性7例；年齡19～52歲，平均31.2歲；左側(cè)9例，右側(cè)12例。致傷原因：交通傷8例，摔傷9例，運(yùn)動(dòng)傷2例，重物砸傷2例。21例均為 Rockwood Ⅲ型患者，排除合并鎖骨骨折、多發(fā)性骨折、閉合性胸部損傷和顱腦損傷。臨床表現(xiàn)為外傷后鎖骨外上方疼痛，鎖骨遠(yuǎn)端向上突起，按壓時(shí)有疼痛和浮動(dòng)感。X線檢查提示：肩鎖關(guān)節(jié)完全分離。21例患者均為新鮮脫位，無合并血管神經(jīng)損傷，手術(shù)時(shí)間為受傷后1～5 d。

二、手術(shù)方法

采用全身麻醉或者頸叢麻醉?；颊呷⊙雠P位或沙灘椅位，頭部轉(zhuǎn)向健側(cè)。切口取自喙突縱形向上延伸至鎖骨后緣的直切口，逐層切開皮膚、皮下組織，鈍性分開三角肌，剝離鎖骨骨膜，顯露肩鎖關(guān)節(jié)、鎖骨遠(yuǎn)端和喙突基底部及內(nèi)側(cè)面。沿鎖骨長(zhǎng)軸切開三角肌和斜方肌筋膜，骨膜下分離顯露鎖骨遠(yuǎn)端，沿三角肌和胸大肌間隙分離顯露喙突內(nèi)外側(cè)緣及韌帶殘端。檢查肩鎖關(guān)節(jié)間隙，清除破裂的纖維軟骨盤。將肩鎖關(guān)節(jié)復(fù)位后，先從肩峰外側(cè)端經(jīng)肩鎖關(guān)節(jié)面穿入克氏針1枚暫時(shí)固定肩鎖關(guān)節(jié)。在距離鎖骨前緣1/3處，用定位導(dǎo)向器鉤住喙突底面與肩鎖關(guān)節(jié)內(nèi)側(cè)約3 cm 成同一矢狀面，按照導(dǎo)向器方向向喙突基底部打入1枚直徑1.0 mm導(dǎo)針，沿導(dǎo)針用3.5 mm空心鉆頭擴(kuò)孔。用測(cè)深器測(cè)量從鎖骨表面到喙突基底部的長(zhǎng)度，選擇適當(dāng)大小的Endobutton帶袢鋼板。用鋼絲對(duì)折從上往下穿過直徑3.5 mm鎖骨隧道與喙突隧道，拉出鋼絲封閉端，剪下一段紐扣鋼板自身所帶牽引線，在袢和鋼絲間做輔助換線連接，牽拉鋼絲，將袢和紐扣鋼板自身所帶牽引線拉出喙突隧道，將牽引線脫出環(huán)線，繼續(xù)牽拉將環(huán)線拉出鎖骨隧道上口，鎖骨遠(yuǎn)端加壓復(fù)位，向上拉出袢，將另一個(gè)不帶袢的紐扣鋼板用持針器插入袢中。先將紐扣鋼板側(cè)放，將線穿過鋼板的兩個(gè)孔，然后翻平紐扣鋼板并確保鋼板貼于喙突基底部而不滑出，將線打結(jié)收緊，使不帶袢鋼板固定于袢。剪除輔助環(huán)線，完成喙鎖韌帶錐狀韌帶部分的重建。再將紐扣鋼板所帶的線鋼絲引導(dǎo)下一端穿過鎖骨上另一個(gè)孔，使之平貼于鎖骨上拉緊打結(jié)，進(jìn)一步加強(qiáng)喙鎖韌帶錐狀韌帶部分的重建。再把已縫在喙鎖韌帶的縫線收緊打結(jié)。沖洗傷口，仔細(xì)修復(fù)肩鎖關(guān)節(jié)囊，重建三角肌和斜方肌在鎖骨遠(yuǎn)端的止點(diǎn)，逐層關(guān)閉切口。

三、術(shù)后處理及療效評(píng)定

術(shù)后常規(guī)抗生素預(yù)防感染24～48 h，患側(cè)予以三角巾或前臂吊帶懸吊固定1～2周，疼痛緩解后開始肩關(guān)節(jié)“鐘擺樣”擺臂鍛煉，隨后逐漸增加運(yùn)動(dòng)范圍，術(shù)后4周內(nèi)以被動(dòng)訓(xùn)練為主，外展、前屈活動(dòng)范圍不超過90°，術(shù)后4周以后開始行主動(dòng)的肩關(guān)節(jié)前屈上舉及外展功能鍛煉，并逐漸增加活動(dòng)量，以恢復(fù)肩關(guān)節(jié)功能，術(shù)后8周內(nèi)應(yīng)避免提拉重物。

患者術(shù)后前3個(gè)月內(nèi)每月隨訪1次，以后每3個(gè)月隨訪1次。隨訪內(nèi)容：肩關(guān)節(jié)正位X線片，肩關(guān)節(jié)活動(dòng)范圍及肌力。末次隨訪時(shí)對(duì)患者肩關(guān)節(jié)功能進(jìn)行評(píng)分，評(píng)分標(biāo)準(zhǔn)包括Constant肩關(guān)節(jié)評(píng)分系統(tǒng)[3]和Karlsson療效評(píng)價(jià)標(biāo)準(zhǔn)[4]。

結(jié) 果

本組21例患者均獲隨訪，時(shí)間12～36個(gè)月，平均16.2個(gè)月。所有切口均Ⅰ期愈合，無傷口感染、血管神經(jīng)損傷和繼發(fā)骨折等并發(fā)癥。1例患者術(shù)后4周出現(xiàn)鋼板脫落和再脫位，但患者自覺肩部疼痛不明顯，肩關(guān)節(jié)活動(dòng)尚可，故未予特殊處理。其他患者術(shù)后X線檢查顯示肩鎖關(guān)節(jié)均獲得解剖復(fù)位，內(nèi)固定在位良好，肩關(guān)節(jié)功能活動(dòng)基本恢復(fù)正常，基本無痛或輕微疼痛，療效滿意。

肩關(guān)節(jié)評(píng)分根據(jù)Constant肩關(guān)節(jié)評(píng)分系統(tǒng)[3]，從疼痛(15分)、日?；顒?dòng)(20分)、活動(dòng)范圍(40分)和肌力(25分)這四方面進(jìn)行評(píng)分。本組患者肩關(guān)節(jié)末次評(píng)分為70～100分，平均92.4分，其中疼痛評(píng)分為13.3(5～15)分，日?；顒?dòng)評(píng)分為18.1(13～20)分，活動(dòng)范圍評(píng)分為37.8(28～40)分，肌力評(píng)分為23.3(15～25)分。

肩關(guān)節(jié)功能根據(jù)Karlsson療效評(píng)價(jià)標(biāo)準(zhǔn)[4]：(1)優(yōu)：不痛，有正常肌力，肩關(guān)節(jié)可自由活動(dòng)，X線片顯示肩鎖關(guān)節(jié)解剖復(fù)位或半脫位間隙<5 mm；(2)良：滿意，微痛，功能受限，肌力中度，肩關(guān)節(jié)活動(dòng)范圍90°～180°，X線片顯示患側(cè)肩鎖關(guān)節(jié)間隙較對(duì)側(cè)大5～10 mm；(3)差：疼痛并在夜間加劇，肌力不佳，肩關(guān)節(jié)活動(dòng)在任何方向皆<90°，X線片顯示肩鎖關(guān)節(jié)仍脫位。本組患者優(yōu)16例(76.2%)、良4例(19.0%)、差1例(4.7%)，優(yōu)良率達(dá)95.2%。

討 論

一、肩鎖關(guān)節(jié)脫位的特點(diǎn)

肩鎖關(guān)節(jié)脫位是一種常見的肩部運(yùn)動(dòng)損傷，約占整個(gè)肩部損傷的12%，約占全身關(guān)節(jié)脫位的3.2%，尤以青年男性較多，男女比例為5∶1[5]。肩鎖關(guān)節(jié)脫位受傷機(jī)制分為兩種:一種是直接暴力；另一種是間接暴力。直接暴力引起的肩鎖關(guān)節(jié)脫位最常見于肩關(guān)節(jié)處于外展、內(nèi)旋位時(shí)，暴力直接作用于肩峰，造成肩鎖韌帶和喙鎖韌帶損傷。間接暴力也可導(dǎo)致肩鎖關(guān)節(jié)脫位，一般為上肢處于伸展位，摔倒時(shí)手部或肘部先著地，外力通過上肢傳導(dǎo)至肩峰及肱骨頭，肱骨頭向上移位時(shí)會(huì)致鎖骨遠(yuǎn)端下移，進(jìn)而導(dǎo)致肩鎖韌帶和喙鎖韌帶牽拉傷甚至斷裂，從而形成肩鎖關(guān)節(jié)脫位。Nielsen[6]觀察研究了116例發(fā)生肩鎖關(guān)節(jié)脫位損傷的患者，總結(jié)出損傷機(jī)制：當(dāng)手或者肘部伸直的時(shí)候發(fā)生跌傷，肱骨頭對(duì)肩峰產(chǎn)生撞擊力，造成肩鎖關(guān)節(jié)損傷，最容易發(fā)生鎖骨遠(yuǎn)端骨折或肩袖的損傷。

肩鎖關(guān)節(jié)的穩(wěn)定由三部分結(jié)構(gòu)維持：(1)關(guān)節(jié)囊及其增厚部分形成的肩鎖韌帶；(2)喙突至鎖骨的喙鎖韌帶；(3)附著于肩峰和鎖骨的三角肌及斜方肌。肩鎖韌帶主要維持關(guān)節(jié)水平方向的穩(wěn)定，而喙鎖韌帶維持鎖骨遠(yuǎn)端垂直方向的穩(wěn)定。從生物力學(xué)分析，肩鎖關(guān)節(jié)參與肩帶活動(dòng)是以胸鎖關(guān)節(jié)為軸心，鎖骨為連接軸，肩鎖韌帶作用力方向與鎖骨夾角極小，力矩??；喙鎖韌帶作用方向幾乎垂直力臂，產(chǎn)生力矩大，因而喙鎖韌帶在維持肩鎖關(guān)節(jié)的穩(wěn)定性中起更重要作用[7]。

二、肩鎖關(guān)節(jié)脫位的分型和治療

肩鎖關(guān)節(jié)脫位常用的分類方法有Tossy分型[8]和Rockwood分型[5]。Tossy分型共分為3型，主要突出影像學(xué)特點(diǎn)和臨床的實(shí)用性。而Rockwood分型則分為6型，分型更精確，臨床最常用。Rockwood Ⅰ、Ⅱ型肩鎖關(guān)節(jié)脫位一般采用非手術(shù)治療即可獲得滿意療效，Rockwood Ⅳ、Ⅴ和Ⅵ型肩鎖關(guān)節(jié)脫位多需切開復(fù)位手術(shù)治療。而對(duì)Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的治療至今尚存很多爭(zhēng)議，更多的學(xué)者傾向手術(shù)治療[9]，尤其是對(duì)年輕及活動(dòng)度大的患者更推薦外科手術(shù)[1]。Leidel及其同事研究表明，急性Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位經(jīng)克氏針臨時(shí)固定能夠取得良好的治療效果，長(zhǎng)期隨訪療效良好[10]。

肩鎖關(guān)節(jié)脫位的手術(shù)治療應(yīng)遵循以下原則：(1)解剖復(fù)位，清理關(guān)節(jié)間隙，恢復(fù)鎖骨外側(cè)端關(guān)節(jié)面的穩(wěn)定；(2)修復(fù)重建韌帶及關(guān)節(jié)囊，盡可能恢復(fù)原有生物力學(xué)形態(tài)；(3)堅(jiān)強(qiáng)內(nèi)固定以達(dá)到韌帶的牢固愈合；(4)早期功能鍛煉；(5)及時(shí)移除堅(jiān)強(qiáng)的內(nèi)置物及穩(wěn)定裝置，防止斷裂、松動(dòng)及關(guān)節(jié)僵硬的發(fā)生。目前手術(shù)方法達(dá)30種以上，但還沒有一種公認(rèn)的有效和理想的手術(shù)方案[2]。傳統(tǒng)的手術(shù)方式種類較多，主要有克氏針固定肩鎖關(guān)節(jié)，以拉力螺釘固定鎖骨及喙突，鎖骨遠(yuǎn)端切除術(shù)，以自體肌腱(掌長(zhǎng)肌腱腓骨長(zhǎng)肌腱、髂脛束或闊筋膜等)重建喙鎖韌帶等。克氏針經(jīng)關(guān)節(jié)固定會(huì)破壞關(guān)節(jié)面，易引起創(chuàng)傷性關(guān)節(jié)炎；而且限制了肩鎖關(guān)節(jié)的微動(dòng)功能，可能導(dǎo)致肩鎖關(guān)節(jié)疼痛和僵硬；克氏針抗旋轉(zhuǎn)能力差，容易引起克氏針退出或斷裂，甚至發(fā)生克氏針刺破胸腔臟器等嚴(yán)重并發(fā)癥[11]。拉力螺釘固定對(duì)螺釘?shù)奈恢眉肮潭ㄙ|(zhì)量要求高，螺釘松動(dòng)、斷裂甚至切出等并發(fā)癥較常見。另外，肩鎖關(guān)節(jié)是活動(dòng)關(guān)節(jié)，前后方向存在著一定程度的微動(dòng)，用螺釘及克氏針鋼絲等硬性材料固定顯然不恰當(dāng)。鎖骨遠(yuǎn)端切除術(shù)這種方法會(huì)破壞關(guān)節(jié)囊，影響肩關(guān)節(jié)生物力學(xué)平衡，損傷較大；若切除鎖骨遠(yuǎn)端較多，三角肌附著點(diǎn)減少，可減弱肌力，影響患肢上舉，還容易導(dǎo)致Ⅱ期肩鎖關(guān)節(jié)后脫位。自體肌腱(掌長(zhǎng)肌腱腓骨長(zhǎng)肌腱、髂脛束或闊筋膜等)重建喙鎖韌帶的方法因手術(shù)創(chuàng)傷大、操作復(fù)雜，常導(dǎo)致肩周肌萎縮，肩關(guān)節(jié)功能受限而逐漸被淘汰。

近年來，鎖骨鉤鋼板已逐漸成為肩鎖關(guān)節(jié)脫位治療的首選，鎖骨鉤鋼板為解剖型設(shè)計(jì)，符合鎖骨的解剖“S”狀外形；肩峰下關(guān)節(jié)外安置，對(duì)肩袖及關(guān)節(jié)影響小，固定可靠。然而其也存在一定的不足[12]：(1)由于胸鎖乳突肌以及胸大肌等肌肉牽拉，鎖骨遠(yuǎn)端活動(dòng)導(dǎo)致鉤鋼板肩峰側(cè)在水平面和冠狀面的側(cè)方活動(dòng)以及矢狀面的旋轉(zhuǎn)等活動(dòng)，會(huì)在一定程度上限制肩關(guān)節(jié)外展、內(nèi)旋功能；(2)鉤鋼板與鎖骨交界處由于應(yīng)力集中導(dǎo)致肩峰端骨折、肩鎖關(guān)節(jié)周圍骨溶解等；(3)鉤鋼板可移位、脫出而導(dǎo)致內(nèi)固定失敗，關(guān)節(jié)再次脫位；(4)肩峰撞擊，肩關(guān)節(jié)疼痛；(5)術(shù)后大部分患者有強(qiáng)烈要求拆除鎖骨鉤鋼板的意愿，且取板時(shí)局部組織損傷大，脫位易復(fù)發(fā)。

三、Endobutton帶袢鋼板技術(shù)的原理及優(yōu)點(diǎn)

2007年Struhl[13]首先報(bào)道使用雙Endobutton帶袢鋼板技術(shù)重建喙鎖韌帶治療肩鎖關(guān)節(jié)完全脫位的方法，其后經(jīng)許多國(guó)內(nèi)學(xué)者的臨床應(yīng)用及生物力學(xué)驗(yàn)證，認(rèn)為雙Endobutton行肩鎖關(guān)節(jié)韌帶重建臨床效果較好[14-15]。該手術(shù)用來重建喙鎖韌帶的Endobutton帶袢鋼板已成功應(yīng)用于膝關(guān)節(jié)交叉韌帶重建多年[16]，兩塊紐扣鋼板通過生物強(qiáng)度遠(yuǎn)高于喙鎖韌帶的不吸收的袢環(huán)在喙突與鎖骨間加壓固定，使肩鎖關(guān)節(jié)的分離應(yīng)力轉(zhuǎn)換成壓應(yīng)力，達(dá)到動(dòng)力穩(wěn)定，從而恢復(fù)肩鎖關(guān)節(jié)的解剖關(guān)系和力學(xué)平衡。 該術(shù)式有如下優(yōu)點(diǎn)：(1)切口小，手術(shù)時(shí)間短，傷口感染等潛在并發(fā)癥風(fēng)險(xiǎn)小；(2)由于雙Endobutton鋼板操作不涉及肩袖，術(shù)后不會(huì)出現(xiàn)肩峰撞擊樣疼痛，所以在術(shù)后早期可進(jìn)行功能鍛煉；(3)由于紐扣鋼板固定的位置離關(guān)節(jié)面遠(yuǎn)，不損傷關(guān)節(jié)面軟骨，對(duì)肩峰和關(guān)節(jié)面無干擾，降低了創(chuàng)傷性關(guān)節(jié)炎的發(fā)生，有效避免了鎖骨鉤鋼板磨損肩峰下關(guān)節(jié)面而引起的骨溶解、疼痛；(4) Endobutton袢環(huán)強(qiáng)度大且具有一定的彈性，不同于沒有韌性的金屬內(nèi)固定物，在組織解剖上更類似于喙鎖韌帶。將肩鎖關(guān)節(jié)及鎖骨固定在解剖位置上，而肩鎖關(guān)節(jié)并未堅(jiān)強(qiáng)固定，使得肩鎖關(guān)節(jié)及喙突與鎖骨之間仍可保持一定的微動(dòng)，使其更接近生理狀態(tài)；(5)Endobutton鋼板為鈦金屬，無毒，生物相容性佳，無降解，可以在體內(nèi)長(zhǎng)期存留，無需二次手術(shù)取出，減輕了患者痛苦，縮短了總住院時(shí)間，節(jié)約了費(fèi)用。

四、Endobutton帶袢鋼板技術(shù)的注意事項(xiàng)

雖然Endobutton帶袢鋼板技術(shù)有著上述的諸多優(yōu)點(diǎn)，但是對(duì)術(shù)者的手術(shù)技巧及經(jīng)驗(yàn)要求高，而且若想獲得良好的手術(shù)療效，還有以下幾個(gè)方面的問題需要注意：(1)術(shù)中若發(fā)現(xiàn)肩鎖關(guān)節(jié)軟骨盤損傷嚴(yán)重，應(yīng)予徹底清理，避免引起創(chuàng)傷性關(guān)節(jié)炎而致術(shù)后疼痛；(2)骨道的定位十分關(guān)鍵，尤其是鎖骨上的位點(diǎn)選擇，因此鎖骨外1/3前后緣及喙突內(nèi)外側(cè)緣要顯露清楚；(3)在喙突上打孔部位應(yīng)選在基底根部，此處骨質(zhì)堅(jiān)固不易發(fā)生鋼板內(nèi)陷及骨折；(4)在向喙突上鉆孔的時(shí)候，應(yīng)壓低鉆頭，指向喙突基底部，方向和人體矢狀面重合，此時(shí)鉆孔的骨道長(zhǎng)度最短，選擇最短的袢能減少?gòu)?fù)位丟失；(5)在測(cè)量鎖骨上緣至喙突基底部的距離時(shí)，一定要將鎖骨壓低至解剖復(fù)位后再測(cè)量，否則會(huì)導(dǎo)致測(cè)得量的距離偏長(zhǎng)，術(shù)后遺留半脫位，影響手術(shù)效果[17]；(6)打孔時(shí)爭(zhēng)取一次成功，避免反復(fù)鉆孔致骨隧道過寬、離骨皮質(zhì)過近，鋼板滑脫甚至喙突骨折；(7)帶袢鋼板的位置應(yīng)放置恰當(dāng)，如袢與鋼板不垂直，將導(dǎo)致袢切割喙突、鎖骨，可能會(huì)導(dǎo)致骨折等嚴(yán)重并發(fā)癥；(8)術(shù)后早期適當(dāng)?shù)墓δ苠憻捠谦@得滿意療效的關(guān)鍵。有研究[18]顯示肩鎖關(guān)節(jié)和喙鎖間隙周圍的軟組織在手術(shù)后4～6周會(huì)瘢痕化，對(duì)縫合的組織和帶袢鋼板有保護(hù)的作用。所以患者應(yīng)予以三角巾或前臂吊帶懸吊固定1～2周，術(shù)后4周內(nèi)適當(dāng)進(jìn)行被動(dòng)訓(xùn)練，外展范圍不超過90°。術(shù)后4周以后待局部瘢痕形成，再進(jìn)行主動(dòng)的更大范圍的活動(dòng)，在術(shù)后8周內(nèi)禁止提重物。

Endobutton帶袢鋼板技術(shù)是一種非剛性的治療Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位的方法，具有操作簡(jiǎn)單、創(chuàng)傷小、接近解剖及生物力學(xué)復(fù)位、對(duì)關(guān)節(jié)干擾小、術(shù)后并發(fā)癥少、允許早期功能鍛煉、無需二次手術(shù)取出內(nèi)固定等優(yōu)點(diǎn)。但是該術(shù)式在臨床開展的時(shí)間尚短，病例數(shù)較少，隨訪時(shí)間不長(zhǎng)，且缺乏一個(gè)對(duì)照組比較，遠(yuǎn)期療效和并發(fā)癥尚需進(jìn)一步觀察和探討。

典型病例：張某，男性,23歲，跑步時(shí)摔傷致Rockwood Ⅲ型肩鎖關(guān)節(jié)脫位，外傷后8 h入院，無血管神經(jīng)癥狀，傷后2 d應(yīng)用Endobutton帶袢鋼板技術(shù)治療(圖1～4)。

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圖1 術(shù)前X線片示肩鎖關(guān)節(jié)完全分離 圖2 術(shù)后X線片示肩鎖關(guān)節(jié)間隙恢復(fù)正常 圖3 術(shù)后3個(gè)月X線片示肩鎖關(guān)節(jié)間隙正常 圖4 術(shù)后3個(gè)月肩關(guān)節(jié)功能基本完全恢復(fù)

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(本文編輯：李靜)

宋哲，張堃，朱養(yǎng)均，等.應(yīng)用Endobutton帶袢鋼板技術(shù)治療RockwoodⅢ型肩鎖關(guān)節(jié)脫位[J/CD].中華肩肘外科電子雜志,2015,3(1):18-23.

Treatment of Rockwood type Ⅲ acromioclavicular joint dislocation with endobutton technique

SongZhe,ZhangKun,ZhuYangjun,LiZhong,ZhuangYan,WeiWei,YangNa.

DepartmentofTraumaticOrthopaedics，Xi′anHonghuiHospital,Xi′an710054,China

ZhangKun,Email：hhyyzk@126.com

Background Acromioclavicular joint dislocation is a common injury which often occurs in heavy manual workers and young athletes.It is usually caused by collision of the shoulder on the ground.Acromioclavicular joint dislocation of Rockwood type Ⅲ often needs surgical treatment.There are several kinds of operation methods reported in the literature,but no universally accepted technique exists.From June 2010 to June 2013,21 patients of Rockwood type Ⅲ acromioclavicular joint dislocation were treated with Endobutton technique in our hospital,shoulder functional and radiological evaluations were performed and the outcome is encouraging.Methods (1)General information：Twenty-one patients were included in this study.Patients were 14 males and 7 females.Nine cases were on the left side and 12 cases were on the right side.The age ranged from 19 to 52 with an average of 31.2 years.The causes were traffic injury in 8 cases,fall damage in 9 cases,sports injury in 2 cases and heavy object hit injury in 2 cases.All patients were diagnosed as acromioclavicular joint dislocation of Rockwood type Ⅲ without clavicle fracture,multiple fractures,closed chest injury and cerebral injury.The clinical presentations included pain over the lateral side of clavicle with its distal end protruding upward,tenderness and a feeling of floating; X-ray examinations revealed that the distal clavicle was higher than the acromion.21 cases were all fresh dislocations without neurovascular injuries; The operation time was 1-5 days after injury.(2)Operation method：After successful general anesthesia or cervical plexus block,the patient was in supine or “beach chair” position with head turned to the uninjured side.The straight incision was extended longitudinally from coracoid upward to the posterior edge of clavicle.The skin and subcutaneous tissue was incised layer by layer.The deltoid muscle was bluntly separated and the periosteum was stripped to expose acromioclavicular joint,distal clavicle and coracoid.The fascias of deltoid muscle and trapezius muscle were divided along the long axis of clavicle and the periosteum was stripped to expose the distal clavicle.The interal between deltoid and pectoralis major muscle was opened and the medial and lateral boarders of coracoid was prepared.The residual coraco-clavicle ligament was reserved.The articular space of acromioclavicular joint was examined and the ruptured fibrous cartilage disc was removed.After reduction of acromioclavicular joint,one Kirschner wire was drilled through the articular surface from the lateral end of acromion to provisionally keep the joint in place.A 1.0 mm guide pin was drilled from distal clavicle into the base of coracoid perpendicularly,3.5 mm canulated drill bit drilled a bone tunnel along the guiding pin.The distance from the surface of clavicle to the base of coracoid was measured with depth scale.The Endobutton was selected properly.A shuttle wire was used to pull the button loop out of clavicle and left the button under coracoid.The distal clavicle was reduced with compression.The loop was pulled upward and the other Endobutton without loop was put into the loop with acutenaculum.First,the Endobutton was laid on its side with sutures pierced through its two holes.Then the Endobutton was laid flat and made sure to attach to the base of coracoid without sliding.The sutures were tightened and knotted to make the Endobutton without loop fixed on the loop.The reconstruction of conoid ligament was finished.Then the suture on the coracoclavicular ligament was tightened and knotted.The wound was irrigated.The acromioclavicular joint capsule was repaired and the deltoid and trapezius muscle were reconstructed at the distal clavicle.The incision was closed layer by layer.(3)Post-operative management and outcome evaluation：Antibiotics were given to prevent infection for 24-48 hours.The shoulder was protected by a sling for 1-2 weeks.Pendulum exercise began after pain relief and the range of motion increased gradually.Only passive motion was permitted in the first 4 weeks and shoulder abduction or anteflexion was limited within 90°.Active motion including anteflexion,elevation and abduction began 4 weeks later.Lifting heavy objects should be avoided within 8 weeks after operation.Postoperative follow-up took place once a month in the first 3 months and then once every 3 months.Anteroposterior X-ray films,range of motion and muscle strength were included in the follow-up.The shoulder function was assessed at the last follow-up according to Constant-Murley score and Karlsson postoperative efficacy grading score.Results Twenty-one patients of this study were followed up for 12-36 months with a mean time of 16.2 months.All the incisions healed without any complication.Infection,neurovascular damage and secondary fracture were not occurred.One patient had plate sliding and redislocation without obvious pain.His shoulder had good activity and therefore he

no treatment.X-ray films revealed anatomical reduction and good internal fixation of acromioclavicular joint in other patients.Their shoulder joints restored normal activities with no or slight pain and the outcome were satisfactory.The shoulder function was assessed according to Constant score which was classified as pain (15 scores),daily activity (20 scores),range of motion (40 scores) and muscle strength (25 scores).The last scores of patients in this group were 70-100 with an average of 92.4,including pain 13.3(5-15),daily activity 18.1(13-20),range of motion 37.8(28-40) and muscle strength 23.3(15-25).The shoulder function was classified according to Karlsson evaluation criteria as follows:Excellent:painlessness,normal muscle strength,free activity and X-ray films revealed anatomical reduction of acromioclavicular joint or less than 5 mm of subluxation; Good:satisfaction,mild pain,dysfunction,medium muscle strength,90°-180°of range of motion and X-ray films revealed acromioclavicular joint dislocation; Bad:pain intensified at night,poor muscle strength,activity of shoulder joint was less than 90° in any direction and X-ray films revealed acromioclavicular joint dislocation.This group had 16 excellent cases (76.2%),4 good cases (19%) and 1 poor case (4.7%).The excellent and good rate was 95.2%.Conclusion Endobutton technique is a nonrigid method for the treatment of Rockwood type Ⅲ acromioclavicular joint dislocation with good outcome.This technique has some advantages such as simple operation,minimal invasive,anatomical and biomechanical reduction,little interference to the joint,less postoperative complications,early functional training,no necessity of reoperation for implant removal,etc.

Acromioclavicular joint;Dislocation;Endobutton technique

10.3877/cma.j.issn.2095-5790.2015.01.005

省科技廳自然基金(2012JM4024)

710054西安市紅會(huì)醫(yī)院創(chuàng)傷骨科

張堃，Email：hhyyzk@126.com

2014-06-13)