劉大海 李開南 母建松 蘭海

·論著·

自體肌腱雙骨隧道重建技術修復肘關節(jié)后外側旋轉不穩(wěn)定

劉大海 李開南 母建松 蘭海

目的 探討自體肌腱雙骨隧道重建橈側尺副韌帶(lateral ulnar collateral ligament,LUCL)治療肘關節(jié)后外側旋轉不穩(wěn)定(posterolateral rotatory instability，PLRI)的手術療效。方法 2008年1月至2013年12月成都大學附屬醫(yī)院收治16例LUCL損傷患者，11例用雙束編制的掌長肌腱對韌帶進行重建，5例用對側半腱肌肌腱重建LUCL治療肘關節(jié)PLRI，移植肌腱穿過肱骨及尺骨雙骨隧道帶線錨釘固定。觀察術后肘關節(jié)活動度、肘關節(jié)側方軸移試驗、外翻外旋應力位X線片。結果 所有患者均獲隨訪，隨訪時間1～5年，平均2.5年?；颊咧怅P節(jié)活動功能明顯改善，主觀滿意，被動外翻、外旋活動時肘關節(jié)完全穩(wěn)定12例，部分不穩(wěn)定但較術前明顯改善4例，優(yōu)良率為75%。術后Mayo評分65～100分，平均85分，新鮮損傷患者術后功能明顯好于陳舊性損傷患者(P<0.05)。結論LUCL是影響肘關節(jié)PLRI最主要的結構，采用自體肌腱肱骨及尺骨雙骨隧道重建LUCL效果良好。

肘關節(jié)；尺副韌帶；韌帶重建

肘關節(jié)后外側旋轉不穩(wěn)定(posterolateralrotatoryinstability，PLRI)的概念已由Chamseddine等[1]于1991年首次提出，發(fā)病的機制是肘關節(jié)橈側副韌帶復合體(lateralcollateralligamentcomplex,LCLC)損傷引起，其中起主要作用的是橈側尺副韌帶(lateralulnarcollateralligament,LUCL)。但是由于大部分醫(yī)師對此類韌帶損傷引起肘關節(jié)功能障礙的認識不夠，造成漏診或沒有得到及時有效的治療，以致于嚴重影響患者的生活質量。在醫(yī)療條件較差、醫(yī)師水平較低的醫(yī)院，對韌帶的損傷往往只是采取保守治療或簡單韌帶縫合，導致韌帶強度不夠、功能鍛煉延遲、治療效果不佳[1]。手術治療效果明顯，但手術方式多樣。Rhyou等[2]只是在肱骨建立橫行的骨隧道供肌腱穿過，而肱骨上僅用錨釘固定，這樣韌帶上端很難附著于肱骨外側髁上。Sanchez-Sotelo等[3]在尺骨、肱骨上建立垂直于韌帶走形方向的骨隧道，用較長的肌腱“8”字形穿過隧道，縫線打結固定，此時肌腱需要一定長度且較細小，容易斷裂或縫線滑脫等。Dehlinger等[4]建立骨隧道的方式與本研究方法相似，肌腱穿過骨隧道后，僅用縫線將肌腱固定在骨隊道上，牢固性欠佳，功能鍛煉時間延遲。本研究就是用自體肌腱肱骨及尺骨雙骨隧道重建韌帶的方式對16例患者進行手術治療，對治療的效果報道如下。

資 料 與 方 法

一、一般資料

2008年1月至2013年12月，本院骨科收治并明確診斷為肘關節(jié)LUCL損傷、肘關節(jié)PLRI患者16例。其中男性11例、女性5例；年齡19～43歲，平均28.8歲；新鮮損傷7例、陳舊性損傷9例；單純尺骨冠狀突骨折4例，肘關節(jié)脫位3例，冠突骨折伴肘關節(jié)脫位5例，“肘關節(jié)恐怖三聯(lián)征”內固定術后4例(均行冠突骨折內固定術)。其中有2例橈骨頭切除，7例患者有內翻畸形(圖1)，5例內翻應力位可見內翻畸形，外翻應力位有肱橈關節(jié)間隙增寬(圖2)，麻醉下肘關節(jié)側方軸移試驗陽性(圖3)。所有患者肘關節(jié)MRI顯示有LUCL損傷或斷裂。患者一般情況見表1。

二、手術方法

患者取仰臥位，取肘關節(jié)外側改良Kocher入路，掀起伸肌總腱起點后，解剖分離肱骨遠端外上髁的LUCL近端起點，顯露LUCL遠端止點以及尺骨旋后肌骨脊，將尺側腕伸肌牽向前側，肘肌牽向后側，探查LUCL的損傷情況。遠側腕橫紋做一長約1cm的橫切口，暴露掌長肌腱并予切斷(也可取對側半腱肌肌腱)，在肌腱中點及移行部各做一長約1.5cm縱切口，分離、切斷、取出肌腱，長約12～15cm，將肌腱對折用1號不可吸收線行雙束編織。在肱骨外上髁LUCL近端起點以及旋后肌骨脊鉆孔創(chuàng)建V型骨隧道，尺骨上兩孔之間相距6～8mm，兩孔連線的方向與LUCL的方向一致，將編制好的肌腱穿入尺骨和肱骨隧道(圖4)。在距隧道出口以遠2mm處各擰入帶線不可吸收錨釘1枚，縫合肌腱、牢固固定，在屈肘30°，前臂盡可能外旋的情況下，收緊移植肌腱和關節(jié)囊縫合線，然后再將移植肌腱與自身韌帶縫合加固(圖5)，同時復位并固定尺骨冠狀突骨折。術畢檢查肘關節(jié)后外側穩(wěn)定性良好，安置引流管，關閉切口，用繃帶包扎傷口，屈肘90°，中立位，石膏托固定。

表1 16例患者一般情況

注：a骨折術后指肘關節(jié)恐怖三聯(lián)征內固定術后；b骨折伴脫位指冠突骨折合并肘關節(jié)后脫位；c關節(jié)脫位指肘關節(jié)后脫位

三、術后處理

術后第2天根據引流情況拔出橡膠引流管，并鼓勵患者下床活動，指導患者伸屈手指。1周后行上臂肌肉無痛性等長收縮鍛煉，2周后去除石膏托，開始進行肘關節(jié)被動伸屈鍛煉，逐漸增加被動運動的幅度及肌力鍛煉的強度，但要避免主動前屈肘關節(jié)、提重物、支撐、旋前、旋后等動作。術后3個月開始適當主動伸屈鍛煉，逐漸增加強度(圖6)，術后6個月時達到正常(圖7、8)。

四、療效評價

采用Mayo肘關節(jié)功能評分評價肘關節(jié)功能，滿分為100分，其中疼痛占45分，活動度占20分，穩(wěn)定性占10分，日?；顒诱?5分?！?0分為優(yōu)，75～89分為良，60～74分為可，<60分為差。

五、統(tǒng)計學分析

圖1 臨床照片可見肘關節(jié)內翻畸形 圖2 肘關節(jié)X線片提示有肘關節(jié)內翻、肱橈關節(jié)間隙增寬 圖3 外側軸移試驗陽性表現(xiàn)為外翻肘關節(jié)、對前臂施以軸向載荷后、內旋前臂，由于橈骨頭半脫位可見皮膚出現(xiàn)凹陷，將肘關節(jié)置于頭頂更易于檢查 圖4 自體肌腱穿過骨隧道 圖5 用帶線錨釘將移植肌腱固定 圖6 術后3個月肘關節(jié)屈曲照片 圖7 術后6個月肘關節(jié)屈曲照片，屈曲增加約10° 圖8 術后肘關節(jié)內翻應力位X線片提示肱橈關節(jié)間隙恢復正常

結 果

一、隨訪結果

本組患者切口一期愈合，住院時間10～17d，平均14.4d。所有患者均獲得門診隨訪，隨訪1～5年，平均2.5年?；颊咧怅P節(jié)活動功能明顯改善，主觀滿意，被動外翻、外旋活動時肘關節(jié)完全穩(wěn)定12例，部分不穩(wěn)定但較術前明顯改善4例，優(yōu)良率為75%。4例肘關節(jié)部分不穩(wěn)定的患者中，全用掌長肌腱帶線錨釘進行LUCL重建，外翻外旋應力位X線片都可反應出輕度不穩(wěn)，其中有2例是恐怖三聯(lián)征內固定+橈骨頭切除術后的患者，1例是陳舊性冠突Ⅱ型骨折未行手術治療的患者，另外1例是新鮮冠狀突Ⅲ型骨折的患者。術后疼痛緩解、肘關節(jié)活動度及Mayo評分,新鮮損傷組都明顯好于陳舊性損傷組(P<0.05)。肘關節(jié)詳細評價結果見表2，術后恢復情況見圖6、7。

表2 16例患者手術前、術后的Mayo評分比較±s)

討 論

維持肘關節(jié)穩(wěn)定性的韌帶主要有LCLC及尺側副韌帶復合體(medial collateral ligament complex，MCLC)。LCLC是由橈骨環(huán)狀韌帶、橈側副韌帶、LUCL組成；MCLC則由前束、后束及斜束組成。Shukla等[5]認為，維持肱尺關節(jié)的穩(wěn)定須具備三個條件：完整的關節(jié)面，完整的MCLC前束和LCLC的LUCL，任何部位的損傷都可影響肘關節(jié)穩(wěn)定性。在Kim等[6]的一項研究中，LUCL的損傷即可導致肘關節(jié)PLRI，但是LCLC其他部分的損傷會加重肘關節(jié)的不穩(wěn)定，因此在治療時要考慮到LCLC的整體修復。目前雖然還沒有證據證實MCLC前束的損傷會導致肘關節(jié)PLRI，但是它的損傷會放大橈骨頭或冠突骨折的作用，因此也應加以重視。在Kamineni等[7]的研究中，肘關節(jié)完全伸直時，橈側副韌帶主要是抵抗肘關節(jié)內翻的應力，所起的作用只有14%，其余都是靠關節(jié)囊及骨面維持，所以肘關節(jié)的穩(wěn)定性除了靠韌帶的作用外，還有尺骨冠狀突、橈骨頭、鷹嘴。尺骨冠狀突也是維持肘關節(jié)前方穩(wěn)定性的重要骨性結構，且X線或CT檢查往往會低估冠突骨折塊的大小[8]，所以對Ⅱ型以上的尺骨冠狀突骨折進行固定就顯得尤為重要。Hall等[9]在一項42例橈骨頭切除后的回顧性研究中顯示，有7例(17%)患者出現(xiàn)了肘關節(jié)后外側不穩(wěn)定。該組病例中2例橈骨頭切除的患者，雖然進行了LUCL重建，術后也出現(xiàn)了輕度不穩(wěn)的表現(xiàn)。

對肘關節(jié)韌帶損傷是否進行手術，主要是根據查體及影像學檢查來確定，其中又以關節(jié)鏡及MRI檢查最為準確，若查體及影像學都支持診斷，則有手術指征[10]。Cain等[11]介紹了一種麻醉狀態(tài)下用關節(jié)鏡對肘關節(jié)間隙進行檢查，肘關節(jié)屈曲70°～90°外翻位，如尺骨與滑車張開距離超過1～2 mm，提示有外側副韌帶的損傷。一但發(fā)生外側副韌帶損傷，其韌帶質量較差或已經發(fā)生攣縮，直接進行縫合修復的效果較差，因而需要用肌腱實施重建手術[12]。當有嚴重肘關節(jié)后脫位時，關節(jié)囊一般都和韌帶同時損傷，所以不管是急性損傷還是陳舊性損傷，在重建韌帶的同時都要對關節(jié)囊進行修復[7]。由于人群當中約有10%缺失掌長肌腱，就算有一側掌長肌腱時，肌腱部分的長度往往也比較短。對于這種情況，只有考慮截取跖肌腱、股薄肌、肱三頭肌肌腱或半腱肌等用做韌帶的移植物[13]。Dehlinger等[14]用肱三頭肌肌腱對47例LUCL損傷的患者進行重建手術治療。也有學者采用同種異體肌腱重建LUCL，但效果尚不確定[15]。本組病例，對掌長肌腱缺失的患者，也可取對側半腱肌肌腱。

雖然目前對LUCL損傷的治療方式較多，基本都是移植肌腱穿過肱骨及尺骨隧道對LUCL進行重建為主，但他們建立骨隧道的方式及肌腱固定的方式不一樣，移植肌腱的牢固性也不一樣。由于功能鍛煉的時間延遲，容易產生關節(jié)僵硬等，由于操作繁瑣或強度的不夠，治療以后往往收不到良好的效果[16]。建立肱骨、尺骨雙骨隧道的方向與LUCL走形方向一致，滿足生物力學要求，掌長肌腱質量不好時可以換用半腱肌，移植肌腱強度可以得到保證。鉆骨性隧道時，要選取合適的鉆頭，操作要輕柔，防止骨質的破壞，導致建立隧道的失敗，用小刮匙對孔的銳利部分進行打磨，防止移植肌腱的損傷。Streubel等[17]起初建議在肱骨外上髁建立開放的隧道，但是后來又對這一技術進行改良，即在肱骨外上髁做末端封閉的隧道，在隧道末端開兩個小孔用做縫線的固定，治療效果也較好。本組病例的兩種手術方式都使用開放的骨隧道，移植肌腱完全穿過骨隧道后再進行固定[4]。這樣既符合韌帶生物力學的分布，又可以牢固的打結固定。

對于陳舊性損傷引起的肘關節(jié)不穩(wěn)定，大多是因為沒有對LUCL進行合理的處理。出現(xiàn)這種情況，除對LUCL進行重建時，還要處理其他引起肘關節(jié)不穩(wěn)的因素，如尺骨冠狀突骨折、橈骨頭塌陷或切除、肘關節(jié)復雜性損傷(恐怖三聯(lián)征)[18]。尺骨冠狀突是維持肘關節(jié)前方穩(wěn)定性的重要骨性結構，對Ⅱ型以上的骨折進行固定就顯得尤為重要。橈骨頭是維持肘關節(jié)外翻穩(wěn)定性的重要結構，如此結構破壞，LUCL就起到了主要作用，此時LUCL的任何損傷都可以影響肘關節(jié)的穩(wěn)定性[18]?？植廊?lián)征就是把以上問題都集中到一起，并發(fā)癥多，處理更加困難，效果當然也不夠理想。肘關節(jié)損傷的并發(fā)癥主要有關節(jié)僵硬、異位骨化、尺神經損傷等。這些問題雖不影響肘關節(jié)穩(wěn)定性，但是會嚴重影響肘關節(jié)的功能。所以在處理陳舊性損傷時，要將關節(jié)囊與周圍組織的粘連帶進行松解，盡量剔除異位骨化組織及骨贅，改善肘關節(jié)功能。

由于肘關節(jié)的損傷容易并發(fā)關節(jié)僵硬，術后康復鍛煉則是功能恢復的重要環(huán)節(jié)。有研究顯示，如果對損傷后的肘關節(jié)進行3周以上的固定，將會對肘關節(jié)造成不可逆的殘疾，所以，合理的康復鍛煉就非常重要。通過重建LUCL治療肘關節(jié)PLRI的效果確切，但是急性損傷治療效果往往要好于陳舊性損傷。由于陳舊性損傷的病例比較少，且比新鮮的損傷復雜，還需要更多的病例、更新的技術來研究治療的效果。

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(本文編輯：李靜)

劉大海,李開南,母建松，等.自體肌腱雙骨隧道重建技術修復肘關節(jié)后外側旋轉不穩(wěn)定[J/CD]. 中華肩肘外科電子雜志,2016,4(1):29-34.

Autogenoustendondoublebone-tunnelreconstructiontechniquetorepairtheposterolateralrotatinginstabilityoftheelbow

LiuDahai,LiKainan,MuJiansong,LanHai.

DepartmentofOrthopedics,theAffiliatedHospitalofChengduUniversity,Chengdu610081,China

Correspondingauthor:LiKainan,Email：likainan1961@126.com

Background The concept of posterolateral rotatory instability (PLRI) of the elbow was proposed in 1991 by O′Driscoll for the first time. The pathogenic mechanism of PLRI is injury to the radial collateral ligament complex at the elbow, among which the lateral ulnar collateral ligament (LUCL) plays a major role. However, because most physicians know little about the elbow dysfunction caused by such ligament injury, missed or delayed diagnosis often prevents timely and effective treatment, leading to seriously impact on the quality of life of patients. Surgical treatment is often very effective, but surgical approaches vary a lot. Rhyou et al established a horizontal bone tunnel cross the humerus for passing through the tendon, but this approach doesn′t allow attachment of the upper end of this ligament on the lateral condyle of the humerus. Sanchez-Sotelo et al. established bone tunnel on ulna and humerus perpendicular to the ligament, and passed longer tendon through the tunnel at an "8" shape, which was immobilized by suture knot. This procedure requires that the tendon have to be a long and thin one while problems such as tendon breakage and suture slippage often happen. The way Dehlinger et al. established the bone tunnel was similar to the present study, i.e., after passing the bone tunnel; the tendon was only fixed to the bone marrow with suture. This method also has the disadvantage of poor stability and delayed functional exercise. This study used autologous tendon and established humerus and ulna double bone tunnel for ligament reconstruction in 16 patients and the treatment effect is reported below.Methods From January 2008 to December 2013, orthopedics division of our hospital admitted and diagnosed 16 cases of elbow LUCL tear with PLRI patients, of which 11 males and 5 females, aged 19-43 years old, average age of 28.8 years old, 7 cases of fresh injuries and 9 cases of old injuries, 4 cases of simple ulnar coronoid process fracture, 3 cases of elbow dislocation, 5 cases of coronoid fracture with elbow dislocation, and 4 cases of "terrible triad injury of the elbow" after internal fixation (all

coronoid fracture internal fixation). There were two cases of radial head resection, 7 patients with varus deformity and 5 cases of varus stress position with visible varus. Valgus stress was shown as widened humeroulnar interval, and positive Lateral Pivot Shift for Elbow test under anesthesia. Elbow MRI of all patients showed radial ulnar collateral ligament injury or breakage.Surgical Methods: The patients were in prone position. Modified Kocher approach was used. The origin of the common extensor tendon was released from epicondyle. The proximal and distal origin of LUCL and ulna supinator ridge was prepared. Then the unlar extensor carpi muscle was pulled medially and anconeus muscle pulled laterally. The tear patterns of the LUCL were explored (13 cases of distal LUCL injury, and 3 cases of proximal LUCL injury). The palmaris longus tendon (alternatively the contralateral semitendinosus tendon) was harvested from volar wrist. The length of graft was about 12-15 cm. The tendon was fold and prepared with No.1 nonabsorbable suture. A V-shape bone tunnel on lateral humeral epicondyle and the supinator ridge was drilled. A 6-8 mm distance was between the two holes on the ulna and the connecting line between the two holes was in line with the direction of LUCL. The graft was passed through tunnels and sutured by suture anchors. The graft should be tensioned in 30° of flexion and maximal supination. The graft could be further strengthened by LUCL remnant. The coronoid fracture should be reduced and fixed. The stability of elbow was checked. Drainage tube was routinely used. The wound was closed in layers. The elbow was immobilized in neutral rotation and 90° of flexion by plaster cast. Post-operative treatment: rubber drainage tube is removed two days after the surgery based on the status of drainage. Patients are encouraged to get out of bed, and guided to flex and extend fingers. Upper arm muscle painless isometric exercise is started 1 week after the surgery. The plaster cast is removed after 2 weeks. Passive elbow flexion exercise is began and gradually increased the magnitude of passive exercise and the strength of the muscle force training, but active flexion of the elbow should be avoided, heavy lifting, supporting, medial and lateral rotation movements also should be avoided. Active flexion exercise is begun after 3 months, and gradually increased the intensity to reach normal activity level after 6 months.Efficacy evaluation: the Mayo elbow performance index was used to evaluate elbow function. Out total of 100 points, pain accounts for 45 points, mobility for 20 points, stability for 10 points, and daily activities for 25 points, ≥90 as excellent, 75-89 as good, 60-74 as acceptable and <60 as poor.Results All patients achieved primary healing of the incision. Hospitalization time ranged 10-17 days, with an average of 14.4 days. All patients are received outpatient follow-up of 1-5 years, with an average follow-up time of 2.5 years. The patients′ elbow motion improved significantly, and patients are generally satisfied. There were 12 cases of patients achieved total stability at passive valgus and lateral rotation, partially instable but significantly improved after the surgery in 4 cases, with a good to excellent rate of 75%. All the 4 patients with partial instability received LUCL reconstruction with suture anchors using the palmaris longus tendon graft. X-ray film can reflect their slight instability at valgus and lateral rotation stress position. Two of these 4 patients were diagnosed as terrible triad injury and received internal fixation plus radial head resection, 1 case of old typeⅡ coronoid fracture patient who did not undergo surgery and 1 case of fresh type Ⅲ coronoid fracture patient.Postoperative pain relief, elbow mobility and Mayo scores of the fresh injury group were all significantly better than those of the old injury group (P<0.05).ConclusionRadialulnarcollateralligamentisthemainstructuretoaffectelbowPLRI,anduseofautologoustendonandhumerusandulnadoublebonetunneltoreconstructtheradialulnarcollateralligamentachievesgoodresults.

Elbowjoint;Ulnarcollateralligament;Ligamentreconstruction

10.3877/cma.j.issn.2095-5790.2016.01.006

國家自然科學基金(81500577)

610081成都大學附屬醫(yī)院骨科

李開南，Email：likainan1961@126.com

2015-09-21)