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 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 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的肘關節功能評分標準,評價術后早期療效。結果患者全部得到隨訪,術后隨訪6～36個月,平均19.6個月,優5例、良3例、中1例,本組病例隨訪時均未發現肘關節感染、強直或脫位,慢性肘關節炎及肘、前臂和腕部長期慢性疼痛等并發癥。結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,遠期療效有待進一步評價。

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,為關節內骨折,約占肘部骨折的17%～19%,約有1/3合并關節其他部位損傷[1],其中伴隨肱骨小頭損傷約1%,隨著損傷的加重,其發生率可達24%。隨著對橈骨小頭在肘關節及前臂穩定性的作用認識的逐漸深入,在治療方法的認識上也逐步明確。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、切開復位“T”型或“L”微型鋼板等治療方法,然而,常出現肘關節不穩、慢性長期疼痛、早期內固定失敗,骨不連和前臂旋轉功能障礙等并發癥。1941年Speed行橈骨小頭置換術治療橈骨小頭粉碎性骨折后,多種假體應運而生,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,它能快速恢復肘關節的穩定結構避免長期固定引起關節功能障礙、內固定失效及骨折不愈合帶來的風險[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,恢復其肘關節功能,保持關節的活動度及穩定性,臨床療效較好,現報道如下:

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4例、右側5例,其中合并內側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:橈骨頭和橈骨頸嚴重的粉碎性骨折;伴發肘關節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、手術方法

在臂叢或全身麻醉成功后,患肢上臂上止血帶,常規消毒鋪巾,取肘關節Kocher入路切口,長約6～8 cm,逐層切開,于尺側腕伸肌及肘后肌之間的間隙分離,顯露外側肘關節囊,在顯露過程中應保持前臂旋前,以保護骨間后側神經。在靠近肱二頭肌結節處切斷橈骨頸,修整橈骨近側骨髓腔,用專用髓腔銼打磨,以便假體的植入,平整切除橈骨近端關節面,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,使之與正常橈骨小頭解剖一致,防止脫位。安裝到位后復位,檢查復位后穩定情況,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的生物型Swanson鈦金屬橈骨小頭假體置換治療),方向是近端關節面朝向外側,復位,再次檢查關節穩定性,被動活動肘關節和前臂時,人工橈骨頭和周圍骨結構或軟組織之間不發生撞擊,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。肘關節不穩定的情況下需修復內側副韌帶,還要修復關節囊、環狀韌帶以及外側副韌帶復合體。沖洗傷口,安放引流管,逐層縫合,術畢。

三、術后處理

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

四、療效評價標準

根據患者肘關節的活動度、肌力、穩定度和疼痛情況,按照Broberg和Morrey的肘關節功能評分標準[5]進行評分。具體方法:肘關節屈伸滿分27分(0.2×肘關節屈伸弧),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,嚴重無力0分;穩定性:正常5分,輕度不穩活動無受限4分,中度不穩部分活動受限2分,嚴重不穩日常活動受限0分;疼痛:無疼痛35分,活動時輕度疼痛無需服用止痛藥28分,活動產生中度疼痛15分,嚴重疼痛0分。滿分為100分,95～100分為優,80～94分為良,60～79分為可,0～5分為差。

結 果

根據Broberg和Morrey的肘關節功能評分標準評定,術后隨訪6～36個月,平均19.6個月,優5例、良3例、中1例,本組病例隨訪時均未發現肘關節感染、強直或脫位,慢性肘關節炎及肘、前臂和腕部長期慢性疼痛等并發癥。

典型病例:患者男性,34歲,為左橈骨小頭陳舊性骨折,傷后3個月出現左肘關節疼痛,關節活動受限,屈曲約120°,伸直約5°,前臂旋前約70°,旋后約45°。術后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

肘關節的穩定系統包括結構性穩定系統(或稱靜力穩定系統)和動力穩定系統。Heim將結構性穩定系統歸結為肘關節的穩定環,由4個柱組成:內側柱、外側柱、前柱和后柱。前柱包括冠狀突、肱肌、前關節囊;后柱包括鷹嘴突、三頭肌、后關節囊;內側柱由尺側副韌帶、冠狀突、內髁或內上髁組成;外側柱由橈骨頭、肱骨小頭和橈側副韌帶組成。如部分破壞時,肘關節穩定性即下降[6]。

目前,對橈骨小頭生物力學和解剖學的研究表明[7],橈骨小頭對肘關節外側柱穩定性起著重要的作用,在穩定肘關節的生物力學功能中占有極為重要的地位,尤其當肘關節內側副韌帶和骨間膜損傷時,是肘關節抵抗外翻應力的重要結構,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,術后可能會出現一系列如肘關節不穩、慢性長期疼痛、外翻強直畸形、異位骨化、創傷性關節炎、下尺橈關節紊亂、腕尺側撞擊征等并發癥。現在已很少選擇此術式。Businger等[9]采用On-table重建技術治療橈骨小頭MasonⅢ型骨折取得了良好的臨床效果。該技術主要是術中將所有橈骨小頭碎骨塊取出,放于手術臺上直視下進行精確復位,盡量做到解剖復位,保證關節面平整光滑,有利于骨折的愈合及肘關節功能的恢復。復位后可通過埋頭螺釘或0.8 mm細克氏針行臨時固定,將所有骨折塊固定為一個整體,構建大體框架[10]。后將橈骨小頭用事先預彎好的微型鋼板固定于橈骨上,鋼板置于后外側“安全區”(橈骨小頭頭頸外側約110°的區域有一弧形“非關節面”,此處不參與關節構成)[11],注意橈骨的旋轉功能不能受限,術中鋼板放置的位置是否恰當是手術成功的關鍵。本手術操作要求較高,骨折塊較小,復位骨折不能反復操作,以免造成更嚴重的骨折,從而影響其穩定性及復位效果。也正因為骨折塊多,固定有限,術后常需功能位石膏托固定,短期內不能功能鍛煉,不利于關節功能恢復。劉麟等[12]對55例MasonⅢ型橈骨小頭骨折患者采取切開復位內固定術,術后采用Broberg和Morrey的肘關節功能評分標準評定療效,優良率為85.5%。Cai等[13]對9例復雜MasonⅢ型橈骨小頭骨折患者采取切開復位微型鋼板內固定治療,隨訪結果顯示優良率僅為22%。在切開復位組中,23例患者中有1例發生骨不連,2例發生較嚴重的異位骨化,3例發生內固定失敗,嚴重影響關節功能,優良率僅65.2%。作者認為,對于不穩定、粉碎性橈骨小頭骨折,內固定失效概率較高,應慎重考慮。

圖1～4 手術前后正側位X線片。圖1橈骨小頭骨折,關節面塌陷,關節間隙增大;圖2橈骨小頭置換術后,假體位置準確,無松動,關節間隙可;圖3橈骨小頭骨折,骨折線波及關節面;圖4橈骨小頭置換術后假體位置準確,關節間隙正常

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癥,恢復了橈骨頭、頸解剖上的完整性,肘關節在生物力學上的平衡,加上術后早期主、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現肘關節感染、強直或脫位,慢性肘關節炎及肘、前臂和腕部長期慢性疼痛等并發癥。另外,術中經常發現術前影像學檢查以為是簡單的骨折,術中卻很粉碎,給復位帶來困難,影響術后療效,有研究表明[14]:對于骨塊多于3塊者,切開復位失效率較高,常需要延期行橈骨頭切除術或橈骨小頭置換術。這不但增加了患者治療費用和手術次數,而且也在一定程度上相應的影響臨床療效。目前多數認同的適應證:(1)MasonⅣ型骨折;(2)MasonⅢ型骨折難以作內固定者;(3)橈骨小頭骨折合并尺骨上端骨折,尤其合并肘內側副韌帶損傷導致的肘關節不穩;(4)陳舊性骨折或經橈骨頭切除后出現明顯前述并發癥患者;(5)肘關節其他疾病影響功能者,如類風濕性關節炎、腫瘤及先天性畸形等[15]。術中應注意:(1)橈骨頸截骨的高度,根據假體試模做出正確判斷,避免過度截骨;(2)假體與肱骨小頭關節面的間隙以2 mm左右為佳,避免被動活動肘關節時發生撞擊;(3)如果伴有尺側副韌帶損傷的,應予以修復,恢復關節穩定性;(4)有橈骨小頭置換適應證的患者應盡早一期置換,避免多次手術導致瘢痕攣縮影響關節功能及增加異位骨化風險。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,與切開復位內固定的治療方法存在爭議,王思成等[16]采用前瞻性隨機對照分析45例不穩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位內固定治療,比較兩組Broberg和Morrey的肘關節功能評分和并發癥發生率,結果假體置換組Broberg和Morrey的肘關節功能評分平均90.1分,并發癥發生率13.6%,切開復位組Broberg和Morrey的肘關節功能評分平均76.8分,并發癥發生率47.9%,兩組比較差異有統計學意義(P<0.01)。與切開復位內固定治療相比較,橈骨小頭置換治療不穩定性粉碎性骨折可獲得更好的關節功能和更低的并發癥發生率。劉鵬程等[17]搜集MasonⅢ型橈骨頭骨折假體置換及切開復位內固定的對照研究并加以系統評價。用Revmen 5.1統計學軟件進行異質性分析及Meta分析。假體置換組與切開復位內固定組相比,均有明顯優勢。現有的有限證據表明,通過優良率、肘關節功能評分及并發癥評價證實,人工假體置換治療MasonⅢ型橈骨小頭骨折較切開復位內固定具有更大優勢,且差異具有統計學意義。

當然,橈骨小頭置換術治療橈骨小頭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,隨著科學技術的發展,假體設計及手術技術的改進,橈骨小頭置換的臨床療效也會更好。

[1] Morrey BF.The elbow and its disorders[M].2nd ed.Philadelphia:WB Saunder,2000:341-364.

[2] Chen X,Wang SC,Cao LH,et al.Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable,multi-fragmented radial head fractures[J].Int Orthop,2001,35(7):1071-1076.

[3] 李龍杰,李宏偉,紀振中,等.橈骨小頭假體置換治療橈骨小頭粉碎性骨折的療效[J].中國老年學雜志,2012,32(4):821-822.

[4] Mason ML.Some observations on fractures of the head of a review of one the radius with undredcases[J].Br J Surg,1954,42(172):123-132.

[5] Broberg MA,Morrey BF.Results of delayed excision of the radial head after fracture[J].J Bone Joint Surg Am,1986,68(5):669-674.

[6] 孫皓民,常敏,楊景帆,等.橈骨小頭假體置換治療橈骨小頭粉碎性骨折[J].中國實用醫藥雜志,2009,4(7):30-32.

[7] 張漢中,劉國龍,韓運.橈骨小頭骨折的手術治療[J].中國醫師進修雜志(外科版),2009,32:53-55.

[8] 劉萬軍,王維光,劉云鵬,等.MasonⅢ型粉碎性橈骨小頭骨折不同手術方法療效分析[J].中華創傷骨科雜志,2006,8(2):127-130.

[9] Businger A,Ruedi TP,Sommer C.On-table reconstruction of comminuted fractures of the radial head[J].Injury,2010,41(6):583-588.

[10] 趙光輝,王浩,劉曙光,等.應用On-table重建技術治療橈骨頭粉碎骨折療效分析[J].實用骨科雜志,2011,17(5):394-397.

[11] 張培訓,徐海林,陳建海,等.橈骨小頭骨折的治療[J].中華創傷雜志,2009,25(4):535-538.

[12] 劉麟,宋暉,王兆利,等.微型鈦板結合加壓螺釘在MasonⅢ型橈骨小頭骨折內固定術中的應用[J].中外醫學研究雜志 ,2014,12(18):19-21.

[13] Cai PH,Mei GH,Fan CY,et al.The clinical therapeutic effect about open reduction and internal fixation of the Mason typeⅢradial head fractures[J].Chin J Othop Trauma,2005,7(5):496-498.

[14] Ring D,Quintero J,Jupiter JB.Open reduction and internal fixation of fractures of the radial head[J].J Bone Joint Surg Am,2002,84-A(10):1811-1815.

[15] 陶海莉,趙勝豪,郭衛春.橈骨小頭假體置換治療成年人橈骨小頭粉碎性骨折[J].臨床外科雜志,2010,17(18):709-710.

[16] 王思成,劉祥飛,楊國慶,等.橈骨小頭置換與切開復位內固定:治療粉碎性橈骨小頭骨折誰更有優勢?[J].中國組織工程研究雜志,2014,18(13):2031-2036.

[17] 劉鵬程,舒和喜,黃昌佳,等.假體置換與切開復位內固定治療成人MasonⅢ型橈骨頭骨折臨床結局的系統評價與Meta分析[J].中國骨與關節外科雜志,2014,12(2):128-133.

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 瀘州醫學院附屬中醫醫院骨關節科

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.