肩關節鏡下喙鎖韌帶重建術治療RockwoodⅢ型肩鎖關節脫位的療效研究

李奉龍 姜春巖

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肩關節鏡下喙鎖韌帶重建術治療RockwoodⅢ型肩鎖關節脫位的療效研究

李奉龍 姜春巖

目的 分析采用肩關節鏡下喙鎖韌帶重建術治療Rockwood Ⅲ型肩鎖關節脫位的臨床療效。方法 回顧性研究2013年2月至2014年1月連續收治并獲得隨訪的21例Rockwood Ⅲ型肩鎖關節脫位患者的資料。其中男性17例，女性4例。平均年齡42.8歲，平均受傷到手術時間11.1 d。所有患者均于肩關節鏡下應用同種異體肌腱重建喙鎖韌帶并高強度縫線捆扎固定喙鎖間隙治療肩鎖關節脫位。術后定期隨訪，記錄患側肩關節活動范圍，并采用疼痛視覺模擬評分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)評分及UCLA(university of California Los Angeles)評分評價患者肩關節功能狀況；同時拍攝肩關節正位、側位及腋位X線片，評估是否有肩鎖關節復位丟失。結果 21例患者術后平均隨訪(14.6±3.9)個月。末次隨訪時肩關節平均前屈上舉為173.9°±10.3°，體側外旋為59.5°±14.3°，內旋為第12胸椎體水平，平均UCLA評分為(34.1±2.5)分，平均ASES評分為(95.5±4.7)分，平均VAS評分(0.3±0.6)分。末次隨訪拍攝肩關節X線片未發現肩鎖關節復位丟失。結論 采用肩關節鏡下喙鎖韌帶重建術治療Rockwood Ⅲ型肩鎖關節脫位的臨床療效滿意，患者術后可獲得良好的肩關節功能。

肩關節；關節鏡；脫位；手術

肩鎖關節脫位是肩關節外科的常見疾病[1],對于Rockwood Ⅰ型、Ⅱ型損傷程度較輕的肩鎖關節脫位患者，可通過保守治療取得滿意效果；對于Rockwood Ⅳ型、Ⅴ型、Ⅵ型等重度肩鎖關節脫位患者則需要進行手術治療，而對于Rockwood Ⅲ型肩鎖關節脫位患者，目前治療仍存爭議[2-5]。隨著關節鏡微創技術的發展，肩關節鏡下韌帶重建手術被逐漸廣泛地應用于治療肩鎖關節脫位。肩關節鏡手術理論上具備微創、術后恢復快等優勢，但目前國內單純針對RockwoodⅢ型肩鎖關節脫位的關節鏡手術治療報道仍較為少見。本文通過回顧性研究，分析近年來我院采用肩關節鏡下異體肌腱移植、喙鎖韌帶重建術治療高運動水平需求的Rockwood Ⅲ型肩鎖關節脫位患者的臨床療效。

對 象 與 方 法

一、一般資料

入選標準：(1)高運動水平要求的Rockwood Ⅲ型損傷患者；(2)于我院行肩關節鏡下喙鎖韌帶重建術的患者；(3)新鮮損傷(手術距離受傷時間不超過3周)；(4)不合并血管神經損傷；(5)術后隨訪時間≥12個月。排除標準：(1)陳舊性損傷(受傷至手術時間>3周)；(2)雙側損傷；(3) 患側肩關節既往手術史；(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，連續于我院接受肩關節鏡下喙鎖韌帶重建術治療的Rockwood Ⅲ型肩鎖關節脫位患者共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，平均受傷到手術時間11.1 d。

二、手術方法

手術在全身麻醉下進行，采取沙灘椅體位。術中建立關節鏡入路通道，包括后方主通道、外側通道、前外側通道和前內側通道，其中，前內側通道位于喙突與鎖骨中間。鎖骨遠端上方喙鎖韌帶止點附近取3 cm小切口，用于固定。首先建立后方主通道，探查盂肱關節內，觀察是否合并關節內損傷。將鏡頭移至肩峰下間隙，建立外側通道，然后鏡頭移到肩峰下外側通道，進行肩峰下清掃。同時建立前外側通道，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側通道，清理喙突周圍的軟組織，注意保護喙鎖韌帶殘端。由于臂叢血管神經于喙突內側走行，所以此步操作需謹慎，注意保護周圍的血管和神經。于鎖骨遠端插入硬膜外針頭，定位肩鎖關節。然后清掃鎖骨下方軟組織，并注意保護喙鎖韌帶鎖骨側止點。于鎖骨上方喙鎖韌帶止點處使用3.5 mm鉆頭建立2個鎖骨骨髓道。通過引導線將異體腘繩肌腱和4根高強度縫合線從喙突下方、喙肩韌帶止點后方穿過，兩端向上拉起并通過鎖骨骨隧道，在關節鏡直視下復位肩鎖關節，并在鎖骨上方依次將高強度縫合線及異體肌腱打結固定，構成喙鎖懸吊結構來固定遠端鎖骨。

三、康復方法

術后采用肩關節吊帶制動6周。手、腕、肘的被動功能鍛煉在術后患者疼痛允許情況下盡早進行。術后6周摘除吊帶，開始肩關節被動及主動活動度練習，根據患者具體康復狀況逐步恢復日常非負重生活活動。術后3個月開始肌肉力量練習。

四、術后隨訪及評價方法

患者分別在術后3周、6周、3個月、6個月、12個月以及末次隨訪時拍攝肩關節正位、側位及腋位X線片，評估是否有肩鎖關節復位丟失。末次隨訪時，通過查體記錄患者肩關節前屈上舉、體側外旋及內旋的活動度，有無肩鎖關節壓痛；采用疼痛視覺模擬評分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)評分及UCLA(university of California Los Angeles)評分評價患者肩關節功能狀況。

結 果

21例患者術后平均隨訪(14.6±3.9)個月(12～19個月)。末次隨訪時肩關節平均前屈上舉為173.9°±10.3°，體側外旋為59.5°±14.3°，內旋為第12胸椎體水平，平均UCLA評分為(34.1±2.5)分(28～35分)，平均ASES評分為(95.5±4.7)分(82～100分)，平均VAS評分(0.3±0.6)分(0～3分)。末次隨訪拍攝肩關節X線片未發現肩鎖關節復位丟失。

所有患者術后未出現感染、神經血管損傷；術后無患者發生喙突或鎖骨骨折。

討 論

一、肩鎖關節脫位的手術指證

有關肩鎖關節脫位的治療，目前較為統一的觀點認為，Rockwood Ⅰ型或Ⅱ型損傷一般采用保守治療，而對于損傷嚴重的Rockwood Ⅳ、Ⅴ型肩鎖關節脫位則建議積極進行手術治療[2-5]。對于Rockwood Ⅲ型損傷的治療，目前仍存在爭議。部分研究表明對于Rockwood Ⅲ型損傷，手術治療與保守治療可得到相似的療效[2]。盡管如此，對于一些對運動水平要求較高或從事重體力勞動的Rockwood Ⅲ型損傷患者，由于其肩胛鎖骨同步運動受損，在高強度運動或工作時可能導致疼痛或活動受限[7-9]。Wojtys等[5]通過對22例保守治療的Rockwood Ⅲ型損傷患者平均2.6年的隨訪發現，保守治療后患側的力量及耐力與健側水平相當，但活動量增大時會出現明顯不適。Gstettner等[10]報道了24例采用鉤鋼板技術治療Rockwood Ⅲ型損傷的病例，術后平均34個月隨訪，肩關節功能評分顯著優于保守治療組(17例)。因此，我們認為對于高運動水平要求或從事重體力勞動的Rockwood Ⅲ型損傷患者可考慮進行手術治療。

二、肩鎖關節脫位的手術方法

早期肩鎖關節脫位的手術治療以剛性固定為主，主要包括經肩鎖關節穿針固定、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度[11]，隨著時間進展，會出現內固定物金屬疲勞甚至折斷的情況，亦有可能在鎖骨遠端、喙突、肩峰的應力集中區域發生骨溶解甚至骨折，術后并發癥發生率較高，而且常需進行二次手術取出內固定物。與之相比，采用高強度縫線加自體或異體肌腱等進行肩鎖關節彈性重建的手術方式逐漸被廣泛接受。隨著關節鏡微創技術的發展，肩關節鏡下韌帶重建手術被逐漸廣泛地應用于治療肩鎖關節脫位，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合喙鎖間隙固定。Salzmann等[12]采用紐扣鋼板技術固定喙鎖間隙治療肩鎖關節脫位，術后兩年隨訪肩關節功能評分明顯改善，但其病例系列中有35%患者術后出現復位失效，原因可能與紐扣鋼板局部應力集中所致喙突和鎖骨骨溶解而導致固定失效有關；另外，單純采用內固定材料重建喙鎖間隙，無法確保喙鎖韌帶的愈合狀況，增加了術后復位失效的風險。Carofino等[13]采用單純肌腱移植重建喙鎖韌帶，并應用擠壓螺釘將移植肌腱固定于鎖骨骨隧道，術后隨訪平均ASES評分92分，但復位失效率仍較高，達17.6%。單純應用肌腱移植重建喙鎖韌帶，術后早期肌腱未愈合，缺乏固定強度，難以維持復位，易發生失效。本研究中采用肌腱移植聯合高強度縫線固定技術以喙鎖懸吊方式重建喙鎖韌帶，其優勢在于術后早期，縫線固定可維持牢固復位，為移植肌腱的愈合提供了穩定的生物力學環境；而移植肌腱的愈合及爬行替代重構則對術后遠期維持復位起到主要作用。另外，我們采用的喙鎖懸吊技術方法簡單，且不需要使用特殊的內固定材料，降低了手術的時間和成本，同時因不需要在喙突基底處鉆孔，從而避免了醫源性喙突骨折的風險。

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，隨訪時間較短，應進一步延長隨訪時間以明確其遠期療效；(2)應設計對照組進一步明確對于高運動水平需求的Rockwood Ⅲ型肩鎖關節脫位患者手術治療的必要性。

總之，采用肩關節鏡下喙鎖韌帶重建術治療高運動水平需求的Rockwood Ⅲ型肩鎖關節脫位患者的臨床療效滿意，患者術后可獲得良好的肩關節功能。

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[2] 汪國友，沈驊睿，曾勝強，等.全關節鏡下治療肩鎖關節脫位[J/CD].中華肩肘外科電子雜志，2014，2(3)：151-156.

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[8] Taft TN,Wilson FC,Oglesby JW.Dislocation of the acromioclavicular joint.An end-result study[J].J Bone Joint Surg Am,1987,69(7):1045-1051.

[9] 羅吉偉，余斌，魏寬海，等.自體掌長肌移植重建喙鎖韌帶結合帶線錨釘固定治療肩鎖關節脫位的療效[J/CD].中華肩肘外科電子雜志，2014，2(1)：25-29.

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[11] 陸偉，王大平，朱偉民，等.關節鏡下四骨道雙束固定治療急性肩鎖關節Rockwood Ⅴ型脫位[J/CD].中華肩肘外科電子雜志，2014，2(3)：157-162.

[12] Salzmann GM,Walz L,Buchmann S,et al.Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations[J].Am J Sports Med,2010,38(6):1179-1187.

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(本文編輯：李靜)

李奉龍，姜春巖.肩關節鏡下喙鎖韌帶重建術治療Rockwood Ⅲ型肩鎖關節脫位的療效研究[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

北京市新世紀百千萬人才工程培養經費；北京市自然科學基金資助項目(7142074)

100035北京積水潭醫院運動損傷科

姜春巖，Email:chunyanj@hotmail.com

2014-12-03)