关节镜下喙锁韧带增强术治疗肩锁关节脱位

皇甫小桥 赵金忠 何耀华 杨星光 刘旭东 刘闻欣 王海明

通讯作者：赵金忠,Email:zhaojinzhong@vip.163.com

【摘要】目的研究关节镜下缝线钢板增强喙锁韧带术治疗肩锁关节脱位的近期治疗效果。方法2010年3月至2011年3月，在关节镜下使用膝关节韧带重建技术的缝线钢板(德国ASCULAP公司，B′BRAUN)增强重建喙锁韧带(三角韧带与斜方韧带)，治疗Rockwood Ⅲ型9例、Ⅴ型3例新鲜肩锁关节脱位。术后行X线片检查，以美国肩肘关节外科医师(America Shoulder Elbow Surgeons，ASES)评分法和Constant评分法评估疗效。术后随访12～18个月。结果12例患者ASES评分：术前28.7分，术后86.9分；Constant评分：术前24分，术后91分。治疗组X线片显示，肩锁关节复位良好。术后1年，91.7%(11/12)病例获得满意治疗效果，83.3%(10/12)恢复到术前运动水平，仅有1例出现肩锁关节半脱位。结论关节镜下缝线钢板喙锁韧带增强术治疗肩锁关节脱位，早期可以获得满意的治疗效果，术后复位良好，并发症少。

【关键词】 肩锁关节脱位； 喙锁韧带； 关节镜

【Abstract】BackgroundAcromioclavicular joint dislocation is commonly seen in shoulder joint injuries. Dysfunction as well as pain and discomfort usually occurred when the integrity of shoulder is damaged, for the acromioclavicular (AC) joint is involved in the connection between the scapula and the body as well as the activities of shoulder joint. Therefore, a consensus has been reached to treat severe AC joint dislocation by surgery. Based on different anatomical and functional cognition, methods for AC joint dislocation are various, which are typically performed by incision to reconstruct its stability and restore function. Attempts had been made by many doctors in the reconstruction of AC joint dislocation with the development of arthroscopy. From March 2010 to March 2011, obvious therapeutic effect was obtained in treating Rockwood type Ⅲ and Ⅴ AC joint dislocation arthroscopically with the suture plate used for the reconstruction of ligaments of knee joint to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament).MethodsFrom March 2010 to March 2011, nine patients with acute AC joint dislocation type Ⅲ and three patients with type V were treated arthroscopically to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament) by the suture plate (ASCULAP Company, Germany, B′Braun) used to reconstruct ligaments of knee joint. Patients were pre and postoperatively evaluated with X-ray examinations, American Shoulder and Elbow Surgeons′ Form (ASES) and Constant-Murley Score (CMS).ResultsAll 12 patients were followed up for at least 12 months (range,12 to 18 months). The average ASES score significantly increased from 28.7 preoperatively to 86.9 postoperatively, and the mean CMS score from 24 to 91, respectively. X-ray data showed a good reduction of the AC joint in the treated group. 91.7% of patients (11 patients) obtained an obvious therapeutic effect after operation. 83.3% of patients (10 patients) returned to their pre-injury level of athletics. Acromioclavicular subluxation was only found in one case.DiscussionAC joint dislocation usually appears in youth and adults with obvious traumatic history, and often results from the direct violence on the adducted shoulder. The stable structure of AC joint is achieved by the connection between the scapula and the clavicle, and the integrity of the sternoclavicular articulation and the scapulothoracic joint. According to the injury level of acromioclavicular stability, AC joint injuries can be classified into six types by Rockwood, type Ⅲ、Ⅳ、Ⅴ、Ⅵ should be fixed through operation for its disruption of stable structures.The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function. Activity of AC joint and its postoperative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility. Arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique is an effective method in treating AC joint dislocation, which restores its anatomy and has advantages over the traditional open surgery.(1)AC joint anatomy and dislocation of classification:AC joint dislocation often occurs in youth and adults trauma, and is usually caused by direct violence on the adducted shoulder. The connection between the scapula and the clavicle, and the integrity of the sternoclavicular articulation and the scapulothoracic joint can help to achieve the stable structure of AC joint, the former of which is the most important. Coracoclavicular ligament (conoid ligament and trapezoid ligament ), the deltoid and trapezius muscle fascia as well as AC joint are involved in the connection between the scapula and the clavicle. Therefore, functionally speaking, the conception of AC joint should be replaced by acromioclavicular connection. When aforementioned anatomical structure cannot be fixed after AC joint dislocation, the connection between the scapula and the clavicle should be restored or reconstructed. And there is no necessity to emphasize the restoration of the anatomical integrity.According to the injury level of acromioclavicular stability, AC joint juries are classified into six types by Rockwood, type I and II of which are only acromioclavicular joint ligament injuries without complete dislocation. Except complete dislocation, AC joint stability of type Ⅲ and above with severe damages of other joints and soft tissues should be fixed through operation to restore the stable structures.(2)Treatment of AC joint dislocation:The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function. AC joint is involved in the shoulder activity of abduction, flexion and extension. The scapula rotates around anteroposterior axis when shoulder joint abducts over 60 degrees, and AC joint is involved in the activity when the upper arm anteflexes to 90 degrees. Corresponding reflects of AC joint and sternoclavicular articulation are due to the relative rotation around the body at any angle by the scapula. Large movement of AC joint is involved in the normal shoulder exercise, and activity of AC joint and its post operative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility such as AC joint Kirschner pin fixation, Coracoclavicular screw fixation and clavicular hook plate. Internal fixation failure results from its abnormal stress caused by the increased range of the shoulder movement. Hence, reliable clavicle reduction should be achieved by clavicle fixation of AC joint or the scapula and the clavicle, while the relative freedom of movement between the scapula and the clavicle should be maintained. Soft fixation between coracoid and clavicle, such as suture, artificial ligament or wire, may be a better choice.Based on the development of arthroscopy, minimally invasive or arthroscopic surgical procedure of shoulder joint has been evolved from open reduction and internal fixation. Minimally invasive surgery had been conducted by some doctors to treat AC joint, and obvious therapeutic effect is achieved through arthroscopic reconstruction of CC ligaments.(3)Advantages of the arthroscopic technique in treating AC joint dislocation:Compared to traditional open surgery, arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique has advantages as follows:(1) minimal trauma. Just three 5-mm small incisions are needed as arthroscopic pathways to expose the coracoclavicular joint without the alteration of the tissues nearby, which helps for the postoperative rehabilitation. (2) Reliable reduction may be attained arthroscopically without necessary intraoperative X-ray confirmation, which shortens the operation time. (3) The suture plate with good biocompatibility augments CC ligaments and has no effect on AC joint anatomy, which is propitious to healing of the fresh joint capsule and the ligament. (4) The flexible anatomic enhanced fixation allows certain ranges of AC joint movement during abduction, flexion and extension of shoulder, which conforms to the biological nature of AC joint.Long learning of the arthroscopic skills is required due to its key role in the arthroscopically assisted augmentation of reconstructed CC ligaments. Additionally, such anatomical structures as coracoid base, AC joint and CC ligament should be known well. While establishing bone tunnel from the clavicle to the coracoid root, arthroscopy travels along the CC ligament to guarantee the uniformity of cortical bone around the tunnel. After arthroscopic reduction, the plate should be carefully fixed in the end of coracoidprocess to avoid rarefaction of bone that loosens fixation, breaks it off and thus leads to failure.In addition, arthroscopically assisted augmentation of the reconstructed CC ligaments is applicable for patients of type Ⅲ and Ⅴ in Rockwood classification. Open surgery is necessary to restore the stability of joint for type Ⅵ and Ⅳ patients with reduction difficulties.ConclusionsAugmentation of CC ligaments with the suture to restore the anatomy of AC joint is an effective method in treating the dislocation. Minimal injury, reliable reduction of AC joint, less complication and rapid recovery of the shoulder joint function are found after the arthroscopic operation. Whether AC joint structure is stabilized and its biomechanic features are self-repaired to restore the normal anatomy and function or not, which required long term follow-up.

【Keywords】 Acromioclavicular joint dislocation； Coracoacromial ligament； Arthroscopy

肩锁关节脱位在肩关节外伤中比较多见，因肩锁关节既参与肩胛骨和躯干的连接，也参与肩关节的活动，当肩锁关节的完整性遭到破坏时，常引起各种肩部疼痛、不适和肩关节功能障碍。因此，对于严重的肩锁关节脱位，采用手术治疗已成为共识。基于对肩锁关节解剖结构以及功能认识的不同，治疗肩锁关节脱位的方法各不相同，一般通过切开重建其稳定结构，以恢复关节的功能[1]。近来随着关节镜器械技术的发展，许多学者尝试关节镜下重建喙锁韧带治疗肩锁关节脱位[2-7]。2010年3月至2011年3月，我们在关节镜下使用膝关节韧带重建技术的缝线钢板，解剖增强重建喙锁韧带(锥形韧带与斜方韧带)治疗RockwoodⅢ、Ⅴ型肩锁关节脱位，取得良好效果。

临床资料

一、一般资料

本组急性肩锁关节脱位12例，其中女性4例，男性8例；右肩9例，左肩3例；年龄17～43岁，平均37岁。按照Rockwood分类，肩锁关节脱位Ⅲ型9例，Ⅴ型3例。均在关节镜下行缝线钢板技术增强喙锁韧带，手术时间为外伤后1～12 d，平均5 d。术后系统随访12～18个月。

二、术前准备

术前常规摄肩锁关节正位X线片确定脱位的类型(图1A)。RockwoodⅣ、Ⅴ、Ⅵ型肩锁关节脱位通过肩关节正位X线片，结合检查即可确诊；为避免将RockwoodⅢ型肩锁关节脱位误诊为Ⅱ型，需要在应力状态下，摄肩关节正位X线片进行诊断。为排除肩峰下其他病变，有时需要进行冈上肌出口位X线片或者肩关节MRI检查。

三、手术方法

本组病例均行臂丛神经肌间沟神经阻滞、气管插管、全身麻醉，成功后摆放体位，取侧卧患肢悬吊位。患肩及上肢消毒无菌巾单包裹。术前对患肩进行全面检查，用无菌笔作锁骨、肩峰与喙突轮廓的解剖标记，注意标记肩锁关节间隙中点。术前在锁骨走行肩锁关节近端3 cm处以尖刀做一小切口，采用标准肩关节镜手术后方入路，进入盂肱关节行关节腔内检查，经前方入路伸进汽化电刀清理，显露喙突基底。

然后通过后方入路进入肩峰下隙，取外侧入路使用汽化电刀和刨刀清理肩峰下隙滑膜组织，检查肩锁关节脱位情况，沿锁骨向近端清理显露锁骨下缘到喙锁韧带。

然后关节镜后方进入盂肱关节，在关节镜监视下，从前方入路伸进膝关节前交叉韧带(Anterior Cruciate Ligament, ACL)重建定位器，勾住喙突基底处(图1B)。通过术前锁骨切口标记处用2.5 mm克氏针建立骨隧道导向针。进入喙突基底后，此时关节镜进入肩峰下隙，观察导向克氏针锁骨下面位置。保证导向针从锁骨中间穿过到喙突基底。然后使用4.5 mm钻头顺导向针建立喙锁增强隧道(图1C)。

然后从锁骨端隧道把牵引钢丝伸进喙突基底，关节镜监视下把带钢板的增强带牵出锁骨端，钢板置于喙突基底(图1D)。关节镜肩峰下观察肩锁关节完全复位后，在锁骨端行增强带纽扣固定(图1E)。手术完毕，关节镜再次观察喙突基底钢板位置以及肩锁复位情况。

术中仅使用30°关节镜头，缝线钢板为BRAUN前交叉韧带重建包。

四、术后处理

术后前2周休息时用颈腕吊带制动，尽早行上肢被动前屈和外旋等功能锻炼，但前屈幅度不宜超过90°，4周后开始主动前屈、外展及外旋功能锻炼。前屈和外展幅度尽可能达到180°，6周后开始进行肩关节各种抗阻力练习，术后12周行各种体力活动或者运动。

五、评价方法

术后定期摄X线片，了解肩锁关节维持复位情况(图1F、G)，以及有无其他异常变化。按照ASES评分标准与Constant[2]评分。术后6周，3、6、12个月各评估一次。

六、统计学分析方法

用SPSS统计学软件包进行数据分析，治疗前、后疗效对比采用自身配对t检验，以P<0.05为差异有统计学意义。

结 果

12例肩锁关节脱位患者ASES评分：术前28.7分，术后86.9分；Constant评分：术前24分，术后91分。治疗组X线片显示，肩锁关节复位良好，仅有1例出现肩锁关节半脱位。术后1年，91.7%(11/12)病例获得满意治疗效果，83.3%(10/12)恢复到术前运动水平。

讨 论

一、肩锁关节结构及其脱位分类

肩锁关节脱位多发生于青壮年，有明确的外伤史，常常直接暴力作用于内收的肩关节所致。肩锁关节的稳定性靠包括肩胛骨和锁骨之间的连续，胸锁关节和肩胸关节的完整性来实现，其中肩胛骨和锁骨之间的连接最为重要。肩胛骨和锁骨之间的连接不仅包括肩锁关节，还包括喙锁韧带(椎状韧带及斜方韧带)以及三角肌-斜方肌筋膜。因此，从功能上讲，应当以肩锁连接的概念取代肩锁关节。当肩锁关节脱位后上述解剖结构不能修复时，只要能恢复或者重建肩胛骨和锁骨之间的可靠连接即可，不必过于强调恢复肩锁关节的解剖学完整性[7-10]。

根据肩锁稳定结构的损伤情况，Rockwood把肩锁脱位分为6型，其中Ⅰ、Ⅱ 型损伤仅仅为肩锁关节韧带损伤，未出现关节的完全脱位，一般采用非手术疗法。Ⅲ 型及Ⅲ 型以上的损伤，除肩锁关节完全脱位外，尚伴有其他关节结构及周围软组织损伤较重，这些情况破坏了关节稳定结构，需要通过手术恢复肩锁关节的稳定性。

二、肩锁关节脱位的治疗

肩锁关节脱位进行外科手术的目的，就是要进行解剖和功能的重建。肩锁关节主要参与肩关节展收和屈伸活动。肩关节外展超过60°即出现肩胛骨围绕矢状轴旋转，上臂前屈至90°即有肩锁关节活动参与。肩胛骨与躯体间的任何角度的相对旋转活动，都通过肩锁关节和胸锁关节有相应的反应。正常肩关节活动涉及肩锁关节较大的活动，任何严格限制肩锁关节活动的手术，如肩锁关节克氏针内固定、喙锁间螺钉内固定、锁骨钩钢板都必然影响肩关节的活动[11-15]，从而影响术后肩关节的康复训练。由于在肩关节活动幅度稍大时，内固定即承受异常应力，易导致内固定失败。因此肩锁关节，或肩胛骨与锁骨间的固定既要达到锁骨可靠的复位，也必须保持肩胛骨与锁骨间的相对活动自由。喙突与锁骨间的软性固定，如缝线、人工韧带或钢丝固定就成为较好的选择[16-19]。

近年来随着微创关节镜技术的发展，对于肩关节切开内固定手术方式已逐渐发展为微创小切口或者关节镜下手术方式，有学者应用肩关节镜下微创术式，行喙锁韧带重建术治疗肩锁关节脱位，取得良好效果[20-27]。

三、关节镜技术治疗肩锁关节脱位的手术优点

关节镜下使用缝线钢板纽扣技术，行喙锁韧带增强重建术治疗肩锁关节脱位，与传统切开方法比较，有其明显的优点：(1)手术创伤小。关节镜手术仅仅需要3个5 mm小切口作为手术的通路完成，仅显露喙锁关节，对周围稳定结构没有干扰，便于术后的康复；(2) 关节镜监视下复位可靠，不需要术中X线确认，缩短了手术时间；(3) 缝线钢板生物相容性好，增强喙锁韧带，对肩锁关节解剖结构没有影响，有利于新鲜关节囊及韧带的修复愈合；(4) 解剖位增强固定属于弹性固定，在肩关节展收屈伸活动中允许肩锁关节有一定的活动度，符合肩锁关节的生物特性。

使用关节镜技术增强重建喙锁韧带，首先关节镜操作技术必须熟练，因此需要较长学习曲线；此外术中需要熟悉镜下喙突基底、肩锁关节以及喙锁韧带的解剖结构；在建立锁骨到喙突根部骨隧道时，沿喙锁韧带方向走行，关节镜显示保证隧道周围骨皮质均匀；关节镜下复位后固定时加强喙突端的钢板固定，避免因骨质疏松，出现固定钢板松动脱落，导致手术失败。

此外关节镜下行喙锁韧带增强重建技术适合Rockwood Ⅲ、V型患者，对于难以复位的Ⅵ、Ⅳ型脱位，则需要通过切开手术恢复关节的稳定。总之，通过缝线增强喙锁韧带结构，恢复肩锁关节解剖位置，是治疗肩锁关节脱位的一种有效方法。关节镜下手术操作创伤小，肩锁关节复位可靠，并发症少，肩关节功能恢复快。但能否使肩锁关节稳定结构及其生物力学特点自行修复，恢复其正常的解剖结构功能，还需要更长期的随访观察。

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