桡骨小头置换治疗MasonⅢ型桡骨小头骨折的临床疗效观察

赵加松 扶世杰 汪国友 沈骅睿 曾胜强 郝琦

桡骨小头置换治疗MasonⅢ型桡骨小头骨折的临床疗效观察

赵加松 扶世杰 汪国友 沈骅睿 曾胜强 郝琦

目的探讨采用桡骨小头置换治疗MasonⅢ型桡骨小头骨折早期临床疗效。方法对2010年3月至2013年3月我院收治的9例MasonⅢ型桡骨小头骨折患者予以桡骨小头置换,采用Broberg和Morrey的肘关节功能评分标准,评价术后早期疗效。结果患者全部得到随访,术后随访6～36个月,平均19.6个月,优5例、良3例、中1例,本组病例随访时均未发现肘关节感染、强直或脱位,慢性肘关节炎及肘、前臂和腕部长期慢性疼痛等并发症。结论桡骨小头置换治疗MasonⅢ型桡骨小头骨折早期临床疗效良好,远期疗效有待进一步评价。

桡骨小头;骨折,粉碎性;置换;治疗,临床研究性

桡骨小头骨折是肘部常见骨折,为关节内骨折,约占肘部骨折的17%～19%,约有1/3合并关节其他部位损伤[1],其中伴随肱骨小头损伤约1%,随着损伤的加重,其发生率可达24%。随着对桡骨小头在肘关节及前臂稳定性的作用认识的逐渐深入,在治疗方法的认识上也逐步明确。MasonⅢ型桡骨小头骨折治疗方法较多,常见的有桡骨小头切除术、切开复位“T”型或“L”微型钢板等治疗方法,然而,常出现肘关节不稳、慢性长期疼痛、早期内固定失败,骨不连和前臂旋转功能障碍等并发症。1941年Speed行桡骨小头置换术治疗桡骨小头粉碎性骨折后,多种假体应运而生,桡骨小头置换对桡骨小头粉碎性骨折也是一种较为合适的选择,它能快速恢复肘关节的稳定结构避免长期固定引起关节功能障碍、内固定失效及骨折不愈合带来的风险[2-3],逐渐成为研究热点。对2010年3月至2013年3月我院收治9例MasonⅢ型桡骨小头骨折患者,予以行桡骨小头置换,恢复其肘关节功能,保持关节的活动度及稳定性,临床疗效较好,现报道如下:

资料与方法

一、一般资料

2010年3月至2013年3月我院收治9例MasonⅢ型桡骨小头骨折患者,男性3例、女性6例,年龄24～36岁,平均29.4岁,左侧4例、右侧5例,其中合并内侧副韧带损伤和骨间膜损伤7例、合并尺骨近端骨折2例,急性损伤7例、陈旧性损伤2例。骨折分型参照桡骨小头骨折Mason分型分类[4],Ⅰ型:桡骨头或颈骨折,无或微小移位;Ⅱ型:桡骨头或颈骨折,脱位>2 mm;Ⅲ型:桡骨头和桡骨颈严重的粉碎性骨折;伴发肘关节脱位及前臂骨间膜损伤的Ⅲ型骨折可称为Mason JohnstonⅣ型。本组9例均为Ⅲ型。

二、手术方法

在臂丛或全身麻醉成功后,患肢上臂上止血带,常规消毒铺巾,取肘关节Kocher入路切口,长约6～8 cm,逐层切开,于尺侧腕伸肌及肘后肌之间的间隙分离,显露外侧肘关节囊,在显露过程中应保持前臂旋前,以保护骨间后侧神经。在靠近肱二头肌结节处切断桡骨颈,修整桡骨近侧骨髓腔,用专用髓腔锉打磨,以便假体的植入,平整切除桡骨近端关节面,使得桡骨与假体颈之间能完全吻合。用假体作为试模,假体近端的凹面朝向外侧,使之与正常桡骨小头解剖一致,防止脱位。安装到位后复位,检查复位后稳定情况,屈伸有无脱位。如果检查合适后,冲洗伤口,放入合适假体(采用美国瑞特公司生产的生物型Swanson钛金属桡骨小头假体置换治疗),方向是近端关节面朝向外侧,复位,再次检查关节稳定性,被动活动肘关节和前臂时,人工桡骨头和周围骨结构或软组织之间不发生撞击,肱骨小头和假体之间要有良好的接触,使假体能够很好的覆盖在桡骨近端,一般要使假体和肱骨小头软骨面之间保持2 mm的间距。肘关节不稳定的情况下需修复内侧副韧带,还要修复关节囊、环状韧带以及外侧副韧带复合体。冲洗伤口,安放引流管,逐层缝合,术毕。

三、术后处理

术后3 d常规使用抗生素预防感染。术后48 h拔除引流管,局部冰敷。术后3～5 d即开始被动屈伸活动功能锻炼,术后14 d开始主动功能锻炼,旋转活动必须在屈肘90°的情况下方能进行。术后常规给予非甾体抗炎药预防骨化性肌炎。

四、疗效评价标准

根据患者肘关节的活动度、肌力、稳定度和疼痛情况,按照Broberg和Morrey的肘关节功能评分标准[5]进行评分。具体方法:肘关节屈伸满分27分(0.2×肘关节屈伸弧),旋前评分满分6分(0.1×旋前角度),旋后评分满分7分(0.1×旋后角度)。此处屈伸弧定义为135°,旋前弧为60°,旋后弧为70°。其他评分有力量:正常20分,轻度无力13分,重度无力5分,严重无力0分;稳定性:正常5分,轻度不稳活动无受限4分,中度不稳部分活动受限2分,严重不稳日常活动受限0分;疼痛:无疼痛35分,活动时轻度疼痛无需服用止痛药28分,活动产生中度疼痛15分,严重疼痛0分。满分为100分,95～100分为优,80～94分为良,60～79分为可,0～5分为差。

结 果

根据Broberg和Morrey的肘关节功能评分标准评定,术后随访6～36个月,平均19.6个月,优5例、良3例、中1例,本组病例随访时均未发现肘关节感染、强直或脱位,慢性肘关节炎及肘、前臂和腕部长期慢性疼痛等并发症。

典型病例:患者男性,34岁,为左桡骨小头陈旧性骨折,伤后3个月出现左肘关节疼痛,关节活动受限,屈曲约120°,伸直约5°,前臂旋前约70°,旋后约45°。术后1个月屈曲约135°,伸直约0°,前臂旋前约85°,旋后约70°(图1～4)。

讨 论

肘关节的稳定系统包括结构性稳定系统(或称静力稳定系统)和动力稳定系统。Heim将结构性稳定系统归结为肘关节的稳定环,由4个柱组成:内侧柱、外侧柱、前柱和后柱。前柱包括冠状突、肱肌、前关节囊;后柱包括鹰嘴突、三头肌、后关节囊;内侧柱由尺侧副韧带、冠状突、内髁或内上髁组成;外侧柱由桡骨头、肱骨小头和桡侧副韧带组成。如部分破坏时,肘关节稳定性即下降[6]。

目前,对桡骨小头生物力学和解剖学的研究表明[7],桡骨小头对肘关节外侧柱稳定性起着重要的作用,在稳定肘关节的生物力学功能中占有极为重要的地位,尤其当肘关节内侧副韧带和骨间膜损伤时,是肘关节抵抗外翻应力的重要结构,并在Essex-Lopresti损伤时防止桡骨近端移位[8]。既往对无法重建的MasonⅢ、Ⅳ型桡骨小头粉碎性骨折,常采用桡骨小头切除术,术后可能会出现一系列如肘关节不稳、慢性长期疼痛、外翻强直畸形、异位骨化、创伤性关节炎、下尺桡关节紊乱、腕尺侧撞击征等并发症。现在已很少选择此术式。Businger等[9]采用On-table重建技术治疗桡骨小头MasonⅢ型骨折取得了良好的临床效果。该技术主要是术中将所有桡骨小头碎骨块取出,放于手术台上直视下进行精确复位,尽量做到解剖复位,保证关节面平整光滑,有利于骨折的愈合及肘关节功能的恢复。复位后可通过埋头螺钉或0.8 mm细克氏针行临时固定,将所有骨折块固定为一个整体,构建大体框架[10]。后将桡骨小头用事先预弯好的微型钢板固定于桡骨上,钢板置于后外侧“安全区”(桡骨小头头颈外侧约110°的区域有一弧形“非关节面”,此处不参与关节构成)[11],注意桡骨的旋转功能不能受限,术中钢板放置的位置是否恰当是手术成功的关键。本手术操作要求较高,骨折块较小,复位骨折不能反复操作,以免造成更严重的骨折,从而影响其稳定性及复位效果。也正因为骨折块多,固定有限,术后常需功能位石膏托固定,短期内不能功能锻炼,不利于关节功能恢复。刘麟等[12]对55例MasonⅢ型桡骨小头骨折患者采取切开复位内固定术,术后采用Broberg和Morrey的肘关节功能评分标准评定疗效,优良率为85.5%。Cai等[13]对9例复杂MasonⅢ型桡骨小头骨折患者采取切开复位微型钢板内固定治疗,随访结果显示优良率仅为22%。在切开复位组中,23例患者中有1例发生骨不连,2例发生较严重的异位骨化,3例发生内固定失败,严重影响关节功能,优良率仅65.2%。作者认为,对于不稳定、粉碎性桡骨小头骨折,内固定失效概率较高,应慎重考虑。

图1～4 手术前后正侧位X线片。图1桡骨小头骨折,关节面塌陷,关节间隙增大;图2桡骨小头置换术后,假体位置准确,无松动,关节间隙可;图3桡骨小头骨折,骨折线波及关节面;图4桡骨小头置换术后假体位置准确,关节间隙正常

对于桡骨小头置换治疗桡骨小头MasonⅢ型骨折,解决了桡骨小头切除后的诸多并发症,恢复了桡骨头、颈解剖上的完整性,肘关节在生物力学上的平衡,加上术后早期主、被动功能锻炼,往往能取得良好的治疗效果。本组病例随访时均未发现肘关节感染、强直或脱位,慢性肘关节炎及肘、前臂和腕部长期慢性疼痛等并发症。另外,术中经常发现术前影像学检查以为是简单的骨折,术中却很粉碎,给复位带来困难,影响术后疗效,有研究表明[14]:对于骨块多于3块者,切开复位失效率较高,常需要延期行桡骨头切除术或桡骨小头置换术。这不但增加了患者治疗费用和手术次数,而且也在一定程度上相应的影响临床疗效。目前多数认同的适应证:(1)MasonⅣ型骨折;(2)MasonⅢ型骨折难以作内固定者;(3)桡骨小头骨折合并尺骨上端骨折,尤其合并肘内侧副韧带损伤导致的肘关节不稳;(4)陈旧性骨折或经桡骨头切除后出现明显前述并发症患者;(5)肘关节其他疾病影响功能者,如类风湿性关节炎、肿瘤及先天性畸形等[15]。术中应注意:(1)桡骨颈截骨的高度,根据假体试模做出正确判断,避免过度截骨;(2)假体与肱骨小头关节面的间隙以2 mm左右为佳,避免被动活动肘关节时发生撞击;(3)如果伴有尺侧副韧带损伤的,应予以修复,恢复关节稳定性;(4)有桡骨小头置换适应证的患者应尽早一期置换,避免多次手术导致瘢痕挛缩影响关节功能及增加异位骨化风险。目前桡骨小头置换治疗桡骨小头粉碎性骨折的临床报道较少,与切开复位内固定的治疗方法存在争议,王思成等[16]采用前瞻性随机对照分析45例不稳定性粉碎性桡骨小头骨折病例,予以桡骨小头置换和切开复位内固定治疗,比较两组Broberg和Morrey的肘关节功能评分和并发症发生率,结果假体置换组Broberg和Morrey的肘关节功能评分平均90.1分,并发症发生率13.6%,切开复位组Broberg和Morrey的肘关节功能评分平均76.8分,并发症发生率47.9%,两组比较差异有统计学意义(P<0.01)。与切开复位内固定治疗相比较,桡骨小头置换治疗不稳定性粉碎性骨折可获得更好的关节功能和更低的并发症发生率。刘鹏程等[17]搜集MasonⅢ型桡骨头骨折假体置换及切开复位内固定的对照研究并加以系统评价。用Revmen 5.1统计学软件进行异质性分析及Meta分析。假体置换组与切开复位内固定组相比,均有明显优势。现有的有限证据表明,通过优良率、肘关节功能评分及并发症评价证实,人工假体置换治疗MasonⅢ型桡骨小头骨折较切开复位内固定具有更大优势,且差异具有统计学意义。

当然,桡骨小头置换术治疗桡骨小头MasonⅢ型骨折,也存在假体松动、磨损及组织相容性等问题,这些仍需要长期临床随访及大样本的临床研究,但我们相信,随着科学技术的发展,假体设计及手术技术的改进,桡骨小头置换的临床疗效也会更好。

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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)

(本文编辑:李静)

10.3877/cma.j.issn.2095-5790.2014.04.006

四川省科技厅基金(2010HH0054)

646000 泸州医学院附属中医医院骨关节科

扶世杰,Email:Fu-fsj@sina.com

赵加松,扶世杰,汪国友,等.桡骨小头置换治疗MasonⅢ型桡骨小头骨折的临床疗效观察[J/CD].中华肩肘外科电子杂志,2014,2(4):235-239.