肩关节镜下喙锁韧带重建术治疗RockwoodⅢ型肩锁关节脱位的疗效研究

李奉龙 姜春岩



肩关节镜下喙锁韧带重建术治疗RockwoodⅢ型肩锁关节脱位的疗效研究

李奉龙 姜春岩

目的 分析采用肩关节镜下喙锁韧带重建术治疗Rockwood Ⅲ型肩锁关节脱位的临床疗效。方法 回顾性研究2013年2月至2014年1月连续收治并获得随访的21例Rockwood Ⅲ型肩锁关节脱位患者的资料。其中男性17例，女性4例。平均年龄42.8岁，平均受伤到手术时间11.1 d。所有患者均于肩关节镜下应用同种异体肌腱重建喙锁韧带并高强度缝线捆扎固定喙锁间隙治疗肩锁关节脱位。术后定期随访，记录患侧肩关节活动范围，并采用疼痛视觉模拟评分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)评分及UCLA(university of California Los Angeles)评分评价患者肩关节功能状况；同时拍摄肩关节正位、侧位及腋位X线片，评估是否有肩锁关节复位丢失。结果 21例患者术后平均随访(14.6±3.9)个月。末次随访时肩关节平均前屈上举为173.9°±10.3°，体侧外旋为59.5°±14.3°，内旋为第12胸椎体水平，平均UCLA评分为(34.1±2.5)分，平均ASES评分为(95.5±4.7)分，平均VAS评分(0.3±0.6)分。末次随访拍摄肩关节X线片未发现肩锁关节复位丢失。结论 采用肩关节镜下喙锁韧带重建术治疗Rockwood Ⅲ型肩锁关节脱位的临床疗效满意，患者术后可获得良好的肩关节功能。

肩关节；关节镜；脱位；手术

肩锁关节脱位是肩关节外科的常见疾病[1],对于Rockwood Ⅰ型、Ⅱ型损伤程度较轻的肩锁关节脱位患者，可通过保守治疗取得满意效果；对于Rockwood Ⅳ型、Ⅴ型、Ⅵ型等重度肩锁关节脱位患者则需要进行手术治疗，而对于Rockwood Ⅲ型肩锁关节脱位患者，目前治疗仍存争议[2-5]。随着关节镜微创技术的发展，肩关节镜下韧带重建手术被逐渐广泛地应用于治疗肩锁关节脱位。肩关节镜手术理论上具备微创、术后恢复快等优势，但目前国内单纯针对RockwoodⅢ型肩锁关节脱位的关节镜手术治疗报道仍较为少见。本文通过回顾性研究，分析近年来我院采用肩关节镜下异体肌腱移植、喙锁韧带重建术治疗高运动水平需求的Rockwood Ⅲ型肩锁关节脱位患者的临床疗效。

对 象 与 方 法

一、一般资料

入选标准：(1)高运动水平要求的Rockwood Ⅲ型损伤患者；(2)于我院行肩关节镜下喙锁韧带重建术的患者；(3)新鲜损伤(手术距离受伤时间不超过3周)；(4)不合并血管神经损伤；(5)术后随访时间≥12个月。排除标准：(1)陈旧性损伤(受伤至手术时间>3周)；(2)双侧损伤；(3) 患侧肩关节既往手术史；(4)合并肩部其他部位骨折；(5)喙突基底骨折行锁骨钩钢板固定治疗的患者。2013年2月至2014年1月期间，连续于我院接受肩关节镜下喙锁韧带重建术治疗的Rockwood Ⅲ型肩锁关节脱位患者共27例，最终有21例(77.8%)获得了随访。其中男性17例，女性4例。平均年龄42.8岁，平均受伤到手术时间11.1 d。

二、手术方法

手术在全身麻醉下进行，采取沙滩椅体位。术中建立关节镜入路通道，包括后方主通道、外侧通道、前外侧通道和前内侧通道，其中，前内侧通道位于喙突与锁骨中间。锁骨远端上方喙锁韧带止点附近取3 cm小切口，用于固定。首先建立后方主通道，探查盂肱关节内，观察是否合并关节内损伤。将镜头移至肩峰下间隙，建立外侧通道，然后镜头移到肩峰下外侧通道，进行肩峰下清扫。同时建立前外侧通道，清扫滑膜，显露喙突，探查喙锁韧带损伤情况。于喙突上方建立前内侧通道，清理喙突周围的软组织，注意保护喙锁韧带残端。由于臂丛血管神经于喙突内侧走行，所以此步操作需谨慎，注意保护周围的血管和神经。于锁骨远端插入硬膜外针头，定位肩锁关节。然后清扫锁骨下方软组织，并注意保护喙锁韧带锁骨侧止点。于锁骨上方喙锁韧带止点处使用3.5 mm钻头建立2个锁骨骨髓道。通过引导线将异体腘绳肌腱和4根高强度缝合线从喙突下方、喙肩韧带止点后方穿过，两端向上拉起并通过锁骨骨隧道，在关节镜直视下复位肩锁关节，并在锁骨上方依次将高强度缝合线及异体肌腱打结固定，构成喙锁悬吊结构来固定远端锁骨。

三、康复方法

术后采用肩关节吊带制动6周。手、腕、肘的被动功能锻炼在术后患者疼痛允许情况下尽早进行。术后6周摘除吊带，开始肩关节被动及主动活动度练习，根据患者具体康复状况逐步恢复日常非负重生活活动。术后3个月开始肌肉力量练习。

四、术后随访及评价方法

患者分别在术后3周、6周、3个月、6个月、12个月以及末次随访时拍摄肩关节正位、侧位及腋位X线片，评估是否有肩锁关节复位丢失。末次随访时，通过查体记录患者肩关节前屈上举、体侧外旋及内旋的活动度，有无肩锁关节压痛；采用疼痛视觉模拟评分(visual analogue score，VAS)、ASES(American shoulder and elbow surgeons)评分及UCLA(university of California Los Angeles)评分评价患者肩关节功能状况。

结 果

21例患者术后平均随访(14.6±3.9)个月(12～19个月)。末次随访时肩关节平均前屈上举为173.9°±10.3°，体侧外旋为59.5°±14.3°，内旋为第12胸椎体水平，平均UCLA评分为(34.1±2.5)分(28～35分)，平均ASES评分为(95.5±4.7)分(82～100分)，平均VAS评分(0.3±0.6)分(0～3分)。末次随访拍摄肩关节X线片未发现肩锁关节复位丢失。

所有患者术后未出现感染、神经血管损伤；术后无患者发生喙突或锁骨骨折。

讨 论

一、肩锁关节脱位的手术指证

有关肩锁关节脱位的治疗，目前较为统一的观点认为，Rockwood Ⅰ型或Ⅱ型损伤一般采用保守治疗，而对于损伤严重的Rockwood Ⅳ、Ⅴ型肩锁关节脱位则建议积极进行手术治疗[2-5]。对于Rockwood Ⅲ型损伤的治疗，目前仍存在争议。部分研究表明对于Rockwood Ⅲ型损伤，手术治疗与保守治疗可得到相似的疗效[2]。尽管如此，对于一些对运动水平要求较高或从事重体力劳动的Rockwood Ⅲ型损伤患者，由于其肩胛锁骨同步运动受损，在高强度运动或工作时可能导致疼痛或活动受限[7-9]。Wojtys等[5]通过对22例保守治疗的Rockwood Ⅲ型损伤患者平均2.6年的随访发现，保守治疗后患侧的力量及耐力与健侧水平相当，但活动量增大时会出现明显不适。Gstettner等[10]报道了24例采用钩钢板技术治疗Rockwood Ⅲ型损伤的病例，术后平均34个月随访，肩关节功能评分显著优于保守治疗组(17例)。因此，我们认为对于高运动水平要求或从事重体力劳动的Rockwood Ⅲ型损伤患者可考虑进行手术治疗。

二、肩锁关节脱位的手术方法

早期肩锁关节脱位的手术治疗以刚性固定为主，主要包括经肩锁关节穿针固定、喙锁间隙螺钉固定、钩钢板固定等。由于锁骨与喙突及肩峰锁骨端之间存在一定角度的活动度[11]，随着时间进展，会出现内固定物金属疲劳甚至折断的情况，亦有可能在锁骨远端、喙突、肩峰的应力集中区域发生骨溶解甚至骨折，术后并发症发生率较高，而且常需进行二次手术取出内固定物。与之相比，采用高强度缝线加自体或异体肌腱等进行肩锁关节弹性重建的手术方式逐渐被广泛接受。随着关节镜微创技术的发展，肩关节镜下韧带重建手术被逐渐广泛地应用于治疗肩锁关节脱位，重建方式主要包括喙锁间隙弹性固定(如纽扣钢板、缝线等)、单纯异体肌腱移植或肌腱移植联合喙锁间隙固定。Salzmann等[12]采用纽扣钢板技术固定喙锁间隙治疗肩锁关节脱位，术后两年随访肩关节功能评分明显改善，但其病例系列中有35%患者术后出现复位失效，原因可能与纽扣钢板局部应力集中所致喙突和锁骨骨溶解而导致固定失效有关；另外，单纯采用内固定材料重建喙锁间隙，无法确保喙锁韧带的愈合状况，增加了术后复位失效的风险。Carofino等[13]采用单纯肌腱移植重建喙锁韧带，并应用挤压螺钉将移植肌腱固定于锁骨骨隧道，术后随访平均ASES评分92分，但复位失效率仍较高，达17.6%。单纯应用肌腱移植重建喙锁韧带，术后早期肌腱未愈合，缺乏固定强度，难以维持复位，易发生失效。本研究中采用肌腱移植联合高强度缝线固定技术以喙锁悬吊方式重建喙锁韧带，其优势在于术后早期，缝线固定可维持牢固复位，为移植肌腱的愈合提供了稳定的生物力学环境；而移植肌腱的愈合及爬行替代重构则对术后远期维持复位起到主要作用。另外，我们采用的喙锁悬吊技术方法简单，且不需要使用特殊的内固定材料，降低了手术的时间和成本，同时因不需要在喙突基底处钻孔，从而避免了医源性喙突骨折的风险。

本研究有一定的局限性：(1)本研究为回顾性研究，且样本量较小，随访时间较短，应进一步延长随访时间以明确其远期疗效；(2)应设计对照组进一步明确对于高运动水平需求的Rockwood Ⅲ型肩锁关节脱位患者手术治疗的必要性。

总之，采用肩关节镜下喙锁韧带重建术治疗高运动水平需求的Rockwood Ⅲ型肩锁关节脱位患者的临床疗效满意，患者术后可获得良好的肩关节功能。

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(本文编辑：李静)

李奉龙，姜春岩.肩关节镜下喙锁韧带重建术治疗Rockwood Ⅲ型肩锁关节脱位的疗效研究[J/CD].中华肩肘外科电子杂志,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

北京市新世纪百千万人才工程培养经费；北京市自然科学基金资助项目(7142074)

100035北京积水潭医院运动损伤科

姜春岩，Email:chunyanj@hotmail.com

2014-12-03)