应用Endobutton带袢钢板技术治疗RockwoodⅢ型肩锁关节脱位

宋哲 张堃 朱养均 李忠 庄岩 魏巍 杨娜



应用Endobutton带袢钢板技术治疗RockwoodⅢ型肩锁关节脱位

宋哲 张堃 朱养均 李忠 庄岩 魏巍 杨娜

目的 探讨应用Endobutton带袢钢板技术治疗Rockwood Ⅲ型肩锁关节脱位的手术方法及疗效。方法 回顾性分析2010年6月至2013年6月收治的Rockwood Ⅲ型肩锁关节脱位患者21例，其中男性14例、女性7例；年龄19～52岁，平均31.2岁。21例患者均Ⅰ期接受手术治疗，通过X线片观察术后肩锁关节脱位修复情况以及内固定牢固程度，并定期按Constant评分和Karlsson疗效评价标准对肩锁关节功能进行评估。结果 21例患者均获得16.2(12～36)个月随访。随访结果如下，Constant评分：平均92.4(70～100)分；Karlsson疗效评价标准：优16例(76.2%)、良4例(19.0%)、差1例(4.7%)，优良率达95.2%。结论 应用Endobutton带袢钢板技术治疗Rockwood Ⅲ型肩锁关节脱位具有临床效果好、手术创伤小、并发症少、不需二次手术等优点。

肩锁关节；脱位；Endobutton技术

肩锁关节脱位是一种常见的损伤，经常发生于重体力劳动者和年轻运动员，多为摔伤时肩部着地引起。Rockwood Ⅲ型肩锁关节脱位通常需要手术治疗[1]，目前文献报道的手术方法有很多种，但没有一种公认的有效和理想的手术方法[2]。自2010年6月至 2013年 6月，我院使用Endobutton带袢钢板内固定技术治疗Rockwood Ⅲ型肩锁关节脱位患者21例，随访12～36个月，并进行肩关节功能及影像学评估，临床疗效满意，现报道如下。

对 象 与 方 法

一、一般资料

肩锁关节脱位患者21例，男性14例，女性7例；年龄19～52岁，平均31.2岁；左侧9例，右侧12例。致伤原因：交通伤8例，摔伤9例，运动伤2例，重物砸伤2例。21例均为 Rockwood Ⅲ型患者，排除合并锁骨骨折、多发性骨折、闭合性胸部损伤和颅脑损伤。临床表现为外伤后锁骨外上方疼痛，锁骨远端向上突起，按压时有疼痛和浮动感。X线检查提示：肩锁关节完全分离。21例患者均为新鲜脱位，无合并血管神经损伤，手术时间为受伤后1～5 d。

二、手术方法

采用全身麻醉或者颈丛麻醉。患者取仰卧位或沙滩椅位，头部转向健侧。切口取自喙突纵形向上延伸至锁骨后缘的直切口，逐层切开皮肤、皮下组织，钝性分开三角肌，剥离锁骨骨膜，显露肩锁关节、锁骨远端和喙突基底部及内侧面。沿锁骨长轴切开三角肌和斜方肌筋膜，骨膜下分离显露锁骨远端，沿三角肌和胸大肌间隙分离显露喙突内外侧缘及韧带残端。检查肩锁关节间隙，清除破裂的纤维软骨盘。将肩锁关节复位后，先从肩峰外侧端经肩锁关节面穿入克氏针1枚暂时固定肩锁关节。在距离锁骨前缘1/3处，用定位导向器钩住喙突底面与肩锁关节内侧约3 cm 成同一矢状面，按照导向器方向向喙突基底部打入1枚直径1.0 mm导针，沿导针用3.5 mm空心钻头扩孔。用测深器测量从锁骨表面到喙突基底部的长度，选择适当大小的Endobutton带袢钢板。用钢丝对折从上往下穿过直径3.5 mm锁骨隧道与喙突隧道，拉出钢丝封闭端，剪下一段纽扣钢板自身所带牵引线，在袢和钢丝间做辅助换线连接，牵拉钢丝，将袢和纽扣钢板自身所带牵引线拉出喙突隧道，将牵引线脱出环线，继续牵拉将环线拉出锁骨隧道上口，锁骨远端加压复位，向上拉出袢，将另一个不带袢的纽扣钢板用持针器插入袢中。先将纽扣钢板侧放，将线穿过钢板的两个孔，然后翻平纽扣钢板并确保钢板贴于喙突基底部而不滑出，将线打结收紧，使不带袢钢板固定于袢。剪除辅助环线，完成喙锁韧带锥状韧带部分的重建。再将纽扣钢板所带的线钢丝引导下一端穿过锁骨上另一个孔，使之平贴于锁骨上拉紧打结，进一步加强喙锁韧带锥状韧带部分的重建。再把已缝在喙锁韧带的缝线收紧打结。冲洗伤口，仔细修复肩锁关节囊，重建三角肌和斜方肌在锁骨远端的止点，逐层关闭切口。

三、术后处理及疗效评定

术后常规抗生素预防感染24～48 h，患侧予以三角巾或前臂吊带悬吊固定1～2周，疼痛缓解后开始肩关节“钟摆样”摆臂锻炼，随后逐渐增加运动范围，术后4周内以被动训练为主，外展、前屈活动范围不超过90°，术后4周以后开始行主动的肩关节前屈上举及外展功能锻炼，并逐渐增加活动量，以恢复肩关节功能，术后8周内应避免提拉重物。

患者术后前3个月内每月随访1次，以后每3个月随访1次。随访内容：肩关节正位X线片，肩关节活动范围及肌力。末次随访时对患者肩关节功能进行评分，评分标准包括Constant肩关节评分系统[3]和Karlsson疗效评价标准[4]。

结 果

本组21例患者均获随访，时间12～36个月，平均16.2个月。所有切口均Ⅰ期愈合，无伤口感染、血管神经损伤和继发骨折等并发症。1例患者术后4周出现钢板脱落和再脱位，但患者自觉肩部疼痛不明显，肩关节活动尚可，故未予特殊处理。其他患者术后X线检查显示肩锁关节均获得解剖复位，内固定在位良好，肩关节功能活动基本恢复正常，基本无痛或轻微疼痛，疗效满意。

肩关节评分根据Constant肩关节评分系统[3]，从疼痛(15分)、日常活动(20分)、活动范围(40分)和肌力(25分)这四方面进行评分。本组患者肩关节末次评分为70～100分，平均92.4分，其中疼痛评分为13.3(5～15)分，日常活动评分为18.1(13～20)分，活动范围评分为37.8(28～40)分，肌力评分为23.3(15～25)分。

肩关节功能根据Karlsson疗效评价标准[4]：(1)优：不痛，有正常肌力，肩关节可自由活动，X线片显示肩锁关节解剖复位或半脱位间隙<5 mm；(2)良：满意，微痛，功能受限，肌力中度，肩关节活动范围90°～180°，X线片显示患侧肩锁关节间隙较对侧大5～10 mm；(3)差：疼痛并在夜间加剧，肌力不佳，肩关节活动在任何方向皆<90°，X线片显示肩锁关节仍脱位。本组患者优16例(76.2%)、良4例(19.0%)、差1例(4.7%)，优良率达95.2%。

讨 论

一、肩锁关节脱位的特点

肩锁关节脱位是一种常见的肩部运动损伤，约占整个肩部损伤的12%，约占全身关节脱位的3.2%，尤以青年男性较多，男女比例为5∶1[5]。肩锁关节脱位受伤机制分为两种:一种是直接暴力；另一种是间接暴力。直接暴力引起的肩锁关节脱位最常见于肩关节处于外展、内旋位时，暴力直接作用于肩峰，造成肩锁韧带和喙锁韧带损伤。间接暴力也可导致肩锁关节脱位，一般为上肢处于伸展位，摔倒时手部或肘部先着地，外力通过上肢传导至肩峰及肱骨头，肱骨头向上移位时会致锁骨远端下移，进而导致肩锁韧带和喙锁韧带牵拉伤甚至断裂，从而形成肩锁关节脱位。Nielsen[6]观察研究了116例发生肩锁关节脱位损伤的患者，总结出损伤机制：当手或者肘部伸直的时候发生跌伤，肱骨头对肩峰产生撞击力，造成肩锁关节损伤，最容易发生锁骨远端骨折或肩袖的损伤。

肩锁关节的稳定由三部分结构维持：(1)关节囊及其增厚部分形成的肩锁韧带；(2)喙突至锁骨的喙锁韧带；(3)附着于肩峰和锁骨的三角肌及斜方肌。肩锁韧带主要维持关节水平方向的稳定，而喙锁韧带维持锁骨远端垂直方向的稳定。从生物力学分析，肩锁关节参与肩带活动是以胸锁关节为轴心，锁骨为连接轴，肩锁韧带作用力方向与锁骨夹角极小，力矩小；喙锁韧带作用方向几乎垂直力臂，产生力矩大，因而喙锁韧带在维持肩锁关节的稳定性中起更重要作用[7]。

二、肩锁关节脱位的分型和治疗

肩锁关节脱位常用的分类方法有Tossy分型[8]和Rockwood分型[5]。Tossy分型共分为3型，主要突出影像学特点和临床的实用性。而Rockwood分型则分为6型，分型更精确，临床最常用。Rockwood Ⅰ、Ⅱ型肩锁关节脱位一般采用非手术治疗即可获得满意疗效，Rockwood Ⅳ、Ⅴ和Ⅵ型肩锁关节脱位多需切开复位手术治疗。而对Rockwood Ⅲ型肩锁关节脱位的治疗至今尚存很多争议，更多的学者倾向手术治疗[9]，尤其是对年轻及活动度大的患者更推荐外科手术[1]。Leidel及其同事研究表明，急性Rockwood Ⅲ型肩锁关节脱位经克氏针临时固定能够取得良好的治疗效果，长期随访疗效良好[10]。

肩锁关节脱位的手术治疗应遵循以下原则：(1)解剖复位，清理关节间隙，恢复锁骨外侧端关节面的稳定；(2)修复重建韧带及关节囊，尽可能恢复原有生物力学形态；(3)坚强内固定以达到韧带的牢固愈合；(4)早期功能锻炼；(5)及时移除坚强的内置物及稳定装置，防止断裂、松动及关节僵硬的发生。目前手术方法达30种以上，但还没有一种公认的有效和理想的手术方案[2]。传统的手术方式种类较多，主要有克氏针固定肩锁关节，以拉力螺钉固定锁骨及喙突，锁骨远端切除术，以自体肌腱(掌长肌腱腓骨长肌腱、髂胫束或阔筋膜等)重建喙锁韧带等。克氏针经关节固定会破坏关节面，易引起创伤性关节炎；而且限制了肩锁关节的微动功能，可能导致肩锁关节疼痛和僵硬；克氏针抗旋转能力差，容易引起克氏针退出或断裂，甚至发生克氏针刺破胸腔脏器等严重并发症[11]。拉力螺钉固定对螺钉的位置及固定质量要求高，螺钉松动、断裂甚至切出等并发症较常见。另外，肩锁关节是活动关节，前后方向存在着一定程度的微动，用螺钉及克氏针钢丝等硬性材料固定显然不恰当。锁骨远端切除术这种方法会破坏关节囊，影响肩关节生物力学平衡，损伤较大；若切除锁骨远端较多，三角肌附着点减少，可减弱肌力，影响患肢上举，还容易导致Ⅱ期肩锁关节后脱位。自体肌腱(掌长肌腱腓骨长肌腱、髂胫束或阔筋膜等)重建喙锁韧带的方法因手术创伤大、操作复杂，常导致肩周肌萎缩，肩关节功能受限而逐渐被淘汰。

近年来，锁骨钩钢板已逐渐成为肩锁关节脱位治疗的首选，锁骨钩钢板为解剖型设计，符合锁骨的解剖“S”状外形；肩峰下关节外安置，对肩袖及关节影响小，固定可靠。然而其也存在一定的不足[12]：(1)由于胸锁乳突肌以及胸大肌等肌肉牵拉，锁骨远端活动导致钩钢板肩峰侧在水平面和冠状面的侧方活动以及矢状面的旋转等活动，会在一定程度上限制肩关节外展、内旋功能；(2)钩钢板与锁骨交界处由于应力集中导致肩峰端骨折、肩锁关节周围骨溶解等；(3)钩钢板可移位、脱出而导致内固定失败，关节再次脱位；(4)肩峰撞击，肩关节疼痛；(5)术后大部分患者有强烈要求拆除锁骨钩钢板的意愿，且取板时局部组织损伤大，脱位易复发。

三、Endobutton带袢钢板技术的原理及优点

2007年Struhl[13]首先报道使用双Endobutton带袢钢板技术重建喙锁韧带治疗肩锁关节完全脱位的方法，其后经许多国内学者的临床应用及生物力学验证，认为双Endobutton行肩锁关节韧带重建临床效果较好[14-15]。该手术用来重建喙锁韧带的Endobutton带袢钢板已成功应用于膝关节交叉韧带重建多年[16]，两块纽扣钢板通过生物强度远高于喙锁韧带的不吸收的袢环在喙突与锁骨间加压固定，使肩锁关节的分离应力转换成压应力，达到动力稳定，从而恢复肩锁关节的解剖关系和力学平衡。 该术式有如下优点：(1)切口小，手术时间短，伤口感染等潜在并发症风险小；(2)由于双Endobutton钢板操作不涉及肩袖，术后不会出现肩峰撞击样疼痛，所以在术后早期可进行功能锻炼；(3)由于纽扣钢板固定的位置离关节面远，不损伤关节面软骨，对肩峰和关节面无干扰，降低了创伤性关节炎的发生，有效避免了锁骨钩钢板磨损肩峰下关节面而引起的骨溶解、疼痛；(4) Endobutton袢环强度大且具有一定的弹性，不同于没有韧性的金属内固定物，在组织解剖上更类似于喙锁韧带。将肩锁关节及锁骨固定在解剖位置上，而肩锁关节并未坚强固定，使得肩锁关节及喙突与锁骨之间仍可保持一定的微动，使其更接近生理状态；(5)Endobutton钢板为钛金属，无毒，生物相容性佳，无降解，可以在体内长期存留，无需二次手术取出，减轻了患者痛苦，缩短了总住院时间，节约了费用。

四、Endobutton带袢钢板技术的注意事项

虽然Endobutton带袢钢板技术有着上述的诸多优点，但是对术者的手术技巧及经验要求高，而且若想获得良好的手术疗效，还有以下几个方面的问题需要注意：(1)术中若发现肩锁关节软骨盘损伤严重，应予彻底清理，避免引起创伤性关节炎而致术后疼痛；(2)骨道的定位十分关键，尤其是锁骨上的位点选择，因此锁骨外1/3前后缘及喙突内外侧缘要显露清楚；(3)在喙突上打孔部位应选在基底根部，此处骨质坚固不易发生钢板内陷及骨折；(4)在向喙突上钻孔的时候，应压低钻头，指向喙突基底部，方向和人体矢状面重合，此时钻孔的骨道长度最短，选择最短的袢能减少复位丢失；(5)在测量锁骨上缘至喙突基底部的距离时，一定要将锁骨压低至解剖复位后再测量，否则会导致测得量的距离偏长，术后遗留半脱位，影响手术效果[17]；(6)打孔时争取一次成功，避免反复钻孔致骨隧道过宽、离骨皮质过近，钢板滑脱甚至喙突骨折；(7)带袢钢板的位置应放置恰当，如袢与钢板不垂直，将导致袢切割喙突、锁骨，可能会导致骨折等严重并发症；(8)术后早期适当的功能锻炼是获得满意疗效的关键。有研究[18]显示肩锁关节和喙锁间隙周围的软组织在手术后4～6周会瘢痕化，对缝合的组织和带袢钢板有保护的作用。所以患者应予以三角巾或前臂吊带悬吊固定1～2周，术后4周内适当进行被动训练，外展范围不超过90°。术后4周以后待局部瘢痕形成，再进行主动的更大范围的活动，在术后8周内禁止提重物。

Endobutton带袢钢板技术是一种非刚性的治疗Rockwood Ⅲ型肩锁关节脱位的方法，具有操作简单、创伤小、接近解剖及生物力学复位、对关节干扰小、术后并发症少、允许早期功能锻炼、无需二次手术取出内固定等优点。但是该术式在临床开展的时间尚短，病例数较少，随访时间不长，且缺乏一个对照组比较，远期疗效和并发症尚需进一步观察和探讨。

典型病例：张某，男性,23岁，跑步时摔伤致Rockwood Ⅲ型肩锁关节脱位，外伤后8 h入院，无血管神经症状，伤后2 d应用Endobutton带袢钢板技术治疗(图1～4)。

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图1 术前X线片示肩锁关节完全分离 图2 术后X线片示肩锁关节间隙恢复正常 图3 术后3个月X线片示肩锁关节间隙正常 图4 术后3个月肩关节功能基本完全恢复

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(本文编辑：李静)

宋哲，张堃，朱养均，等.应用Endobutton带袢钢板技术治疗RockwoodⅢ型肩锁关节脱位[J/CD].中华肩肘外科电子杂志,2015,3(1):18-23.

Treatment of Rockwood type Ⅲ acromioclavicular joint dislocation with endobutton technique

SongZhe,ZhangKun,ZhuYangjun,LiZhong,ZhuangYan,WeiWei,YangNa.

DepartmentofTraumaticOrthopaedics，Xi′anHonghuiHospital,Xi′an710054,China

ZhangKun,Email：hhyyzk@126.com

Background Acromioclavicular joint dislocation is a common injury which often occurs in heavy manual workers and young athletes.It is usually caused by collision of the shoulder on the ground.Acromioclavicular joint dislocation of Rockwood type Ⅲ often needs surgical treatment.There are several kinds of operation methods reported in the literature,but no universally accepted technique exists.From June 2010 to June 2013,21 patients of Rockwood type Ⅲ acromioclavicular joint dislocation were treated with Endobutton technique in our hospital,shoulder functional and radiological evaluations were performed and the outcome is encouraging.Methods (1)General information：Twenty-one patients were included in this study.Patients were 14 males and 7 females.Nine cases were on the left side and 12 cases were on the right side.The age ranged from 19 to 52 with an average of 31.2 years.The causes were traffic injury in 8 cases,fall damage in 9 cases,sports injury in 2 cases and heavy object hit injury in 2 cases.All patients were diagnosed as acromioclavicular joint dislocation of Rockwood type Ⅲ without clavicle fracture,multiple fractures,closed chest injury and cerebral injury.The clinical presentations included pain over the lateral side of clavicle with its distal end protruding upward,tenderness and a feeling of floating; X-ray examinations revealed that the distal clavicle was higher than the acromion.21 cases were all fresh dislocations without neurovascular injuries; The operation time was 1-5 days after injury.(2)Operation method：After successful general anesthesia or cervical plexus block,the patient was in supine or “beach chair” position with head turned to the uninjured side.The straight incision was extended longitudinally from coracoid upward to the posterior edge of clavicle.The skin and subcutaneous tissue was incised layer by layer.The deltoid muscle was bluntly separated and the periosteum was stripped to expose acromioclavicular joint,distal clavicle and coracoid.The fascias of deltoid muscle and trapezius muscle were divided along the long axis of clavicle and the periosteum was stripped to expose the distal clavicle.The interal between deltoid and pectoralis major muscle was opened and the medial and lateral boarders of coracoid was prepared.The residual coraco-clavicle ligament was reserved.The articular space of acromioclavicular joint was examined and the ruptured fibrous cartilage disc was removed.After reduction of acromioclavicular joint,one Kirschner wire was drilled through the articular surface from the lateral end of acromion to provisionally keep the joint in place.A 1.0 mm guide pin was drilled from distal clavicle into the base of coracoid perpendicularly,3.5 mm canulated drill bit drilled a bone tunnel along the guiding pin.The distance from the surface of clavicle to the base of coracoid was measured with depth scale.The Endobutton was selected properly.A shuttle wire was used to pull the button loop out of clavicle and left the button under coracoid.The distal clavicle was reduced with compression.The loop was pulled upward and the other Endobutton without loop was put into the loop with acutenaculum.First,the Endobutton was laid on its side with sutures pierced through its two holes.Then the Endobutton was laid flat and made sure to attach to the base of coracoid without sliding.The sutures were tightened and knotted to make the Endobutton without loop fixed on the loop.The reconstruction of conoid ligament was finished.Then the suture on the coracoclavicular ligament was tightened and knotted.The wound was irrigated.The acromioclavicular joint capsule was repaired and the deltoid and trapezius muscle were reconstructed at the distal clavicle.The incision was closed layer by layer.(3)Post-operative management and outcome evaluation：Antibiotics were given to prevent infection for 24-48 hours.The shoulder was protected by a sling for 1-2 weeks.Pendulum exercise began after pain relief and the range of motion increased gradually.Only passive motion was permitted in the first 4 weeks and shoulder abduction or anteflexion was limited within 90°.Active motion including anteflexion,elevation and abduction began 4 weeks later.Lifting heavy objects should be avoided within 8 weeks after operation.Postoperative follow-up took place once a month in the first 3 months and then once every 3 months.Anteroposterior X-ray films,range of motion and muscle strength were included in the follow-up.The shoulder function was assessed at the last follow-up according to Constant-Murley score and Karlsson postoperative efficacy grading score.Results Twenty-one patients of this study were followed up for 12-36 months with a mean time of 16.2 months.All the incisions healed without any complication.Infection,neurovascular damage and secondary fracture were not occurred.One patient had plate sliding and redislocation without obvious pain.His shoulder had good activity and therefore he

no treatment.X-ray films revealed anatomical reduction and good internal fixation of acromioclavicular joint in other patients.Their shoulder joints restored normal activities with no or slight pain and the outcome were satisfactory.The shoulder function was assessed according to Constant score which was classified as pain (15 scores),daily activity (20 scores),range of motion (40 scores) and muscle strength (25 scores).The last scores of patients in this group were 70-100 with an average of 92.4,including pain 13.3(5-15),daily activity 18.1(13-20),range of motion 37.8(28-40) and muscle strength 23.3(15-25).The shoulder function was classified according to Karlsson evaluation criteria as follows:Excellent:painlessness,normal muscle strength,free activity and X-ray films revealed anatomical reduction of acromioclavicular joint or less than 5 mm of subluxation; Good:satisfaction,mild pain,dysfunction,medium muscle strength,90°-180°of range of motion and X-ray films revealed acromioclavicular joint dislocation; Bad:pain intensified at night,poor muscle strength,activity of shoulder joint was less than 90° in any direction and X-ray films revealed acromioclavicular joint dislocation.This group had 16 excellent cases (76.2%),4 good cases (19%) and 1 poor case (4.7%).The excellent and good rate was 95.2%.Conclusion Endobutton technique is a nonrigid method for the treatment of Rockwood type Ⅲ acromioclavicular joint dislocation with good outcome.This technique has some advantages such as simple operation,minimal invasive,anatomical and biomechanical reduction,little interference to the joint,less postoperative complications,early functional training,no necessity of reoperation for implant removal,etc.

Acromioclavicular joint;Dislocation;Endobutton technique

10.3877/cma.j.issn.2095-5790.2015.01.005

省科技厅自然基金(2012JM4024)

710054西安市红会医院创伤骨科

张堃，Email：hhyyzk@126.com

2014-06-13)