自体肌腱双骨隧道重建技术修复肘关节后外侧旋转不稳定

刘大海 李开南 母建松 兰海

·论著·

自体肌腱双骨隧道重建技术修复肘关节后外侧旋转不稳定

刘大海 李开南 母建松 兰海

目的 探讨自体肌腱双骨隧道重建桡侧尺副韧带(lateral ulnar collateral ligament,LUCL)治疗肘关节后外侧旋转不稳定(posterolateral rotatory instability，PLRI)的手术疗效。方法 2008年1月至2013年12月成都大学附属医院收治16例LUCL损伤患者，11例用双束编制的掌长肌腱对韧带进行重建，5例用对侧半腱肌肌腱重建LUCL治疗肘关节PLRI，移植肌腱穿过肱骨及尺骨双骨隧道带线锚钉固定。观察术后肘关节活动度、肘关节侧方轴移试验、外翻外旋应力位X线片。结果 所有患者均获随访，随访时间1～5年，平均2.5年。患者肘关节活动功能明显改善，主观满意，被动外翻、外旋活动时肘关节完全稳定12例，部分不稳定但较术前明显改善4例，优良率为75%。术后Mayo评分65～100分，平均85分，新鲜损伤患者术后功能明显好于陈旧性损伤患者(P<0.05)。结论LUCL是影响肘关节PLRI最主要的结构，采用自体肌腱肱骨及尺骨双骨隧道重建LUCL效果良好。

肘关节；尺副韧带；韧带重建

肘关节后外侧旋转不稳定(posterolateralrotatoryinstability，PLRI)的概念已由Chamseddine等[1]于1991年首次提出，发病的机制是肘关节桡侧副韧带复合体(lateralcollateralligamentcomplex,LCLC)损伤引起，其中起主要作用的是桡侧尺副韧带(lateralulnarcollateralligament,LUCL)。但是由于大部分医师对此类韧带损伤引起肘关节功能障碍的认识不够，造成漏诊或没有得到及时有效的治疗，以致于严重影响患者的生活质量。在医疗条件较差、医师水平较低的医院，对韧带的损伤往往只是采取保守治疗或简单韧带缝合，导致韧带强度不够、功能锻炼延迟、治疗效果不佳[1]。手术治疗效果明显，但手术方式多样。Rhyou等[2]只是在肱骨建立横行的骨隧道供肌腱穿过，而肱骨上仅用锚钉固定，这样韧带上端很难附着于肱骨外侧髁上。Sanchez-Sotelo等[3]在尺骨、肱骨上建立垂直于韧带走形方向的骨隧道，用较长的肌腱“8”字形穿过隧道，缝线打结固定，此时肌腱需要一定长度且较细小，容易断裂或缝线滑脱等。Dehlinger等[4]建立骨隧道的方式与本研究方法相似，肌腱穿过骨隧道后，仅用缝线将肌腱固定在骨隊道上，牢固性欠佳，功能锻炼时间延迟。本研究就是用自体肌腱肱骨及尺骨双骨隧道重建韧带的方式对16例患者进行手术治疗，对治疗的效果报道如下。

资 料 与 方 法

一、一般资料

2008年1月至2013年12月，本院骨科收治并明确诊断为肘关节LUCL损伤、肘关节PLRI患者16例。其中男性11例、女性5例；年龄19～43岁，平均28.8岁；新鲜损伤7例、陈旧性损伤9例；单纯尺骨冠状突骨折4例，肘关节脱位3例，冠突骨折伴肘关节脱位5例，“肘关节恐怖三联征”内固定术后4例(均行冠突骨折内固定术)。其中有2例桡骨头切除，7例患者有内翻畸形(图1)，5例内翻应力位可见内翻畸形，外翻应力位有肱桡关节间隙增宽(图2)，麻醉下肘关节侧方轴移试验阳性(图3)。所有患者肘关节MRI显示有LUCL损伤或断裂。患者一般情况见表1。

二、手术方法

患者取仰卧位，取肘关节外侧改良Kocher入路，掀起伸肌总腱起点后，解剖分离肱骨远端外上髁的LUCL近端起点，显露LUCL远端止点以及尺骨旋后肌骨脊，将尺侧腕伸肌牵向前侧，肘肌牵向后侧，探查LUCL的损伤情况。远侧腕横纹做一长约1cm的横切口，暴露掌长肌腱并予切断(也可取对侧半腱肌肌腱)，在肌腱中点及移行部各做一长约1.5cm纵切口，分离、切断、取出肌腱，长约12～15cm，将肌腱对折用1号不可吸收线行双束编织。在肱骨外上髁LUCL近端起点以及旋后肌骨脊钻孔创建V型骨隧道，尺骨上两孔之间相距6～8mm，两孔连线的方向与LUCL的方向一致，将编制好的肌腱穿入尺骨和肱骨隧道(图4)。在距隧道出口以远2mm处各拧入带线不可吸收锚钉1枚，缝合肌腱、牢固固定，在屈肘30°，前臂尽可能外旋的情况下，收紧移植肌腱和关节囊缝合线，然后再将移植肌腱与自身韧带缝合加固(图5)，同时复位并固定尺骨冠状突骨折。术毕检查肘关节后外侧稳定性良好，安置引流管，关闭切口，用绷带包扎伤口，屈肘90°，中立位，石膏托固定。

表1 16例患者一般情况

注：a骨折术后指肘关节恐怖三联征内固定术后；b骨折伴脱位指冠突骨折合并肘关节后脱位；c关节脱位指肘关节后脱位

三、术后处理

术后第2天根据引流情况拔出橡胶引流管，并鼓励患者下床活动，指导患者伸屈手指。1周后行上臂肌肉无痛性等长收缩锻炼，2周后去除石膏托，开始进行肘关节被动伸屈锻炼，逐渐增加被动运动的幅度及肌力锻炼的强度，但要避免主动前屈肘关节、提重物、支撑、旋前、旋后等动作。术后3个月开始适当主动伸屈锻炼，逐渐增加强度(图6)，术后6个月时达到正常(图7、8)。

四、疗效评价

采用Mayo肘关节功能评分评价肘关节功能，满分为100分，其中疼痛占45分，活动度占20分，稳定性占10分，日常活动占25分。≥90分为优，75～89分为良，60～74分为可，<60分为差。

五、统计学分析

图1 临床照片可见肘关节内翻畸形 图2 肘关节X线片提示有肘关节内翻、肱桡关节间隙增宽 图3 外侧轴移试验阳性表现为外翻肘关节、对前臂施以轴向载荷后、内旋前臂，由于桡骨头半脱位可见皮肤出现凹陷，将肘关节置于头顶更易于检查 图4 自体肌腱穿过骨隧道 图5 用带线锚钉将移植肌腱固定 图6 术后3个月肘关节屈曲照片 图7 术后6个月肘关节屈曲照片，屈曲增加约10° 图8 术后肘关节内翻应力位X线片提示肱桡关节间隙恢复正常

结 果

一、随访结果

本组患者切口一期愈合，住院时间10～17d，平均14.4d。所有患者均获得门诊随访，随访1～5年，平均2.5年。患者肘关节活动功能明显改善，主观满意，被动外翻、外旋活动时肘关节完全稳定12例，部分不稳定但较术前明显改善4例，优良率为75%。4例肘关节部分不稳定的患者中，全用掌长肌腱带线锚钉进行LUCL重建，外翻外旋应力位X线片都可反应出轻度不稳，其中有2例是恐怖三联征内固定+桡骨头切除术后的患者，1例是陈旧性冠突Ⅱ型骨折未行手术治疗的患者，另外1例是新鲜冠状突Ⅲ型骨折的患者。术后疼痛缓解、肘关节活动度及Mayo评分,新鲜损伤组都明显好于陈旧性损伤组(P<0.05)。肘关节详细评价结果见表2，术后恢复情况见图6、7。

表2 16例患者手术前、术后的Mayo评分比较±s)

讨 论

维持肘关节稳定性的韧带主要有LCLC及尺侧副韧带复合体(medial collateral ligament complex，MCLC)。LCLC是由桡骨环状韧带、桡侧副韧带、LUCL组成；MCLC则由前束、后束及斜束组成。Shukla等[5]认为，维持肱尺关节的稳定须具备三个条件：完整的关节面，完整的MCLC前束和LCLC的LUCL，任何部位的损伤都可影响肘关节稳定性。在Kim等[6]的一项研究中，LUCL的损伤即可导致肘关节PLRI，但是LCLC其他部分的损伤会加重肘关节的不稳定，因此在治疗时要考虑到LCLC的整体修复。目前虽然还没有证据证实MCLC前束的损伤会导致肘关节PLRI，但是它的损伤会放大桡骨头或冠突骨折的作用，因此也应加以重视。在Kamineni等[7]的研究中，肘关节完全伸直时，桡侧副韧带主要是抵抗肘关节内翻的应力，所起的作用只有14%，其余都是靠关节囊及骨面维持，所以肘关节的稳定性除了靠韧带的作用外，还有尺骨冠状突、桡骨头、鹰嘴。尺骨冠状突也是维持肘关节前方稳定性的重要骨性结构，且X线或CT检查往往会低估冠突骨折块的大小[8]，所以对Ⅱ型以上的尺骨冠状突骨折进行固定就显得尤为重要。Hall等[9]在一项42例桡骨头切除后的回顾性研究中显示，有7例(17%)患者出现了肘关节后外侧不稳定。该组病例中2例桡骨头切除的患者，虽然进行了LUCL重建，术后也出现了轻度不稳的表现。

对肘关节韧带损伤是否进行手术，主要是根据查体及影像学检查来确定，其中又以关节镜及MRI检查最为准确，若查体及影像学都支持诊断，则有手术指征[10]。Cain等[11]介绍了一种麻醉状态下用关节镜对肘关节间隙进行检查，肘关节屈曲70°～90°外翻位，如尺骨与滑车张开距离超过1～2 mm，提示有外侧副韧带的损伤。一但发生外侧副韧带损伤，其韧带质量较差或已经发生挛缩，直接进行缝合修复的效果较差，因而需要用肌腱实施重建手术[12]。当有严重肘关节后脱位时，关节囊一般都和韧带同时损伤，所以不管是急性损伤还是陈旧性损伤，在重建韧带的同时都要对关节囊进行修复[7]。由于人群当中约有10%缺失掌长肌腱，就算有一侧掌长肌腱时，肌腱部分的长度往往也比较短。对于这种情况，只有考虑截取跖肌腱、股薄肌、肱三头肌肌腱或半腱肌等用做韧带的移植物[13]。Dehlinger等[14]用肱三头肌肌腱对47例LUCL损伤的患者进行重建手术治疗。也有学者采用同种异体肌腱重建LUCL，但效果尚不确定[15]。本组病例，对掌长肌腱缺失的患者，也可取对侧半腱肌肌腱。

虽然目前对LUCL损伤的治疗方式较多，基本都是移植肌腱穿过肱骨及尺骨隧道对LUCL进行重建为主，但他们建立骨隧道的方式及肌腱固定的方式不一样，移植肌腱的牢固性也不一样。由于功能锻炼的时间延迟，容易产生关节僵硬等，由于操作繁琐或强度的不够，治疗以后往往收不到良好的效果[16]。建立肱骨、尺骨双骨隧道的方向与LUCL走形方向一致，满足生物力学要求，掌长肌腱质量不好时可以换用半腱肌，移植肌腱强度可以得到保证。钻骨性隧道时，要选取合适的钻头，操作要轻柔，防止骨质的破坏，导致建立隧道的失败，用小刮匙对孔的锐利部分进行打磨，防止移植肌腱的损伤。Streubel等[17]起初建议在肱骨外上髁建立开放的隧道，但是后来又对这一技术进行改良，即在肱骨外上髁做末端封闭的隧道，在隧道末端开两个小孔用做缝线的固定，治疗效果也较好。本组病例的两种手术方式都使用开放的骨隧道，移植肌腱完全穿过骨隧道后再进行固定[4]。这样既符合韧带生物力学的分布，又可以牢固的打结固定。

对于陈旧性损伤引起的肘关节不稳定，大多是因为没有对LUCL进行合理的处理。出现这种情况，除对LUCL进行重建时，还要处理其他引起肘关节不稳的因素，如尺骨冠状突骨折、桡骨头塌陷或切除、肘关节复杂性损伤(恐怖三联征)[18]。尺骨冠状突是维持肘关节前方稳定性的重要骨性结构，对Ⅱ型以上的骨折进行固定就显得尤为重要。桡骨头是维持肘关节外翻稳定性的重要结构，如此结构破坏，LUCL就起到了主要作用，此时LUCL的任何损伤都可以影响肘关节的稳定性[18]。恐怖三联征就是把以上问题都集中到一起，并发症多，处理更加困难，效果当然也不够理想。肘关节损伤的并发症主要有关节僵硬、异位骨化、尺神经损伤等。这些问题虽不影响肘关节稳定性，但是会严重影响肘关节的功能。所以在处理陈旧性损伤时，要将关节囊与周围组织的粘连带进行松解，尽量剔除异位骨化组织及骨赘，改善肘关节功能。

由于肘关节的损伤容易并发关节僵硬，术后康复锻炼则是功能恢复的重要环节。有研究显示，如果对损伤后的肘关节进行3周以上的固定，将会对肘关节造成不可逆的残疾，所以，合理的康复锻炼就非常重要。通过重建LUCL治疗肘关节PLRI的效果确切，但是急性损伤治疗效果往往要好于陈旧性损伤。由于陈旧性损伤的病例比较少，且比新鲜的损伤复杂，还需要更多的病例、更新的技术来研究治疗的效果。

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(本文编辑：李静)

刘大海,李开南,母建松，等.自体肌腱双骨隧道重建技术修复肘关节后外侧旋转不稳定[J/CD]. 中华肩肘外科电子杂志,2016,4(1):29-34.

Autogenoustendondoublebone-tunnelreconstructiontechniquetorepairtheposterolateralrotatinginstabilityoftheelbow

LiuDahai,LiKainan,MuJiansong,LanHai.

DepartmentofOrthopedics,theAffiliatedHospitalofChengduUniversity,Chengdu610081,China

Correspondingauthor:LiKainan,Email：likainan1961@126.com

Background The concept of posterolateral rotatory instability (PLRI) of the elbow was proposed in 1991 by O′Driscoll for the first time. The pathogenic mechanism of PLRI is injury to the radial collateral ligament complex at the elbow, among which the lateral ulnar collateral ligament (LUCL) plays a major role. However, because most physicians know little about the elbow dysfunction caused by such ligament injury, missed or delayed diagnosis often prevents timely and effective treatment, leading to seriously impact on the quality of life of patients. Surgical treatment is often very effective, but surgical approaches vary a lot. Rhyou et al established a horizontal bone tunnel cross the humerus for passing through the tendon, but this approach doesn′t allow attachment of the upper end of this ligament on the lateral condyle of the humerus. Sanchez-Sotelo et al. established bone tunnel on ulna and humerus perpendicular to the ligament, and passed longer tendon through the tunnel at an "8" shape, which was immobilized by suture knot. This procedure requires that the tendon have to be a long and thin one while problems such as tendon breakage and suture slippage often happen. The way Dehlinger et al. established the bone tunnel was similar to the present study, i.e., after passing the bone tunnel; the tendon was only fixed to the bone marrow with suture. This method also has the disadvantage of poor stability and delayed functional exercise. This study used autologous tendon and established humerus and ulna double bone tunnel for ligament reconstruction in 16 patients and the treatment effect is reported below.Methods From January 2008 to December 2013, orthopedics division of our hospital admitted and diagnosed 16 cases of elbow LUCL tear with PLRI patients, of which 11 males and 5 females, aged 19-43 years old, average age of 28.8 years old, 7 cases of fresh injuries and 9 cases of old injuries, 4 cases of simple ulnar coronoid process fracture, 3 cases of elbow dislocation, 5 cases of coronoid fracture with elbow dislocation, and 4 cases of "terrible triad injury of the elbow" after internal fixation (all

coronoid fracture internal fixation). There were two cases of radial head resection, 7 patients with varus deformity and 5 cases of varus stress position with visible varus. Valgus stress was shown as widened humeroulnar interval, and positive Lateral Pivot Shift for Elbow test under anesthesia. Elbow MRI of all patients showed radial ulnar collateral ligament injury or breakage.Surgical Methods: The patients were in prone position. Modified Kocher approach was used. The origin of the common extensor tendon was released from epicondyle. The proximal and distal origin of LUCL and ulna supinator ridge was prepared. Then the unlar extensor carpi muscle was pulled medially and anconeus muscle pulled laterally. The tear patterns of the LUCL were explored (13 cases of distal LUCL injury, and 3 cases of proximal LUCL injury). The palmaris longus tendon (alternatively the contralateral semitendinosus tendon) was harvested from volar wrist. The length of graft was about 12-15 cm. The tendon was fold and prepared with No.1 nonabsorbable suture. A V-shape bone tunnel on lateral humeral epicondyle and the supinator ridge was drilled. A 6-8 mm distance was between the two holes on the ulna and the connecting line between the two holes was in line with the direction of LUCL. The graft was passed through tunnels and sutured by suture anchors. The graft should be tensioned in 30° of flexion and maximal supination. The graft could be further strengthened by LUCL remnant. The coronoid fracture should be reduced and fixed. The stability of elbow was checked. Drainage tube was routinely used. The wound was closed in layers. The elbow was immobilized in neutral rotation and 90° of flexion by plaster cast. Post-operative treatment: rubber drainage tube is removed two days after the surgery based on the status of drainage. Patients are encouraged to get out of bed, and guided to flex and extend fingers. Upper arm muscle painless isometric exercise is started 1 week after the surgery. The plaster cast is removed after 2 weeks. Passive elbow flexion exercise is began and gradually increased the magnitude of passive exercise and the strength of the muscle force training, but active flexion of the elbow should be avoided, heavy lifting, supporting, medial and lateral rotation movements also should be avoided. Active flexion exercise is begun after 3 months, and gradually increased the intensity to reach normal activity level after 6 months.Efficacy evaluation: the Mayo elbow performance index was used to evaluate elbow function. Out total of 100 points, pain accounts for 45 points, mobility for 20 points, stability for 10 points, and daily activities for 25 points, ≥90 as excellent, 75-89 as good, 60-74 as acceptable and <60 as poor.Results All patients achieved primary healing of the incision. Hospitalization time ranged 10-17 days, with an average of 14.4 days. All patients are received outpatient follow-up of 1-5 years, with an average follow-up time of 2.5 years. The patients′ elbow motion improved significantly, and patients are generally satisfied. There were 12 cases of patients achieved total stability at passive valgus and lateral rotation, partially instable but significantly improved after the surgery in 4 cases, with a good to excellent rate of 75%. All the 4 patients with partial instability received LUCL reconstruction with suture anchors using the palmaris longus tendon graft. X-ray film can reflect their slight instability at valgus and lateral rotation stress position. Two of these 4 patients were diagnosed as terrible triad injury and received internal fixation plus radial head resection, 1 case of old typeⅡ coronoid fracture patient who did not undergo surgery and 1 case of fresh type Ⅲ coronoid fracture patient.Postoperative pain relief, elbow mobility and Mayo scores of the fresh injury group were all significantly better than those of the old injury group (P<0.05).ConclusionRadialulnarcollateralligamentisthemainstructuretoaffectelbowPLRI,anduseofautologoustendonandhumerusandulnadoublebonetunneltoreconstructtheradialulnarcollateralligamentachievesgoodresults.

Elbowjoint;Ulnarcollateralligament;Ligamentreconstruction

10.3877/cma.j.issn.2095-5790.2016.01.006

国家自然科学基金(81500577)

610081成都大学附属医院骨科

李开南，Email：likainan1961@126.com

2015-09-21)