关节镜下清理术治疗创伤后肘关节僵硬的临床研究

王思成 李全 吴献民 李广峰 曹烈虎 曹中华 张鑫 杨国庆张友忠 苏佳灿

关节镜下清理术治疗创伤后肘关节僵硬的临床研究

王思成1李全2吴献民1李广峰1曹烈虎2曹中华1张鑫1杨国庆1张友忠1苏佳灿2

目的评估关节镜下肘关节清理术治疗创伤后肘关节僵硬的临床疗效。方法回顾性分析2012年1月至2016年12月上海中冶医院收治的42例创伤后肘关节僵硬患者，全部给予关节镜下清理术，术后第1天即在疼痛控制下进行肘关节屈伸功能锻炼，比较手术前后肘关节主动活动的关节活动度（range of motion，ROM），Mayo肘关节功能评分（Mayo elbow performance score，MEPS）及疼痛视觉模拟评分（visual analogue scale，VAS）。结果全部患者获得随访，分别于术后3、6、12个月进行随访。术后肘关节ROM较术前有明显改善，差异有统计学意义（P ＜0.05）。术后3～6个月改善较为明显，6～12个月改善幅度降低。在MEPS评分方面从术前的（69.5±15.5）分增加至末次随访的（90.4±22.4）分，平均改善了20.9分（P ＜0.001）。术后MEPS评分结果为优22例，良17例，中3例，优良率达92.86%。术后较术前VAS均明显降低（P ＜0.05）。结论 关节镜下清理术是治疗创伤后肘关节僵硬一个很好的治疗方式，创伤小，疼痛轻，有利于术后早期功能锻炼，能够改善肘关节功能。

肘关节； 创伤后关节僵硬； 关节镜； 关节清理术

肘关节僵硬是肘关节创伤或术后一种常见的难以处理的并发症，会严重干扰患者的活动和生活质量［1］，发病率超过5%［2］。创伤后肘关节僵硬的病因可以是关节内因素，也可以是关节外因素。关节内因素常见骨赘增生、骨软骨炎、滑膜炎、关节不对称或关节内游离体等。而关节外因素常见异位骨化、关节囊挛缩、韧带损伤、筋膜炎和皮肤组织疾患等。这些因素改变正常的肘关节运动导致关节僵硬。关节内与关节外因素混合出现也很常见［3-4］。保守治疗失败的患者是手术治疗的明确指征。目前有许多开放式外科手术用来治疗肘关节创伤后僵硬。然而，传统的开放手术创伤大，手术路径可能造成额外的组织损伤，增加软组织的挛缩复发风险，容易产生异位骨化，而且因为疼痛难以实施早期康复功能训练［5］。因此考虑到肘关节僵硬的诸多因素，开放手术存在明显的限制和风险。随着手术技术和医疗设备的发展，关节镜下清理松解技术有了显著的提高。它可以很好的观察处理关节内、外的各种问题，同时大大减少手术创伤，减轻疼痛，有利于开始早期康复训练。但是，关节镜下肘关节清理术是具有挑战性的，因为神经血管结构接近手术切口，并且工作空间有限，容易引起并发症［6］。本研究的目的是评估关节镜下肘关节清理术治疗创伤后肘关节僵硬的疗效，介绍这项外科手术技术，讨论可能存在的困难和风险。

资料与方法

一、一般资料

2012年1月至2016年12月上海中冶医院收治的42例创伤后肘关节僵硬患者，其中男24例、女18例，平均年龄42.3岁（21～59岁），左肘18例、右肘24例。全部患者的症状主要为关节活动受限伴疼痛，术前进行X线片和计算机断层扫描（CT）检查，评估关节僵硬的原因。其中骨赘增生及异位骨化32例，关节内游离体28例。42例患者中31例有手术史。

二、纳入及排除标准

纳入标准：（1）肘关节活动度不能达到30～130°；（2）患者接受非手术治疗6个月以上，肘关节活动度无明显改善；（3）有或没有骨赘形成，X射线显示肘关节间隙仍然存在，没有连续性的骨痂通过关节。

排除标准：（1）肘关节的骨性畸形明显，需要进行矫正手术；（2）原发性退行性或炎性肘关节炎的患者；（3）术后无法配合进行主、被动功能训练者；（4）肘关节周围皮肤感染或烧伤引起的疤痕挛缩；（5）肘关节骨化性肌炎；（6）肘关节关节间隙几乎消失，如关节骨性强直；（7）尺神经手术史或多次肘关节手术史尺神经位置不明。

三、手术方法

手术在臂丛麻醉或者全麻下进行，患者取侧卧位，肩关节外展90°，肘关节屈曲90°，于上臂上止血带止血。术前在皮肤上绘制体表解剖标识，将尺神经的行走路径特别标记。利用表面标识，经软点注入20 ml生理盐水扩张关节腔，便于关节镜置入。于肱骨外上髁近端2 cm，前方1 cm处，切开皮肤，钝性分离组织，置入关节镜设备，建立第一个工作通道—近端外侧入路。然后，透过从近端外侧肘关节入路进入的关节镜到达对侧皮下组织，于肱骨内上髁远端2 cm，前方2 cm处建立近端内侧入路。通过这两个入路处理肘关节前室。于尺骨鹰嘴近端3 cm，沿肱骨外上髁嵴进入肘后关节腔，建立后外侧入路，于后外侧入路内侧2 cm处建立后正中入路，处理肘关节后室。通过手术入路，关节镜的监控及操作下，使用3.5 mm磨钻去除所有的影响关节功能的骨赘和异位骨化，磨除部分冠状突、尺骨鹰嘴；用异物钳取出关节内游离体；用刨刀及射频清除滑膜，纤维组织等，对肘关节前方病灶清除需要对冠突窝进行清理，对于肘关节后方的病灶需要清理鹰嘴窝。然后，松解挛缩的关节囊。小心地保持刨刀的钝边朝向尺神经及内侧关节囊。避免损伤尺神经。之后，再次采用手法松解以获得满意的肘关节功能，根据术前肘关节功能障碍情况将肘关节固定在伸直或屈曲位矫形器。术后应用吲哚美辛栓防止异位骨化。

四、术后处理

术后第1天开始在静脉镇痛泵的镇痛下进行无痛持续被动运动（continuous passive motion，CPM）。CPM功能训练4次/d，20 min/次，功能训练遵循动静结合的原则。每天锻炼后使用上肢矫形器维持肘关节已经改善了的关节活动度（range of motion，ROM），每天可以拆卸下来进行4～6次肘关节运动训练，该矫形器应使用至少6周，大概每天有1～2 h的训练时间，训练结束后再用矫形器固定。术后2～4 d开始进行主动功能训练，6周后逐渐进行抗阻训练，用以增强肌肉力量。主动及被动训练应持续不少于6个月。功能训练过程中注意控制疼痛和水肿。

五、疗效评价

分别于术后3,6及12个月进行随访，手术前后采用Mayo肘关节功能评分（Mayo elbow performance score，MEPS）及疼痛视觉模拟评分（visual analogue scale，VAS）对患者进行评估，并测量肘关节主动活动的ROM。

六、统计学分析

采用SPSS17.0统计软件进行分析。所有的计量数据均以 x-±s表示，术前和术后3、6、12个月ROM、MEPS 评分及 VAS 评分比较采用配对t检验，P＜0.05为差异有统计学意义。

结 果

全部患者获得随访，没有患者转换为开放性手术或需要二次手术治疗。患者伤后平均手术时间为17个月（11～47个月）。术后肘关节ROM较术前有明显改善，从术前的（50.7±18.3）°增加到（119.7±23.6）°，平均增加了69°，差异有统计学意义（P ＜0.001）。术后3和6个月时改善较为明显，6和12个月时改善幅度降低，说明早期的功能锻炼意义较大。在MEPS评分方面从手术前的（69.5±15.5）分，增加至末次随访的（90.4±22.4）分，平均改善了20.9分（P ＜0.001）。术前MEPS评分优0例，良 6例，中 25例，差11例。术后MEPS评分结果为优22例，良17例，中3例，差0例，优良率达92.86%。术后疼痛VAS评分均较术前明显降低（P ＜0.05），见表1。

在随访过程中，1例患者出现异位骨化，这例患者术前即存在异位骨化现象，给予吲哚美辛治疗后异位骨化程度较术前轻，术后最终ROM达到了95°。术后4例患者出现尺神经支配区麻木，经保守治疗6个月内全部恢复。全部病例无感染出现。

表1 手术前后肘关节ROM、MEPS评分及VAS评分比较（n=42, x-±s）

讨 论

创伤后肘关节僵硬治疗方案的选择可分为保守治疗和手术治疗。保守治疗包括物理治疗、动态夹板、静态渐进式夹板和麻醉下手法松解，并应持续至少6个月［7-9］。保守治疗失败后，建议采取手术治疗［10］。活动末期的疼痛，关节僵硬，形成骨刺和关节内游离体是最常见的手术指征［11-13］。一些文献已经描述了开放手术和关节镜技术治疗创伤后肘关节僵硬的情况［14-19］，在改善肘关节ROM和减轻患者疼痛等方面，关节镜提供了良好的满意结果［20-21］。另外是否采用关节镜手术，还取决于外科医师对肘关节镜的专业知识技能水平、尺神经的状态、异位骨化的形态和位置、关节挛缩程度及关节面损伤的情况等［14］。

本组患者术前肘关节ROM有中度僵硬的占41%，重度僵硬的占21%。在末次随访评估中，91.2%的患者肘关节ROM为轻度受限或无僵硬，仅4%有严重的僵硬。肘关节ROM平均改善为69°，与最近的文献报道中增加的情况一致［7，13，17，20-21］。在临床评分方面，平均改善20.7分，VAS评分改善明显，这些结果与Kim等报道结果类似［12，15-16］。

目前，关节镜下松解治疗创伤后肘关节僵硬已经被认为是一个安全的手术操作，并发症发生率低［12］。Pederzini等［22］对关节镜手术治疗243例创伤后或退行性肘关节僵硬患者进行评价，结果术后肘关节功能改善显著。Phillips等［23］对25例患者进行了关节镜手术，其中15例为创伤后关节粘连，10例为退行性骨关节炎所造成关节挛缩，平均随访18个月，术后平均屈伸活动度改善了41°，肘关节ROM取得了明显的改善，其中创伤后关节僵硬的患者表现出更大的改善。Kim等［24］描述了63例肘关节挛缩患者行关节镜手术治疗的情况，这些患者症状持续时间小于1年，术后取得满意的临床结果，肘关节ROM平均增加 49°。Kelly等［25］发现25例肘关节僵直患者中的24例治疗效果在术后2年中呈现“好的”或“更好的”结果。Cefo等［14］的研究探讨肘关节镜对创伤后肘关节僵硬的疗效，他们表示，关节镜下松解对患者创伤后肘关节挛缩症是一种安全可靠的治疗方法，优点包括手术创伤小、手术疤痕小、能改善关节的外观、减少疼痛、加速康复、缩短住院时间等。

本研究最重要的发现是关节镜下关节清理治疗肘关节僵硬是创伤后肘关节僵硬的一个很好的治疗选择，它能够改善肘关节功能。并且术后的早期主/被动术后康复对患者康复是非常必要的。关节镜下松解术最常见的并发症是持续ROM丢失，因此需要再次手术进行松解。良好的ROM通常可以在手术中获得，但随着时间的推移，没有有效的锻炼的情况下改进的ROM不能保持。因此，在最终的随访中，临床结果往往令人失望。在这项研究中，术后第1天即开始鼓励患者进行无痛下的主动和被动肘关节运动，目的是为了获得一个更好的ROM。在最后的随访中，结果39例均为优良，3例为中，没有患者表现出较差的结果，优良率达到92.86%。

无论是开放手术还是关节镜手术，血管神经并发症的报道都有，但关节镜手术似乎更多见［25］。为了避免这些问题，规范的操作技术显得非常重要，并应该被严格遵循。本研究并没有出现类似的并发症是因为严格按照操作规范进行手术，并由经验丰富的医师完成。同时必须强调对于有多次手术史，尺神经位置不明确的患者，是不能行关节镜手术的。

肘关节镜手术是微创手术，它提供了完整的和准确的关节表面的可视化，确保快速恢复，相比开放技术具有较低的并发症的风险［26］。然而，本研究仍存在几个局限性：首先，病例数较少；第二，没有设置开放手术或保守治疗的对照组；第三，随访时间短，难以客观地评价远期临床结果。因此，未来需要大规模的、多中心的及长期随访的病例对照研究。

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Su Jiacan, Email:drsujiacan@163.com

Efficacy of arthroscopic debridement for treatment of post-traumatic elbow stiffness

Wang Sicheng1, Li Quan2, Wu Xianmin1, Li Guangfeng1, Cao Liehu2, Cao Zhonghua1, Zhang Xin1, Yang Guoqing1, Zhang Youzhong1, Su Jiacan2.1Department of Orthopedic Surgery, Shanghai Zhongye Hospital Shanghai 200941, China;2Department of Orthopedics Trauma, Changhai Hospital of Second Military Medical University, Shanghai 200433, China

BackgroundWith over 5% of morbidity, elbow stiffness is a common and difficult complication after elbow trauma or surgery, which can severely interfere with the daily activities and life quality of patient. The post-traumatic elbow stiffness may be caused by intraarticular or extra-articular factors. The common intra-articular factors include osteophytosis,osteochondritis, synovitis, joint asymmetry and loose bodies, while the common extra-articular factors include heterotopic ossification, joint capsule contracture, ligament injury, fasciitis and skin diseases. These factors result in joint stiffness by altering normal elbow motions. The mixed presence of intra-articular and extra-articular factors is also common. The failure of conservative treatment is a definite indication of surgical treatment. Currently, there are many options of open surgery for the treatment of post-traumatic elbow stiffness. However, the large trauma of traditional open surgery and the additional soft tissue damage possibly caused by surgical approach increase the risk of relapse of soft tissue contracture and the chance of heterotopic ossification occurrence. Furthermore, it is difficult to perform early functional rehabilitation because of pain. Therefore, considering the several factors of elbow stiffness, the open surgery has obvious limitations and risks. With the development of surgical technique and medical equipment, the technique of debridement and arthrolysis under arthroscopy has been remarkably improved, which observes and deals with various intra-articular and extra-articular problems well. At the same time, this technique is beneficial to the initiation of early functional rehabilitation by reducing the operation trauma and relieving the pain. However, the arthroscopic elbow debridement is challenging because of the limitation of working space, the proximity between surgical incision and neurovascular structure and the easiness of triggering complication. The purposes of this study are to evaluate the efficacy of arthroscopic debridement for the treatment of post-traumatic elbow stiffness, to introduce this surgical technique and to discuss the possible difficulties and risks.Methods（1）General information. From January 2012 to December 2016, 42 patients （24 males and 18 females） with post-traumatic elbow stiffness were treated in Shanghai Hospital of metallurgical corporation of China LTD（MCC）.The age ranged from 21 to 59 years with an average of 42.3 years. 18 cases had the left side affected, and 24 cases had the right side affected. The symptoms of all patients were mainly limited joint motion and pain. The causes of joint stiffness were evaluated by preoperative X-ray films and computed tomography （CT）, which included osteophytosis and heterotopic ossification for 32 cases and loose bodies for 28 cases. Of the 42 patients, 31 cases had the history of surgery.（2）Inclusion and exclusion criteria. Inclusion criteria:① The range of elbow motion cannot reach 30-130°; ② The patient receives conservative treatment for more than 6 months, while the range of elbow motion does not improve obviously; ③ With or without the formation of osteophyte, elbow joint space still exists under fluoroscopy, and no successive bone callus passes through joint. Exclusion criteria: ① The bony deformity of elbow joint is obvious and requires corrective surgery; ② The patient with primary or inflammatory elbow arthritis;③The patient who cannot cooperate with postoperative active and passive functional trainings; ④ The skin infection around elbow or the scar contracture caused by burn; ⑤ Myositis ossificans of elbow joint;⑥ Elbow joint space almost disappears, such as joint ankylosis;⑦ The location of ulnar nerve is unknown because the patient had ulnar nerve surgery or elbow surgery for multiple times before.（3）Operative methods. The operation was performed under brachial plexus block or general aesthesia. The patient was in lateral position with shoulder abduction of 90° and elbow flexion of 90°, and the upper arm was tied with tourniquet. The anatomic landmarks of body surface were drawn on the skin preoperatively, and the pathway of ulnar nerve was marked specially. Based on the surface landmarks, the expansion of joint cavity was achieved by injecting 20 ml of saline via soft point, which facilitated the insertion of arthroscopy. The skin was cut open at 2 cm proximal to the humeral supracondylar and 1 cm ahead, and the soft tissue was bluntly separated for the insertion of arthroscopy. In this way, the first working path-proximal lateral approach was established. Then, the arthroscopy from proximal lateral elbow approach reached the contralateral subcutaneous tissue to establish proximal medial approach at 2 cm distal to the condylus medialis humeri and 2 cm ahead. The anterior compartment of elbow joint was debrided via these two approaches. At 3 cm proximal to the olecranon, the arthroscopy entered posterior joint cavity along the humeral supracondylar ridge to establish posterolateral approach. Posterior median approach was established at 2 cm medial to the posterolateral approach. The posterior compartment of elbow joint was debrided via the posterolateral and posterior median approaches. Under the monitoring and operation of arthroscopy, a 3.5 cm power drill was used to remove all the osteophyte and heterotopic ossification that affected joint function and part of coronoid process and olecranon through the approaches mentioned above. Intra-articular loose bodies were taken out with foreign-body forceps. synovial membrane and fibrous tissue were removed with planer and Radiofrequency.The debridement of coronoid fossa was required for the removal of the anterior lesion of elbow joint, while the debridement of olecranon fossa was required for the removal of the posterior lesion of elbow joint. Then, the contractural joint capsule was loosened. To avoid the injury of ulnar nerve, the blunt edge of planer was carefully kept toward the ulnar nerve and medial capsule. Afterward, the manual loosening was applied again to obtain satisfactory elbow joint function. According to the preoperative dysfunction, the elbow joint was fixed in extension or flexion orthosis. Indomethacin suppository was used postoperatively to prevent heterotopic ossification.（4）Postoperative management.Started from the 1st postoperative day, continuous passive motion （CPM） was carried out under the analgesia of intravenous analgesic pump. The CPM functional training was performed 4 times per day and 20 minutes per time, which followed the principles of combination of static and dynamic. Upper limb orthosis was used to maintain the improved ROM of elbow joint after training every day, which can be disassembled to carry out elbow joint exercise for 4-6 times per day. The orthosis should be used for at least 6 weeks with 1-2 hours of training per day. Active functional training was started 2-4 days after operation. 6 weeks later, resistance exercise was gradually carried out to enhance muscle strength. Active and passive training should last no less than 6 months. During the process of functional training,attention should be paid to control pain and edema.（5）Curative effect evaluation.Follow up was carried out at the 3rd, 6th and 12th months. Mayo elbow performance score （MEPS） and visual analogue scale （VAS） were used for patient evaluation before and after operation, and the active range of motion （ROM） of elbow joint was measured. （6）Statistical analysis. The SPSS17.0 statistical software was used for analysis. All the measured data were expressed as . The ROM of elbow, MEPS and VAS were compared in the 3rd, 6th and 12th months before and after the operation were compared using paired t test, and P ＜0.05 was considered statistical difference.Results All patients were followed up, and no patient was converted to open surgery or required secondary procedure. The mean time from injury to operation was 17 months （11-47 months）.The ROM of elbow joint improved significantly after operation, which increased from （50.7±18.3）°to （119.7±23.6）° with an average increment of 69°. The difference was statistically significant（P ＜0.001）. After operation, the improvement was obvious at the 3rd and 6th months and reduced at the 6th and 12th months. This indicated that early functional exercise was of great significance.The MEPS increased from preoperative （69.5±15.5） points to （90.4±22.4）points during the last follow up, and the mean improved score was 20.9 points （P ＜0.01）. According to MEPS, the preoperative function was excellent in 0 case, good in 6 cases, moderate in 25 cases and poor in 11 cases. The outcome of postoperative MEPS showed 22 cases of excellence, 17 cases of good and 3 cases of moderate. The good and excellent rate was 92.86%. The postoperative VAS scores all decreased remarkably compared to those before operation （P ＜0.05）. During the follow-up, 1 patient who was found to have heterotopic ossification before operation turned less severe with indomethacin for treatment. The final ROM of this patient reached 95°. After operation, 4 patients presented with the numbness in ulnar nerve innervation area and recovered in 6 months with conservative treatment. No infection occurred in all cases.ConclusionsArthroscopic debridement is a great option for the treatment of post-traumatic elbow stiffness. This strategy achieves minimal invasion, small scar, little pain and short hospital stay to allow postoperative early functional training and to improve the appearance and function of elbow joint.

Elbow joint; Post-traumatic stiffness; Arthroscopy; Debridement

10.3877/cma.j.issn.2095-5790.2017.03.009

国家自然国际合作基金（8141101156）；上海市科委生物医药专项（154119500600）；上海市卫计委科研课题面上项目（201640156）

200941上海中冶医院骨外科1；200433上海，第二军医大学附属长海医院创伤骨科2

苏佳灿， Email:drsujiacan@163.com

2016-10-13）

（本文编辑：李静；英文编辑：陈建海、张晓萌、张立佳）

王思成,李全,吴献民,等. 关节镜下清理术治疗创伤后肘关节僵硬的临床研究［J/CD］.中华肩肘外科电子杂志,2017,5（3）：207-212.