李彥林 王國梁 何川 李建 鄭家禮 陳廣超 李松 余洋

·論著·

關(guān)節(jié)鏡下治療創(chuàng)傷復(fù)發(fā)性Bankart損傷療效分析

李彥林 王國梁 何川 李建 鄭家禮 陳廣超 李松 余洋

目的探討肩關(guān)節(jié)鏡下Bankart損傷重建術(shù)治療復(fù)發(fā)性肩關(guān)節(jié)前脫位的臨床療效。方法自2010年6月至2014年4月隨訪60例應(yīng)用肩關(guān)節(jié)鏡下Bankart損傷重建術(shù)治療的復(fù)發(fā)性肩關(guān)節(jié)前脫位患者,隨訪10～38個月,平均26.6個月;年齡15～45歲,平均29歲。60例患者均為前方單方向性不穩(wěn)定,術(shù)前平均脫位次數(shù)為6.5次(2～17次)。手術(shù)中采用縫合錨進行Bankart損傷重建術(shù)。隨訪時采用ASES評分和Constant-Murley評分進行功能評估。結(jié)果60例患者手術(shù)前及終末隨訪時ASES平均評分為(83.5±3.2)分與(97.1±2.1)分(t=4.79,P>0.01),肩關(guān)節(jié)平均前屈上舉角度為(163.8±6.0)°與(185.4±3.9)°(t=4.87,P>0.01),外展角度為(90±1.1)°與(135.4±9.9)°(t=6.40,P>0.01),外旋角度為(57.6±4.3)°與(86.5±5.2)°(t=5.43,P>0.01);術(shù)前及終末隨訪時Constant-Murley平均評分為(77.6±3.5)分與(97.2±3.2)分(t=5.06,P>0.01)。終末隨訪時所有病例均未發(fā)生術(shù)后再脫位,術(shù)后殘存恐懼試驗陽性4例(6.7%)。所有患者均恢復(fù)術(shù)前工作,52例(86.7%)恢復(fù)到第一次脫位前的運動水平。結(jié)論肩關(guān)節(jié)鏡下微創(chuàng)行Bankart損傷重建手術(shù)是治療復(fù)發(fā)性肩關(guān)節(jié)前脫位的有效方法之一,術(shù)前病例選擇、術(shù)中關(guān)節(jié)鏡下操作技術(shù)及術(shù)后功能康復(fù)鍛煉是手術(shù)成功的關(guān)鍵。

肩關(guān)節(jié)脫位;關(guān)節(jié)鏡;Bankart損傷

復(fù)發(fā)性肩關(guān)節(jié)脫位(或創(chuàng)傷性肩關(guān)節(jié)不穩(wěn))始于第一次肩關(guān)節(jié)脫位,該脫位損傷了穩(wěn)定肩關(guān)節(jié)的韌帶。當盂唇從關(guān)節(jié)盂上撕裂時,這些韌帶的穩(wěn)定作用就不復(fù)存在,創(chuàng)傷性肩關(guān)節(jié)不穩(wěn)定的發(fā)展與盂緣和周圍韌帶損傷的類型和程度密不可分。Bankart損傷是發(fā)生肩關(guān)節(jié)復(fù)發(fā)性前脫位最常見的原因,修復(fù)和重建肩關(guān)節(jié)前方的穩(wěn)定結(jié)構(gòu),是治療復(fù)發(fā)性肩關(guān)節(jié)前脫位的關(guān)鍵。隨著關(guān)節(jié)鏡技術(shù)的發(fā)展和普及,肩關(guān)節(jié)鏡下微創(chuàng)治療復(fù)發(fā)性肩關(guān)節(jié)前脫位已被越來越多的醫(yī)師采用。2010年6月至2014年4月,我們于關(guān)節(jié)鏡下采用金屬縫合錨內(nèi)固定修復(fù)Bankart損傷治療60例復(fù)發(fā)性肩關(guān)節(jié)前脫位患者,取得良好臨床療效,現(xiàn)報道如下:

資料與方法

一、一般資料

我院自2010年6月至2014年4月,在肩關(guān)節(jié)鏡下行Bankart損傷重建術(shù)治療60例復(fù)發(fā)性肩關(guān)節(jié)前脫位患者。隨訪10～38個月,平均26.6個月。年齡15～45歲,平均29歲。60例患者均為前方單方向性不穩(wěn)定,術(shù)前平均脫位次數(shù)為6.5次(2～17次)。術(shù)后肩關(guān)節(jié)功能恢復(fù)時間為6周,均未發(fā)生再脫位。本組患者均除外肩袖全層撕裂、肩峰撞擊征等。

二、影像學(xué)檢查

術(shù)前均拍攝肩關(guān)節(jié)正位、側(cè)位及肩關(guān)節(jié)岡上肌出口位X線片(圖1～3),CT掃描、MRI及肩關(guān)節(jié)去除肱骨頭后CT三維重建(圖4),術(shù)前X線片均未見肩關(guān)節(jié)明顯的骨折,CT三維重建未見明確的骨性Bankart損傷,所有MRI均表現(xiàn)為前側(cè)盂唇與關(guān)節(jié)盂緣之間有高信號,其中3例盂唇消失(圖4,5)。

圖1 肩關(guān)節(jié)正位片,未見異常

圖2 肩關(guān)節(jié)側(cè)位片,無異常

圖3 肩關(guān)節(jié)岡上肌出口位片,為正常肩峰結(jié)構(gòu)

三、手術(shù)方法

全身麻醉,側(cè)臥位,沖洗用的生理鹽水每3 000 ml加0.1%腎上腺素1 ml,可調(diào)式水泵的壓力維持在60 mm Hg。術(shù)前標記肩關(guān)節(jié)骨性標記及手術(shù)入口。后方入口/關(guān)節(jié)鏡入口:位于肩峰后角向下約2 cm,向內(nèi)側(cè)約1 cm。前上方入口:在喙突外側(cè),關(guān)節(jié)內(nèi)位于肱二頭肌長頭腱和肩胛下肌腱上緣之間。前下方入口:在前上方入口下2～3 cm處,關(guān)節(jié)內(nèi)盡可能接近肩胛下肌腱上緣。前方兩入口安裝工作套管,作為器械操作通道。于后方入口進入關(guān)節(jié)鏡,按順序進行肩關(guān)節(jié)探查,本組所有病例均可見盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體與盂唇分離、移位(圖6),前關(guān)節(jié)囊和韌帶組織松弛。損傷部位多位于肩盂1～5點鐘的范圍。7例伴有肱骨頭軟骨損傷,5例伴有盂肱關(guān)節(jié)軟骨退變。采用低溫等離子射頻消融和刨刀行關(guān)節(jié)軟骨損傷和退變處表面清理。

圖4 肩關(guān)節(jié)去除肱骨頭后CT三維重建,盂唇無骨缺損

圖5 MRI表現(xiàn)為前側(cè)盂唇與關(guān)節(jié)盂緣之間有高信號

使用肩關(guān)節(jié)軟組織剝離器在肩盂受損處前部,向肩胛頸方向剝離黏連的盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體。用肩盂銼銼去肩唇受損處纖維組織,露出新鮮骨面。通過前下方入口工作套管,將定位器置于肩盂緣2、3、4、5點鐘位置。于關(guān)節(jié)盂成45°角,骨錘叩擊定位器,使其在肩盂緣新鮮骨面上形成一個導(dǎo)向孔。移去內(nèi)芯,金屬縫合錨插入定位器中央并擰入至肩盂內(nèi),以穿刺縫合器穿刺縫合盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體,進行打結(jié)收緊完成固定。固定完成后以探鉤再次檢查修復(fù)效果,用射頻消融刀清理創(chuàng)緣(圖7)。

圖6 關(guān)節(jié)鏡下可見Bankart損傷,盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體與盂唇分離

圖7 Bankart損傷重建術(shù)后可見分離盂唇已縫合至原位

四、術(shù)后處理

術(shù)后復(fù)查肩關(guān)節(jié)正側(cè)位片(圖8,9),術(shù)后采用肩關(guān)節(jié)外展位支具固定6周,6周內(nèi)禁止做主動活動。囑患者活動肘、腕及手,并進行局部理療、消腫止痛及冰敷治療。6周后進行保護性康復(fù)訓(xùn)練,包括鐘擺訓(xùn)練,滑輪器訓(xùn)練。3個月后進行肌力強度康復(fù)訓(xùn)練,包括增加關(guān)節(jié)活動度范圍和肌肉的抗阻力訓(xùn)練,耐力訓(xùn)練。6個月后進行運動功能康復(fù)訓(xùn)練,加強肩關(guān)節(jié)周圍肌肉鍛煉,本體感覺鍛煉等,并可進行非對抗性體育活動,包括恢復(fù)運動訓(xùn)練功能的專項訓(xùn)練,負重上舉、啞鈴訓(xùn)練等。術(shù)后即刻在康復(fù)醫(yī)師和治療師的指導(dǎo)下進行術(shù)后早期物理治療和康復(fù)訓(xùn)練。物理治療主要包括早期冷療減輕疼痛和腫脹,超短波治療改善局部血液循環(huán),促進腫痛消退和組織愈合,康復(fù)訓(xùn)練可改善循環(huán),促進關(guān)節(jié)囊-盂唇復(fù)合體的愈合,加強肌力,增加關(guān)節(jié)的穩(wěn)定性,防止關(guān)節(jié)僵直、腫脹等并發(fā)癥。

表1 肩關(guān)節(jié)復(fù)發(fā)性脫位手術(shù)前、后肩關(guān)節(jié)功能比較(±s)

表1 肩關(guān)節(jié)復(fù)發(fā)性脫位手術(shù)前、后肩關(guān)節(jié)功能比較(±s)

組別 ASES評分 肩關(guān)節(jié)前屈(°) 肩關(guān)節(jié)外展(°) 肩關(guān)節(jié)外旋(°) Constant-Murley.5術(shù)后 97.1±2.1 185.4±3.9 135.4±9.9 86.5±5.2 97.2±3.2t值評分術(shù)前 83.5±3.2 163.8±6.0 90.0±1.1 57.6±4.3 77.6±3 4.79 4.87 6.40 5.43 5.06P值 <0.01 <0.01 <0.01 <0.01 <0.01

圖8 術(shù)后肩關(guān)節(jié)正位片,錨釘位置良好

圖9 術(shù)后肩關(guān)節(jié)側(cè)位片,錨釘位置良好

結(jié) 果

術(shù)后3周、6周、3個月、6個月及1年門診隨訪,此后每年隨訪一次,60例患者手術(shù)前及終末隨訪時進行ASES平均評分,肩關(guān)節(jié)前屈上舉、外展、外旋角度及終末隨訪時平均Constant-Murley評分采用配對t檢驗處理,P<0.05差異有統(tǒng)計學(xué)意義,見表1。終末隨訪時所有病例均未發(fā)生術(shù)后再脫位,術(shù)后殘存恐懼試驗陽性4例(6.7%)。

討 論

肩關(guān)節(jié)由關(guān)節(jié)盂和肱骨頭以及周圍的肩關(guān)節(jié)囊和韌帶組成,正常情況下肱骨頭在關(guān)節(jié)盂內(nèi),當外傷造成肱骨頭脫出關(guān)節(jié)盂即為肩關(guān)節(jié)脫位,根據(jù)肱骨頭脫位的方向分為肩關(guān)節(jié)前脫位和后脫位。常見的是肩關(guān)節(jié)前脫位,致傷原因有跌倒壓在外展并強力被迫過頂?shù)氖直凵?、肩部的直接擊打、手臂強力被迫外?肩關(guān)節(jié)向后脫位不常見,常常與癲癇發(fā)作或電擊有關(guān),此時肩部的肌肉強力收縮造成脫位。Bankart損傷是肩關(guān)節(jié)盂唇前下方在前下盂肱韌帶復(fù)合體附著處的撕脫性損傷,因肩關(guān)節(jié)前脫位引起,是造成習(xí)慣性前方不穩(wěn)定和脫位的基本損傷。Bankart損傷經(jīng)常伴隨發(fā)生關(guān)節(jié)囊的異常,超過30%的患者會有前下盂肱韌帶復(fù)合體的延長及松弛。經(jīng)典的Bankart損傷為纖維性Bankart損傷:即關(guān)節(jié)囊破裂,盂肱韌帶連同附著的關(guān)節(jié)盂唇從關(guān)節(jié)盂上撕脫,肩關(guān)節(jié)前脫位時最常見的是下盂肱韌帶-盂唇復(fù)合體損傷,占創(chuàng)傷性肩關(guān)節(jié)前脫位的85%。治療因患者首次脫位時的年齡而異,當患者首次脫位時年齡<30歲,再次脫位的可能性>80%,建議手術(shù)治療,修補撕裂的韌帶及盂唇;但如果患者首次脫位時年齡>30歲,再次脫位的可能性就大為減少,可以先行保守治療[1-2]。本組患者均有明確的外傷史,傷后首診均為手足牽引復(fù)位關(guān)節(jié),復(fù)位后未得到充分的制動固定,盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體未能愈合,這樣易致復(fù)發(fā)性脫位。

關(guān)節(jié)鏡輔助下治療復(fù)發(fā)性肩關(guān)節(jié)脫位已經(jīng)成為治療肩關(guān)節(jié)疾病的一種不可或缺的治療手段,Bankart損傷采用關(guān)節(jié)鏡手術(shù)的理想患者是從事非接觸性運動伴有Bankart病變,而且其盂唇本身沒有變性,肩關(guān)節(jié)盂肱下韌帶及盂肱中韌帶質(zhì)量良好者[3]。許多研究[4-7]報道,關(guān)節(jié)鏡下治療Bankart損傷修復(fù)肩關(guān)節(jié)前方不穩(wěn)的效果優(yōu)于切開手術(shù)。

本組采用的金屬帶線錨釘在松質(zhì)骨中具有多點固定和高穩(wěn)定性,其釘尾帶有縫針的不可吸收縫線,適合腱骨結(jié)合處韌帶肌腱的固定,操作簡便,效果可靠,安全有效,對韌帶肌腱的修復(fù)與重建提供了極大的方便[8]。金屬骨錨具有以下優(yōu)勢:(1)操作簡便,只需暴露骨面,能簡便地完成肌腱與骨的接觸固定,手術(shù)時間短,固定牢固;(2)手術(shù)創(chuàng)傷小,手術(shù)剝離范圍小,軟組織損傷輕;(3)避免了對骨骼進行過多操作所帶來的骨骼畸形而影響生長發(fā)育的并發(fā)癥;(4)Press-fit固定方式使其在皮質(zhì)骨下固定牢靠,預(yù)置的Ethibond縫線在軟組織愈合期間能保持長時間拉力,使肌腱修復(fù)后強度良好,且與骨質(zhì)連結(jié)緊密,適宜于術(shù)后早期開展功能鍛煉,防止關(guān)節(jié)僵硬;(5)由于骨錨固定牢靠,手術(shù)后關(guān)節(jié)內(nèi)固定時間由6周減少到3～4周,適宜于早期進行功能鍛煉,減少關(guān)節(jié)僵硬的機會;(6)骨錨為永久置入物,若無骨錨松動退出,影響關(guān)節(jié)活動、壓迫皮膚或出現(xiàn)無法控制的傷口感染,一般無需取出,避免二次手術(shù)的痛苦[9-10]。

本組病例術(shù)后均獲隨訪,平均隨訪時間為26.6個月,均未發(fā)現(xiàn)再脫位現(xiàn)象。通過分析本組病例手術(shù)前、后肩關(guān)節(jié)的功能,術(shù)后肩關(guān)節(jié)平均前屈上舉角度明顯提高,平均外展90°外旋明顯增加,Gonstant-Murley評分明顯增多。本組病例有4例術(shù)后殘存恐懼試驗陽性,考慮患者盂唇-肩關(guān)節(jié)囊-韌帶復(fù)合體與盂唇分離較大,術(shù)中難以完全復(fù)位及患者不適當?shù)倪\動有關(guān)。因此,關(guān)節(jié)鏡下行Bankart重建手術(shù)能恢復(fù)復(fù)發(fā)性前脫位肩關(guān)節(jié)的穩(wěn)定性,術(shù)后肩關(guān)節(jié)的功能得到明顯改善,取得較好的療效,鏡下實施Bankart重建手術(shù),可改善預(yù)后,促進肩關(guān)節(jié)功能恢復(fù),加速康復(fù)進程,值得臨床推廣。鑒于本研究病例樣本量相對較少,隨訪時間較短,遠期效果還有待臨床進一步觀察。

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Clinical curative effect of the arthroscopic reconstruction for recurrent anterior dislocation of the shoulder

Li Yanlin,Wang Guoliang,He Chuan,Li Jian,Zheng Jiali,Chen Guangchao,Li Song,Yu Yang.Department of Sports Medicine,the First Affiliated Hospital of Kunming Medical University,Kunming 650032,China

BackgroundRecurrent dislocation of shoulder joint(or traumatic shoulder instability)initiates from the first shoulder dislocation,compromising the ligaments for stability of the shoulder.When the labrum is torn from the glenoid,the stable function of these ligaments is lost.The progression of traumatic shoulder instability and the type and degree of injuries in glenoid labrum and surrounding ligaments are inextricably linked.Bankart injury is the most common cause of recurrent anterior shoulder dislocation,and the rehabilitation and reconstruction of stable structure in anterior shoulder is critical for the treatment of recurrent anterior dislocation of the shoulder joint.With the development and popularization of the arthroscopic technique,shoulder arthroscopic surgery in the treatment of recurrent anterior dislocation of the shoulder joint has been adopted by increasing surgeons.From June 2010 to April 2014,60 patients of recurrent anterior shoulder dislocation were treated arthroscopically with metallic suture anchor Bankart repair to explore its clinical efficacy.MethodsClinical data:From June of 2010 to April of 2014,sixty patients in our hospital were treated with arthroscopic reconstruction for Bankart injury of recurrent anterior dislocation of the shoulder.The patients were followed up for 10～38 months and the mean time was 26.6 months.Their agesranged from 15 to 45 years with an average of 29 years.Each of 60 cases had a unidirectional instability of anterior shoulder,and the average number of dislocation before surgery was 6.5 times(2-17 times).Suture anchor was applied for reconstruction of Bankart injury.ASES score and Constant-Murley score were adopted for the functional assessment during follow-ups.The postoperative recovery time of shoulder function was 6 weeks without redislocation in each case.Complete rotator cuff tear,subacromial impingement syndrome,etc.were excluded from this group of patients.Imaging examination:X-ray films of anteroposterior view,lateral view and supraspinatus outlet view,CT scanning,MRI and CT three-dimensional reconstruction with humeral head removed were done preoperatively.No obvious bone defect was shown on preoperative X-ray films,no definite bony Bankart injury was revealed on CT three-dimensional reconstruction,and all MRI showed hyperintense between anterior labrum and glenoid rim with 3 cases of glenoid labrum disappeared.Operative methods:After successful general anesthesia,the patient was placed in lateral position.Every 3000 ml saline for flushing purpose was added with 1 ml of 0.1%epinephrine,and the pressure of adjustable water pump was maintained at 60 mm Hg.The bony markers and surgical portals were marked before operation.Posterior portal/arthroscopic portal:2 cm below the posterior corner of acromion.Anterosuperior portal:in the lateral side of coracoid process and between the long head of the biceps tendon and upper margin of the subscapularis tendon inside the joint.Antroinferior portal:2～3 cm below the anterosuperior portal and close to the upper margin of the subscapularis tendon inside the joint as much as possible.Two arthroscopic working cannulas were positioned as working channels.The arthroscopy was put in through the posterior portal to explore the shoulder joint in order.The labrum-shoulder joint capsule-ligament complex was found detached and shifted from the glenoid labrum and the anterior joint capsule and ligaments were aneuros in all cases of this group.The injury sites were often located in the range of 1～5 o′clock.7 patients were with articular cartilage lesion of humeral head and 5 patients were with glenohumeral cartilage degeneration.Radiofrequency ablation and cartilage-plasty were adopted for surface cleaning of articular cartilage injury and degeneration.The shoulder joint soft tissue detacher was used in the front of the damaged glenoid to dissect the adhesive labrum-shoulder joint capsule-ligament complex to the direction of scapular neck.The fibrous tissue was rasped off at the damage of labrum with glenoid file,exposing the fresh bone.The locator was put at the glenoid rim of 2,3,4,5 o′clock position through the antroinferior working cannula.Employed the bone mallet to percuss the locator with in an angle of 45°with glenoid to make a pilot hole on the fresh bony surface of glenoid.The inner core was removed and the metal suture anchor was put in the center of locator and screwed in the glenoid.The labrum-shoulder joint capsule-ligament complex was sutured with suture penetrator device with the knot tied to complete the fixation.After finishing the fixation,the repair effect was rechecked with probe and the wound margin was cleaned by radiofrequency ablation.Postoperative management:Postoperative examination of shoulder joint includes radiographs,and the shoulder joint is fixed with abduction orthosis for 6 weeks with active movement prohibited.The patient is advised to exercise elbow,wrist and hand,and be given local physical therapy,pain relief and icing.Protective rehabilitation,including pendulum training and pulley device training,is allowed 6 weeks later.Rehabilitation for muscle strength begins 3 months later,consisting of increased joint range of motion,resistance training of muscle and endurance training.After 6 months motor function recovery is initiated to strengthen the exercises of muscles around the shoulder joint,proprioception,etc.,and non-contact sports activities can be engaged,including special training of restoration movement function,weight lifting,dumbbell training,etc.Immediate postoperative physical therapy and rehabilitation is performed under the guidance of rehabilitation physicians and therapists.Physical therapy mainly contains early cold compress to relieve pain and disperse swelling,ultrashort wave therapy to improve local blood circulation and promotion of soreness subsiding and tissue healing.Rehabilitation can improve circulation,promote joint capsule-labrum complex healing,strengthen muscle,increase joint stability,and prevent joint stiffness,swelling and other complications.ResultsOutpatient follow-upswere carried out 3 week,6 week,3 month,6 month and 1 year after operation and henceforth once each year.The mean ASES score before operation and at the final follow-ups,the angle of anteflexion,abduction and external rotation,and the mean Constant-Murley score at the final followups of 60 patients were processed by paired t-test and a value ofP<0.05 was considered statistically significant.No postoperative redislocation occurred in all patients during the final follow-up.Postoperative residual Crank test was positive in 4 patients(6.7%).All patients restored preoperative work with 52 patients(86.7%)restored to the sports level before the first dislocation.DiscussionArthroscopic Bankart repair is one of the effective methods for treatment of recurrent anterior dislocation of the shoulder,the proper case selection,and arthroscopic technique during operation and strict postoperative functional rehabilitation are the keys to successful operation.

Shoulder dislocation;Arthroscopy;Bankart Injury

Wang Guoliang,Email:200301144@163.com

2014-08-07)

(本文編輯:李靜)

10.3877/cma.j.issn.2095-5790.2014.04.003

云南省醫(yī)學(xué)學(xué)科帶頭人項目(D-201207);云南省創(chuàng)新團隊項目(2014HC018)

650032 昆明醫(yī)科大學(xué)第一附屬醫(yī)院運動醫(yī)學(xué)科

王國梁,Email:200301144@163.com

李彥林,王國梁,何川,等.關(guān)節(jié)鏡下治療創(chuàng)傷復(fù)發(fā)性Bankart損傷療效分析[J/CD].中華肩肘外科電子雜志,2014,2(4):219-224.