中华肩肘外科电子杂志
中華肩肘外科電子雜誌
중화견주외과전자잡지
Chinese Journal of Shoulder and Elbow (Electronic Edition)
2013年
1期
40-45
,共6页
皇甫小桥%赵金忠%何耀华%杨星光%刘旭东%刘闻欣%王海明
皇甫小橋%趙金忠%何耀華%楊星光%劉旭東%劉聞訢%王海明
황보소교%조금충%하요화%양성광%류욱동%류문흔%왕해명
肩锁关节脱位%喙锁韧带%关节镜
肩鎖關節脫位%喙鎖韌帶%關節鏡
견쇄관절탈위%훼쇄인대%관절경
Acromioclavicular joint dislocation%Coracoacromial ligament%Arthroscopy
目的：研究关节镜下缝线钢板增强喙锁韧带术治疗肩锁关节脱位的近期治疗效果。方法2010年3月至2011年3月,在关节镜下使用膝关节韧带重建技术的缝线钢板(德国 ASCULAP 公司, B′BRAUN)增强重建喙锁韧带(三角韧带与斜方韧带),治疗 Rockwood Ⅲ型9例、Ⅴ型3例新鲜肩锁关节脱位。行 X线片、美国肩肘关节外科医师(America Shoulder Elbow Surgeons,ASES)评分和 Constant 评分,随访12~18个月。结果 ASES 评分：术前28.7分,术后86.9分；Constant 评分：术前24分,术后91分。治疗组 X线片显示,肩锁关节复位良好。术后1年,91.7%(11/12)病例获得满意治疗效果,83.3%(10/12)恢复到术前运动水平,仅有1例出现肩锁关节半脱位。结论关节镜下缝线钢板喙锁韧带增强术治疗肩锁关节脱位,早期可以获得满意的治疗效果,术后复位良好,并发症少。
目的：研究關節鏡下縫線鋼闆增彊喙鎖韌帶術治療肩鎖關節脫位的近期治療效果。方法2010年3月至2011年3月,在關節鏡下使用膝關節韌帶重建技術的縫線鋼闆(德國 ASCULAP 公司, B′BRAUN)增彊重建喙鎖韌帶(三角韌帶與斜方韌帶),治療 Rockwood Ⅲ型9例、Ⅴ型3例新鮮肩鎖關節脫位。行 X線片、美國肩肘關節外科醫師(America Shoulder Elbow Surgeons,ASES)評分和 Constant 評分,隨訪12~18箇月。結果 ASES 評分：術前28.7分,術後86.9分；Constant 評分：術前24分,術後91分。治療組 X線片顯示,肩鎖關節複位良好。術後1年,91.7%(11/12)病例穫得滿意治療效果,83.3%(10/12)恢複到術前運動水平,僅有1例齣現肩鎖關節半脫位。結論關節鏡下縫線鋼闆喙鎖韌帶增彊術治療肩鎖關節脫位,早期可以穫得滿意的治療效果,術後複位良好,併髮癥少。
목적：연구관절경하봉선강판증강훼쇄인대술치료견쇄관절탈위적근기치료효과。방법2010년3월지2011년3월,재관절경하사용슬관절인대중건기술적봉선강판(덕국 ASCULAP 공사, B′BRAUN)증강중건훼쇄인대(삼각인대여사방인대),치료 Rockwood Ⅲ형9례、Ⅴ형3례신선견쇄관절탈위。행 X선편、미국견주관절외과의사(America Shoulder Elbow Surgeons,ASES)평분화 Constant 평분,수방12~18개월。결과 ASES 평분：술전28.7분,술후86.9분；Constant 평분：술전24분,술후91분。치료조 X선편현시,견쇄관절복위량호。술후1년,91.7%(11/12)병례획득만의치료효과,83.3%(10/12)회복도술전운동수평,부유1례출현견쇄관절반탈위。결론관절경하봉선강판훼쇄인대증강술치료견쇄관절탈위,조기가이획득만의적치료효과,술후복위량호,병발증소。
Objective Acromioclavicular joint dislocation is commonly seen in shoulder joint injuries. Dysfunction as well as pain and discomfort usually occurred when the integrity of shoulder is damaged,for the acromioclavicular (AC)joint is involved in the connection between the scapula and the body as well as the activities of shoulder joint.Therefore,a consensus has been reached to treat severe AC joint dislocation by surgery.Based on different anatomical and functional cognition,methods for AC joint dislocation are various,which are typically performed by incision to reconstruct its stability and restore function.Attempts had been made by many doctors in the reconstruction of AC joint dislocation with the development of arthroscopy.From March 2010 to March 2011,obvious therapeutic effect was obtained in treating Rockwood type Ⅲ and Ⅴ AC joint dislocation arthroscopically with the suture plate used for the reconstruction of ligaments of knee joint to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament).Methods From March 2010 to March 2011,nine patients with acute AC joint dislocation type Ⅲ and three patients with type V were treated arthroscopically to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament ) by the suture plate (ASCULAP Company, Germany,B′Braun)used to reconstruct ligaments of knee joint.Patients were pre and postoperatively evaluated with X-ray examinations,American Shoulder and Elbow Surgeons′Form (ASES)and Constant-Murley Score (CMS).Results All 1 2 patients were followed up for at least 1 2 months (range,1 2 to 1 8 months).The average ASES score significantly increased from 28.7 preoperatively to 86.9 postoperatively, and the mean CMS score from 24 to 91,respectively.X-ray data showed a good reduction of the AC joint in the treated group.9 1 .7% of patients (1 1 patients)obtained an obvious therapeutic effect after operation. 83.3% of patients (10 patients)returned to their pre-injury level of athletics.Acromioclavicular subluxation was only found in one case.Discussion AC joint dislocation usually appears in youth and adults with obvious traumatic history,and often results from the direct violence on the adducted shoulder.The stable structure of AC joint is achieved by the connection between the scapula and the clavicle,and the integrity of the sternoclavicular articulation and the scapulothoracic joint.According to the injury level of acromioclavicular stability,AC joint injuries can be classified into six types by Rockwood,type Ⅲ、Ⅳ、Ⅴ、Ⅵ should be fixed through operation for its disruption of stable structures.The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function. Activity of AC joint and its postoperative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility. Arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique is an effective method in treating AC joint dislocation,which restores its anatomy and has advantages over the traditional open surgery.(1)AC joint anatomy and dislocation of classification:AC joint dislocation often occurs in youth and adults trauma,and is usually caused by direct violence on the adducted shoulder.The connection between the scapula and the clavicle,and the integrity of the sternoclavicular articulation and the scapulothoracic joint can help to achieve the stable structure of AC joint,the former of which is the most important.Coracoclavicular ligament (conoid ligament and trapezoid ligament ),the deltoid and trapezius muscle fascia as well as AC joint are involved in the connection between the scapula and the clavicle. Therefore,functionally speaking,the conception of AC joint should be replaced by acromioclavicular connection.When aforementioned anatomical structure cannot be fixed after AC joint dislocation,the connection between the scapula and the clavicle should be restored or reconstructed.And there is no necessity to emphasize the restoration of the anatomical integrity.According to the inj ury level of acromioclavicular stability,AC joint juries are classified into six types by Rockwood,type I and II of which are only acromioclavicular joint ligament injuries without complete dislocation.Except complete dislocation, AC joint stability of type Ⅲ and above with severe damages of other joints and soft tissues should be fixed through operation to restore the stable structures.(2)Treatment of AC joint dislocation:The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function.AC joint is involved in the shoulder activity of abduction,flexion and extension.The scapula rotates around anteroposterior axis when shoulder joint abducts over 60 degrees,and AC joint is involved in the activity when the upper arm anteflexes to 90 degrees.Corresponding reflects of AC joint and sternoclavicular articulation are due to the relative rotation around the body at any angle by the scapula.Large movement of AC joint is involved in the normal shoulder exercise,and activity of AC joint and its post operative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility such as AC joint Kirschner pin fixation,Coracoclavicular screw fixation and clavicular hook plate.Internal fixation failure results from its abnormal stress caused by the increased range of the shoulder movement.Hence,reliable clavicle reduction should be achieved by clavicle fixation of AC joint or the scapula and the clavicle,while the relative freedom of movement between the scapula and the clavicle should be maintained.Soft fixation between coracoid and clavicle,such as suture,artificial ligament or wire,may be a better choice.Based on the development of arthroscopy,minimally invasive or arthroscopic surgical procedure of shoulder joint has been evolved from open reduction and internal fixation.Minimally invasive surgery had been conducted by some doctors to treat AC joint,and obvious therapeutic effect is achieved through arthroscopic reconstruction of CC ligaments.(3) Advantages of the arthroscopic technique in treating AC joint dislocation:Compared to traditional open surgery,arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique has advantages as follows:(1 )minimal trauma.Just three 5-mm small incisions are needed as arthroscopic pathways to expose the coracoclavicular joint without the alteration of the tissues nearby,which helps for the postoperative rehabilitation.(2 )Reliable reduction may be attained arthroscopically without necessary intraoperative X-ray confirmation,which shortens the operation time.(3)The suture plate with good biocompatibility augments CC ligaments and has no effect on AC joint anatomy,which is propitious to healing of the fresh joint capsule and the ligament.(4)The flexible anatomic enhanced fixation allows certain ranges of AC joint movement during abduction,flexion and extension of shoulder,which conforms to the biological nature of AC joint.Long learning of the arthroscopic skills is required due to its key role in the arthroscopically assisted augmentation of reconstructed CC ligaments. Additionally, such anatomical structures as coracoid base,AC joint and CC ligament should be known well.While establishing bone tunnel from the clavicle to the coracoid root,arthroscopy travels along the CC ligament to guarantee the uniformity of cortical bone around the tunnel.After arthroscopic reduction,the plate should be carefully fixed in the end of coracoidprocess to avoid rarefaction of bone that loosens fixation,breaks it off and thus leads to failure.In addition,arthroscopically assisted augmentation of the reconstructed CC ligaments is applicable for patients of type Ⅲ and Ⅴ in Rockwood classification.Open surgery is necessary to restore the stability of joint for type Ⅵ and Ⅳ patients with reduction difficulties.Conclusions Augmentation of CC ligaments with the suture to restore the anatomy of AC joint is an effective method in treating the dislocation.Minimal injury,reliable reduction of AC joint,less complication and rapid recovery of the shoulder joint function are found after the arthroscopic operation.Whether AC joint structure is stabilized and its biomechanic features are self-repaired to restore the normal anatomy and function or not,which required long term follow-up.
