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)
2014年
1期
23-27
,共5页
陈爱民%鹿楠%叶添文%杨鹏%朱磊%李菁
陳愛民%鹿楠%葉添文%楊鵬%硃磊%李菁
진애민%록남%협첨문%양붕%주뢰%리정
肩锁关节%脱位%喙锁固定%LARS人工韧带
肩鎖關節%脫位%喙鎖固定%LARS人工韌帶
견쇄관절%탈위%훼쇄고정%LARS인공인대
Dislocation of acromioclavicular joint%Tossy Ⅲ%Artificial ligaments%Reconstruction
目的：评价通过 LARS人工韧带重建并加强喙锁韧带的方法治疗肩锁关节脱位的临床效果。方法应用 LARS人工韧带重建喙锁韧带治疗8例 Tossy Ⅲ型肩锁关节脱位,其中男性5例,女性3例；年龄21~45岁；左肩3例,右肩5例。致伤原因：摔倒7例,车祸1例。临床评价采用Constant评分和 VAS评分。采用双侧肩锁关节的Zanca位片和患侧肩关节腋位片进行影像学评价。结果所有患者获得平均24(5~40)个月的随访。8例肩锁关节脱位均获得复位,肩关节 Constant评分从术前的(59.3±6.9)分提高到(96.5±9.3)分(t=300,P<0.05)。VAS评分从术前的(5.4±1.3)分下降到(0.7±0.9)分(t=300,P <0.05)。术后 X 线片显示7例患者获得了解剖复位,有1例复位轻度丢失。发现2例喙锁韧带钙化,1例肩锁关节退变,未发现挤压螺钉周围骨溶解。结论应用 LARS人工韧带进行喙锁韧带重建可以为肩锁关节提供可靠的初期强度,并允许患者早期进行功能锻炼,可以使患者得到较好的临床疗效,而且并发症少。
目的：評價通過 LARS人工韌帶重建併加彊喙鎖韌帶的方法治療肩鎖關節脫位的臨床效果。方法應用 LARS人工韌帶重建喙鎖韌帶治療8例 Tossy Ⅲ型肩鎖關節脫位,其中男性5例,女性3例；年齡21~45歲；左肩3例,右肩5例。緻傷原因：摔倒7例,車禍1例。臨床評價採用Constant評分和 VAS評分。採用雙側肩鎖關節的Zanca位片和患側肩關節腋位片進行影像學評價。結果所有患者穫得平均24(5~40)箇月的隨訪。8例肩鎖關節脫位均穫得複位,肩關節 Constant評分從術前的(59.3±6.9)分提高到(96.5±9.3)分(t=300,P<0.05)。VAS評分從術前的(5.4±1.3)分下降到(0.7±0.9)分(t=300,P <0.05)。術後 X 線片顯示7例患者穫得瞭解剖複位,有1例複位輕度丟失。髮現2例喙鎖韌帶鈣化,1例肩鎖關節退變,未髮現擠壓螺釘週圍骨溶解。結論應用 LARS人工韌帶進行喙鎖韌帶重建可以為肩鎖關節提供可靠的初期彊度,併允許患者早期進行功能鍛煉,可以使患者得到較好的臨床療效,而且併髮癥少。
목적：평개통과 LARS인공인대중건병가강훼쇄인대적방법치료견쇄관절탈위적림상효과。방법응용 LARS인공인대중건훼쇄인대치료8례 Tossy Ⅲ형견쇄관절탈위,기중남성5례,녀성3례；년령21~45세；좌견3례,우견5례。치상원인：솔도7례,차화1례。림상평개채용Constant평분화 VAS평분。채용쌍측견쇄관절적Zanca위편화환측견관절액위편진행영상학평개。결과소유환자획득평균24(5~40)개월적수방。8례견쇄관절탈위균획득복위,견관절 Constant평분종술전적(59.3±6.9)분제고도(96.5±9.3)분(t=300,P<0.05)。VAS평분종술전적(5.4±1.3)분하강도(0.7±0.9)분(t=300,P <0.05)。술후 X 선편현시7례환자획득료해부복위,유1례복위경도주실。발현2례훼쇄인대개화,1례견쇄관절퇴변,미발현제압라정주위골용해。결론응용 LARS인공인대진행훼쇄인대중건가이위견쇄관절제공가고적초기강도,병윤허환자조기진행공능단련,가이사환자득도교호적림상료효,이차병발증소。
Background Currently,the clinical perspectives of surgical treatment for Tossy Ⅲacromioclavicular(AC)joint dislocations are relatively identical.Due to the post-traumatic ruptures of the acromioclavicular ligament and coracoclavicular(CC)ligament which are used to maintain stability of the joint,the clavicle moves backward and upward,and the upper arm and the scapula drops downward for the gravity of the upper arm and the influence of the sternocleidomastoid muscle.Since such complications as reduction difficulties,redislocation after external fixation,pressure ulcers of the skin,and so forth are particularly prone to occur in the conservative therapy,the operative treatment is more inclined to be adopted for the Tossy Ⅲ dislocation of the AC joint.With the single repair and fixation of the CC ligament,redislocation is likely to happen after implant removal because the ruptured ligaments healed as scar tissue.Therefore,this study uses an operative method of reconstructing and augmenting the CC ligament with LARS artificial ligament for the treatment of Tossy Ⅲ AC joint dislocation,and evaluates its clinical effect.Methods From November 2006 to July 2009,8 patients with acute AC joint dislocation of Tossy Ⅲ were admitted into our hospital.Five patients were male and 3 were female,and their ages ranged from 21 to 45.Sides:3 injuries were on the left and 5 were on the right.Seven patients suffered from falling on the ground,and 1 patient was inj ured in a traffic accident.All the patients were treated with LARS artificial ligaments to reconstruct the CC ligament.Constant score and VAS score were adopted in clinical evaluation.Zanca view of the bilateral AC joint and the axillary radiograph of the affected shoulder joint were employed for imaging evaluation.All the patients were simple Tossy Ⅲ dislocation of AC joint with no trauma of other parts and skin breakdown.Regular pre-operative examinations and evaluations were carried out after admission,and LARS artificial ligament was used to reconstruct the CC ligament.Surgeries of all the patients were performed under general anesthesia within 2 to 5 days after inj ury,and the operation time ranged from 60 to 90 minutes.After successful anesthesia,the patient lied on a beach chair position with the affected shoulder bolstered up.Attachment points of trapezoid ligament and conoid ligament are evaluated preoperatively through the length of clavicle among all the patients.The incision is made along the affected acromion and distal clavicle,curved downward to expose the clavicle and the tip of coracoid process.Find the ruptured CC ligament and then repair it with absorbable stiches by mattress-suture,leaving the reserved sutures unknotted.Then reconfirm the attachment point of CC ligament is on the location of coronal section,and if possible,the location can be identified by the exposure of CC ligament.Drill a hole separately with a diameter of 4.5 mm bit,and make sure that the drilling position is in the sagittal plane close to the front on the premise of intensity.Make the LARS artificial ligament pass through the root of coracoid with a drilling guide,and thread the two ends of ligament through the clavicular bone tunnel.After the confirmation of satisfactory reduction,tighten up the artificial ligament and fix the interference screws.Weave and knot the two sides of the ligament,suture with non-absorbent stitches and cut off the redundant part.Strain the absorbable suture on CC ligament and tie a knot.The routine anti-infection treatments were given and the affected arm was slung with scarf bandage.The patient was told to carry out functional activities of fingers and the forearm postoperatively.Active mobilization of the shoulder was initiated after 3 days and regular movements were in process without scarf bandage 3 weeks later.Such strenuous activities as physical exercise were forbidden within 3 months.Constant score and VAS score were adopted in clinical evaluation.Zanca view of the bilateral AC joint and the axillary radiograph of the affected shoulder joint were employed for imaging evaluation.Results All the patients were followed up for 5 to 40 months.Constant score of the affected arm increased from (59.3±6.9)preoperatively to (96.5±9.3)postoperatively (T=300,P < 0.05 ),and VAS score decreased from (5.4 ± 1.3 ) preoperatively to (0.7 ± 0.9 ) postoperatively (T=300,P<0.05).Zanca view of the bilateral AC joint revealed that 7 patients had an anatomical reduction,except for one patient with slight loss of reduction.No re-dislocation occurred.Two cases of CC ligament calcification and one case of AC joint degeneration were found,and no osteolysis around the interference screw was detected.No shift of the distal clavicle in the horizontal direction was found in the axial view,and neither was backing out of the screws,the clavicular fracture,or the coracoid fracture.Discussion AC joint is a non-typical ball-and-socket joint,the center of which is located between the AC joint and the CC ligament.The stability of the distal clavicle mainly depends on the integrity of CC ligament.The optimal method for dislocation of the AC joint is to reconstruct the CC ligament,which is decided by the anatomical characters of the AC joint.Otherwise, redislocation might still occur after the removal of the internal fixator even if the AC joint is reduced. Previous primary principle of the operation method was the repair of CC ligament with the fixation of AC joint at the same time.However,single repair of the ligament had a low healing rate,and the scar tissue of the ligament hardly bore the tension required for the early functional exercise.Hence,after a long period of recovery procedure,patients suffered from different degrees of functional incapacitation, which postponed their schedule of returning to work.Some scholars afterwards started using the method of ligament reconstruction to perform the surgery.Autografts and allografts are sources for ligament reconstruction. The process of necrosis, revascularization, cell multiplication, and ligamentization is needed for autogenous grafts,which will take around 1 year.Therefore,proper limitation of patient’s early activities is inconsistent with our original intentions of early training to reduce the loss of function.Laxity of grafts is likely to be observed during the late period with decreased stretching resistance,and still has difficulty in avoiding osteoarthritis eventually.With the development of the material technology subsequently,we start the operation of repair and reconstruction with the application of artificial ligament.Compared to autologous and allogeneic grafts, artificial ligament has obvious advantages:(1 )Less inj ury:The trauma is decreased since there is no need for the surgery to harvest tendons from his or her own body.(2 )Quick recovery:Artificial ligament has a certain degree of the mechanical strength without necessities of the process of necrosis, revascularization,cell multiplication,and ligamentization inside the body.Accordingly,the application of artificial ligaments shortens the recovery time with less medical resources and society costs.We adopt the French LARS polyester fiber ligament of bracket type as our surgical materials for this study.This kind of ligaments has features as follows:(1)Higher biocompatibility:The PET polyester fiber is identical with sutures and artificial blood vessels and has excellent biocompatibility,the free fiber inside which can induce the ingrowth of fibrous connective tissue of the human body itself.(2 ) Pass the “tension-bending-torsion”hybrid test:It may bear the pulling force of 5000 Newton.(3) Preserve the intraoperative remnant tissue of the ligament and keep the physiological proprioception. From the points above we can see that:The permanent-stent ligament we adopt had good histocompatibility and can provide excellent tensile resistance.The micropores of 30~50μm inside the fibers are suitable for the ingrowth of the autologous connective tissue,and can play the role of“support”,not only as physical remediation,but also with the function of the biological tissue engineering repair.This ligament can provide better early strength in the initial stage,and is able to withstand the intensity required by patients’early functional training.The ultimate intensity will be ensured with the ingrowth and restoration of the autologous tissue in the late stage.The restorative procedure is a kind of physiological reconstruction,which can also be applied for obsolete dislocations. Hence,the permanent-scaffold ligament is an effective method for the treatment of AC joint dislocations,especially the old dislocation.The key issue of the ligament reconstruction is how to determine the location and direction of drilling on the clavicle.Since it is ligament reconstruction,we consider that it is the most consistent with physiological features as the prosthetic ligament travels along the walking direction of the original one,which can maximally guarantee the ingrowth of the human tissue into the artificial ligament to achieve its physiological reconstruction.This prosthetic ligament has limitations as well.First,it is expensive,which restricts its extensive application in the current situation of China.Second,fixation of the ligament mainly relies on interference screws,and it is not suitable for the patients with osteoporosis.Once again,the obj ective of the use of artificial ligaments is to restore patients’preoperative function to the maximum extent.Therefore,artificial ligament is not most suitable for patients who have the loss of preoperative function or patients with not-so-high requirement for function.We consider that the technology of CC ligament reconstruction with LARS artificial ligament is a feasible method in the treatment of the AC joint dislocation.Such ligament can offer credible strength in the early period,which provides a preferable biomechanical environment for the primary healing of the CC ligament,and the merits of the ligament of bracket type reliably assure the preservation of the repair strength in the late stage.In addition,the advantage of artificial ligaments is unnecessary to remove implant by a second surgery,which decreases the patient suffering and financial burdens.Conclusions CC ligament reconstruction with the LARS artificial ligament can offer reliable early strength for AC joint,and it allows early functional training of patients.This enables patients to acquire better clinical outcome and less complication.
