联合腱与喙肩韧带双束重建喙锁韧带修复RockwoodⅢ型肩锁关节脱位：解剖学及临床试验验证

摘要

背景：Rockwood Ⅲ型肩锁关节脱位的修复方法繁多，其中大部分通过各种内固定物(如锁骨钩钢板钢板、螺钉、克氏针等)来达到肩锁关节的初次稳定性和复位。但术中内固定物对肩锁关节不同程度的占位及损伤，以及术后取出内固定后复位丢失均较为常见。n　　目的：应用联合腱与喙肩韧带双束重建喙锁韧带修复 RockwoodⅢ型肩锁关节脱位，并通过尸体解剖提供理论基础，临床病例随访分析其修复效果。n　　方法：①尸体解剖形态学研究：于2012年9至11月在新疆医科大学解剖教研室行成人肩部尸体解剖共46例，观察肩锁关节解剖形态并测量相关骨性标志和韧带的形态学参数。②临床病例分析：对2012至2014年采用联合腱外侧半肌腱与喙肩韧带内侧半肌腱双束共同重建喙锁韧带修复RockwoodⅢ型肩锁关节脱位的11例患者进行随访。最终随访时应用放射学评估术后肩锁关节恢复情况，并采用美国肩肘外科协会评分、Constant-Murley肩关节功能评定法、美国加州大学洛杉矶分校评分系统及肩关节简明测试问卷评价患者肩关节功能，目测类比评分法评价疼痛情况。n　　结果与结论：①尸体解剖形态学研究结果：试验获得了肩锁关节及其周围组织、肌皮神经较为详细的形态学参数，为该部位手术提供了解剖学资料。②临床病例分析结果：11例RockwoodⅢ型患者行联合腱外侧半肌腱与喙肩韧带内侧半肌腱双束共同重建喙锁韧带治疗肩锁关节脱位，随访2-24个月，平均美国肩肘外科协会评分为92.3分，平均Constant-Murley肩关节功能评分为90.4分，平均美国加州大学洛杉矶分校评分31.6分，平均目测类比评分1.4分，平均肩关节简明测试问卷肯定答案为8个，总体优良率为91%(10/11)。1例患者修复结果较差。课题通过解剖重建肩锁关节的静态稳定性结构(如喙锁韧带)和动态稳定性结构(如关节囊、斜方肌和三角肌)实现了肩锁关节的解剖复位。总而言之，联合腱与喙肩韧带双束重建喙锁韧带修复RockwoodⅢ型肩锁关节脱位是一种有效的修复方法。%BACKGROUND:There are many surgical methods for treatment of acromioclavicular joint dislocation. Through various internal fixation materials (such as hook plate, screws, K-wire, etc.), we can achieve the initial stability and restoration of the acromioclavicular joint. But these internal fixators can cause varying degrees of occupancy and damage to the acromioclavicular joint, and the joint reduction often miss after removal of the internal fixators. n OBJECTIVE:To use conjoined tendon and coracoacromial ligament transfer for coracoclavicular ligament reconstruction in the repair of RockwoodIII acromioclavicular joint dislocation, to provide the theoretical foundation through the autopsy, and to analyze the clinical efficacy based on clinical fol ow-up results. n METHODS:(1) Autopsy morphology research:From September 2012 to November 2012, total y 46 adult cadaveric human shoulders were dissected in the Department of Anatomy, Xinjiang Medical University. The anatomical morphology of the acromioclavicular joint was observed and the relevant morphological parameters of the ligament were measured. (2) Case analysis:Eleven patients who received coracoclavicular ligament reconstruction with the lateral half of the conjoined tendon and medial half of the coracoacromial ligament for repair of RockwoodIII acromioclavicular joint dislocation from 2012 to 2014 were fol owed up. At the last fol ow-up visit, postoperative radiographic evaluation was done for the acromioclavicular joint recovery, and the American Shoulder and Elbow Surgeons (ASES) scores, Constant-Murley shoulder scores and UCLA shoulder scores, Simple Shoulder Test Form were adopted to evaluate the shoulder functions;visual analog scale scores were used for pain evaluation. n RESULTS AND CONCLUSION:(1) Results of autopsy morphology research:Detail morphology data of the acromioclavicular joint, its surrounding tissues and musculocutaneous nerve were given, which provide the anatomical data for operation at this region. (2) Result of case analysis:After 2-24 months of fol ow-up, the mean ASES score was 92.3, the mean Coustant-Murley score was 90.4, the mean UCLA shoulder score was 31.6, and the mean visual analog scale score for pain was 1.4. The number of positive answer to the Simple Shoulder Test Form was 6, and the overal excel ent rate was 90.9%(10/11). Poor results were found in one case. Through the anatomical reconstruction of the static stability (such as coracoclavicular ligaments) and dynamic stability (such as joint capsule, trapezius muscle and deltoid muscle) of the acromioclavicular joint, the anatomical reduction of the acromioclavicular joint can be implemented. In a word, the double-beam coracoclavicular ligament reconstruction using the conjoined tendon and coracoacromial ligament is an effective method to repair RockwoodIII acromioclavicular joint dislocation.