全关节镜下治疗肩锁关节脱位

Arthroscopic treatment of acromioclavicular joint dislocation

目的：探讨 Rockwood Ⅲ型急性肩锁关节脱位治疗方法,并比较两种喙锁韧带重建的临床疗效。方法回顾性分析自2010年1月至2013年6月收治的29例 Rockwood Ⅲ型急性肩锁关节脱位患者资料。经随机分组,其中16例在全关节镜下行自体半腱肌肌腱重建喙锁、肩锁韧带(自体韧带组),13例在全关节镜下行双 Endobutton 钢板结合爱惜帮线重建喙锁韧带(爱惜帮线组)。比较两组患者末次随访时的 Constant 评分及 CC-Dist 值的改善率。结果29例患者术后获得1~4年(平均2.5年)随访。末次随访时自体韧带组和爱惜帮线组患者 Constant 评分改善率分别为47.31%和47.01%,差异无统计学意义(t =0.136,P =0.893)。自体韧带组和爱惜帮线组患者 CC-Dist 值改善率分别为38.51%和43.16%,两组比较差异有统计学意义(t =-2.895,P =0.007)。结论全关节镜下行自体半腱肌肌腱重建喙锁、肩锁韧带和双 Endobutton 钢板结合爱惜帮线重建喙锁韧带均能有效改善肩关节功能,两者各有优势。

Background The dislocation of acromioclavicular joint is a common injury clinically.This study is to investigate the treatment of acute acromioclavicular joint dislocation(Rockwood typeⅢ)and compare the clinical effect of two different ways of coracoclavicular ligament reconstruction.Methods We select the patients with fresh Rockwood type Ⅲ to V dislocation of acromioclavicular joint from January 2008 to June 2013.After randomization,16 cases received the reconstruction of coracoclavicular and acromioclavicular ligament arthroscopically with semitendinosus tendon(autogenous group).Among them,12 were males and 4 were females,aged 16-62 years old,the average age is 39.8years old.They were followed up for 9-39 months,the average follow-up was25.6months;13cases underwent the reconstruction of coracoclavicular ligament with the double Endobutton plate and Ethibond suture(Ethibond suture group),including 9cases of male,4cases of female,aging from 19 to 57years old,the average age is 36.5years old,were followed up for 12-35 months with a mean follow-up of 19.6 months.The reason of injury:12cases of traffic injuries,9cases of sports injury,4cases of fall,bruise in 2cases and 2cases of other injuries.The time between injury to operation was 3-11 d,averagely 6d.8patients were accompanied by SLAP injury of shoulder joint(5cases of autologous ligament group,3cases of Ethibond suture group),3patients were accompanied by rotator cuff injury(1cases of autologous ligament group,2cases of Ethibond suture group).2patients were combined with glenohumeral joint cartilage injury(1case of autologous ligament group 1case,1case of love help group),2patients were combined with Bankart injury(both in autologous ligament group),1 patient was combined with glenoid fracture(Ethibond suture group).The age,sex,cause of injury,injury side and time from getting injured to operation of the two groups are without significant differences(P >0.05).Autologous ligament group arthroscopic semitendinosus tendon reconstruction of coracoclavicular ligament coracoclavicular ligament.All patients underwent operation under general anesthesia with endotracheal intubation.Patients were placed at 75°beach chair position.Bony landmarks were marked.The ipsilateral semitendinosus tendon was harvested first.Glenohumeral examination was first done through posterior viewing portal.Then the under surface of coracoid was exposed by shaver.Then establish the bone tunnel of clavicle,basal part of coracoid and acromial,transplant and fix the grafted tendon,wash the wound,suture the wound layer by layer.Ethibond suture group arthroscopic double Endobutton plate and Ethibond reconstruction of coracoclavicular ligament.The arthroscopic explosion and tunnel reconstruction is the same with the group mentioned above,use double Endobutton plate and Ethibond suture to reconstruct coracoclavicular ligament.Make sure the button completely stuck in the upper surface of the coracoid clavicle and underlying surface,abduct the shoulder joint,press the clavicle to get the acromioclavicular joint reduced,tighten Ethibond tail and fix the knot,close the wound.Two groups of patients were immobilized by neck wrist sling for 6weeks.The immediate postoperative activity of elbow and wrist joint were demanded,shoulder joint passive exercise beginning at 2weeks,then start the shoulder joint initiative and resistance strength training after 6to 8 weeks.After 6 months the patients were allowed to engage in some contact sports activities.Through clinical examination,X-ray and CC-Dist measurements,then calculate the improvement rate,(CC-Dist value:the vertical distance between coracoid plane and the subclavian plane on the shoulder joint radiograph)and the Constant score was used to evaluate the curative effect.The Constant score,composed of the following 8parts:the shoulder pain(15points),daily activities(20points),range of motion of the shoulder joint(40points)(external rotation,internal rotation,abduction,flexion,each 10points),strength test(25points),wherein the objective score accounted for 65%,subjective scores accounted for 35%.The higher total score is,the better function the shoulder joint has.Excellent:≥90;good:80~89;general:70-79;poor≤70.All the data were analysed by SPSS 19.0statistical software.The imaging measurements,postoperative pain and functional scores were compared for the treatment group.Use t test orχ2 test data to analysis statistically,the difference was statistically significant when P <0.05.Results 29 patients obtained a 1to 4years(mean 2.5years)follow-up.At last the improvement rate of the Constant score of autologous ligament group and Ethibond suture group were 47.31% and47.01%,with no significant difference between them(t=0.136,P =0.893).The improvement rate of CC-Dist value of the Autologous ligament group and Ethibond suture group were 38.51% and43.16%,there was an significant difference between the two groups(t =-2.895,P =0.007).Postoperative complications:two patients had a slight loss of reduction of the acromioclavicular joint.The autograft ligament group is more severe than the Ethibond suture group.Among them there were4 cases of the autologous ligament group,3cases of the Ethibond suture group.The 4patients of the autologous ligament group were satisfied with the appearance and function.The 3patients were not significantly abnormal,but 2patients complained a tightness of the shoulder and a soreness discomfort of the upper limbs.Conclusions The arthroscopic reconstruction of coracoclavicular and acromioclavicular ligament with semitendinosus tendon and the reconstruction with double EndoButton plate and Ethibond suture could improve the function of the shoulder joint,both the two have different advantages.