合并肘关节内翻或外翻的肘管综合征的临床疗效探讨

Clinical efficacy of combined wedge osteotomy and ulnar nerve transposition for the treatment of cubital tunnel syndrome associated with cubitus varus or valgus

目的：探讨肱骨髁上楔型截骨联合尺神经松解前置术治疗合并肘管综合征的成人肘外翻或内翻畸形的手术指征、手术技术和疗效。方法我科于2004年2月至2013年8月，对12例合并有肘管综合征的成人肘外翻或内翻畸形患者进行肱骨髁上楔形截骨和肘部尺神经松解前置手术治疗。本组患者中肘外翻畸形9例，提携角(29.5±4.2)°(24°~38°)，其中7例伴有肱骨外髁骨不连。肘内翻畸形3例，内翻角(25.3±9.1)°(17°~35°)。12例肘关节均无法达到完全伸直，伸肘(24.8±7.9)°(16°~40°)，屈肘(116.9±11)°(100°~143°)。所有患者均有肘部尺神经卡压的症状，手部握力(17.4±6.2)kg(9~30 kg)，手部尺神经支配区两点辨别觉(7.3±3.6)mm(3~14 mm)。依据Dellon推荐的分期标准：中度3例、重度9例。结果术后随访时间为8~35个月，平均24个月。肱骨髁上截骨平均愈合时间为15.4周，术后平均提携角为11.3°。术后肘关节伸肘(20.8±9.9)°(10°~42°)，屈肘(115.2±11.4)°(95°~140°)，手部握力(23.7±8.2)kg(13~42 kg)，手部尺神经支配区皮肤两点辨别觉(4.3±1.9)mm(2~8 mm)，平均DASH 评分由术前的35分降为17分。结论肱骨髁上楔形截骨联合尺神经松解前置手术不仅能纠正肘关节的内翻或外翻畸形，而且可以使长期被牵拉或不稳定而麻痹的尺神经功能获得改善，因此是治疗成人肘外翻或内翻畸形合并肘管综合征患者的良好选择。

Background The aim of this study is to evaluate the clinical efficacy of combined wedge osteotomy and ulnar nerve transposition for the treatment of cubital tunnel syndrome associated with cubitus varus or valgus.Patients with cubitus varus or cubitus valgus are subject to cubital tunnel syndrome.The consequent symptoms of ulnar nerve palsy such as hand muscle atrophy,limitation in meticulous motions and paresthesia can seriously affect hand function.The anterior transposition of the ulnar nerve alone is less effective for such patients.Methods We performed supracondylar wedge osteotomy of the humerus combined with anterior transposition of the ulnar nerve in twelve adult patients with cubitus valgus or cubitus varus with cubital tunnel syndrome from February 2004 to August 2013.This group of patients included nine cases of cubitus valgus with the carrying angle of29.5±4.2(24~38)degrees,in which seven cases were complicated with nonunion of the lateral humeral condyle.There also included three cases of cubitus varus,with the varus angle of 25.3±9.1(17~35)degrees.In all of the cases,patients were unable to reach full elbow extension,with the elbow extension of 24.8±7.9(16~40)degrees and elbow flexion of 116.9±11(100~143)degrees.They all had symptoms of ulnar nerve entrapment,with the hand-grip strength of 17.4±6.2(9~30)kg and two-point discrimination in ulnar nerve area of 7.3±3.6(3~14)mm.They were divided into moderate cases(n =3)and severe cases(n =9)according to the classification criteria recommended by Dellon.Operating techniques:Arc longitudinal incisions were performed across the posterior elbow,with the length of about 14 cm.First,the tissue was dissected by layers into the sulcus to explore ulnar nerve.The ulnar nerve ranging from 7cm above to 5cm below the medial epicondyle were explored and retracted with rubber strips.Second,a longitudinal incision was made on the muscle fiber in the central axis of the dorsal triceps muscle to expose the distal humerus.The distal osteotomy line was set approximately 2cm above the dorsal elbow capsule at the attached site,which should be parallel to the horizontal line of elbow.The angle of wedge osteotomy for cubitus valgus was equal to the difference between the measured ipsilateral and contralateral carrying angles,and the bottom of bone block was located medial side.The angle of wedge osteotomy for cubitus varus was equal to the sum of measured varus angle and ipsilateral carrying angle,and the bottom of bone block was located outside.After correction of the deformity,temporary fixation with Kirschner wires was performed.Then the plate was used for the final fixation at the osteotomy site.It was noted that if the plate was placed in the inferior lateral humerus,the radial nerve should be protected.Finally,the external neurolysis and subcutaneous anterior transposition of the ulnar nerve were performed under the microscope.Results The postoperative follow-up time ranged from 8to 35 months,with the average of 24 months.All patients underwent supracondylar wedge osteotomy of the humerus achieved bony union,with the healing time from 13 to 18weeks,with an average of 15.4weeks.The postoperative carrying angle was 5~13degrees,with the average of 11.3degrees.The postoperative elbow extension was 20.8±9.9(10~42)degrees and elbow flexion was 115.2±11.4(95~140)degrees.The hand-grip strength was 23.7±8.2(13~42)kg.The two-point discrimination in ulnar nerve area was 4.3±1.9(2~8)mm.Among seven patients with claw hand deformity prior to surgery,four cases of deformities were completely disappeared and three cases of deformities were relieved.Among nine patients with hand muscle atrophy prior to surgery,three cases were basically recovered in the muscle shape after 18 months and the remaining six cases were mildly improved.The mean DASH score was dropped from preoperative 35 points to postoperative 17 points.DiscussionSupracondylar wedge osteotomy of the humerus combined with anterior transposition of the ulnar nerve can not only correct varus or valgus deformity of the elbow,but also improve the ulnar nerve paralysis caused by long-term traction or instability due to elbow deformity.This is a good choice for treatment of adult patients with cubitus varus or cubitus valgus complicated with cubital tunnel syndrome.