内外侧联合入路治疗创伤性肘关节僵硬

Open release for post-traumatic stiff elbow with combined medial-lateral approaches

目的：探讨内外侧联合入路肘部松解治疗创伤性肘关节僵硬的手术技巧及临床效果。方法回顾性分析自2009年1月至2014年1月山东省立医院采用内外侧联合入路肘部松解治疗的创伤性肘关节僵硬患者42例,其中男23例、女19例,年龄20～63岁,平均为36.5岁。原始损伤：肱骨髁上骨折5例,肱骨内侧髁骨折3例,肱骨外侧髁骨折4例,髁间骨折6例,尺骨鹰嘴骨折6例,冠状突骨折2例,桡骨小头骨折10例,单纯肘关节脱位4例,不伴有骨折或脱位的软组织损伤2例。手术方法：采用静脉全身麻醉或臂丛麻醉,肘关节内外侧联合切口,彻底松解,25例加用肘关节铰链支架,术后口服消炎痛25 mg,1天3次,持续6周,第2天即开始功能锻炼,8～12周去除外固定架。结果40例患者获得随访,随访时间12～36个月,平均16个月。肘关节屈伸活动度从术前平均36°提高到术后最近复查的105°,肘部功能根据 Mayo 评分由术前平均50分增加到87分,患者手术前后的关节功能相比,差异有统计学意义（P 〈0.05）。结论内外侧联合入路可以彻底切除影响肘关节活动的骨赘、瘢痕、关节囊以及部分韧带,松解关节,加用肘关节铰链支架可以稳定肘关节,增加肘关节间隙,有助于早期活动及功能锻炼,从而获得良好临床效果。

Background Elbow stiffness seriously affects patients′daily activities and trauma is the main cause of elbow stiffness.The therapeutic goal of this condition is to get a painless,well-functioned and stable elbow.With in-depth studies in biomechanics of the elbow,improvement of surgical approaches and surgical instrument, and standardization of postoperative rehabilitation protocols,surgical release has become a relatively good choice for elbow stiffness after failed conservative therapies.Due to the complex causes of elbow stiffness,surgical release methods also vary.How to choose an appropriate surgical approach for improved surgical results is worthy of further exploration.We used combined medial and lateral surgical approach to perform surgical release of traumatic elbow stiffness,and applied hinged external fixator in patients with postoperative elbow instability.With proper postoperative exercise,patients achieved satisfactory results,as reported below.Methods Our hospital treated 42 cases of traumatic elbow stiffness patients with combined medial and lateral surgical approach from January 2009 to January 2014,including 23 males and 1 9 females,aged 20-63 years old,with an average age of 36.5 years old.Primary injury：5 cases of supracondylar fracture,3 cases of medial humeral condyle fracture,4 cases of lateral humeral condyle fracture,6 cases of intercondylar fracture,6 cases of olecranon fracture,2 cases of coronoid process fracture,10 cases of radial head fracture,4 cases of simple elbow dislocation,and 2 cases of soft tissue injury without fracture or dislocation.All fractures were clinically healed,but elbow stiffness＆amp;nbsp;was not improved after functional exercise,physical therapy and other conservative treatment.There were different degrees of elbow pain,seriously affecting daily life of the patients.Average time from trauma to surgical release was 1 6 months （6-37 months）.Surgical methods：all patients received combined medial and lateral approach.Lateral approach：cut at 4-5 cm above the lateral epicondyle, extend down the incision by 3-4 cm,peel the triceps back,release adhesions between the triceps and humeral shaft,clean scar tissues and osteophytes within the olecranon fossa,then peel brachioradialis and origination of radial extensor carpi off the lateral epicondyle,retract the brachioradialis together with radial nerve medially to expose the anterior joint capsule,protect the lateral collateral ligament bundle,cut joint capsule towards the medial side and remove the lateral portion,clean the capitulum radii and coronoid fossa,remove osteophytes on the ulna coronoid process,use progressive external force to gradually restore maximal elbow flexion.Don′t force flexion and extension if restoration is ineffective,add the medial approach for further release.Medial approach：lift the front half of brachial muscle and pronator teres muscle,lift the medial portion of triceps from back of the humerus,isolate and protect the ulnar nerve,retain the anterior bundle of the medial collateral ligament in order to avoid valgus instability,remove the remaining medial collateral ligament along with part of the joint capsule.Isolate flexor and pronator teres under periosteum,remove medial coronoid osteophytes and contracted anterior joint capsule,improve elbow flexion,then separate humeral insertion of triceps to reveal posterior elbow and olecranon fossa,clean foreign ossification tissues,remove scar tissue, posterior joint capsule and olecranon osteophytes, and improve elbow extension.Through this combined medial and lateral approach,both anterior and posterior sides of the brachial ulnar joint and brachioradial joint can be optimally exposed and released,and the ulnar nerve can be placed anteriorly. After the release,place drainage tube and suture layer by layer.If it is found during the surgery that elbow joint space is too narrow,or surgery release affects stability of the elbow,proper phase I repair of ligament should be done,and hinged external fixator should be added.Total of 25 cases in this study used hinged external fixator.At forearm neutral position,the external fixator is placed lateral to humerus and posterior to ulna.The rotational center of the elbow was determined by intraoperative C-arm X-ray, then vertically penetrates the positioning guide pin of the external fixator into the rotational center as the rotational axis,pierce at slight proximal end of the rotational center so that up-shifting of the center with release of stiff elbow is taken into consideration,place the external fixator at the rotational axis,nail 2 bracket screws each at the humeral and ulnar side,usually nail the distal screw followed by the proximal screw,keep the screws at the same plane as and parallel to the rotational axis,tighten the retaining clips,examine and ensure good flexion and extension activities of the elbow,and lastly remove the positioning guide pin at the rotational axis.Postoperative treatment：request the patient to move the elbow actively at the 2nd day postoperatively,1-2 times elbow flexion and extension per day,move the elbow at the maximal range that could be obtained during the surgery,gradually increase frequency of exercise according to tolerance of the patients.Patients who did not receive external fixator may perform exercise with assistance of CPM,2 times per day at morning and evening,for duration of 0.5-1 h each,gradually increase exercise time.Patients who received hinged external fixator can alternately fix the elbow at maximal flexion and extension at daytime at an 2 h interval,set to functional position at evening time,remove the external fixator after 8-12 weeks,taking 25 mg indomethacin,3 times a day for 4-6 weeks after the surgery.Evaluation criteria：measure elbow flexion and extension and forearm rotation of the patients before and after the surgery to assess elbow function of the patients.Using Mayo elbow performance score to assess four aspects of the efficacy including elbow pain,range of motion （ROM）,stability and daily life ability. Out of 100 points,excellent is ≥90,good is 75-89,acceptable is 60-74 and poor is 〈60.Statistical analysis：SPSS 13.0 software was used.Measurement data were shown as x- ± s .Comparison of preoperative and postoperative scores used t test.P 〈 0.05 was considered statistically significant. Results Forty patients were followed up for 12-36 months, with an average of 1 6 months. Comparison of preoperative and postoperative elbow function was shown in Table 2.The preoperative＆amp;nbsp;ROM for elbow flexion and extension （36.21 ±5.32 ）° was improved to postoperative ROM of （105.83± 1 1.52 ）°.The difference was statistically significant （P 〈 0.05 ）.Forearm rotation range was improved from the preoperative average of （95.67 ± 13.73 ）° to （135.40 ± 1 5.84 ）° after the surgery.The Mayo elbow performance score was improved from preoperative score of （49.46±8.62） to postoperative score of （87.29 ± 12.94）.The difference was statistically significant （P 〈 0.05 ）. Preoperative Mayo elbow performance score：excellent in 0 cases,good in 4 cases,acceptable in 1 5 cases and poor in 21 cases;postoperative Mayo elbow score：excellent in 12 cases,good in 1 9 cases, acceptable in 9 cases and poor in 0 case.Follow-up did not find any cases of elbow instability.Two patients had brief ulnar nerve palsy after the surgery,but their symptoms disappeared two weeks after the surgery.One patient had radial nerve palsy, and symptoms disappeared after treatment by neurotrophic drugs and rehabilitation exercises for 5 months.Conclusions Combined medial and lateral approach can completely resect osteophytes,scar,joint capsule and some ligaments that affect elbow activities and release the joint.Addition of hinged external fixator can stabilize the elbow, increase the articular space and thus help early activity and functional training,leading to good clinical results.