腕关节镜治疗舟骨骨折不愈合进行性塌陷的效果

Application of wrist arthroscopy in treating scaphoid nonunion advanced collapse

目的探讨腕关节镜下治疗舟骨骨折不愈合进行性塌陷（SNAC）的临床疗效。方法采用回顾性病例系列研究分析2011年3月-2016年1月收治的15例舟骨腰部骨折SNAC患者的临床资料，其中男12例，女3例；年龄26—43岁，平均32岁。右腕9例，左腕6例。受伤至手术时间14～72个月，平均18个月。腕关节镜下检查评估腕关节炎累及的范围：SNACI期9例，Ⅱ期4例，Ⅲ期2例。对Ⅰ期患者，采用腕关节镜辅助下桡骨茎突切除，舟骨硬化骨去除，取髂骨植骨内固定术；对Ⅱ期、Ⅲ期患者，采用腕关节镜下摘除大部分舟骨，头状骨与月骨融合固定。记录骨折及融合头月关节愈合时间、术前和末次随访时视觉模拟评分（VAS）、关节活动度、握力；末次随访采用改良Mayo腕关节功能评分评估患者腕关节功能。结果患者均获随访9～23个月，平均14个月。患者均Ⅰ期骨性愈合，SNACI期患者平均骨折愈合时间11．7周，Ⅱ期、Ⅲ期患者头月关节融合平均骨性愈合时间11周。VAS由术前（5．9±0．8）分降至（1．6±0．9）分；腕关节掌屈、背伸、桡偏、尺偏分别由术前的（38．7±6．3）°、（28．6±11．2）°、（19．8±1．4）°、（22．7±5．7）°提高至（54．1±5．8）°、（43．3±9．3）°、（22．0±1．9）°、（30．3±4．3）°；握力由术前（10．7±2．4）kg提高至（15．0±1．9）kg（P均〈0．05）。改良Mayo腕关节功能评分由术前的（57．9±7．3）分提高至（84．5±6．9）分（P〈0．05），其中优1例，良9例，可5例。结论对于SNAC患者，需要通过腕关节镜下评估明确分期，对Ⅰ期患者行腕关节镜下舟骨植骨，对Ⅱ期、Ⅲ期患者采用腕关节镜下摘除大部分舟骨，头状骨与月骨融合固定，可促进骨折愈合，减轻疼痛，改善腕关节功能。

Objective To investigate the clinical effect of wrist arthroscopy in the treatment of scaphoid nonunion advanced collapse （SNAC）. Methods A retrospective case series study was performed on the clinical data of 15 SNAC patients admitted from March 2011 to January 2016. There were 12 males and three females, with a mean age of 32 years （range, 26-43 years）. There were nine cases of right wrist injury and six cases of left wrist injury. The injury duration was 14-72 months, with an average of 18 months. According to the evaluation of the extent of wrist joint inflammation involvement under wrist arthroscopy, there were nine cases at SNAC Ⅰ stage, four at stage Ⅱ, and two at stage Ⅲ. Stage Ⅰ patients underwent wrist arthroscopy assisted radius styloid process resection, scaphoid sclerosis bone removal, and iliac bone grafting and internal fixation. Stage Ⅱ and Ⅲ patients underwent wrist arthroscopy assisted removal of most of the scaphoid and fusion fixation of skull bone and lunate bone. Joint healing time in the first month of fracture and fusion, visual analogue score （VAS） before operation and at the last follow up, joint mobility, and grip strength were recorded. Wrist function was evaluated by modified Mayo wrist function score at the last follow up. Results The patients were followed up for 9-23 months, with an average of 14 months. All cases were seen primary bone healing. The mean time of fracture healing was 11.7 weeks in stage Ⅰ SNAC patients and the mean healing time was 11 weeks in stage Ⅱ and Ⅲ patients in the first month of joint fusion. VAS decreased from （ 5.9 ± 0.8 ） points to （ 1.6 ± 0.9） points. Range of motion of the wrist including the flexion/extension arc and the radial/ulnar deviation arc increased respectively from preoperative （38.7 ± 6.3） °, （28.6 ± 11.2）° , （ 19.8 ±1.4） ° and （22.7±5.7） ° to postoperative （54.1 ±5.8）°, （43.3±9.3）°, （22.0±1.9） ° and （30.3 ± 4.3）° . Grip strength was improved from preoperative （ 10.7 ± 2.4） kg to postoperative （ 15.0 ± 1.9） kg （ all P 〈 0.05 ）. The modified Mayo wrist score was increased from preoperative （ 57.9 ± 7.3 ） points to postoperative （84.5 ± 6.9） points （P 〈 0. 05 ）. According to modified Mayo wrist scores, the result was excellent in one case, good in nine cases and fair in five. Conclusions For patients with SNAC, it is necessary to evaluate the staging under wrist arthroseopy. Arthroscopy assisted scaphoid bone grafting can be applied to stage Ⅰ patients. For stage Ⅱand Ⅲ patients, wrist arthroscopy-assisted removal of most of the scaphoid and fusion fixation of skull bone and lunate bone is helpful to facilitate bone healing, relieve pain, and improve function.