重建外侧副韧带复合体治疗产瘫继发肘关节尺侧脱位的疗效

Primary result of surgical reconstruction of lateral collateral ligament complex in treatment of elbow joint ulnar dislocation secondary to obstetric palsy

目的探讨重建外侧副韧带复合体治疗产瘫后继发肘关节尺侧脱位的疗效。方法回顾分析2015年8月至2016年10月在北京积水潭医院接受手术治疗的5例产瘫后继发肘关节尺侧脱位患者的病历资料。年龄2～10岁,平均6.2岁。5例患者均有分娩性臂丛神经损伤史,体格检查示肘关节屈伸及前臂旋转活动受限,肘关节屈曲挛缩畸形。肘关节正、侧位X线示尺骨鹰嘴向后内侧脱位,与肱骨内上髁形成假关节。5例患者均经肘后"S"形切口松解尺骨鹰嘴与肱骨尺侧之间的粘连带及韧带,充分显露尺骨鹰嘴与肱骨内上髁形成的假关节。纵行切开肱三头肌桡侧缘,显露肱桡关节、环状韧带及桡侧副韧带。切断瘢痕化的桡侧副韧带及环状韧带,松解掌侧关节囊。将尺骨鹰嘴向桡侧移位,复位肘关节,用异体肌腱重建外侧副韧带复合体(环状韧带、桡侧副韧带及外侧尺幅韧带),观察肘关节的屈伸活动是否稳定。对于尺骨鹰嘴向尺侧明显倾斜者,需行楔形截骨钢板内固定。结果 5例患者术中完全复位肘关节,其中3例行尺骨鹰嘴楔形截骨钢板内固定。随访时间13～36个月,平均24.4个月。复查肘关节X线示肱尺关节位置正常。术前患者肘关节屈伸活动度40°～130°,平均88°,屈曲120°～140°,平均128°,伸直-10°～-80°,平均-40°;术后肘关节屈伸活动度50°～120°,平均92°,屈曲110°～130°,平均122°,伸直-10°～-60°,平均-30°。结论对于继发于产瘫的肘关节尺侧脱位患者,通过手术松解及重建外侧副韧带复合体可取得令人满意的疗效。

Objective To investigate the effect of surgical reconstruction of lateral collateral ligament complex in treatment of elbow joint ulnar dislocation secondary to obstetric palsy.Methods Five patients with elbow joint ulnar dislocation secondary to obstetric palsy after surgery were retrospectively enrolled between August 2015 and October 2016 in Beijing Jishuitan Hospital.The mean age was 6.2 years(range,2-10 years).All patients presented with limitation of elbow flexion and extension,forearm supination and pronation.Radiographs showed a posterior and medial dislocation of the radius and ulna on the humerus and a pseudarthrosis formed by the ulna and the medial epicondyle of humerus.All patients were performed surgery with"S"incision by posterior approach.Released the adhesion and ligaments on the ulnar side and fully exposed the pseudarthrosis formed by the ulna and the medial epicondyle of humerus.The radiocapitellar joint was exposed through longitudinal incision of the radial margin of triceps brachii.Scarring of the annular ligament and the radial collateral ligament were cut off.The elbow joint was reduced and the lateral collateral ligament complex including the annular ligament,radial collateral ligament and lateral collateral ulnar ligament was reconstructed with allogenic tendon to make sure the stability.The patient with marked ulnar deviation of olecranon was also underwent wedge osteotomy and plate internal fixation.Results Elbow reduction was achieved in 5 patients and 3 patients underwent wedge osteotomy.The mean follow-up duration was 24.4 months(range,13-36 months).The mean preoperative range of motion was 88°(range,40°-130°).The mean preoperative elbow flexion was 128°(range,120°-140°)and elbow extension was-40°(range,-10°--80°).There was no recurrent elbow dislocation.The mean postoperative range of motion was 92°(range,50°-120°).The mean postoperative elbow flexion was 122°(range,110°-130°)and elbow extension was-30°(range,-10°--60°).Conclusion For patients with obstetric palsy who presented with elbow flexion contracture,complicating elbow dislocation should be taken into consideration and surgical reconstruction of lateral collateral ligament complex could achieve good outcomes.