肱骨远端骨性结构畸形的肘关节松解和阶梯治疗方案

Step therapy plan for stiff elbow associated with distal humeral bony structure deformity

目的探讨肘关节僵硬合并肱骨远端骨性结构畸形的分类及其阶梯治疗方案。方法纳入2008年1月至2019年6月北京积水潭医院收治且随访资料完整的91例肱骨远端骨性结构畸形的肘关节僵硬患者。其中左侧48例,右侧43例;术前屈肘60°~90°,平均79.34°±10.09°,伸肘30°~90°,平均54.40°±19.51°,屈伸活动范围0°~60°,平均24.95°±21.88°;前臂旋前0°~90°,平均81.43°±18.23°,旋后0°~90°,平均89.01°±9.44°,旋转活动范围0°~180°,平均170.44°±24.17°。将91例患者根据骨性结构畸形分为陷窝填塞、关节对合不匹配和关节面破坏三大类。其中陷窝填塞者58例,行桡骨头窝、冠突窝和鹰嘴窝加深再塑形治疗;关节对合不匹配者21例,行截骨内固定治疗;关节面破坏者12例,行真皮间隔成形术治疗。术后定期随访,了解患者的肘关节屈伸活动度、前臂旋转活动度、肘关节稳定性、疼痛及并发症发生情况等。结果91例患者随访8~88个月,平均(29.09±16.58)个月。末次随访时屈肘120°~140°,平均131.98°±8.06°,伸肘0°~30°,平均14.18°±11.55°,屈伸活动范围100°~140°,平均117.80°±12.72°;前臂旋前60°~90°,平均84.11°±7.01°,旋后60°~90°,平均89.67°±3.16°,旋转活动范围120°~180°,平均173.78°±8.69°。2例患者出现前外侧异位骨化,轻度影响屈肘活动,但无需特殊处理。1例间隔成形患者发生表浅的伤口感染,换药后好转。2例间隔成形患者术后出现轻度内外翻不稳定,未进一步处理。结论复杂的肱骨远端骨性畸形可分为陷窝填塞、关节对合不匹配和关节面破坏三大类,在软组织松解后按照“陷窝再塑形—截骨内固定—间隔成形”的阶梯治疗方案进行处理,可获得较好的疗效。

Objective The purpose of this study is to propose the classification of elbow stiffness with distal humeral bony structure deformity and the corresponding step treatment plan.Method From January 2008 to June 2019,91 cases of stiffness with distal humeral bony deformity were included in the study,including 48 left and 43 right.Before operation,the average elbow flexion was 79.34°±10.09°(60°-90°),the average elbow extension was 54.40°±19.51°(30°-90°),the average range of flexion and extension was 24.95°±21.88°(0°-60°),the average forearm pronation was 81.43°±18.23°(0°-90°),the average supination was 89.01°±9.44°(0°-90°),and the average range of rotation was 170.44°±24.17°(0°-180°).According to the deformity of bony structure,it can be classified into three categories:“fossa obstruction”,“joint incongruity”and“articular surface destruction”.In the first group“fossa obstruction”,58 patients underwent“fossa reconturing”of radial head fossa,coronoid fossa and olecranon fossa,in the second group,21 patients underwent“osteotomy and internal fixation”for“joint incongruity”,and in the third group,12 patients underwent“interpositional arthroplasty”for“articular surface destruction”.Postoperative follow-up included chief complaint,elbow flexion and extension range of motion,forearm rotation range of motion,elbow joint stability,pain,X-ray and complications.Result The average follow-up was 8-88 months,averaged(29.09±16.58)months.The average elbow flexion was 131.98°±8.06°(120°-140°),the average elbow extension was 14.18°±11.55°(0°-30°),the average flexion-extension range was 117.80°±12.72°(100°-140°),the average forearm pronation was 84.11°±7.01°(60°-90°),the average supination was 89.67°±3.16°(60°-90°),and the average rotation range was 173.78°±8.69°(120°-180°).Two patients had ectopic ossification,which slightly affected elbow flexion,but did not need to be treated.One case of interpositional arthroplasty developed superficial wound infection,which improved after dressing change.Two patients with interpositional arthroplasty had mild instability and need no further treatment.Conclusion Based on the different treatment methods,the complex types of bone deformity can be divided into three categories:“fossa obstrction”,“joint incongruity”and“articular surface destruction”.After soft tissue release,the treatment of bone deformity according to the“lacunar reconturing-osteotomy and internal fixation-interpositional arthroplasty”ladder treatment scheme can achieve better results.