桡骨远端髓芯减压结合腕关节镜探查诊治复杂慢性腕关节痛的临床疗效观察

Clinical observation on the treatment of complex chronic wrist pain with distal radius core decompression combined with wrist arthroscopy exploration

目的在桡骨远端髓芯减压术前进行腕关节镜探查,镜下检视腕关节内是否存在引起疼痛的其他病因并及时修复,提升髓芯减压手术治疗腕关节疼痛的整体疗效。方法自2019年7月至2022年12月,共有6例患者接受本治疗方案,6例术前MRI均提示患侧桡骨远端及舟、月骨存在骨髓水肿,1例合并ⅡB期月骨无菌性坏死,3例三角纤维软骨复合体(TFCC)损伤。6例患者先行关节镜检查,再行桡骨远端髓芯减压术,随访疗效,通过视觉模拟量表(VAS评分)评估术后疼痛改善程度;术前术后腕关节背伸、掌屈、尺偏、桡偏活动度(ROM)对比评估腕关节功能改善程度;术前术后的腕关节X线/CT/MR进行影像学对比;随访术后是否出现骨窗不愈合、桡骨远端骨折、神经痛等并发症。结果本研究对6例病程均超过6个月的中重度腕关节痛患者(术前VAS评分范围7~8分)进行桡骨远端髓芯减压术联合腕关节镜探查,关节镜下见TFCC 2A型损伤1例,2B型1例,均镜下行尺侧韧带修复;1B型损伤1例,行关节腔清理;2B型损伤2例,但因缺损过大未行修复;1例患者镜下并未发现明显病变。患者平均年龄为36岁(21~55岁),最短随访时间12个月(随访时间分别为18、16、12、12、14、12个月),最后一次随访5例患者术后疼痛明显缓解(术后VAS评分范围0~3分),1例患者缓解不明显(术后VAS评分为5分)。结论利用腕关节镜对腕部原发病变进行探查和(或)修复,再行桡骨远端髓芯减压术,去除腕关节的原发病因同时打破"高压-疼痛"的恶性循环,可使多数患者腕部慢性疼痛缓解,为慢性腕关节疼痛患者提供一种治疗选择。

Objective To improve the overall efficacy of core decompression surgery for wrist pain,before the distal radius core decompression,the wrist arthroscopy should be performed to check whether there are other causes of pain in the wrist joint and repair them in time.Methods From July 2019 to December 2022,a total of 6 patients received this treatment scheme.The preoperative MRI results showed that there was bone marrow edema in the distal radius,scaphoid and lunate bone of the affected side.Among them,1 case was complicated with stageⅡB Kienböck′s disease,and 3 cases had triangular fibrocartilage complex(TFCC)injury.Six patients were examined by arthroscopy before the distal radius core decompression.In the efficacy follow-up,the degree of postoperative pain improvement was evaluated by visual analogue scale(VAS),the degree of improvement in wrist joint function was evaluated by comparing the range of motion(ROM)of wrist joint dorsiflexion,palmar flexion,ulnar deviation,and radial deviation before and after surgery,the X-ray/CT/MR imaging results of wrist joint was compared before and after surgery.Whether there were complications such as nonunion of bone window,fracture of distal radius,neuralgia was also followed up.Results In this study,6 patients with moderate to severe wrist pain whose course of disease was more than 6 months(preoperative VAS ranged from 7 to 8 points)were treated with the distal radius core decompression combined with wrist arthroscopy exploration.Under Arthroscopy,1 case of TFCC type 2A injury and 1 case of type 2B injury were seen,and ulnar ligament repair was performed under arthroscopy.One case of type 1B injury underwent joint cavity cleaning.There were 2 cases of type 2B injury,but the defect was too large and not repaired.No obvious lesions were found under the arthroscopy in one patient.The average age of the patient was 36 years(ranged,21 to 55 years old),and the shortest follow-up time was 12 months(follow-up time was 18,16,12,12,14,and 12 months respectively).At the last follow-up,5 patients showed significant postoperative pain relief(postoperative VAS ranged from 0 to 3 points),while 1 patient did not show significant relief(postoperative VAS was 5 points).Conclusion The use of wrist arthroscopy to explore and(or)repair the primary lesions of the wrist,and then perform the distal radius core decompression,to remove the primary cause of the wrist joint and break the vicious circle of"high pressure pain",can alleviate most patients′wrist chronic pain,and provide a treatment option for patients with chronic wrist pain.