尺骨“Z”形缩短截骨联合腕关节镜下三角纤维软骨复合体深层修复治疗尺骨撞击综合征伴中度以上下尺桡关节不稳定的疗效

Efficacy of ulnar Z‑shaped shortening osteotomy combined with arthroscopic deep repair of the triangular fibrocartilage complex in the treatment of ulnar impaction syndrome with moderate or severe distal radioulnar joint instability

目的比较尺骨“Z”形缩短截骨联合腕关节镜下缝线锚钉三角纤维软骨复合体(TFCC)深层修复与单纯尺骨“Z”形缩短截骨治疗尺骨撞击综合征伴中度以上下尺桡关节不稳定的疗效。方法采用回顾性队列研究分析2016年1月至2023年6月青岛大学附属医院收治的30例尺骨撞击综合征伴中度以上下尺桡关节不稳定患者的临床资料,其中男16例,女14例;年龄27~58岁[(42.4±9.9)岁]。患者均为TFCCⅠB型损伤并累及TFCC深层,存在尺骨正变异。15例采用单纯尺骨“Z”形缩短截骨治疗(单纯截骨组),15例采用尺骨“Z”形缩短截骨联合腕关节镜下缝线锚钉TFCC深层修复治疗(截骨联合修复组)。比较两组手术时间、术中出血量、尺骨截骨长度;术前,术后6、12个月及末次随访时前臂旋转度、尺桡偏角、掌背屈角、握力、视觉模拟评分(VAS)、患者自评腕关节功能状况(PRWE)评分、改良Mayo腕关节评分和上肢功能障碍评定量表(DASH)评分;术后并发症发生率。结果患者均获随访6~24个月[(15.8±4.9)个月]。截骨联合修复组手术时间为3.0(2.3,3.0)h,长于单纯截骨组的1.5(1.3,2.0)h(P<0.01)。两组术中出血量、尺骨截骨长度差异均无统计学意义(P>0.05)。两组术前前臂旋转度、尺桡偏角、掌背屈角、握力、VAS、PRWE评分、改良Mayo腕关节评分和DASH评分差异均无统计学意义(P>0.05)。截骨联合修复组术后6、12个月及末次随访时前臂旋转度为(130.3±8.8)°、(135.2±7.9)°、(141.9±6.9)°,尺桡偏角为23.0(23.0,26.5)°、33.0(30.0,36.0)°、36.0(32.5,41.5)°,均大于单纯截骨组的(120.5±9.4)°、(123.7±10.2)°、(130.9±8.5)°和22.0(20.0,23.0)°、23.0(23.0,28.0)°、25.0(23.0,33.5)°(P<0.05或0.01)。截骨联合修复组术后12个月及末次随访时掌背屈角为(125.8±10.8)°、(132.9±16.8)°,均大于单纯截骨组的(99.1±15.7)°、(121.2±17.4)°(P<0.01);但术后6个月两组掌背屈角差异无统计学意义(P>0.05)。截骨联合修复组术后6个月握力为(14.6±1.0)N,大于单纯截骨组的(12.8±1.8)N(P<0.05);但术后12个月及末次随访时两组握力差异均无统计学意义(P>0.05)。截骨联合修复组术后6、12个月及末次随访时VAS为(4.3±1.9)分、(2.7±1.1)分、(2.1±0.7)分,PREW评分为(57.6±4.1)分、(47.3±2.4)分、(35.0±3.4)分,均低于单纯截骨组的(6.5±2.5)分、(4.7±1.4)分、(4.3±0.9)分和(67.8±4.5)分、(53.1±4.4)分、(43.5±4.1)分(P<0.05或0.01)。截骨联合修复组术后6、12个月及末次随访时改良Mayo腕关节评分为(78.3±2.9)分、(80.1±3.0)分、(83.5±3.9)分,均高于单纯截骨组的(69.0±4.3)分、(75.5±2.9)分、(78.8±2.4)分(P<0.01)。截骨联合修复组术后12个月及末次随访时DASH评分为(35.8±4.6)分、(28.4±5.4)分,均低于单纯截骨组的(43.3±5.0)分、(34.2±4.4)分(P<0.01);但术后6个月两组DASH评分差异无统计学意义(P>0.05)。两组术后各时间点前臂旋转度、尺桡偏角、掌背屈角、握力和改良Mayo腕关节评分均大于术前(P<0.05),VAS、PREW评分和DASH评分均低于术前(P<0.05),且术后各时间点差异均有统计学意义(P<0.01)。截骨联合修复组术后并发症发生率为6.7%(1/15),低于单纯截骨组的46.7%(7/15)(P<0.05)。结论与单纯尺骨“Z”形缩短截骨术相比,尺骨“Z”形缩短截骨联合腕关节镜下缝线锚钉TFCC深层修复治疗尺骨撞击综合征伴中度以上下尺桡关节不稳定,具有术后腕关节活动度增加、疼痛减轻、功能改善和并发症发生率低等优势。

Objective To compare the efficacy of ulnar Z‑shaped shortening osteotomy combined with arthroscopic deep suture anchor repair of the triangular fibrocartilage complex(TFCC)and ulnar Z‑shaped shortening osteotomy alone in the treatment of ulnar impaction syndrome with moderate or severe distal radioulnar joint instability.Methods A retrospective cohort study was conducted to analyze the clinical data of 30 patients with ulnar impaction syndrome accompanied by moderate or severe distal radioulnar joint instability,who were admitted to Affiliated Hospital of Qingdao University from January 2016 to June 2023,including 16 males and 14 females,aged 27‑58 years[(42.4±9.9)years].All the patients presented with positive ulnar variance and TFCC type IB injury,with the deep layer of TFCC affected.Fifteen patients were treated with Z‑shaped shortening osteotomy of the ulna alone(osteotomy alone group),while the other 15 patients received Z‑shaped shortening osteotomy of the ulna combined with arthroscopic suture anchor repair of the deep layer of TFCC(osteotomy combined with repair group).The operation time,intraoperative blood loss,and length of ulnar shortening were compared between the two groups.The forearm rotation,ulnar‑radial deviation angle,palmar‑dorsal flexion angle,grip strength,visual analogue scale(VAS),patient‑rated wrist evaluation(PRWE)score,modified Mayo wrist score,and disabilities of the arm,shoulder,and hand(DASH)questionnaire score were assessed preoperatively,at 6 and 12 months postoperatively,and at the last follow‑up.The incidence of postoperative complications was recorded.Results The patients were followed up for 6‑24 months[(15.8±4.9)months].The operation time in the osteotomy combined with repair group was 3.0(2.3,3.0)hours,longer than 1.5(1.3,2.0)hours in the osteotomy alone group(P<0.01).There were no significant differences in intraoperative blood loss and the length of ulnar shortening between the two groups(P>0.05).There were no significant differences in forearm rotation,ulnar‑radial deviation angle,palmar‑dorsal flexion angle,grip strength,VAS,PRWE score,modified Mayo wrist score,and DASH score between the two groups preoperatively(P>0.05).At 6 and 12 months postoperatively,and at the last follow‑up,the forearm rotation degrees in the osteotomy combined with repair group were(130.3±8.8)°,(135.2±7.9)°,and(141.9±6.9)°,greater than(120.5±9.4)°,(123.7±10.2)°,and(130.9±8.5)°in the osteotomy alone group;the ulnar‑radial deviation angles in the osteotomy combined with repair group were 23.0(23.0,26.5)°,33.0(30.0,36.0)°,and 36.0(32.5,41.5)°,greater than 22.0(20.0,23.0)°,23.0(23.0,28.0)°,and 25.0(23.0,33.5)°in the osteotomy alone group(P<0.05 or 0.01).In the osteotomy combined with repair group,the palmar‑dorsal flexion angles at 12 months postoperatively and at the last follow‑up were(125.8±10.8)°and(132.9±16.8)°,greater than those in the osteotomy alone group[(99.1±15.7)°and(121.2±17.4)°](P<0.01),while there was no significant difference in the palmar‑dorsal flexion angle between the two groups at 6 months postoperatively(P>0.05).In the osteotomy combined with repair group,the grip strength at 6 months postoperatively was(14.6±1.0)N,greater than(12.8±1.8)N in the osteotomy alone group(P<0.05),while there was no significant difference in grip strength between the two groups at 12 months postoperatively and at the last follow‑up(P>0.05).At 6,12 months postoperatively,and at the last follow‑up,the VAS scores in the osteotomy combined with repair group were(4.3±1.9)points,(2.7±1.1)points,and(2.1±0.7)points,lower than(6.5±2.5)points,(4.7±1.4)points,and(4.3±0.9)points in the osteotomy alone group;the PREW scores were(57.6±4.1)points,(47.3±2.4)points,and(35.0±3.4)points,lower than(67.8±4.5)points,(53.1±4.4)points,and(43.5±4.1)points in the osteotomy alone group(P<0.05 or 0.01).The modified Mayo wrist scores in the osteotomy combined with repair group at 6,12 months postoperatively,and at the last follow‑up were(78.3±2.9)points,(80.1±3.0)points,and(83.5±3.9)points,higher than those in the osteotomy alone group[(69.0±4.3)points,(75.5±2.9)points,(78.8±2.4)points](P<0.01).The DASH scores in the osteotomy combined with repair group at 12 months postoperatively and at the last follow‑up were(35.8±4.6)points and(28.4±5.4)points,lower than(43.3±5.0)points and(34.2±4.4)points in the osteotomy alone group(P<0.01),while there was no significant difference in DASH scores between the two groups at 6 months postoperatively(P>0.05).In both groups,forearm rotation,ulnar‑radial deviation angle,palmar‑dorsal flexion angle,grip strength,and modified Mayo wrist scores at all time points postoperatively were all higher than the preoperative values(P<0.05),while the postoperative VAS,PREW,and DASH scores were lower than the preoperative values(P<0.05),with statistically significant differences among different time points postoperatively(P<0.01).The incidence of postoperative complications in the osteotomy combined with repair group was 6.7%(1/15),lower than 46.7%(7/15)in the osteotomy alone group(P<0.05).Conclusion Compared with the ulnar Z‑shaped shortening osteotomy alone,ulnar Z‑shaped shortening osteotomy with arthroscopic suture anchor deep repair of TFCC has the advantages of increased wrist range of motion,reduced pain,improved function,and lower incidence of complications,etc in treating ulnar impaction syndrome with moderate or severe instability of the distal radioulnar joint.