关节镜清理联合原位尺神经松解术治疗骨关节炎性肘僵硬并发迟发性尺神经炎

Arthroscopic debridement combined with in situ release of ulnar nerve for osteoarthritic elbow stiffness with tardy ulnar neuritis

目的探讨关节镜清理联合原位尺神经松解术治疗骨关节炎性肘僵硬并发迟发性尺神经炎的临床疗效。方法回顾性分析2018年1月至2022年12月间接受关节镜清理联合原位尺神经松解术治疗36例骨关节炎性肘僵硬并发迟发性尺神经炎患者的病历资料,男29例、女7例,年龄(51.3±6.5)岁(范围40~62岁),左侧8例、右侧28例,均为单侧优势肘。患肘Kellgren-Lawrence分级Ⅱ~Ⅳ级,Ⅱ级16例、Ⅲ级15例、Ⅳ级5例。骨关节炎病程(4.2±1.8)年(范围2~8年);尺神经卡压病程(4.6±3.2)个月(范围2~12个月)。术前及术后12个月通过患侧肘关节屈曲、伸直活动度,Mayo肘关节功能指数(Mayo elbow performance index,MEPI),疼痛视觉模拟评分(visual analogue scale,VAS)评价肘关节功能及疼痛改善情况;通过患侧手握力、捏持力、小指两点辨别觉评价尺神经功能情况;通过神经肌电图检查评价尺神经运动神经传导速度(motor nerve conduction velocity,MNCV)和感觉神经传导速度(sensory nerve conduction velocity,SNCV)。结果36例患者手术时间为(151.4±16.2)min(范围125~180 min),住院时间为(6.5±1.0)d(范围5~8 d)。1例患者术后出现尺神经松解切口处皮肤边缘坏死;其余患者手术切口均一期愈合。术前与术后12个月的肘关节伸直活动度[26.00°(20.00°,30.00°)和6.00°(5.00°,10.00°),Z=-5.235,P<0.001]、肘关节屈曲活动度[98.00°(88.25°,100.00°)和120.50°(109.00°,128.00°),Z=-5.234,P<0.001]、疼痛VAS评分[(7.5±0.9)分和(1.8±0.8)分,t=32.788,P<0.001]、MEPI[32.50(26.25,43.75)和85.00(80.00,85.00),Z=-5.269,P<0.001]、握力[(24.1±2.4)N和(35.0±2.7)N,t=30.745,P<0.001]、捏持力[(16.2±1.3)N和(23.8±1.7)N,t=40.239,P<0.001]、小指两点辨别觉[16.00(14.00,18.00)mm和5.00(3.00,7.00)mm,Z=-5.270,P<0.001]、尺神经MNCV[(27.5±3.0)m/s和(41.6±3.0)m/s,t=53.673,P<0.001]和SNCV[(25.1±2.7)m/s和(35.0±2.9)m/s,t=47.538,P<0.001],差异均有统计学意义。术后12个月时5例患肘伸直受限仍超过15°(范围18°~20°),但肘屈曲功能均恢复至100°以上;1例患肘术后尺神经症状缓解欠佳,残留一定功能障碍。3例患者术后1周康复训练时出现肘关节屈伸过程中尺神经症状加重,改变康复训练方式后尺神经症状逐渐改善,术后1年时尺神经症状基本消失。结论关节镜清理联合原位尺神经松解术治疗骨关节炎性肘僵硬并发迟发性尺神经炎是一种安全、有效的手术方法,手术创伤小,并发症发生率低。

Objective To evaluate the clinical outcomes of arthroscopic debridement combined with in situ ulnar nerve release in patients with osteoarthritic elbow stiffness complicated by tardy ulnar neuritis.MethodsA retrospective chart review was conducted on 36 patients with osteoarthritic elbow stiffness and tardy ulnar neuritis who underwent arthroscopic debridement and in situ ulnar nerve release between January 2018 and October 2022.The mean patient age was 51.3±6.5 years(range:40-62 years),with 29 males and 7 females.The procedure was performed on 28 right and 8 left elbows,all on the dominant side.Radio-graphic classification of elbow osteoarthritis(OA)revealed 16 cases of Kellgren-Lawrence grade II,15 cases of grade III,and 5 cas-es of grade IV.The duration of OA was 4.2±1.8 years(range:2-8 years),and the duration of ulnar nerve compression symptoms was 4.6±3.2 months(range:2months-1 year).Elbow function and pain were assessed preoperatively and 12 months postoperative-ly using flexion-extension range of motion,the Mayo Elbow Performance Index(MEPI),and the Visual Analogue Scale(VAS)for pain.Ulnar nerve function was evaluated through grip strength,pinch strength,two-point discrimination of the little finger,and mo-tor and sensory nerve conduction velocities(MNCV and SNCV).Results The mean operation time was 151.4±16.2 minutes(range:125-180 minutes),with an average hospital stay of 6.5±1.0 days(range:5-8 days).One patient(2.8%)experienced skin necrosis at the ulnar nerve release incision,while all other incisions healed at the first stage.At the 12-month follow-up,signifi-cant improvements were observed in elbow extension[26.00°(20.00°,30.00°)vs.6.00°(5.00°,10.00°),Z=-5.235,P<0.001],flex-ion range of motion[98.00°(88.25°,100.00°)vs.120.50°(109.00°,128.00°),Z=-5.234,P<0.001],VAS pain scores(7.5±0.9 vs.1.8±0.8,1=32.788,P<0.001),andMEPI[32.50(26.25,43.75)vs.85.00(80.00,85.00),Z=-5.269,P<0.001].Improvements in grip strength(24.1±2.4 Nvs.35.0±2.7 N,t=30.745,P<0.001),pinch strength(16.2±1.3 Nvs.23.8±1.7 N.t=40.239,P<0.001),two-point discrimination[16.00(14.00,18.00)mm vs.5.00(3.00,7.00)mm,Z=-5.270,P<0.001],and MNCV(27.5±3.0 m/s vs.41.6±3.0 m/s,1=53.673,P<0.001)/SNCV(25.1±2.7 m/s vs.35.0±2.9 m/s,t=47.538,P<0.001)were also noted.At the 12-month follow-up,5 patients(13.9%)had an elbow extension lag greater than 15°(range:18°-20°),though elbow flexion recovered to at least 100°,sufficient for daily activities.One patient(2.8%)had incomplete relief of ulnar nerve symptoms postoperatively,but was gen-erally satisfied with the outcome.Three patients(8.3%)experienced temporary worsening of ulnar nerve symptoms during rehabili-tation,which improved with adjusted exercise routines,and the symptoms resolved by the 1-year follow-up.Conclusion Ar-throscopic debridement combined with in situ ulnar nerve release is a safe and effective treatment for osteoarthritic elbow stiffness complicated by tardy ulnar neuritis.This minimally invasive procedure is associated with a low complication rate and yields signifi-cant functional improvements.