锁骨钩板内固定联合Endobutton韧带重建治疗RockwoodⅢ型肩锁关节脱位

张培训 马明太 刘中砥 王依林 付中国 陈建海 薛峰 韩娜 寇玉辉

锁骨钩板内固定联合Endobutton韧带重建治疗RockwoodⅢ型肩锁关节脱位

张培训 马明太 刘中砥 王依林 付中国 陈建海 薛峰 韩娜 寇玉辉

目的探讨锁骨钩板内固定联合Endobutton喙锁韧带重建治疗RockwoodⅢ型肩锁关节脱位的临床疗效。方法回顾性分析2012年8月至2015年12月北京大学人民医院创伤骨科采用锁骨钩板内固定联合Endobutton喙锁韧带重建治疗Rockwood Ⅲ型肩锁关节脱位的患者11例，其中男7例，女 4例；年龄 22～65岁，平均（37.50±8.75）岁。受伤至手术时间为 2～8 d，平均（4.50±1.95）d，均为闭合性损伤。损伤机制：直接暴力损伤9例，间接暴力损伤2例。对11例患者进行临床效果评价。结果患者的手术时间35～100 min，术后所有患者切口均为1/甲级愈合。随访时间6～18个月，平均（10.60±6.67）个月。所有患者术后均未发生锁骨钩脱落、断裂。术后10～18个月取出内固定，钢板取出后无再脱位等并发症。按美国肩肘外科协会标准化肩关节评定量表（American shoulder elbow surgeons standardized shoulder assessment form，ASES）评价疗效，优（100～90分）9例，良（89～75分）1例，一般（74～51分）1例，差（≤50分）0例，优良率90.91%。结论锁骨钩板内固定联合Endobutton喙锁韧带重建治疗Rockwood Ⅲ型肩锁关节脱位手术操作简单，术后肩关节功能恢复好，并发症少，可临床推广应用。

肩锁关节脱位； 锁骨钩板； Endobutton； 韧带重建

肩锁关节脱位临床常见，约占肩部损伤的12%［1］。肩关节遭受高能量直接或间接暴力时容易发生肩锁关节脱位，主要是关节周围相关韧带断裂所致。目前针对Rockwood Ⅲ～V型肩锁关节脱位应行手术治疗已达成共识［2］。肩锁关节脱位的手术治疗屡有创新性报道，但最佳处理措施尚存争议。传统方式以坚强内固定理念为主，但并发症较多、临床疗效不满意。近年来治疗理念已逐渐由坚强固定转向弹性固定，以解剖方式重建喙锁韧带的带袢Endobutton治疗肩锁关节脱位为研究热点［3-4］。本文回顾性分析了本院创伤骨科2012年8月至2015年12月采取锁骨钩板内固定联合Endobutton喙锁韧带重建治疗Rockwood Ⅲ型肩锁关节脱位的11例患者，取得了较好的治疗效果，总结如下：

资料与方法

一、一般资料

本组患者共11例，其中男7例，女4例；年龄22～65岁，平均（37.50±8.75）岁。其中右侧6例，左侧5例。受伤至手术时间为2～8 d，平均（4.50±1.95）d，均为闭合性损伤。损伤机制：直接暴力损伤9例，间接暴力损伤2例。11例患者经X线检查未见骨折。损伤类型根据Rockwood分型均为Rockwood Ⅲ型肩锁关节脱位。临床表现为患侧肩部略微肿胀，锁骨远端有浮动感，“琴键征”阳性，局部瘀斑青紫，压痛明显，患侧肩关节活动受限。

二、治疗方法

患者入院后患肢悬垂制动。完善术前检查，臂丛神经阻滞麻醉或全身麻醉下半坐卧位，患侧垫高20～30 cm，头部转向健侧。在锁骨的中外1/3交界处由外上沿下经过喙突做约5 cm的斜行切口，逐层切开皮肤和皮下组织，分离三角肌，暴露锁骨及喙突，在喙突基底附近接近和锁骨中外1/3处钻孔，将肩锁关节的锁骨远端下压至解剖位置，将带袢Endobutton钢板导入喙突下，另外一块带袢Endobutton钢板置于锁骨上方靠近后侧（不影响锁骨钩板的放置）的位置，丝线拉紧并打Nice滑动加压结。带袢的Endobutton钢板放置完成后进行常规的锁骨钩板内固定。探明肩峰后方锁骨钩端插入位置，将4孔或6孔锁骨钩锁定钢板钩端插入肩峰下缘，钢板近端先钻孔并拧上普通螺钉固定，加压使钢板贴合更好，再间断钻孔并拧入锁定螺钉，探查肩锁关节固定稳定后冲洗、缝合，放置引流（典型病例如图1～3所示）。术后预防性输入抗生素1 d，术后第2天即开始小幅度主、被动功能锻炼。

三、评定标准

根据美国肩肘外科协会标准化肩关节评定量表（American shoulder elbow surgeons standardized shoulder assessment form, ASES）评价疗效，100～90分为优， 89～75分为良， 74～51分为一般，≤50分为差。

结 果

本组11例患者的手术时间35～100 min，术后11例患者切口均为1/甲级愈合。随访时间6～18个月，平均（10.60±6.67）个月。11例患者术后均未发生锁骨钩脱落、断裂。术后10～18个月取出内固定，钢板取出后无再脱位等并发症。按ASES等级评分评定疗效，优（100～90分）9例，良（89～75分）1例，一般（74～51分）1例，差（≤50分）0例，优良率90.91%。

讨 论

一、肩锁关节脱位的解剖和分类

肩锁关节是由扁平的肩峰内缘与锁骨的远端构成，属于微动关节，其主要功能为提供锁骨与肩峰间的滑动以及肩胛骨相对于锁骨的旋转［5］。在上肢活动时，肩锁关节有三种移位方式，分别是前后、上下移动和锁骨沿长轴旋转。肩锁关节的稳定性主要依靠韧带保持。喙锁韧带的功能为维持肩胛骨与锁骨间的恒定关系，从而在保持肩锁关节在上下方向上的稳定性起重要作用。肩锁关节脱位的分类方法很多，传统采用 Allman、Tossy或 Zlotsky等的三分法［6］，这些分类方法突出影像学特点，其中Ⅲ型均提示肩锁和喙锁韧带完全断裂。Rockwood于1984年改进了Allman和Tossy的三分法，把肩锁关节脱位分为六型，用以指导其临床诊疗。目前对于Rockwood Ⅲ型以上的损伤类型采取手术治疗已经达成共识。

二、肩锁关节的手术方式

肩锁关节脱位根据不同的分型，其治疗方式也不同，有单纯的克氏针固定法、克氏针张力带固定法、喙锁韧带钢丝和钛缆内固定法、人工韧带或者肌腱重建喙锁韧带法、锁骨钩钢板治疗法以及近年来出现的关节镜下Endobutton单袢固定法和双袢固定法等。

单纯的克氏针固定肩锁关节脱位适合于喙锁韧带未完全断裂的肩锁关节脱位，同时克氏针的固定也存在固定不牢固、容易出现克氏针退出等情况。克氏针张力带的固定稳定性比单纯的克氏针固定有所提升，但是仍然存在钢针的末端护理困难，应用范围有限。

锁骨钩板是通过锁骨远端钢板固定和穿过肩峰的钩形成杠杆作用，在锁骨远端产生持续而稳定的压力，为肩锁、喙锁韧带及周围软组织的创伤后愈合提供一个适宜的环境。锁骨钩板的固定容许肩锁关节一定范围内的微小活动，固定牢固可以早期进行主、被动功能锻炼［7］。有学者报道锁骨钩的临床使用过程当中存在脱钩、断钩、锁骨应力性骨折等并发症。也有学者报道锁骨钩的应用过程中会产生肩峰下间隙的持续刺激而导致肩关节的疼痛不适［8］。回顾性分析本组11例锁骨钩板内固定治疗肩锁关节Ⅲ型以上脱位的病例中，无一例出现脱钩、断板、锁骨应力骨折以及肩峰下间隙持续刺激性疼痛，临床效果满意。

肩锁关节脱位一般都伴有肩锁韧带的断裂［9］。轻度的肩锁关节脱位（喙锁韧带未完全断裂）可以通过简单的固定来获得喙锁韧带的紧缩和肩锁韧带的愈合。伴有喙锁韧带损伤的肩锁关节脱位一般都属于Rockwood Ⅲ型以上的损伤程度，其临床处理尚未达成共识［10］。有学者认为可以通过固定肩锁关节来获得喙锁韧带的瘢痕修复；也有学者认为喙锁韧带损伤的Ⅲ型以上的肩锁关节脱位不仅仅需要韧带重建，还需要肩锁关节的固定；也有学者认为Ⅲ型以上的肩锁关节脱位可以单纯通过喙锁韧带的重建来获得较好的稳定性，不需要肩锁关节的固定［2-3］。近年来有学者也报道通过关节镜下的Endobutton袢钢板的固定来治疗肩锁关节脱位，Endobutton袢钢板的固定需要借助于强度较大的丝线的弹性固定；有学者认为单一的Endobutton袢钢板只能相对有效的解决锁骨的上移而无法有效限制锁骨远端的前后移位；进而有学者也报道了双Endobutton袢钢板在不同的位置上对锁骨远端的上移和前后移动做了限制，取得了较好的治疗效果［11］。

自从锁骨钩钢板应用于临床以来，有学者认为急性肩锁关节脱位手术治疗可以单纯采用锁骨钩板固定，而不修复喙锁韧带。作者通过回顾性分析发现：也有部分术前可疑喙锁韧带完全断裂的肩锁关节脱位单纯通过锁骨钩板的固定而获得了肩锁关节的稳定，二期手术取出钩板后未见脱位再次发生。但是作者认为：肩锁关节完全性脱位时喙锁韧带完全断裂，肩锁韧带也同时撕裂。手术中内固定的作用只是暂时替代喙肩和喙锁韧带以维持其垂直方向的稳定，持久的稳定仍需要修复喙肩和喙锁韧带来提供，尤其是喙锁韧带。喙锁韧带单纯拉伸损伤未完全断裂的肩锁关节脱位可能可以通过固定肩锁关节获得肩锁韧带和喙锁韧带的愈合，但是伴有喙锁韧带完全断裂的肩锁关节脱位，应尽可能在术中重建韧带，可以选择自体韧带、联合腱，也可以选择Endobutton袢钢板甚至单纯的丝线弹性固定，不建议使用钢丝、钛缆非弹性固定方式。至于本研究中Rockwood Ⅲ型以上的11例患者，术中重建了喙锁韧带，又采用锁骨钩板固定了远端与肩峰，临床随访中肩关节功能恢复满意，未见肩锁关节再次脱位发生，临床效果好，优良率达到90%以上，因此作者认为锁骨钩板内固定联合Endobutton喙锁韧带重建是治疗肩锁关节脱位的一种有效的方法。综合分析认为，该方法具有以下优势：（1）重建了喙锁韧带，保持了锁骨远端在冠状面的稳定性，拆除锁骨远端的内固定后不容易造成脱位复发；（2） 有效固定了肩锁关节，可以早期进行功能锻炼。

图1 右侧Ⅲ型肩锁关节脱位

图2 锁骨钩Endobutton重建固定

图3 锁骨钩Endobutton重建固定后1年去除锁骨钩内固定

［1］陈元庄, 张敏, 马滚韶. 锁骨钩钢板的临床应用及并发症分析［J］.中国修复重建外科杂志, 2011, 25（1）：117-118．

［2］Tauber M, Valler D, Lichtenberg S, et al. Arthroscopic stabilization of chronic acromioclavicular joint dislocations: triple-versus single-bundle reconstruction［J］. Am J Sports Med, 2016, 44（2）: 482-489.

［3］Torkaman A, Bagherifard A, Mokhatri T, et al. Double-button fixation system for management of acute acromioclavicular joint dislocation［J］. Arch Bone Jt Surg, 2016, 4（1）: 41-46.

［4］Cutbush K, Hirpara KM. All-arthroscopic technique for reconstruction of acute acromioclavicular joint dislocations［J］.Arthrosc Tech, 2015, 4（5）: e475-e481.

［5］李奉龙, 姜春岩. 肩关节镜下喙锁韧带重建术治疗RockwoodⅢ型肩锁关节脱位的疗效研究［J/CD］.中华肩肘外科电子杂志, 2015, 2（1）：14-17．

［6］Braun S, Beitzel K, Buchmann S, et al. Arthroscopically assisted treatment of acute dislocations of the acromioclavicular joint［J］.Arthrosc Tech, 2015, 4（6）: e681-e685.

［7］皇甫小桥, 赵金忠, 何耀华, 等.关节镜下喙锁韧带增强术治疗肩锁关节脱位［J/CD］.中华肩肘外科电子杂志, 2013, 1（1）：40-45．

［8］董启榕, 陈明.肩锁关节脱位的治疗进展［J/CD］.中华肩肘外科电子杂志, 2013, 1（1）：13-17．

［9］Lee SK, Song DG, Choy WS. Anatomical double-bundle coracoclavicular reconstruction in chronic acromioclavicular dislocation［J］. Orthopedics, 2015, 38（8）: e655-e662.

［10］汪国友, 沈骅睿, 曾胜强, 等.全关节镜下治疗肩锁关节脱位［J/CD］.中华肩肘外科电子杂志, 2014, 2（3）：151-156．

［11］宋哲, 张堃, 朱养均, 等.应用 Endobutton 带袢钢板技术治疗RockwoodⅢ型肩锁关节脱位［J/CD］.中华肩肘外科电子杂志 , 2015, 3（1）：18-23．

Han Na, Email:876804725@qq.com

Treatment of Rockwood typeⅢ acromioclavicular joint dislocation with clavicular hook plate internal fixation and Endobutton ligament reconstruction

Zhang Peixun, Ma Mingtai, Liu Zhongdi,Wang Yilin, Fu Zhongguo, Chen Jianhai, Xue Feng, Han Na.Department of Trauma and Orthopedics,Peking University People's Hospital, Beijing 100044, China

BackgroundAccounting for around 12% of all shoulder injuries, the acromioclavicular joint dislocation is common in clinic. The shoulder joint is prone to acromioclavicular dislocation when direct or indirect high energy violence leads to the rupture of the ligament around joint. Currently, it has been widely acknowledged that Rockwood type Ⅲ—V of acromioclavicular joint dislocation should be treated with surgical interventions. Although innovative surgical treatments of acromioclavicular joint dislocation have been reported several times, the optimal treatment is still controversial. The traditional method is based on rigid internal fixation, but high rate of complications and unsatisfactory clinical efficacy are resulted. In recent years, the treatment concept has gradually switched from rigid fixation to elastic fixation, and the treatment of acromioclavicular dislocation through the anatomic reconstruction of acromioclavicular ligament with Endobuttons becomes the focus of research. This study provides a retrospective analysis of 11 cases with Rockwood typeⅢ acromioclavicular joint dislocation treated by clavicular hook plate fixationcombined with the Endobutton reconstruction of coracoclavicular ligament in our hospital from August 2012 to December 2015.All cases achieved satisfactory therapeutic effect. Methods （1）General information. The group included 11 patients （7 males and 4 females）.The age ranged from 22-65 years with an average of （37.50±8.75） years. Six cases had the right side affected, and 5 cases had the left side affected. The time from injury to operation ranged from 2-8 days with an average of （4.50±1.95） days, and all cases were closed injuries. Injury mechanisms: 9 cases of direct violent injury and 2 cases of indirect violent injury. No fracture was discovered in patients under fluoroscopy.According to the Rockwood classification, all injuries were acromioclavicular dislocation of Rockwood typeⅢ. Clinical manifestations of ipsilateral shoulder included slight swollen, floating feeling of clavicle, positive 'piano sign', local ecchymoses and bruises, tenderness,limitation of shoulder joint motion.（2）Therapeutic method. All patients had the affected limb fixed with suspension braking after admission. After preoperative examination was taken, the patient

brachial plexus block or general anaesthesia and was placed in semirecumbent position for operation. The ipsilateral shoulder was elevated for 20-30 cm with pad, and the head was turned to the unaffected side. A 5-cm oblique incision was made at the border between the middle 1/3 and the lateral 1/3 of clavicle downward through coronoid process, and the skin and subcutaneous tissue were cut open layer by layer. Afterward, the deltoid muscle was separated to expose clavicle and coronoid process. A hole was drilled nearthe lateral 1/3 of clavicle around basal coronoid process. As the distal clavicle was pressed to anatomical position, two Endobutton plates were imported under coronoid process and placed on the posterosuperior side of clavicle（that did not affect the placement of clavicular hook plate） respectively. Then, a Nice knot was made for sliding compression. After the placement of Endobutton plate, the clavicular hook plate was placed in routine. Following the exploration of the insertion position for hook plate at the back of acromion,the 4-hole or 6-hole clavicular hook plate was inserted into the inferior margin of acromion.Initially,the proximal end of plate was drilled and fixed with cortical screws. The compression was applied subsequentially for better fit. Then, the holes were drilled discontinuously and inserted with locking screws. After the fixation of acromioclavicular joint was checked for stability, the wound was irrigated and sutured with drainage. The postoperative prophylactic antibiotics was given on the 1st day only. Active and passive exercises with minor range of motion were started from the 2nd day after operation.（3）Evaluative criteria. The therapeutic effect was evaluated based on the rating scale of American shoulder and elbow surgeons surgeons standardized shoulder assessment form （ASES）:100-90 points as excellent; 89-75 points as good; 74-51 points as moderate;≤50 points as poor.ResultsThe operation time in the group ranged from 35 to 100 minutes, and all incisions belonged to stage I/Class A healing after operation. The patients were followed up for 6-18 months with an average of （10.60±6.67） months. No patient had clavicular hook loosening or rupture. The internal fixator was removed 10-18 months after operation. No complication such as recurrence of joint dislocation occurred after the removal of plate. According to the rating scale of ASES, 9 cases were excellent （100-90 points）, 1 case was good （89-75 points）, 1 case was moderate （74-51 points）,and no case was poor （≤50 points）. The good and excellent rate was 90.91%.ConclusionsThe clavicular hook plate fixation combined with Endobutton ligament reconstruction is an effective method to treat acromioclavicular dislocation.Comprehensive analysis shows that this method has the following advantages: （1） The reconstruction of coracoclavicular ligament maintains the stability of distal clavicle on coronal plane. The chance of dislocation recurrence is reduced after the removal of internal fixatior; （2） The effective fixation of acromioclavicular joint is conducive to early functional exercises.

Acromioclavicular joint dislocation; Clavicular hook plate; Endobutton;Ligament reconstruction

10.3877/cma.j.issn.2095-5790.2017.03.003

国家科技部973计划（2014CB542201）；国家科技部863计划（SS2015AA020501）；教育部创新团队（IRT1201）；国家自然科学基金（31571235）；国家自然科学基金（31671248）；国家自然科学基金（31771322）；教育部新世纪优秀人才计划（BMU20110270）

100044 北京大学人民医院创伤骨科

韩娜，Email：876804725@qq.com；寇玉辉，Email：yukuikou@bjma.edu.cn

2016-05-31）

（本文编辑：李静；英文编辑：陈建海、张晓萌、张立佳）

张培训,马明太,刘中砥,等.锁骨钩板内固定联合Endobutton韧带重建治疗RockwoodⅢ型肩锁关节脱位［J/CD］.中华肩肘外科电子杂志,2017,5（3）：168-172.