陳愛民 鹿楠 葉添文 楊鵬 朱磊 李菁

應(yīng)用LARS人工韌帶治療急性肩鎖關(guān)節(jié)脫位的初步報(bào)告

陳愛民 鹿楠 葉添文 楊鵬 朱磊 李菁

目的評(píng)價(jià)通過LARS人工韌帶重建并加強(qiáng)喙鎖韌帶的方法治療肩鎖關(guān)節(jié)脫位的臨床效果。方法應(yīng)用LARS人工韌帶重建喙鎖韌帶治療8例TossyⅢ型肩鎖關(guān)節(jié)脫位，其中男性5例，女性3例；年齡21～45歲；左肩3例，右肩5例。致傷原因：摔倒7例，車禍1例。臨床評(píng)價(jià)采用Constant評(píng)分和VAS評(píng)分。采用雙側(cè)肩鎖關(guān)節(jié)的Zanca位片和患側(cè)肩關(guān)節(jié)腋位片進(jìn)行影像學(xué)評(píng)價(jià)。結(jié)果所有患者獲得平均24（5～40）個(gè)月的隨訪。8例肩鎖關(guān)節(jié)脫位均獲得復(fù)位，肩關(guān)節(jié)Constant評(píng)分從術(shù)前的（59．3±6．9）分提高到（96．5±9．3）分（t＝300，P ＜0．05）。VAS評(píng)分從術(shù)前的（5．4±1．3）分下降到（0．7±0．9）分（t＝300，P ＜0．05）。術(shù)后X線片顯示7例患者獲得了解剖復(fù)位，有1例復(fù)位輕度丟失。發(fā)現(xiàn)2例喙鎖韌帶鈣化，1例肩鎖關(guān)節(jié)退變，未發(fā)現(xiàn)擠壓螺釘周圍骨溶解。結(jié)論應(yīng)用LARS人工韌帶進(jìn)行喙鎖韌帶重建可以為肩鎖關(guān)節(jié)提供可靠的初期強(qiáng)度，并允許患者早期進(jìn)行功能鍛煉，可以使患者得到較好的臨床療效，而且并發(fā)癥少。

肩鎖關(guān)節(jié)； 脫位； 喙鎖固定； LARS人工韌帶

目前，臨床上對(duì)于手術(shù)治療TossyⅢ型肩鎖關(guān)節(jié)脫位的看法比較一致［1］。由于損傷后維系關(guān)節(jié)穩(wěn)定的喙肩韌帶和喙鎖韌帶斷裂，受上肢重力和胸鎖乳突肌等作用，鎖骨向后、向上移位，上肢和肩胛骨下沉移位。保守治療易出現(xiàn)諸如復(fù)位困難、外固定后再脫位以及引發(fā)皮膚壓迫性潰瘍等并發(fā)癥，故對(duì)Ⅲ型肩鎖關(guān)節(jié)脫位多傾向于手術(shù)治療。由于韌帶的修復(fù)只能靠瘢痕修復(fù)，單純修復(fù)并固定喙鎖韌帶有可能在去除內(nèi)固定后發(fā)生再次脫位。因此，本研究采用重建喙鎖韌帶的手術(shù)方法治療TossyⅢ型肩鎖關(guān)節(jié)脫位。

資料與方法

一、一般資料

自2006年11月至2009年7月，我院共收治了8例TossyⅢ型肩鎖關(guān)節(jié)脫位患者，均為急性病例，其中男性5例，女性3例；年齡21～45歲；左肩3例，右肩5例；摔倒7例，車禍1例。應(yīng)用LARS人工韌帶重建喙鎖韌帶的治療方法。

二、治療方法

所有患者均為單純肩鎖關(guān)節(jié)的TossyⅢ型脫位，不伴有其他部位的創(chuàng)傷和皮膚破損。入院后，完善常規(guī)的術(shù)前檢查和評(píng)估，采用LARS人工韌帶進(jìn)行重建喙鎖穩(wěn)定結(jié)構(gòu)治療。所有患者的手術(shù)均在傷后2～5d內(nèi)在全麻下進(jìn)行，手術(shù)時(shí)間60～90min。

麻醉成功后，取沙灘椅位，患者仰臥位，患側(cè)肩部墊高。所有患者均在術(shù)前通過鎖骨長(zhǎng)度估計(jì)斜方韌帶和錐狀韌帶的附麗點(diǎn)。切口沿患側(cè)肩峰、鎖骨遠(yuǎn)端弧形向前下至喙突，顯露鎖骨、喙突尖。找出斷裂的喙鎖韌帶，然后用可吸收線褥式縫合喙鎖韌帶，預(yù)留線不打結(jié)。然后再次確定喙鎖韌帶的附麗點(diǎn)在冠狀面上的位置，有條件的可以在術(shù)中通過喙鎖韌帶的顯露來確定，用直徑4．5mm的鉆頭各鉆一個(gè)孔，鉆孔位置在保證強(qiáng)度的前提下，應(yīng)在矢狀面上盡量靠前方。用通過導(dǎo)向器將LARS人工韌帶穿過喙突根部，從LARS人工韌帶的兩端分別穿過鎖骨骨隧道，確認(rèn)整復(fù)達(dá)到滿意復(fù)位后，收緊人工韌帶，擠壓螺釘固定，編織打結(jié)韌帶兩側(cè)，用不可吸收線縫合，剪除多余部分。將修復(fù)喙鎖韌帶上的可吸收縫線拉緊并打結(jié)。

術(shù)后給予常規(guī)的抗感染等處理，三角巾懸吊患肢。術(shù)后即囑患者行手指和前臂功能活動(dòng)，3d后可以開始行肩關(guān)節(jié)主動(dòng)活動(dòng)，3周后患者可以去除三角巾，進(jìn)行日?；顒?dòng)，3個(gè)月內(nèi)禁止劇烈活動(dòng)。

臨床評(píng)價(jià)采用Constant評(píng)分和VAS評(píng)分，對(duì)術(shù)前、術(shù)后的評(píng)分進(jìn)行秩和檢驗(yàn)，以P＜0．05為差異有統(tǒng)計(jì)學(xué)意義。采用雙側(cè)肩鎖關(guān)節(jié)的Zanca位片和患側(cè)肩關(guān)節(jié)腋位片進(jìn)行影像學(xué)評(píng)價(jià)（圖1）。

圖1 術(shù)后雙側(cè)對(duì)比X線片

結(jié) 果

所有患者隨訪5～40個(gè)月?；紓?cè)肩關(guān)節(jié)的Constant評(píng)分由術(shù)前的（59．3±6．9）分提高到術(shù)后的（96．5±9．3）分（t＝300，P ＜0．05），VAS評(píng)分由術(shù)前的（5．4±1．3）分下降到（0．7±0．9）分（t＝300，P＜0．05）。肩鎖關(guān)節(jié)的雙側(cè)Zanca位片顯示7例患者均獲得了完全的解剖復(fù)位，1例患者有輕度的復(fù)位丟失。沒有患者發(fā)生再次脫位。發(fā)現(xiàn)2例喙鎖韌帶鈣化，1例肩鎖關(guān)節(jié)退變，未發(fā)現(xiàn)擠壓螺釘周圍骨溶解。所有患者在軸位片上未見到鎖骨遠(yuǎn)端在水平方向上的移位，未發(fā)現(xiàn)螺釘退出、鎖骨骨折或喙突骨折。

討 論

肩鎖關(guān)節(jié)是一個(gè)不典型的球窩關(guān)節(jié)，其運(yùn)動(dòng)中心位于肩鎖關(guān)節(jié)和喙鎖韌帶之間。鎖骨外端穩(wěn)定的主要因素是喙鎖韌帶的固定作用。肩鎖關(guān)節(jié)的這種解剖性質(zhì)決定了肩鎖關(guān)節(jié)脫位損傷修復(fù)最佳的辦法就是重建喙鎖韌帶，如果未能重建喙鎖韌帶，即使將肩鎖關(guān)節(jié)復(fù)位，在固定物取出后，仍然可能發(fā)生再脫位［23］。以往的手術(shù)方法主要原理是在固定肩鎖關(guān)節(jié)的同時(shí)修復(fù)喙鎖韌帶。但是單純修復(fù)韌帶，愈合率較低，且韌帶初期愈合的疤痕組織難以承受早期功能鍛煉所需要承受的張力［4－6］。因此，患者在經(jīng)歷了漫長(zhǎng)的恢復(fù)過程后，都存在不同程度的功能喪失［7］，延后了患者作為一名正常人重返社會(huì)的時(shí)間。后來，有學(xué)者開始應(yīng)用韌帶重建的方法來實(shí)施手術(shù)［8］。重建韌帶的材料早期主要來源于自體取材和異體移植。自體取材的移植物要經(jīng)過壞死－再血管化－細(xì)胞增殖－韌帶化的過程，該過程約需一年的時(shí)間。因此早期必須適當(dāng)限制患者的活動(dòng)，這與早期鍛煉，盡量減少功能喪失的初衷是不符合的。后期自體移植物容易出現(xiàn)松弛，抗拉力下降，最終仍難避免出現(xiàn)骨性關(guān)節(jié)炎。隨著材料技術(shù)的進(jìn)步，我們開始應(yīng)用人工韌帶進(jìn)行修復(fù)重建手術(shù)。相比于自體和異體組織，人工韌帶有著明顯的優(yōu)勢(shì)：（1）創(chuàng)傷?。河捎谑中g(shù)不需要從自己身體上取材，減少了創(chuàng)傷；（2）恢復(fù)快：人工韌帶具有一定的力學(xué)強(qiáng)度，不需要在人體內(nèi)進(jìn)行壞死－再血管化－細(xì)胞增殖－韌帶化的過程。因此，縮短了恢復(fù)時(shí)間，節(jié)省了醫(yī)療資源和社會(huì)成本。

我們采用法國(guó)LARS聚酯纖維支架型韌帶作為本研究的手術(shù)材料。這種韌帶具有以下特點(diǎn)：（1）具有較高的生物相容性：PET聚酯纖維與縫線和人造血管相同，生物相容性好，其內(nèi)部的自由纖維適合引導(dǎo)人體本身的纖維結(jié)締組織長(zhǎng)入；（2）通過了“拉力－彎曲－扭轉(zhuǎn)”混合測(cè)試：可以承受5 000牛頓的拉力；（3）術(shù)中可以保存韌帶殘余組織，保持生理本體感受。以上幾點(diǎn)可以看出：我們所采用的韌帶是一種永久－支架型韌帶，組織相容性好，能夠提供很好的抗拉力。其纖維內(nèi)30～50μm微孔適合組織的長(zhǎng)入，可以起到“支架”的作用，引導(dǎo)自身結(jié)締組織長(zhǎng)入，不僅起到了物理修復(fù)的作用，亦能起到生物組織工程修復(fù)的作用。這種韌帶在早期可以提供較好的初期強(qiáng)度，能夠承受患者進(jìn)行早期功能鍛煉所需要的強(qiáng)度；在后期，隨著自體組織的長(zhǎng)入和修復(fù)，最終強(qiáng)度能夠得到保證。這種修復(fù)方法是一種生理性重建，對(duì)于陳舊性的脫位也可以采用。因此，永久－支架型人工韌帶是一種治療肩鎖關(guān)節(jié)脫位尤其是陳舊性脫位的有效治療方法。韌帶重建手術(shù)的關(guān)鍵是如何確定在鎖骨上鉆孔的位置和方向。既然是重建韌帶，我們認(rèn)為：沿著原有韌帶走行方向是最符合生理的，也能最大限度的保證人體組織長(zhǎng)入人工韌帶，以達(dá)到生理性的重建。此種人工韌帶也有其局限性。首先，它的價(jià)格比較昂貴，在我國(guó)現(xiàn)有國(guó)情下限制了其廣泛的應(yīng)用；其次，韌帶的固定大部分要靠擠壓螺釘，對(duì)于骨質(zhì)疏松的患者不太適合；再次，人工韌帶的應(yīng)用目的是最大限度的恢復(fù)患者的術(shù)前功能，對(duì)于術(shù)前功能已有喪失和對(duì)功能要求不高的患者來說，人工韌帶并不是最適合他們的方法。

本研究認(rèn)為，LARS人工韌帶重建喙鎖韌帶技術(shù)是治療肩鎖關(guān)節(jié)脫位的一個(gè)可行的方法。此種韌帶可以提供可靠的初期強(qiáng)度，為喙鎖韌帶的一期愈合提供了較好的生物力學(xué)環(huán)境，其支架型韌帶可為后期修復(fù)體強(qiáng)度的維持提供可靠的保證。另外，人工韌帶無需二次手術(shù)取出內(nèi)固定，減少了患者的痛苦和經(jīng)濟(jì)負(fù)擔(dān)。

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The treatment of the acute acromioclavicular joint dislocation with LARS artificial ligament：apreliminary report

Chen Aimin，Lu Nan，Ye Tianwen，Yang Peng，Zhu Lei，Li Jing．Department of Orthopedic，Changzheng Hospital Affiliated to Second Military Medical University，Shanghai 200003，China

BackgroundCurrently，the clinical perspectives of surgical treatment for Tossy Ⅲacromioclavicular（AC）joint dislocations are relatively identical．Due to the post－traumatic ruptures of the acromioclavicular ligament and coracoclavicular（CC）ligament which are used to maintain stability of the joint，the clavicle moves backward and upward，and the upper arm and the scapula drops downward for the gravity of the upper arm and the influence of the sternocleidomastoid muscle．Since such complications as reduction difficulties，redislocation after external fixation，pressure ulcers of the skin，and so forth are particularly prone to occur in the conservative therapy，the operative treatment is more inclined to be adopted for the Tossy Ⅲ dislocation of the AC joint．With the single repair and fixation of the CC ligament，redislocation is likely to happen after implant removal because the ruptured ligaments healed as scar tissue．Therefore，this study uses an operative method of reconstructing and augmenting the CC ligament with LARS artificial ligament for the treatment of TossyⅢ AC joint dislocation，and evaluates its clinical effect．MethodsFrom November 2006to July 2009，8patients with acute AC joint dislocation of Tossy Ⅲ were admitted into our hospital．Five patients were male and 3were female，and their ages ranged from 21to 45．Sides：3injuries were on the left and 5were on the right．Seven patients suffered from falling on the ground，and 1patient was injured in a traffic accident．All the patients were treated with LARS artificial ligaments to reconstruct the CC ligament．Constant score and VAS score were adopted in clinical evaluation．Zanca view of the bilateral AC joint and the axillary radiograph of the affected shoulder joint were employed for imaging evaluation．All the patients were simple TossyⅢ dislocation of AC joint with no trauma of other partsand skin breakdown．Regular pre－operative examinations and evaluations were carried out after admission，and LARS artificial ligament was used to reconstruct the CC ligament．Surgeries of all the patients were performed under general anesthesia within 2to 5days after injury，and the operation time ranged from 60to 90minutes．After successful anesthesia，the patient lied on a beach chair position with the affected shoulder bolstered up．Attachment points of trapezoid ligament and conoid ligament are evaluated preoperatively through the length of clavicle among all the patients．The incision is made along the affected acromion and distal clavicle，curved downward to expose the clavicle and the tip of coracoid process．Find the ruptured CC ligament and then repair it with absorbable stiches by mattresssuture，leaving the reserved sutures unknotted．Then reconfirm the attachment point of CC ligament is on the location of coronal section，and if possible，the location can be identified by the exposure of CC ligament．Drill a hole separately with a diameter of 4．5mm bit，and make sure that the drilling position is in the sagittal plane close to the front on the premise of intensity．Make the LARS artificial ligament pass through the root of coracoid with a drilling guide，and thread the two ends of ligament through the clavicular bone tunnel．After the confirmation of satisfactory reduction，tighten up the artificial ligament and fix the interference screws．Weave and knot the two sides of the ligament，suture with nonabsorbent stitches and cut off the redundant part．Strain the absorbable suture on CC ligament and tie a knot．The routine anti－infection treatments were given and the affected arm was slung with scarf bandage．The patient was told to carry out functional activities of fingers and the forearm postoperatively．Active mobilization of the shoulder was initiated after 3days and regular movements were in process without scarf bandage 3weeks later．Such strenuous activities as physical exercise were forbidden within 3months．Constant score and VAS score were adopted in clinical evaluation．Zanca view of the bilateral AC joint and the axillary radiograph of the affected shoulder joint were employed for imaging evaluation．ResultsAll the patients were followed up for 5to 40months．Constant score of the affected arm increased from （59．3±6．9）preoperatively to（96．5±9．3）postoperatively（T ＝300，P ＜0．05），and VAS score decreased from （5．4±1．3）preoperatively to（0．7±0．9）postoperatively（T＝300，P ＜0．05）．Zanca view of the bilateral AC joint revealed that 7patients had an anatomical reduction，except for one patient with slight loss of reduction．No re－dislocation occurred．Two cases of CC ligament calcification and one case of AC joint degeneration were found，and no osteolysis around the interference screw was detected．No shift of the distal clavicle in the horizontal direction was found in the axial view，and neither was backing out of the screws，the clavicular fracture，or the coracoid fracture．Discussion AC joint is a non－typical ball－and－socket joint，the center of which is located between the AC joint and the CC ligament．The stability of the distal clavicle mainly depends on the integrity of CC ligament．The optimal method for dislocation of the AC joint is to reconstruct the CC ligament，which is decided by the anatomical characters of the AC joint．Otherwise，redislocation might still occur after the removal of the internal fixator even if the AC joint is reduced．Previous primary principle of the operation method was the repair of CC ligament with the fixation of AC joint at the same time．However，single repair of the ligament had a low healing rate，and the scar tissue of the ligament hardly bore the tension required for the early functional exercise．Hence，after a long period of recovery procedure，patients suffered from different degrees of functional incapacitation，which postponed their schedule of returning to work．Some scholars afterwards started using the method of ligament reconstruction to perform the surgery．Autografts and allografts are sources for ligament reconstruction．The process of necrosis，revascularization，cell multiplication，and ligamentization is needed for autogenous grafts，which will take around 1year．Therefore，proper limitation of patient’s early activities is inconsistent with our original intentions of early training to reduce the loss of function．Laxity of grafts is likely to be observed during the late period with decreased stretching resistance，and still has difficulty in avoiding osteoarthritis eventually．With the development of the material technology subsequently，we start the operation of repair and reconstruction with the application of artificial ligament．Compared to autologous and allogeneic grafts，artificial ligament has obvious advantages：（1）Less injury：The trauma is decreased since there is no need for the surgery toharvest tendons from his or her own body．（2）Quick recovery：Artificial ligament has a certain degree of the mechanical strength without necessities of the process of necrosis，revascularization，cell multiplication，and ligamentization inside the body．Accordingly，the application of artificial ligaments shortens the recovery time with less medical resources and society costs．We adopt the French LARS polyester fiber ligament of bracket type as our surgical materials for this study．This kind of ligaments has features as follows：（1）Higher biocompatibility：The PET polyester fiber is identical with sutures and artificial blood vessels and has excellent biocompatibility，the free fiber inside which can induce the ingrowth of fibrous connective tissue of the human body itself．（2）Pass the“tension－bending－torsion”hybrid test：It may bear the pulling force of 5000Newton．（3）Preserve the intraoperative remnant tissue of the ligament and keep the physiological proprioception．From the points above we can see that：The permanent－stent ligament we adopt had good histocompatibility and can provide excellent tensile resistance．The micropores of 30～50μm inside the fibers are suitable for the ingrowth of the autologous connective tissue，and can play the role of“support”，not only as physical remediation，but also with the function of the biological tissue engineering repair．This ligament can provide better early strength in the initial stage，and is able to withstand the intensity required by patients’early functional training．The ultimate intensity will be ensured with the ingrowth and restoration of the autologous tissue in the late stage．The restorative procedure is a kind of physiological reconstruction，which can also be applied for obsolete dislocations．Hence，the permanent－scaffold ligament is an effective method for the treatment of AC joint dislocations，especially the old dislocation．The key issue of the ligament reconstruction is how to determine the location and direction of drilling on the clavicle．Since it is ligament reconstruction，we consider that it is the most consistent with physiological features as the prosthetic ligament travels along the walking direction of the original one，which can maximally guarantee the ingrowth of the human tissue into the artificial ligament to achieve its physiological reconstruction．This prosthetic ligament has limitations as well．First，it is expensive，which restricts its extensive application in the current situation of China．Second，fixation of the ligament mainly relies on interference screws，and it is not suitable for the patients with osteoporosis．Once again，the objective of the use of artificial ligaments is to restore patients’preoperative function to the maximum extent．Therefore，artificial ligament is not most suitable for patients who have the loss of preoperative function or patients with not－so－h(huán)igh requirement for function．We consider that the technology of CC ligament reconstruction with LARS artificial ligament is a feasible method in the treatment of the AC joint dislocation．Such ligament can offer credible strength in the early period，which provides a preferable biomechanical environment for the primary healing of the CC ligament，and the merits of the ligament of bracket type reliably assure the preservation of the repair strength in the late stage．In addition，the advantage of artificial ligaments is unnecessary to remove implant by a second surgery，which decreases the patient suffering and financial burdens．Conclusions CC ligament reconstruction with the LARS artificial ligament can offer reliable early strength for AC joint，and it allows early functional training of patients．This enables patients to acquire better clinical outcome and less complication．

Dislocation of acromioclavicular joint； Tossy Ⅲ； Artificial ligaments；Reconstruction

Chen Aimin，Email：aiminchen＠aliyun．com

2013－12－20）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．01．005

200003 上海，第二軍醫(yī)大學(xué)附屬長(zhǎng)征醫(yī)院骨科

陳愛民，Email：aiminchen＠aliyun．com

陳愛民，鹿楠，葉添文，等．應(yīng)用LARS人工韌帶治療急性肩鎖關(guān)節(jié)脫位的初步報(bào)告［J／CD］．中華肩肘外科電子雜志，2014，2（1）：23－27．