網球肘手術治療與效果評價

1、網球肘手術治療與效果評價,2013級臨床5班 弓伊寧2016.11.13,什么是網球肘,肘關節(jié)外側疼痛最常見病因之一?。?！,歷史發(fā)展,簡介,該病在人群中的發(fā)病率大約為1.3%，而且不僅發(fā)生于網球運動員，普通人也可以出現網球肘，尤其是那些吸煙、肥胖與從事重體力勞動的人群，網球運動員僅占了10%[5]。但是，有50%的網球運動員會發(fā)生肘關節(jié)的疼痛，在各種原因中網球肘占75%。,,對于網球肘，90%的人經保守治療可好轉[6]，包括休息、使

2、用支具、物理治療、體外沖擊波治療、注射治療、經皮超聲腱切斷術、細胞再生治療等[7]。當保守治療失敗后，應當考慮手術治療。對于保守治療的時間，不同的學者說法不一，有的人認為應當經過6~12個月[10]或者至少6個月[8]的保守治療，有的認為應該至少9個月，尤其是在這期間經過三次以上激素治療無效的[9]。,Although most patients respond to non-operative management, surgical

3、 treatment is necessary in some cases. The number of patients requiring surgery varies. Boyd and McLeod reported that 4%~11% required operative management; a study by Bowen et al reported that 25% of patients required op

4、erative management for disabling refractory symptoms.,,無論國內還是國外，現在大多數人都將網球肘的手術治療分為切開治療、關節(jié)鏡下治療、經皮治療三種治療方式[1, 7, 9]。然而，網球肘的發(fā)病機制至今還不是很清楚，所以，根據不同的假說，又可以將手術治療分為不同的治療方式。,基于不同假說的手術治療分類,對伸肌總腱、ERCB、ERCL、EDC等的處理。,經典的Nirschl術式對伸肌

5、總腱的處理,經典的Nirschl術式,A gently curved incision approximately 7.6 centimeterslong is made, extending from 2.5 centimeters proximal to the lateral epicondyle to five centimeters distal to it.,,The deep fascia, which liesimm

6、ediately over the extensor aponeurosis, is incised andgently retracted.,,The extensor carpi radialis longus formsan interface with and lies directly anterior to the extensor aponeurosis（腱膜）.,,A hemostat（止血鉗） identifies

7、 the interface between the extensor longus and the extensor aponeurosis . The arrow identifies the lateral epicondyle . Muscle tissue of the extensor longus is visible anterior to the hemostat.,,,The extensor longus is d

8、issected from the lateral epicondyle to the radial head with a scalpel and scissors. Release and retraction of the extensor carpi radialis longus from the anterior edge of the extensor aponeurosis then reveals the origin

9、 of the extensor carpi radialis brevis .,,Inspection of the tendon’s superficial surface usually reveals gross alteration in the tendon .,,All fibrous and granulation tissue is excised sharply and removed . A small openi

10、ng is made in the synovial membrane if one is not already present, so that the lateral compartment of the joint can be inspected . If excess or abnormal synovial fluid is present, wider exploration is undertaken. This si

11、tuation occurs infrequently, however.,,If further inspection reveals any alteration of the Antenor edge of the extensor digitorum communis aponeurosis or of the extensor carpi radialis longus, thisgranulation tissue is

12、removed as well. Evidence of major pathological processes in either area has been unusual.,,The lesion is resected. A defect is left after resection of the proximal part of the extensor brevis tendon. The aponeurosis is

13、retracted by the lower retractor（牽開器） and its attachment to the lateral epicondyle is not disturbed.,,Complete removal of the abnormal granulation tissue generally encompasses 75 per cent of the origin of the extensor br

14、evis (from the lateral epicondyle to the joint line（合模線）). The remaining part of the extensor brevis tendon does not retract because of close fascial adherence to the extensor longus muscle.,,To ensure improved blood sup

15、ply, a small area of the exposed lateral condyle is decorticated with an osteotome or by drilling multiple small holes. It should be emphasized that since the extensor aponeurosis has not been released and the lateral ep

16、icondyle is fully covered by soft tissue, the decortication is done anterior and slightly distal to the lateral epicondyle.,,The technique for repair is quite simple, as the extensor brevis origin does not retract and su

17、ture is not necessary. The interface between the extensor carpi radialis longus and the anterior edge of the extensor aponeurosis is repaired with a running 0 chromic suture.,,The subcutaneous and skin layers are closed

18、with a subcuticular 3-0 polyethylene suture and Steri-strips（免縫膠帶）.,對伸肌總腱的處理,肘外側小切口伸肌總腱切斷： 手術方法:患者仰臥手術臺上,患肢外展90度,常規(guī)消毒鋪巾,局部浸潤麻醉,在肱骨外上髁遠側0.5cm處行橫行小切口約1~1.5cm,切開皮膚及皮下組織直達伸肌總腱止點處,在止點遠側0.5cm處切斷伸肌總腱,周圍組織稍加分離,壓迫傷口止血后,切口

19、縫合2針,繃帶稍加壓包扎,術后三角巾懸吊患肢1周,口服抗生素、止痛劑,12d拆線,患肢進行功能鍛煉。,,The anconeus muscle flap has been elevated off its insertion on the ulna（尺骨） and rotated over the defect in the common extensor origin. The left side of the photograph

20、is proximal and the right side is distal.,伸肌總腱清理伴旋轉肘肌,,Under tourniquet control, a 5-cm lateral incision is made over the epicondyle and carried distally toward the insertion of the anconeus muscle on the ulna. Subcutane

21、ous dissection is carried out to expose the anconeus muscle from its origin on the lateral epicondyle to its insertion on the ulna. After the anconeus is exposed, debridement of the common extensor origin is carried out

22、as described for patients in group 1. The anconeus is then sharply elevated from its insertion distally on the ulna. By dissection from a distal to proximal direction,the muscle is elevated off the ulna. The anconeus is

23、then rotated into the defect created by the excision of the degenerative tissue from the common extensor origin and sutured into place with absorbable sutures. The flap is loosely inset with 2 sutures placed 1 cm distal

24、to the tip of the flap and secured anteriorly to the epicondyle, thus providing coverage of the common extensor repair and the bone.,對微血管神經束的處理,伸肌總腱深處有一細小的微血管神經束，從肌肉、肌腱發(fā)出，穿過肌筋膜或肌腱膜進入皮下。壓痛點就在微血管神經束穿過肌筋膜處，微血管神經束在此受到卡壓[16]。

25、所以，有學者認為切除神經血管束，即顯微手術可以治療該疾病[12, 21, 22]。,,以肘關節(jié)外側壓痛點最明顯部位為中心，在局麻下(或臂叢麻醉下)，取肱橈關節(jié)處斜形切口，長約2~2.5 cm，顯露前臂伸肌總腱表面。在手術顯微鏡下，仔細尋找從肌筋膜穿出直徑為0.15 mm的微血管及直徑為0.12 mm的小神經束。用顯微剪刀將周圍疤痕及粘連進行松解并修整好，切斷神經前先用1%利多卡因注射、封閉，再銳性切除穿出的一段神經，血管予以11-0手術

26、線在顯微鏡下結扎止血，并將神經支殘端近端常規(guī)用多余的神經外膜包埋殘端，有時切斷神經后神經外膜不夠包埋，用周圍剪下的小而薄的筋膜包裹后用11-0手術線進行顯微縫合處理，縫合在近端神經鞘膜上，神經血管束近端均埋于肌腹處，可防止神經瘤發(fā)生。最后縫合皮下組織、皮膚各2~3針，可放置小皮片引流。,,陸曉文等[22]將顯微手術與伸肌總腱起點松解術進行比較，結果顯示二組療效無顯著差異,而且認為前臂伸肌總腱起點剝離、松解術手術不但造成肌肉、肌腱及環(huán)狀韌

27、帶的損傷,還造成肘關節(jié)損傷、肱骨外上髁骨性損傷,手術創(chuàng)傷大,并發(fā)癥也較多，而顯微松解、切斷神經支手術不但療效非常顯著而且創(chuàng)傷小、療程短、恢復快。,對橈神經分支的處理,解剖學研究顯示，前臂后皮神經的分支通過肱骨外上髁，而疼痛則是通過神經傳入中樞，所以，切除橈神經分支對于緩解網球肘引起的疼痛會產生一定效果[23]。,,Skin drawing of the branches from the posterior cutaneous nerv

28、e of the forearm innervating the lateral epicondyle.,切除前臂后皮神經的后支,,Anatomic dissection of the branches from the posterior cutaneous nerve of the forearm innervating the lateral epicondyle. The actual surgical incision is

29、much smaller. Vessel loupe indicates the posterior branch of the posterior cutaneous nerve of the forearm（PBPCNF）.,,A 3 to 4cm incision is made 2 fingerbreadths proximal to the lateral epicondyle. The red loupe indicates

30、 the posterior cutaneous nerve of the forearm. Blue background indicates the PBPCNF. Distal is to the left.,,The patient is placed in the supine position. The extremity is prepped and draped and placed on an arm board. A

31、 sterile tourniquet is optimal. A 3- to 4-cm transverse or horizontal incision is made 2 fingerbreadths proximal to the lateral epicondyle. The nerve or nerves to the lateral epicondyle consist of the posterior branches

32、of the posterior cutaneous nerve of the forearm (PCNF).,,These branches to the lateral epicondyle are termed the PBPCNF. Gentle superficial dissection is carried into the subcutaneous fat to identify the PBPCNF and disti

33、nguish it from the PCNF (Fig. 3). Care must be taken not to dissect too deeply in the subcutaneous fat because the nerves tend to be superficial. The size and number of branches of the PBPCNF can vary. Once the posterior

34、 branch nerve or nerves are found, care is taken to ensure that one has identified the branches to the lateral epicondyle (PBPCNF) and not the more longitudinally oriented PCNF, which should be preserved. Gentle traction

35、 on the PCNF will result in skin movement distally in the forearm, whereas gentle traction on the PBPCNF will result in subtle skin movement over the lateral epicondyle. Assessment of nerve orientation can also help dist

36、inguish the PCNF, which has a more longitudinal path down the forearm, from the PBPCNF, which heads more posteriorly toward the lateral epicondyle (Figs. 1,2). Rarely, the PBPCNF can be subfascial at this level.,,Once ap

37、propriately identified, the PBPCNF is mobilized as far distally and proximally as possible. Microdissection to separate the PBPCNF from its PCNF origin proximally may be necessary to allow adequate mobilization. The PBPC

38、NF is then injected with 0.5% bupivacaine, transected (Fig. 4), and buried within the lateral head of the triceps musculature posteriorly. No suture is used to bury the nerve. Operative 3.5 loupes are sufficient for magn

39、ification.,,An italic S incision was made,centred in the epicondyle, extending along 1.5 cm proximal length and drawing a posterior concavity curve to the distal edge,四步法,,Initially, we performed denervation of the later

40、al humeral epicondyle with a bipolar electric scalpeland sectioned the sensitive epicondylar branches describedby Wilhelm (branches from the radial nerve which emerge proximal to the radial tunnel and lead to sensory inn

41、ervation of the lateral epicondyle),,We located the ECRB and sectioned it lengthwise to resection the Nirschl angiofibrob-lastic degeneration nodule usually located at a profound and anterior level, through the distal fi

42、nger to the epicondyle.,,We performed a discreet epicondylectomy, or decortication of the epicondyle with a gauge needle.,,We finally released the PIN at the level of the 4 most common compression areas: the recurrent ra

43、dial blood vessels, the aponeurosis proximal to ECRB, the arcade of Fröhse and the distal edge of the supinator .,,We closed the ECRB incision on the nodule and sutured the flesh with dissolvable 4/0 braided sutures

44、. The arm was kept in a sling for 7 days.,對環(huán)狀韌帶、滑膜等的處理,現有的臨床研究很少有單純處理環(huán)狀韌帶以及滑膜等的，大多與其他的手術方法合并使用。如Reddy V R M等[25]在切除環(huán)狀韌帶與滑膜的同時也對伸肌總腱進行了松解。而Jeavons R等[26]則同時做了ECRB的清理和環(huán)狀韌帶與滑膜的切除。除了聯合處理肌腱，陸曉文等[22]在切除神經血管束時也進行了環(huán)狀韌帶的切除。,Reddy

45、 V R M等,A 5-cm longitudinal incision is made 2 cm proximal to the lateral epicondyle extending distally. The common extensor origin is sharply dissected and reflected distally from the underlying bone and soft tissues. A

46、dequate precautions are taken to protect the radial collateral ligament and annular ligament. A small flap of the proximal portion of the annular ligament along with the synovial fold of the radio humeral joint is remove

47、d. Debridement of the ECRB tendon is carried out. The superior cortex of the lateral condyle is excised with a sharp osteotome, and the bone decompressed with 2–3 drill holes. Finally, the common extensor tendon issuture

48、d back to the lateral epicondyle.,Jeavons R等,The Boyd–McLeod technique, as utilized by the senior author (NB), involved a 5-cm longitudinal incision centred over the lateral epicondyle. Sharp dissection down to the muscl

49、e fascia was made.,,The superior half of the extensor attachment was incised inline with its fibres and lifted sharply from the lateral epicondyle, with the lateral collateral ligament left undisturbed.,,Any mucinous deg

50、enerate tissue was debrided from the extensor carpi radialis brevis (ERCB). The conjoint flap was then raised distally to expose the annular ligament and the proximal 2mm of the ligament was resected, taking with it the

51、synovial lining of the radiohumeral joint. At this point, an inspection of the elbow joint could be made.,,The radial head is not destabilized because a large cuff of annular ligament remains. The lateral epicondyle is t

52、hen debrided, decorticated using an osteotome and decompressed by drilling several holes with 2.0-mm K-wire.,陸曉文等,手術在臂叢麻醉下進行,從肱骨外上髁向后做7 cm長切口,切開深筋膜將外上髁的伸肌向下剝離,寬度約115 cm,再將環(huán)狀韌帶的近側半切斷,外上髁鑿去015 cm并挫平,然后將剝離的肌腱重新縫合到外上髁軟組織上。,近

53、年來關于網球肘切開治療的臨床研究,本文重點探討切開手術的臨床研究。筆者檢索了中國知網、萬方、維普、Pubmed、Sciencedirect、SpringerLink六個數據庫，并從相關文獻的參考文獻中尋找與本文有關的臨床研究，現將2000年以后（含2000年）的有關網球肘切開治療的臨床研究，參考Wright等[27]介紹的證據水平分級將相關研究依年代順序列舉如下。,臨床研究檢索策略,專業(yè)檢索語：中文：((網球肘[Title/Abstr

54、act]) OR (肱骨外上髁炎[Title/Abstract]) OR (肘關節(jié)外側腱病[Title/Abstract])) AND 切開手術[Title/Abstract])；英文：((tennis elbow[Title/Abstract]) OR (lateral epicondylitis[Title/Abstract]) OR (Lateral elbow tendinopathy [Title/Abstract])) A

55、ND (open surgery[Title/Abstract]),中國知網,47篇,萬方,14篇,維普,6篇,pubmed,34篇,springer,47篇,Science direct,39篇,,相關推薦文章其他文章（article+review）中的參考文獻,文章等級評定,,,術中手術方案,2000年以后（含2000年）有關網球肘切開治療的臨床研究一共35篇，國內13篇，國外22篇，其中有一篇未提供手術例數，僅提供了手術治療肘數

56、，余臨床研究例數合計1449例。在國內的13篇臨床研究中，分別有4篇（30.8%）和5篇（38.5%）對ECRB和伸肌總腱進行了處理，并且有1篇（7.7%）對ECRL也進行了處理；而國外的22篇臨床研究中并無處理ECRL的報道，但是除了分別有9篇（40.9%）和10篇（45.5%）處理ECRB和伸肌總腱外，還有2篇（9.1%）臨床研究中處理了EDC，1篇（4.5%）臨床研究中處理了肘肌。對于神經血管束的處理，國內一共有8篇（61.5%）

57、臨床研究，而國外的研究并未涉及。國內和國外都有對橈神經分支處理臨床研究，分別有1篇（7.7%）和3篇（13.6%）。至于文中上述提到的對環(huán)狀韌帶、滑膜等的處理，也有一些研究報道，國內有3篇（23.1%）研究處理了環(huán)狀韌帶，2篇研究處理了滑囊（15.4%），而國外分別有2篇（9.1%）、1篇（4.5%）、1篇（4.5%）和2篇（9.1%）研究對環(huán)狀韌帶、滑膜、滑囊和關節(jié)囊進行了處理。此外，另有兩篇研究中并未提及所處理的結構。具體情況如下（

58、見表3）。,,,對于各臨床研究中手術涉及到的處理措施筆者也進行了統(tǒng)計（見表4）。無論國內還是國外，清理、松解、鉆孔均占據了一定的比例，分別有9篇（69.2%）、3篇（23.1%）、3篇（23.1%）國內臨床研究和10篇（45.5%）、11篇（50.0%）、6篇（27.3%）國外臨床研究中進行了這三項處理。而且國外進行去皮質的臨床研究數量和比例均大于國內，國內和國外分別有9篇（40.9%）和1篇（7.7%）。國內有3篇（23.1%）研究進

59、行了止點重建，3篇（23.1%）研究進行了直接縫合，2篇（15.4%）研究進行了錨釘縫合，而國外的研究中分別有5篇（22.7%）和2篇（9.1%）進行了止點重建和錨釘縫合，無進行直接縫合的報道。而且國內有2篇（15.4%）研究進行了伸肌總腱起點剝離，7篇（53.8%）研究進行了神經血管束切斷的處理，國外也沒有相應的研究。對于橈神經分支的處理也采用切除的方式，分別有1篇（7.7%）國內研究和3篇（13.6%）國外研究對此進行了報道。同樣，

60、國內有3篇（23.1%）研究進行了切除環(huán)狀韌帶，有2篇（15.4%）研究進行了切除滑囊，國外進行切斷環(huán)狀韌帶、切除滑囊、切除滑膜和松解關節(jié)囊的研究分別有2篇（9.1%）、1篇（4.5%）、1篇（4.5%）和2篇（9.1%）。此外，國外還有1篇（4.5%）研究中對伸肌總腱進行了V-Y延長。,,,從上表可以看出經典的Nirschl手術中提到的清理病變組織、松解伸肌肌腱、外上髁鉆孔或去皮質等[19]仍是當今各手術治療的重點。部分學者對于清理病

61、變組織后留下的伸肌腱裂隙進行了直接縫合或者錨釘縫合[11, 41]。關于止點重建，大部分學者采用將剝離或松解后的肌腱重新縫回外上髁[21, 24, 42]，也有人將松解后的肌腱與肘肌或肱三頭肌進行縫合[20]。支持微血管神經卡壓學說的學者，則在手術中著重進行了神經血管束的切斷，之后進行血管結扎止血與神經包埋[12, 28, 31]。對于橈神經分支的切除，可以有不同的選擇，比如PBPCNF[22]或PIN[23]。也有臨床研究在手術中進行

62、了切斷環(huán)狀韌帶[21, 24, 25]、切除滑囊[24, 27]或滑膜[25]、松解關節(jié)囊[47, 50]的處理。Rayan G M等[36]則對伸肌總腱進行了V-Y延長來治療網球肘，國內也有類似的對ERCB進行“z”形延長的手術[30]。,手術效果評價,當前，不同臨床研究中對于網球肘術后效果評價的指標各不相同，參考2000年以后（含2000年）有關網球肘切開治療的臨床研究，評價指標有以下幾種（見表5）。,,,對術后疼痛緩解的評估包括V

63、AS評分[11, 23, 45]、疼痛評級[37]或者不作評分，僅用是否緩解[30, 33, 38]來判斷，但采用VAS評分者占多數。同樣，對肘關節(jié)功能恢復的評價通常采用Mayo12點評分[20, 25, 29]，但也有采用其他評價標準的[37]，此外，Ruch D S等[18]則用肘關節(jié)活動度來作為評判標準。握力的恢復也是許多國外臨床研究中關注的焦點，有許多研究采用了此項評價指標[18, 20, 22]。有的學者也將患者的滿意度列為研

64、究中衡量手術效果的標準[11, 37, 44]。Nirschl等[19]在其研究中，將患者手術效果分為了優(yōu)（excellent）、良（good）、中（fair）和差（failure）四組，之后有很多臨床研究也采用了該評級系統(tǒng)，但部分研究[14]評級標準有所不同。國內部分學者采用了治愈率或有效率作為評判標準[12, 16]，但是國外該項標準應用較少[24]。國外也有一部分學者采用DASH評分或QuickDASH評分[18, 23, 47,

65、 50]。此外，國內和國外分別各有一篇臨床研究采用恢復時間評價手術效果，包括恢復日?；顒訒r間、重返工作時間和重返運動時間[11, 24]。除了上述評價指標，還有許多評分標準，如Das和Maffulli綜合評分[11]、Oxford Elbow評分[25]、Hospital for Special Surgery評分[20]、Roles & Maudsley 評分[40, 45]、Nirschl tennis elbow評分[44

66、]、American Shoulder and Elbow Surgeons評分[44]、Numeric Pain Intensity Scale pain評分[44]、Andrews-Carson評分[41]、Morrey評分[40]、Broberg and Morrey評分系統(tǒng)[23]等，但使用較少。,VAS評分,visual analogue scale (VAS: 0 = no pain, 10 =unbearable pai

67、n) at rest, during daily activities, and duringsports or work.,非VAS評分,不做評分,Nineteen patients, including one who was unavailablefor the current follow-up evaluation but with detailedinformation on his first year recove

68、ry process, reportedpain disappearance by on average 3 months aftersurgery (range 1–12 months).Results: Eighteen patientsreported recovery from pain,,18例(72％)從不疼痛或偶爾疼痛，4例(16％)輕日?；顒訒r疼痛，3例(12％)重活動時疼痛；,,術后全部病人即感原有疼痛消失。

69、,Mayo12點評分,the Mayo ElbowPerformance Score (MEPS).11 The MEPS considersfour areas: pain, stability, range of movement and function,giving a total score out of 100; the higher thescore, the better the outcome. If the

70、total scorefalls between 90 and 100 points, it is considered excellent;between 75 and 89 points, it is considered good;between 60 and 74 points, it is considered fair; less than60 points, it is considered poor.12–15,