游离肌腱填塞对月骨摘除术后腕关节功能影响及疗效分析

发布时间：2018-05-08 15:09

本文选题：月骨 + 游离肌腱　；参考：《河北医科大学》2015年硕士论文

【摘要】：目的:月骨无菌性坏死又称Kienbock病,好发于青壮年优势腕,病因至今不明,可分为内因和外因,是多种因素共同作用导致的结果,随着现代影像学技术的发展,临床诊断较为明确,但治疗方案多样化。根据临床分期,月骨无菌性坏死早期可行保守治疗,而大量文献资料报道,多数晚期病人均需通过手术治疗,且手术方案繁多,主要分为生物学手术、生物力学手术、月骨单纯摘除和月骨替代术、近排腕骨切除术及桡腕关节融合术。目前较为常用的治疗晚期月骨无菌性坏死的术式是月骨摘除游离肌腱填塞术,常选择掌长肌腱腱球作为月骨替代物,但对于填塞后能否确保腕关节稳定性及功能恢复,腕部解剖关系的改变是否会造成新的腕部创伤,至今显有报道,因此我们考虑能否通过分析比较在治疗晚期月骨无菌性坏死的过程中采取或未采取游离肌腱填塞的患者临床资料随访,探讨肌腱填塞后对腕关节稳定性及功能的影响。对比两种治疗晚期月骨无菌性坏死的术式,为临床工作中肌腱切除的必要性及切除后肌腱填塞的效果提供一定的参考依据,为月骨无菌性坏死的治疗提供更好的选择。方法:研究对象:根据研究的需要制定出病例选择标准:①根据患者病史、体格检查、X线及CT三维成像技术,确诊为晚期月骨无菌性坏死的患者②按照临床常用的Lichtman分期,病情属Ⅲ、Ⅳ期患者③无中枢系统疾病或其他腕关节损伤性疾病④无代谢性疾病、无患侧腕关节炎症、腕部骨折及脱位病史、手术史的患者⑤无影响手术治疗的全身性疾病。我们将选择回顾河北医科大学第三医院自2005-2014过去9年内所收治的月骨无菌性坏死患者共55例,其中早期患者10例(Ⅰ期、Ⅱ期),不作为此次研究对象。将符合上述筛选标准的晚期月骨无菌性坏死患者45例,共计45侧,所有检查患者中右手为优势手40例,左手5例。分为对照组:行单纯月骨摘除术20例(20侧)。研究组:行月骨摘除掌长肌腱填塞术25例(25侧),平均随访时间为术后6个月~9年,分别测定两组患者Cooney评分,术前及术后改良腕高率、改良腕高指数,并利用上肢功能障碍评定量表(PRWE)评定患者术后生活质量,所测得的数据采用SPSS21.0统计学软件进行分析。计量资料用χ—±S表示,组间比较采用t检验及秩和检验。结果:1一般结果两组患者共45例(45侧),通过门诊随访,其中行传统单纯月骨摘除术20例(20侧),行月骨摘除游离掌长肌腱填塞术25例(25侧),患者住院时间平均15天,手术切口均未出现感染、血肿、皮缘坏死、瘢痕粘连等并发症,平均拆线时间12天,均达到一期愈合,术后随访无一例患者出现腕关节功能障碍,正中神经卡压,畸形及疼痛加重等并发症,所有获得随访患者临床症状均有不同程度的改善,腕关节屈伸活动范围及患肢握力值较术前明显增大,腕部正中神经Tinel征(-)。2疗效评价、改良腕高率及改良腕高比值的测定2.1疗效评价按照Cooney腕关节评分法,传统单纯月骨摘除术组:优12例,良4例,可3例,差1例,优良率80%。月骨摘除游离掌长肌腱填塞组:优20例,良3例,可2例,差0例,优良率92%,两组患者手术疗效优良率比较差异无统计学意义(P0.05)。2.2改良腕高率及改良腕高指数的测定本次研究中采用Nattran提出的改良腕高率及改良腕高指数作为术后腕骨排列是否紊乱的测定标准,分别测定两组患者术前、术后改良腕高率及改良腕高指数。术前两组患者改良腕高率测定结果比较差异无统计学意义(P0.05)。术前两组患者改良腕高指数测定结果比较差异无统计学意义(P0.05)。术后两组患者改良腕高率测定结果比较差异有统计学意义(P0.05)。术后两组患者改良腕高指数测定结果比较差异有统计学意义(P0.05)。3患者PRWE评分测定根据Mac Dermid提出的PRWE(Patient-Rated Wrist Evaluation)腕关节功能评分,术后随访两组患者PRWE评分比较差异有统计学意义(P0.05)。结论:1对于晚期月骨无菌性坏死病人行月骨摘除游离掌长肌腱填塞术是一种有效的手术方法。2腕月骨摘除后游离掌长肌腱填塞术疗效确切,手术操作简便,创伤小,患者恢复时间短,花费少,可做为晚期月骨坏死病人首选术式。3填塞肌腱对腕骨稳定性有一定的支撑作用,可防止腕骨排列的紊乱。
[Abstract]:Objective: the aseptic necrosis of the moon bone, called Kienbock's disease, is well distributed in the dominant wrist of the young and middle-aged. The cause of the disease is not clear so far. It can be divided into internal and external causes. It is the result of a variety of factors. With the development of modern imaging technology, the clinical diagnosis is more clear, but the treatment scheme is diversified. According to clinical stages, the early osteonecrosis of the bone is possible. Conservative treatment, and a large number of literature reports, most advanced patients need surgical treatment, and there are various surgical procedures, mainly divided into biological surgery, biomechanical surgery, bone removal and bone replacement, near row carpal and radial wrist arthrodesis. The most commonly used treatment of advanced osteonecrosis of the moon bone is currently used. There is a report on whether the change of the wrist anatomical relationship will cause a new wrist trauma, but we consider whether or not it is possible to treat the late month bone by analysis and comparison. In the process of bacterial necrosis, the clinical data of patients with or without free tendon tamponade were followed up to explore the effects of tendon tamponade on the stability and function of the wrist. Two methods for the treatment of advanced osteonecrosis of the moon were compared to provide a certain reference for the necessity of tendon excision and the effect of the tendon tamponade in the clinical work. To provide a better choice for the treatment of aseptic necrosis of the bone. Methods: according to the needs of the study, the case selection criteria were established: (1) patients with advanced aseptic necrosis of the bone were diagnosed according to the patient's history, physical examination, X - ray and CT three-dimensional imaging techniques, according to the commonly used Lichtman staging. There is no metabolic disease, no metabolic disease, no lateral wrist inflammation, wrist fracture and dislocation, and no surgical history of patients with systemic disease. We will choose to review the Third Hospital of Hebei Medical University since 2005-2014 for the past 9 years. There were 55 cases of bacterial necrosis. 10 of the early patients (stage I, stage II) were not the subject of this study. 45 patients with advanced osteonecrosis of the month bone, which were in line with the above screening criteria, total 45 sides, 40 cases of the right hand and 5 left hand in all patients, were divided into the control group: 20 cases (20 sides) were performed simple months of bone extirpation. The study group: A Study Group: 25 cases (25 sides) of long term tendon tamponade were removed. The average follow-up time was 6 months ~9 years after the operation. The Cooney score was measured in two groups of patients. The rate of wrist height was improved before and after the operation, the wrist high index was improved, and the quality of life after the operation was evaluated by the upper limb dysfunction rating scale (PRWE). The measured data were measured by SPSS21.0 statistics software. The measurement data were expressed with chi square S, and the t test and rank sum test were used in the group. Results: 45 cases (45 sides) were compared with 45 cases (45 sides). 20 cases (20 sides) were performed traditional simple monthly bone extirpation and 25 cases (25 sides) were removed with free metacarpal long tendon. The average hospitalization time was 15 days, and all the surgical incisions were in the patients. There was no infection, hematoma, necrosis of skin margin, scar adhesion and other complications. The average time of breaking the line was 12 days. All patients were followed up with one stage healing. None of the patients were followed up with wrist joint dysfunction, median nerve compression, malformation and aggravation of pain. All patients were followed up with different degrees of improvement in clinical symptoms and flexion and extension of wrist joint. The dynamic range and the value of the grip strength of the affected limb were significantly higher than that before the operation. The evaluation of the effect of the median nerve Tinel sign (-).2 of the wrist, the improved wrist high rate and the improved wrist high ratio were evaluated according to the Cooney wrist joint scoring method and the traditional simple month bone extirpation group: excellent 12 cases, good 4 cases, 3 cases, 1 poor cases, and excellent rate of 80%. month bone removal free palmar long muscle tendon tamponade Group: excellent 20 cases, good 3 cases, 2 cases, poor 0 cases, good rate 92%, two groups of patients have no significant difference in operation effect (P0.05).2.2 improved wrist high rate and improved wrist high index measurement in this study using Nattran proposed improved wrist high rate and improved wrist high finger number as the postoperative carpal arrangement disorder determination criteria, The improved wrist high rate and improved wrist height index were not measured before operation in the two groups. There was no significant difference between the two groups before the operation (P0.05). There was no significant difference between the two groups before the operation of improved wrist height index (P0.05). The results of the improved wrist high rate in the two groups were different after the operation. There was statistical significance (P0.05). The results of improved wrist height index in two groups were statistically significant (P0.05) the PRWE score of.3 patients was measured according to the PRWE (Patient-Rated Wrist Evaluation) wrist joint function score based on Mac Dermid, and there was a significant difference in PRWE score between the two groups of patients after the operation (P0.05). Conclusion: 1 For patients with advanced osteonecrosis of the bone, free palmar long tendon tamponade is an effective operative method for the patients with osteonecrosis of the bone. The free palmar long tendon tamponade after.2 wrist extirpation is effective. The operation is simple, the trauma is small, the recovery time is short, and the cost is less. It is the first choice of the surgical.3 tamponade to the wrist in the late month of the osteonecrosis patients. Bone stability has a certain supporting function to prevent the disorder of carpal arrangement.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.4

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