肌腱—骨复合组织移植治疗夹板固定失败后的锤状指

发布时间：2018-10-13 12:12

【摘要】：锤状指是手指终腱及伸肌腱止点因突然的暴力擢伤,如生活和工作中的意外(打球、挤压、暴力冲击),手指末节屈曲而发生的断裂,由于屈肌力量大于伸肌力量,造成屈伸力量不平衡,手指远端指间关节屈曲畸形。随着时间延长,畸形会逐渐加重,引起患指疼痛、功能活动受限和生活不便。最大限度的恢复手指的功能与缓解疼痛。是该研究的主要目的。锤状指最好的治疗方法是夹板固定,但不是每一个患者都能成功。多因残存着不同程度伸指功能受限而不满意。归其原因多为夹板固定的范围不够,未固定掌指关节和腕关节不合理的随意活动,使肌腱断端间隙增大,而被瘢痕纤维组织桥接,影响伸肌腱的肌肉-肌腱-骨的力臂结构,其延长使力学效应减弱,伸指功能仍然受到限制。加之患者不规范或不正确的使用夹板,过早去除往往也是治疗失败的原因,使肌腱断端愈合不牢靠,肌腱断裂再次发生,成为陈旧性锤状指。如果病人保守治疗失败,就需要手术治疗。虽然各种手术技术已广泛使用,但这些治疗技术仍存在很多争议。外科医生试图将肌腱指点重建,但失败可能性很大。原因在于肌腱与骨骼之间存在一个间隙,即使在肌腱松解和指间关节过伸位置的情况下,在这个间隙任然存在。Levante建议把肌腱的指点缝合在甲床末梢的周围组织上,在一些患者中获得成功。腱—骨愈合为不同种组织间愈合,这一过程慢且不可靠,与同种组织间愈合相比要慢很多(如肌腱与肌腱愈合,骨与骨愈合)。综上所述,锤状指畸形就会再次发生。本课题主要介绍通过肌腱—骨复合组织,移植治疗打夹板治疗失败以后剩余角度大于25°的锤状指,评价其可行性及有效性。肌腱—骨复合组织是由桡侧腕短伸肌与第三掌骨基底部组成,通过该移植物重建止点,来治疗夹板固定失败后的锤状指。目的:为了探讨肌腱—骨移植组织治疗夹板固定失败后的陈旧性腱性锤状指的手术方法与临床效果。从2010年1月到2012年3月共有28例锤状指患者接受治疗,所有的患者均为在夹板固定了6—8周以后,末节指间关节伸指受限角度仍大于25°,其中还有4位患者进行了第二次夹板固定,治疗仍然失败。采用肌腱—骨复合组织移植物,移植治疗夹板固定失败后的锤状指。肌腱—骨移植物是由桡侧腕短伸肌与第三掌骨基底部组成,用来重建止点。受伤与手术的时间平均为74天(53-105天),术前平均伸展受限角度为34°,5名患者远指间关节伴有疼痛。最后对患者进行随访评价。患者远指间关节和腕关节的疼痛程度采用视觉量表评价,关节活动度采用crawford标准进行分级,手功能的评定采用disabilitiesoftheshoulder,arm,andhand(dash)问卷,外观满意程度根据密歇根大学的手问卷调查结果。术前还观察到有4根手指为天鹅颈畸形。术前手功能评价通过dash问卷平均得分是3(范围:0-7)。通过密歇根手问卷结果,2例患者对外观非常不满意,19人有点不满意,7人对外观表示不在意,2例患者远指间关节处存在不同程度的疼痛。结果术后28例患指伤口均为Ⅰ期愈合,所有患者平均在5周后达到骨愈合,移植骨未突出末节指骨骨面。后续随访12—18个月,(平均15个月),未发现指甲畸形、未发现远侧指间关节或腕关节疼痛,未观察到有天鹅颈畸形。远指间关节疗(dip)平均屈曲角度是65°(范围57°-75°),对侧指dip测量角度是71°(范围62°-76°)。关节没有过度伸展位,伸展角度是6°(标准差为4°)。远指间关节疗剩余扩展滞后角度为4°(标准偏差为4°)。通过crawford关节活动效果评分调查,28例患指,优24例(86%);良4例(14%),优秀率为86%。通过disabilitiesoftheshoulder,arm,andhand(dash)问卷,平均得分是1(范围0-3)。根据密歇根大学的手问卷调查,27位患者对手外观满意,1位患者对手外观感觉不太满意。本组治疗的28例患者术后随访未发现畸形复发。结论:通过肌腱—骨复合组织移植物移植是治疗夹板固定失败后锤状指的有效可靠的手术方法。其手术治疗独特创新点在于,采用自体肌腱—骨复合组织移植,再造止点,将肌腱—骨愈合界面,转化为容易愈合的肌腱—肌腱和骨—骨界面,由于组织相同,愈合更为可靠快速。我认为肌腱—骨方法:复合组织移植治疗夹板固定失败后的锤状指,其适应征广泛,骨折和畸形愈合等陈旧性锤状指都可以应用,虽然这种手术方法比常规手术多一个腕背部的切口,破坏了桡侧腕短伸肌,术后需要外固定,但其愈合过程相对较快,且不需二次手术,同时配合克氏针固定远指间关节确保愈合固定牢固可靠,为夹板等保守治疗失败后的难治性锤状指提出一种新的治疗方法。
[Abstract]:Hammer refers to the fracture caused by sudden violent injury due to sudden violent injury due to sudden violent injury, such as life and accident (playing, squeezing, violent impact), finger bending and buckling, and because the flexor muscle strength is greater than the extensor force, the flexion and extension force is not balanced, The distal finger of the finger refers to the flexion deformity of the joint. As the time is extended, the deformity will gradually increase, causing pain, limited function, and inconvenience of life. Maximize your finger's function and ease pain. It is the main purpose of this study. Hammer-like means the best treatment method is splint immobilization, but not every patient can succeed. It is not satisfied that the function is limited due to the existence of different degree of extension. due to the fact that the fixation of the splint is not enough, the free movement of the metacarpal bone and the wrist joint is not fixed, the clearance of the broken end of the tendon is increased, and the muscle-tendon-bone force arm structure of the extensor tendon is affected by the bridging of the tendon, and the elongation of the tendon is prolonged, so that the mechanical effect is weakened, extension finger function is still limited. Combined with the patient's irregular or incorrect use of the splint, premature removal is often the cause of failure of treatment, so that the fracture healing of the tendon is not reliable, and the tendon rupture occurs again and becomes an old hammer-like finger. Surgical treatment is required if the patient's conservative treatment fails. Although various surgical techniques have been widely used, there are still many disputes over these techniques. The surgeon attempted to track the tendon for reconstruction, but the probability of failure was great. The reason is that there is a gap between the tendon and the bone, even in the case where the tendon releases and the finger joint overstretched position. Levante recommends suturing the tendon's instructions to the surrounding tissue of the tip of the nail bed to succeed in some patients. Tendon healing is healing for different tissues, which is slow and unreliable, much slower than healing of the same tissue (e.g. tendon and tendon healing, bone and bone healing). To sum up, the hammer-shaped finger deformity will happen again. This topic mainly introduces the feasibility and validity of the hammer-shaped finger with the residual angle of more than 25 掳 after the failure of the treatment of the splint after the failure of the treatment of the splint. The composite tissue of the tendon and bone is composed of the side wrist short extension muscle and the third metacarpal bone base, and a stop point is reconstructed through the graft to treat the hammer-shaped finger after the splint fixation failure. Objective: To investigate the operative method and clinical effect of the old tendon-like finger after splint fixation failure in tendon allograft tissue treatment. From January 2010 to March 2012, a total of 28 hammer-like fingers were treated and all patients had been fixed for 6-8 weeks at the splint, and the finger-to-finger joint extension was still greater than 25 掳, where there were 4 patients who underwent a second splint fixation and the treatment continued to fail. The invention discloses a hammer-shaped finger after fixation failure of a splint by using a tendon and bone-bone composite tissue graft. The tendon and bone graft is composed of the short extension of the wrist and the base of the third metacarpal bone, which is used to reconstruct the stop point. The mean time for injury and surgery was 74 days (53-105 days), and the pre-operative mean extension was 34 掳 and 5 patients were far away from the joints with pain. Finally, the patients were followed up for evaluation. The degree of pain in the patient's distal finger joints and wrist joints was evaluated using a visual scale, and the range of motion was graded according to the crawford standard. The evaluation of hand function was based on the results of the hand survey of the University of Michigan. Four fingers were observed to be swan neck deformity before operation. The average score for preoperative hand function was 3 (range: 0-7). By the results of the Michigan hand questionnaire, 2 patients were very dissatisfied with the appearance, 19 were somewhat dissatisfied, 7 were not interested in appearance, and 2 patients were far from the joints at different levels of pain. Results All the 28 cases were healed with stage 鈪，

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