网球肘手术治疗与效果评价

网球肘手术治疗与效果评价2013级临床5班弓伊宁2016.11.13什么是网球肘网球肘肱骨外上髁炎桡侧腕短伸肌腱病肘关节外侧腱病近侧腕伸肌腱病历史发展1873年由RungeF报道--writer’scramp1883年MajorHP将其命名为“网球肘”1933年Hohmann第一次行手术治疗网球肘1979年Nirschl：现行大多数手术起源1982年BaumgardandSchwartz：经皮简介该病在人群中的发病率大约为1.3%，而且不仅发生于网球运动员，普通人也可以出现网球肘，尤其是那些吸烟、肥胖与从事重体力劳动的人群，网球运动员仅占了10%[5]。但是，有50%的网球运动员会发生肘关节的疼痛，在各种原因中网球肘占75%。非网球运动员网球运动员对于网球肘，90%的人经保守治疗可好转[6]，包括休息、使用支具、物理治疗、体外冲击波治疗、注射治疗、经皮超声腱切断术、细胞再生治疗等[7]。当保守治疗失败后，应当考虑手术治疗。对于保守治疗的时间，不同的学者说法不一，有的人认为应当经过6~12个月[10]或者至少6个月[8]的保守治疗，有的认为应该至少9个月，尤其是在这期间经过三次以上激素治疗无效的[9]。Althoughmostpatientsrespondtonon-operativemanagement,surgicaltreatmentisnecessaryinsomecases.Thenumberofpatientsrequiringsurgeryvaries.BoydandMcLeodreportedthat4%~11%requiredoperativemanagement;astudybyBowenetalreportedthat25%ofpatientsrequiredoperativemanagementfordisablingrefractorysymptoms.无论国内还是国外，现在大多数人都将网球肘的手术治疗分为切开治疗、关节镜下治疗、经皮治疗三种治疗方式[1,7,9]。然而，网球肘的发病机制至今还不是很清楚，所以，根据不同的假说，又可以将手术治疗分为不同的治疗方式。•穿出伸肌总腱微血管神经束切断术•桡神经肱桡关节支及肱骨外上髁支切断术•环状韧带切除移位术•伸肌总腱附着处剥离术伸肌总腱起始部损伤学说环状韧带创伤性炎症变性学说微血管神经卡压学说桡神经分支受累学说基于不同假说的手术治疗分类对伸肌总腱、ERCB、ERCL、EDC等的处理。对微血管神经束的处理对桡神经分支的处理对环状韧带、滑膜等的处理对伸肌总腱、ERCB、ERCL、EDC等的处理。经典的NIRSCHL术式对伸肌总腱的处理经典的NIRSCHL术式Agentlycurvedincisionapproximately7.6centimeterslongismade,extendingfrom2.5centimetersproximaltothelateralepicondyletofivecentimetersdistaltoit.Thedeepfascia,whichliesimmediatelyovertheextensoraponeurosis,isincisedandgentlyretracted.Theextensorcarpiradialislongusformsaninterfacewithandliesdirectlyanteriortotheextensoraponeurosis（腱膜）.Ahemostat（止血钳）identifiestheinterfacebetweentheextensorlongusandtheextensoraponeurosis.Thearrowidentifiesthelateralepicondyle.Muscletissueoftheextensorlongusisvisibleanteriortothehemostat.Theextensorlongusisdissectedfromthelateralepicondyletotheradialheadwithascalpelandscissors.Releaseandretractionoftheextensorcarpiradialislongusfromtheanterioredgeoftheextensoraponeurosisthenrevealstheoriginoftheextensorcarpiradialisbrevis.Inspectionofthetendon’ssuperficialsurfaceusuallyrevealsgrossalterationinthetendon.Allfibrousandgranulationtissueisexcisedsharplyandremoved.Asmallopeningismadeinthesynovialmembraneifoneisnotalreadypresent,sothatthelateralcompartmentofthejointcanbeinspected.Ifexcessorabnormalsynovialfluidispresent,widerexplorationisundertaken.Thissituationoccursinfrequently,however.IffurtherinspectionrevealsanyalterationoftheAntenoredgeoftheextensordigitorumcommunisaponeurosisoroftheextensorcarpiradialislongus,thisgranulationtissueisremovedaswell.Evidenceofmajorpathologicalprocessesineitherareahasbeenunusual.Thelesionisresected.Adefectisleftafterresectionoftheproximalpartoftheextensorbrevistendon.Theaponeurosisisretractedbythelowerretractor（牵开器）anditsattachmenttothelateralepicondyleisnotdisturbed.Completeremovaloftheabnormalgranulationtissuegenerallyencompasses75percentoftheoriginoftheextensorbrevis(fromthelateralepicondyletothejointline（合模线）).Theremainingpartoftheextensorbrevistendondoesnotretractbecauseofclosefascialadherencetotheextensorlongusmuscle.Toensureimprovedbloodsupply,asmallareaoftheexposedlateralcondyleisdecorticatedwithanosteotomeorbydrillingmultiplesmallholes.Itshouldbeemphasizedthatsincetheextensoraponeurosishasnotbeenreleasedandthelateralepicondyleisfullycoveredbysofttissue,thedecorticationisdoneanteriorandslightlydistaltothelateralepicondyle.Thetechniqueforrepairisquitesimple,astheextensorbrevisorigindoesnotretractandsutureisnotnecessary.Theinterfacebetweentheextensorcarpiradialislongusandtheanterioredgeoftheextensoraponeurosisisrepairedwitharunning0chromicsuture.Thesubcutaneousandskinlayersareclosedwithasubcuticular3-0polyethylenesutureandSteri-strips（免缝胶带）.对伸肌总腱的处理肘外侧小切口伸肌总腱切断：手术方法:患者仰卧手术台上,患肢外展90度,常规消毒铺巾,局部浸润麻醉,在肱骨外上髁远侧0.5CM处行横行小切口约1~1.5CM,切开皮肤及皮下组织直达伸肌总腱止点处,在止点远侧0.5CM处切断伸肌总腱,周围组织稍加分离,压迫伤口止血后,切口缝合2针,绷带稍加压包扎,术后三角巾悬吊患肢1周,口服抗生素、止痛剂,12D拆线,患肢进行功能锻炼。Theanconeusmuscleflaphasbeenelevatedoffitsinsertionontheulna（尺骨）androtatedoverthedefectinthecommonextensororigin.Theleftsideofthephotographisproximalandtherightsideisdistal.伸肌总腱清理伴旋转肘肌Undertourniquetcontrol,a5-cmlateralincisionismadeovertheepicondyleandcarrieddistallytowardtheinsertionoftheanconeusmuscleontheulna.Subcutaneousdissectioniscarriedouttoexposetheanconeusmusclefromitsoriginonthelateralepicondyletoitsinsertionontheulna.Aftertheanconeusisexposed,debridementofthecommonextensororiginiscarriedoutasdescribedforpatientsingroup1.Theanconeusisthensharplyelevatedfromitsinsertiondistallyontheulna.Bydissectionfromadistaltoproximaldirection,themuscleiselevatedofftheulna.Theanconeusisthenrotatedintothedefectcreatedbytheexcisionofthedegenerativetissuefromthecommonextensororiginandsuturedintoplacewithabsorbablesutures.Theflapislooselyinsetwith2suturesplaced1cmdistaltothetipoftheflapandsecuredanteriorlytotheepicondyle,thusprovidingcoverageofthecommonextensorrepairandthebone.对微血管神经束的处理伸肌总腱深处有一细小的微血管神经束，从肌肉、肌腱发出，穿过肌筋膜或肌腱膜进入皮下。压痛点就在微血管神经束穿过肌筋膜处，微血管神经束在此受到卡压[16]。所以，有学者认为切除神经血管束，即显微手术可以治疗该疾病[12,21,22]。以肘关节外侧压痛点最明显部位为中心，在局麻下(或臂丛麻醉下)，取肱桡关节处斜形切口，长约2~2.5CM，显露前臂伸肌总腱表面。在手术显微镜下，仔细寻找从肌筋膜穿出直径为0.15MM的微血管及直径为0.12MM的小神经束。用显微剪刀将周围疤痕及