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,肘关节外侧疼痛最常见病因之一！,历史发展,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%。,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612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。,Although most patients respond to non-operative management, surgical 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 operative management for disabling refractory symptoms.,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。,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。,经典的Nirschl术式对伸肌总腱的处理,经典的Nirschl术式,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 liesimmediately 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（止血钳） identifies 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 dissected 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 of the extensor carpi radialis brevis .,Inspection of the tendons superficial surface usually reveals gross alteration in the tendon .,All fibrous and granulation tissue is excised sharply and removed . A small opening 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 situation 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 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 retracted by the lower retractor（牵开器） 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 brevis (from the lateral epicondyle to the joint line（合模线）). 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 supply, 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 epicondyle 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 suture 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 with a subcuticular 3-0 polyethylene suture and Steri-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11.5cm,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。,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 is proximal and the right side is distal.,伸肌总腱清理伴旋转肘肌,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. Subcutaneous 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 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 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 to the tip of the flap and secured anteriorly to the epicondyle, thus providing coverage of the common extensor repair and the bone.,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22.5 cm，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0.15 mm的微血管及直径为0.12 mm的小神经束。用显微剪刀将周围疤痕及粘连进行松解并修整好，切断神经前先用1%利多卡因注射、封闭，再锐性切除穿出的一段神经，血管予以11-0手术线在显微镜下结扎止血，并将神经支残端近端常规用多余的神经外膜包埋残端，有时切断神经后神经外膜不够包埋，用周围剪下的小而薄的筋膜包裹后用11-0手术线进行显微缝合处理，缝合在近端神经鞘膜上，神经血管束近端均埋于肌腹处，可防止神经瘤发生。最后缝合皮下组织、皮肤各23针，可放置小皮片引流。,陆晓文等22将显微手术与伸肌总腱起点松解术进行比较，结果显示二组疗效无显著差异,而且认为前臂伸肌总腱起点剥离、松解术手术不但造成肌肉、肌腱及环状韧带的损伤,还造成肘关节损伤、肱骨外上髁骨性损伤,手术创伤大,并发症也较多，而显微松解、切断神经支手术不但疗效非常显著而且创伤小、疗程短、恢复快。,对桡神经分支的处理,解剖学研究显示，前臂后皮神经的分支通过肱骨外上髁，而疼痛则是通过神经传入中枢，所以，切除桡神经分支对于缓解网球肘引起的疼痛会产生一定效果23。,Skin drawing of the branches from the posterior cutaneous nerve of the forearm innervating the lateral epicondyle.,切除前臂后皮神经的后支,Anatomic dissection of the branches from the posterior cutaneous nerve of the forearm innervating the lateral epicondyle. The actual surgical incision is 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 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 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 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 distinguish 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 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 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 distinguish 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 appropriately 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 PBPCNF 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 magnification.,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 lateral 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 innervation 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 finger 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 radial blood vessels, the aponeurosis proximal to ECRB, the arcade of Frhse 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. The arm was kept in a sling for 7 days.,对环状韧带、滑膜等的处理,现有的临床研究很少有单纯处理环状韧带以及滑膜等的，大多与其他的手术方法合并使用。如Reddy V R M等25在切除环状韧带与滑膜的同时也对伸肌总腱进行了松解。而Jeavons R等26则同时做了ECRB的清理和环状韧带与滑膜的切除。除了联合处理肌腱，陆晓文等22在切除神经血管束时也进行了环状韧带的切除。,Reddy 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. Adequate 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 removed. 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 23 drill holes. Finally, the common extensor tendon issutured back to the lateral epicondyle.,Jeavons R等,The BoydMcLeod technique, as utilized by the senior author (NB), involved a 5-cm longitudinal incision centred over the lateral epicondyle. Sharp dissection down to the muscle 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 degenerate 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 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 then debrided, decorticated using an osteotome and decompressed by drilling several holes with 2.0-mm K-wire.,陆晓文等,手术在臂丛麻醉下进行,从肱骨外上髁向后做7 cm长切口,切开深筋膜将外上髁的伸肌向下剥离,宽度约115 cm,再将环状韧带的近侧半切断,外上髁凿去015 cm并挫平,然后将剥离的肌腱重新缝合到外上髁软组织上。,近年来关于网球肘切开治疗的临床研究,本文重点探讨切开手术的临床研究。笔者检索了中国知网、万方、维普、Pubmed、Sciencedirect、SpringerLink六个数据库，并从相关文献的参考文献中寻找与本文有关的临床研究，现将2000年以后（含2000年）的有关网球肘切开治疗的临床研究，参考Wright等27介绍的证据水平分级将相关研究依年代顺序列举如下。,临床研究检索策略,专业检索语：中文：(网球肘Title/Abstract) OR (肱骨外上髁炎Title/Abstract) OR (肘关节外侧腱病Title/Abstract) AND 切开手术Title/Abstract)；英文：(tennis elbowTitle/Abstract) OR (lateral epicondylitisTitle/Abstract) OR (Lateral elbow tendinopathy Title/Abstract) AND (open surgeryTitle/Abstract),中国知网,47篇,万方,14篇,维普,6篇,pubmed,34篇,springer,47篇,Science direct,39篇,相关推荐文章其他文章（article+review）中的参考文献,文章等级评定,术中手术方案,2000年以后（含2000年）有关网球肘切开治疗的临床研究一共35篇，国内13篇，国外22篇，其中有一篇未提供手术例数，仅提供了手术治疗肘数，余临床研究例数合计1449例。在国内的13篇临床研究中，分别有4篇（30.8%）和5篇（38.5%）对ECRB和伸肌总腱进行了处理，并且有1篇（7.7%）对ECRL也进行了处理；而国外的22篇临床研究中并无处理ECRL的报道，但是除了分别有9篇（40.9%）和10篇（45.5%）处理ECRB和伸肌总腱外，还有2篇（9.1%）临床研究中处理了EDC，1篇（4.5%）临床研究中处理了肘肌。对于神经血管束的处理，国内一共有8篇（61.5%）临床研究，而国外的研究并未涉及。国内和国外都有对桡神经分支处理临床研究，分别有1篇（7.7%）和3篇（13.6%）。至于文中上述提到的对环状韧带、滑膜等的处理，也有一些研究报道，国内有3篇（23.1%）研究处理了环状韧带，2篇研究处理了滑囊（15.4%），而国外分别有2篇（9.1%）、1篇（4.5%）、1篇（4.5%）和2篇（9.1%）研究对环状韧带、滑膜、滑囊和关节囊进行了处理。此外，另有两篇研究中并未提及所处理的结构。具体情况如下（见表3）。,对于各临床研究中手术涉及到的处理措施笔者也进行了统计（见表4）。无论国内还是国外，清理、松解、钻孔均占据了一定的比例，分别有9篇（69.2%）、3篇（23.1%）、3篇（23.1%）国内临床研究和10篇（45.5%）、11篇（50.0%）、6篇（27.3%）国外临床研究中进行了这三项处理。而且国外进行去皮质的临床研究数量和比例均大于国内，国内和国外分别有9篇（40.9%）和1篇（7.7%）。国内有3篇（23.1%）研究进行了止点重建，3篇（23.1%）研究进行了直接缝合，2篇（15.4%）研究进行了锚钉缝合，而国外的研究中分别有5篇（22.7%）和2篇（9.1%）进行了止点重建和锚钉缝合，无进行直接缝合的报道。而且国内有2篇（15.4%）研究进行了伸肌总腱起点剥离，7篇（53.8%）研究进行了神经血管束切断的处理，国外也没有相应的研究。对于桡神经分支的处理也采用切除的方式，分别有1篇（7.7%）国内研究和3篇（13.6%）国外研究对此进行了报道。同样，国内有3篇（23.1%）研究进行了切除环状韧带，有2篇（15.4%）研究进行了切除滑囊，国外进行切断环状韧带、切除滑囊、切除滑膜和松解关节囊的研究分别有2篇（9.1%）、1篇（4.5%）、1篇（4.5%）和2篇（9.1%）。此外，国外还有1篇（4.5%）研究中对伸肌总腱进行了V-Y延长。,从上表可以看出经典的Nirschl手术中提到的清理病变组织、松解伸肌肌腱、外上髁钻孔或去皮质等19仍是当今各手术治疗的重点。部分学者对于清理病变组织后留下的伸肌腱裂隙进行了直接缝合或者锚钉缝合11, 41。关于止点重建，大部分学者采用将剥离或松解后的肌腱重新缝回外上髁21, 24, 42，也有人将松解后的肌腱与肘肌或肱三头肌进行缝合20。支持微血管神经卡压学说的学者，则在手术中着重进行了神经血管束的切断，之后进行血管结扎止血与神经包埋12, 28, 31。对于桡神经分支的切除，可以有不同的选择，比如PBPCNF22或PIN23。也有临床研究在手术中进行了切断环状韧带21, 24, 25、切除滑囊24, 27或滑膜25、松解关节囊47, 50的处理。Rayan G M等36则对伸肌总腱进行了V-Y延长来治疗网球肘，国内也有类似的对ERCB进行“z”形延长的手术30。,手术效果评价,当前，不同临床研究中对于网球肘术后效果评价的指标各不相同，参考2000年以后（含2000年）有关网球肘切开治疗的临床研究，评价指标有以下几种（见表5）。,对术后疼痛缓解的评估包括VAS评分11, 23, 45、疼痛评级37或者不作评分，仅用是否缓解30, 33, 38来判断，但采用VAS评分者占多数。同样，对肘关节功能恢复的评价通常采用Mayo12点评分20, 25, 29，但也有采用其他评价标准的37，此外，Ruch D S等18则用肘关节活动度来作为评判标准。握力的恢复也是许多国外临床研究中关注的焦点，有许多研究采用了此项评价指标18, 20, 22。有的学者也将患者的满意度列为研究中衡量手术效果的标准11, 37, 44。Nirschl等19在其研究中，将患者手术效果分为了优（excellent）、良（good）、中（fair）和差（failure）四组，之后有很多临床研究也采用了该评级系统，但部分研究14评级标准有所不同。国内部分学者采用了治愈率或有效率作为评判标准12, 16，但是国外该项标准应用较少24。国外也有一部分学者采用DASH评分或QuickDASH评分18, 23, 47, 50。此外，国内和国外分别各有一篇临床研究采用恢复时间评价手术效果，包括恢复日常活动时间、重返工作时间和重返运动时间11, 24。除了上述评价指标，还有许多评分标准，如Das和Maffulli综合评分11、Oxford Elbow评分25、Hospital for Special Surgery评分20、Roles & Maudsley 评分40, 45、Nirschl tennis elbow评分44、American Shoulder and Elbow Surgeons评分44、Numeric Pain Intensity Scale pain评分44、Andrews-Carson评分41、Morrey评分40、Broberg and Morrey评分系统23等，但使用较少。,VAS评分,visual analogue scale (VAS: 0 = no pain, 10 =unbearable pain) at rest, during daily activities, and duringsports or work.,非VAS评分,不做评分,Nineteen patients, including one who was unavailablefor the current follow-up evaluation but with detailedinformation on his first year recovery process, reportedpain disappearance by on average 3 months aftersurgery (range 112 months).Results: Eighteen patientsreported recovery from pain,18例(72)从不疼痛或偶尔疼痛，4例(16)轻日常活动时疼痛，3例(12)重活动时疼痛；,术后全部病人即感原有疼痛消失。,Mayo12点评分,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 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.1215,肘关节功能评级,肘关节活动度,握力,Grip strength of 10 patients in group 1 and 11 patients ingroup 2 was measured at final follow-up by a Jamardynamometer (Patterson Medical, Warrenville, IL, USA)with the elbow flexed and extended.assessment.23 Grip strengths of both hands were measured witha Jamar hydraulic hand dynamometer (Sammons Preston Rolyan,Bolingbrook, IL) with the patient blinded to the display,满意度,满意度：非常满意1分；部分满意2分；不满意3分。,优良率,excellent, full return to all activitywith no pain; good, full return to all activity with occasionalmild pain; fair, normal activity with no pain, sig