外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。

Effectiveness of lateral approach combined with anteromedial approach for the treatment of terrible triad of the elbow injuries

Objective To investigate the outcomes of lateral approach combined with anteromedial approach for the treatment of terrible triad of the elbow injuries. Methods Data of 23 patients with terrible triad of the elbow injuries treated at our hospital using this modified surgical technique from July 2008 to January 2011 were retrospectively analyzed. Two patients lost to follow-up leaving 21 patients (21 elbows) for evaluation. There were 17 males and 4 females with a mean age of 38.4 years (range, 17-63 years). The 21 elbows were treated surgically after a mean of 4 days from the injury. According to O''Driscoll classification of coronoid fractures, there were 5 cases of type A1, 12 of A2, and 4 of B2. According to Mason classification of radial head fracture, there were 2 cases of type I, 12 of II, and 7 of III. According to Zhong Biao classification of soft tissue injury in terrible triad of the elbow, there were 6 cases of type I, 12 of II, and 3 of III. Our surgical procedure included fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial approach. Mayo elbow performance score (MEPS) was determined for each patient at the latest clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis. Results The mean follow-up period was 32 months. At the latest follow-up the mean flexion-extension arc of the elbow was 126° (range, 115°-135°) and the mean forearm rotation was 139° (range, 125°-145°）. The mean MEPS was 95 points (range, 85-100 points), with 19 excellent Results and 2 good Results . Concentric stability was restored in all cases. Early post-operative complication occurred in one patient as a wound infection, which healed uneventfully after surgical debridement and antibiotic therapy. Late post-operative complication occurred in four patients including two cases of heterotopic ossification, 1 case of radial head nonunion, and one case of ulnar nerve neuropathy, but none of them required additional surgery. Conclusion Lateral approach combined with anteromedial approach for terrible triad of the elbow provided both bony and soft-tissue stability, thereby allowing early active motion as well as functional recovery of the elbow.