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  • 腕关节镜监视下腕横韧带松解术治疗腕管综合征的疗效及切口美观度分析

腕关节镜监视下腕横韧带松解术治疗腕管综合征的疗效及切口美观度分析

来源:用户上传      作者:高飞 曹建华 胡永梅

  [摘要]目的:^察腕关节镜监视下腕横韧带松解术治疗腕管综合征的疗效、并发症及切口美观度情况。方法:纳入2019年9月-2020年9月笔者医院收治的90例腕管综合征患者作为研究对象,采用非随机同期对照及患者自愿原则进行分组,观察组52例实施腕关节镜监视下腕横韧带松解术治疗,对照组38例实施开放腕横韧带松解术治疗,术后随访6个月以上。比较两组围术期参数(手术时间及术中出血量),临床疗效,术后并发症发生情况,术前及术后末次随访关节活动度(屈伸活动度、尺桡活动度)和Michigan手功能评分(Michigan hand outcomes questionnaire,MHQ)情况。结果:所有患者均顺利完成手术及随访,观察组平均随访时间(8.72±1.63)个月,对照组平均随访时间(8.90±1.47)个月,组间比较差异无统计学意义(P>0.05)。观察组手术时间短于对照组,术中出血量小于对照组差异有统计学意义(P<0.05)。两组总体疗效优良率比较差异无统计学意义(P>0.05)。观察组疼痛性瘢痕及并发症总发生率均低于对照组,差异有统计学意义(P<0.05)。两组术后末次随访屈伸活动度、尺桡活动度均较术前提高,且观察组高于对照组,差异有统计学意义(P<0.05)。两组MHQ疼痛评分均较术前降低,且观察组低于对照组;切口美观度、日常生活、总体满意度评分均较术前提高,且观察组高于对照组,差异有统计学意义(P<0.05)。结论:腕关节镜监视下腕横韧带松解术治疗腕管综合征可获得与开放腕横韧带松解术相当的疗效,但并发症更少,术后远期关节活动功能恢复更佳,切口美观度、患者满意度更高。
  [关键词]腕关节镜;腕横韧带松解术;腕管综合征;疗效;并发症;美观度;疼痛
  [中图分类号]R622 [文献标志码]A [文章编号]1008-6455(2022)12-0020-04
  Analysis of Efficacy and Incision Aesthetics of Arthroscopically Monitored Transverse Carpal Ligament Release in the Treatment of Carpal Tunnel Syndrome
  GAO Fei,CAO Jianhua,HU Yongmei
  (Department of Hand Surgery,Beijing Jishuitan Hospital,Beijing 100035,China)
  Abstract: Objective To observe the efficacy, complications and incision aesthetics of arthroscopically monitored transverse carpal ligament release in the treatment of carpal tunnel syndrome. Methods 90 patients with carpal tunnel syndrome in the hospital between September 2019 and September 2020 were enrolled as research subjects, and they were grouped according to the non-randomized concurrent control and principle of voluntariness of patients. 52 patients in the observation group underwent transverse carpal ligament release under wrist arthroscopic monitoring, and 38 patients in the control group underwent open transverse carpal ligament release, and they were followed up for more than 6 months after surgery. The perioperative parameters (surgical time, intraoperative blood loss), clinical efficacy, occurrence of postoperative complications and joint activity (flexion and extension activity, radioulnar activity) and MHQ score before surgery and at the last follow-up after surgery were compared between the two groups. Results All patients successfully completed the surgery and follow-up, and the average follow-up time was (8.72±1.63) months in the observation group, and was (8.90±1.47) months in the control group, there was no statistically significant difference between groups (P>0.05). The surgical time in the observation group was shorter than that in the control group, and the intraoperative blood loss was less than that in the control group, the differences were statistically significant (P<0.05). The difference in the excellent and good rate of overall efficacy between the two groups was not statistically significant (P>0.05). The incidence rate of painful scars and total incidence rate of complications were lower in the observation group than those in the control group (P<0.05). The flexion and extension activity and radioulnar activity at the last follow-up after surgery were improved in the two groups compared with those before surgery, and the two indicators in the observation group were higher than those in the control group (P<0.05). The pain score of MHQ in the two groups were reduced compared to before surgery, and the score in the observation group was lower compared to the control group (P<0.05). And the scores of incision aesthetics, daily life and overall satisfaction were increased compared to before surgery, and the scores were higher in the observation group compared with those in the control group (P<0.05). Conclusion Arthroscopically monitored transverse carpal ligament release for the treatment of carpal tunnel syndrome can achieve comparable efficacy to open transverse carpal ligament release, but the former one has fewer complications, better postoperative long-term recovery of joint activity, higher incision aesthetics and higher satisfaction of patients.

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  Key words: arthroscopically; transverse carpal ligament release; carpal tunnel syndrome; efficacy; complication; aesthetics; pain
  腕管综合征是一种周围神经卡压性疾病,为骨纤维管道卡压正中神经所致,主要症状表现为手部肌肉萎缩,腕部活动及感觉障碍,影响生活质量[1]。对于轻度腕管综合征患者可采取保守治疗,但中重度患者或保守治疗后反复发作者需实施外科手术治疗,腕横韧带松解术为首选手术方式[2]。传统开放腕横韧带松解术优点为术野清晰,正中神经解压彻底,疗效确切,但其创伤较大,即便已在切口形状、长度方面进行诸多改良,但仍难以避免一系列并发症,包括腕掌部手术瘢痕及疼痛性瘢痕[3]。随着近年来微创技术的发展,腕关节镜在腕管综合征的治疗中开展应用,并得到了广泛认可[4]。本研究旨在对比腕关节镜监视下腕横韧带松解术与开放腕横韧带松解术治疗腕管综合征的疗效、并发症及对切口美观度的影响,具体报道如下。
  1 资料和方法
  1.1 一般资料:纳入2019年9月-2020年9月笔者医院收治的90例腕管综合征患者为研究对象,采用非随机同期对照及患者自愿原则进行分组,观察组52例实施腕关节镜监视下腕横韧带松解术治疗,对照组38例实施开放腕横韧带松解术。两组患者一般资料比较差异无统计学意义(P>0.05),具有可比性,见表1。
  1.2 纳入标准:符合腕管综合征诊断标准[5]且经保守治疗无效;均为单侧发病;符合手术指征;知晓本研究并自愿配合;接受定期随访。
  1.3 排除标准:有既往手腕部创伤或手术史者;痛风、囊肿导致神经压迫者;合并其他周围神经疾病者。
  1.4 手术方法
  1.4.1 观察组:实施腕关节镜监视下腕横韧带松解术。局部麻醉下,患者取仰卧位,患侧大拇指外展。沿尺侧做一横线,由环指桡侧至腕横纹做一垂直线,交点处做其角平分线,延伸1 cm至尺侧,作为腕管出口。以桡侧1.5 cm,豆骨近端1.5 cm作为腕管入口。腕管入口处切开5 mm,钝性分离皮下及粘连组织,置入穿刺锥与带槽套管,经出口穿出。患者维持腕关节背伸位,经套管远端置入关节镜,关节镜下找到腕横韧带,另一端插入钩刀将其推开或切开,此时可见脂肪组织膨入套管中,探钩探查,确保腕横韧带完全切开,确认出血情况,拔除器械,伤口粘贴创口贴,加压包扎。
  1.4.2 对照组:实施开放腕横韧带松解术。局部麻醉下,患者取仰卧位,患侧大拇指外展。于环指桡侧缘延长线、腕部远端交叉处,横切1 cm至屈肌支持带,松解神经,电凝止血后缝合。所有患者均由同一主刀医生完成手术,并配备统一的围手术期管理措施。
  1.5 观察指标:比较两组患者围术期参数、临床疗效、术后并发症发生情况、术前及术后末次随访关节活动度和MHQ评分。①记录两组患者手术时间及术中出血量;②根据Kelly分级评定临床疗效[6]。症状消失为优;症状显著缓解为良;症状轻微改善为一般;症状无改善甚至加重为差。计算总体优良率;③统计血管损伤、神经损伤、疼痛性瘢痕等术后并发症发生情况;④采用腕关节尺测量屈伸活动度、尺桡活动度;⑤MHQ评分[7]是分别对疼痛、切口美观度、日常生活、总体满意度进行评分,各项评分越高,分别表明疼痛越重/切口美观度越高/日常生活受限越小/总体满意度越高。
  1.6 统计学分析:采用统计学软件SPSS 22.0分析数据,计数资料以百分率表示,采用χ2检验,等级资料采用秩和检验;计量资料以均数±标准差表示,组间比较采用独立样本t检验,同组手术前后比较采用配对样本t检验。均以P<0.05为差异有统计学意义。
  2 结果
  2.1 两组手术及随访情况:所有患者均顺利完成手术并完整随访,观察组平均随访时间(8.72±1.63)个月,对照组平均随访时间(8.90±1.47)个月,两组平均随访时间比较差异无统计学意义(t=0.539,P=0.591)。
  2.2 两组围术期参数比较:观察组手术时间短于对照组,术中出血量小于对照组,差异有统计学意义(P<0.05),见表2。
  
  2.3 两组临床疗效比较:两组总体优良率比较差异无统计学意义(P>0.05),见表3。
  
  2.4 两组术后并发症情况比较:观察组疼痛性瘢痕及并发症总发生率均低于对照组,差异有统计学意义(P<0.05),见表4。
  
  2.5 两组手术前后关节活动度比较:两组术后末次随访屈伸活动度、尺桡活动度均较术前提高,且观察组高于对照组,差异有统计学意义(P<0.05),见表5。
  
  2.6 两组手术前后MHQ评分比较:两组MHQ疼痛评分均较术前降低,且观察组低于对照组,差异有统计学意义(P<0.05);切口美观度、日常生活、总体满意度评分均较术前提高,且观察组均高于对照组,差异有统计学意义(P<0.05)。见表6。
  
  2.7 观察组典型病例
  2.7.1 病例1:某女,57岁,2个月前左手持续性麻木,口服甲钴胺后未见缓解,2周前出现右手麻木,口服甲钴胺后症状缓解,诊断为双侧腕管综合征,左手建议手术治疗,图1A、B分别为腕关节镜监视下腕横韧带松解术术前及术后即刻状态,切口位于腕横纹处,美观度良好。
  
  2.7.2 病例2:某男,42q,10个月前左手疼痛、活动受限,因疼痛加重就诊,诊断为左侧腕管综合征,行腕关节镜监视下腕横韧带松解术,图2A、B分别为术前及术后即刻状态,切口较小。
  3 讨论
  腕管综合征是一种常见的周围神经卡压性疾病。腕管为屈肌支持带、腕骨构成的骨-纤维支持带,其中有正中神经与屈肌腱通过,腕横韧带增厚、腕骨脱位或变异、骨折、肿块等均可能造成腕管压力增大,使正中神经受到压迫[8]。对于保守治疗无效或症状严重影响日常生活者,首选手术治疗。

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  腕横韧带松解术是治疗腕管综合征的经典手术方法。对于腕管内压力升高所引起的正中神经压迫,行腕横韧带切开松解可促进神经脱髓鞘后髓鞘重建,改善局部微循环,利于神经功能恢复[9]。开放腕横韧带松解术自皮肤切开至神经外膜,可获得清晰的手术视野,实现彻底解压,短期疗效已得到充分证实[10]。但临床应用发现,因其创伤较大,术后易出现疼痛性瘢痕,美观度不佳[11]。腕关节镜下腕横韧带松解术为微创手术,可减少切口相关并发症,但也有对其疗效的质疑,认为其视野有限,可致松解不彻底甚至血管、神经误伤[12]。本研究对比两种术式发现,两组疗效总体优良率比较差异无统计学意义,且观察组血管损伤、神经损伤、疼痛性瘢痕总发生率低于对照组,表明腕关节镜监视下腕横韧带松解术可获得与开放性手术相当的疗效,且可降低并发症发生率。考虑可能原因是腕关节镜手术组织切除少,工作套管潜行切断腕横韧带,避免切开皮肤与皮下组织,减少多组织粘连,进而降低术后疼痛性瘢痕的发生率[13]。而血管、神经误伤的发生与医疗器械的正确使用、术者操作等有关,可通过规范操作、提高操作者熟练度而尽可能避免[14]。同时,术中保持手指与腕关节背伸,保证腕管内结构靠近背侧,可避免血管与神经损伤,采用探钩探查,确认松解彻底,以保证手术效果。
  本研究结果显示,观察组手术时间短于对照组,术中出血量小于对照组,证实腕关节镜腕横韧带松解术更加微创,组织干扰相对较小。开放腕横韧带松解术切开手掌部皮肤,易造成正中神经掌皮支损伤,虽该术式经一系列改良后,切口形状、长度有所不同,但都难以避免残留瘢痕,或因掌皮支神经瘤而行疼痛性瘢痕[15]。本研究中,腕关节镜下腕横韧带松解术切口设计包括近端入口与远端出口,术中正中神经显露先对清晰,故便于彻底松解,术后瘢痕较小,无疼痛性瘢痕,具有明显优势。观察组术后末次随访屈伸活动度、尺桡活动度均大于φ兆椋提示从术后远期效果来看,关节镜腕横韧带松解术后腕关节活动度恢复更佳,可能原因是术中手内肌、掌腱膜损伤较小。除此之外,观察组MHQ疼痛评分低于对照组,切口美观度、日常生活、总体满意度评分高于对照组,进一步说明腕关节镜腕横韧带松解术术后远期总体效果、切口美观度及患者满意度更佳。
  综上所述,腕关节镜监视下腕横韧带松解术治疗腕管综合征与开放腕横韧带松解术疗效相当,但并发症更少,术后远期关节活动功能恢复更佳,切口美观度、患者满意度更高,值得临床推广应用。
  [参考文献]
  [1]倪建龙,时志斌,张晨,等.内镜下松解治疗腕管综合征的临床研究[J].中国内镜杂志,2019,25(9):7-11.
  [2]肖府庭,马艳,裴子文,等.神经松动术联合体外冲击波治疗轻中度腕管综合征的疗效观察[J].中华物理医学与康复杂志,2021,43(9):829-831.
  [3]余晓军,陈雪松,管力,等.改良显露的小切口法治疗腕管综合征42例报告[J].西南国防医药,2019,29(6):672-674.
  [4]陈鹏,邱勋永,王琰.有限切开与关节镜下松解治疗中重度腕管综合征的临床对比研究[J].中国医师杂志,2019,21(10):101-103.
  [5]顾玉东.手外科手术学[M].上海:复旦大学出版社,2010:72-74.
  [6]谢振军.腕管综合征诊断和治疗新进展[J].中华实用诊断与治疗杂志,2017,12(11):5-7.
  [7]Busuioc S A,Karim M,Bourbonnais D,et al.Cross-cultural adaptation, validity, reliability and clinical applicability of the michigan hand outcomes questionnaire, and its brief version, to Canadian French[J].J Hand Ther,2018,31(1):145-146.
  [8]梁伟,李青松,宋开芳,等.掌部小切口治疗腕管综合征的临床体会[J].中华显微外科杂志,2019,42(1):73-75.
  [9]冉永旺,石爱军,陈金叶.特发性腕管综合征与腕部疾病患者腕关节MRI腕横韧带形态的研究[J].中国医学装备,2019,16(8):36-38.
  [10]Li M,Jiang J,Zhou Q,et al.Sonographic follow-up after endoscopic carpal tunnel release for severe carpal tunnel syndrome: a one-year neuroanatomical prospective observational study[J].BMC Musculoskelet Disord,2019,20(1):157.
  [11]王岩,刘会仁,张艳茂,等.安全角引导小切口掌腱膜下腕横韧带切开治疗腕管综合征[J].中国临床解剖学杂志,2020,38(5):74-76.
  [12]刘靖波,劳杰,刘宇洲,等.正中神经掌皮支尺侧支损伤-腕管综合征术后柱状痛的重要病因[J].中华手外科杂志,2018,34(4):270-272.
  [13]Keskin Y,Kilic G,Taspinar O,et al.Effectiveness of home exercise in pregnant women with carpal tunnel syndrome: Randomized Control Trial[J].J Pak Med Assoc,2020,70(2):202-207.
  [14]Jin S P,Won H C,Oh J Y,et al.Value of cross-sectional area of median nerve by MRI in carpal tunnel syndrome[J].Asian J Surg,2020,43(6):654-659.
  [15]Suba P K,Güler T,Yurdakul F G,et al.Carpal tunnel syndrome in patients with rheumatoid arthritis and psoriatic arthritis: an electrophysiological and ultrasonographic study[J].Rheumatol Int,2021,41(2):361-368.
  [收稿日期]2021-12-06
  本文引用格式:高飞,曹建华,胡永梅.腕关节镜监视下腕横韧带松解术治疗腕管综合征的疗效及切口美观度分析[J].中国美容医学,2022,31(12):20-23.

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