慢性舟月不稳定的治疗

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2. 5　背侧关节囊固定术　最近流行软组织术式用以修复慢性舟月不稳定。将这两种类型的术式,即Berger型背侧关节囊固定术和Brunelli腱固定术的治疗结果进行比较[ 17219 ]。行关节囊固定术的14例患者和行腱固定术的15例患者平均随访3年,比较其临床和影像学数据。研究中的患者为动态或静态舟月不稳定,病程> 3个月。两组患者在腕关节运动范围、握力、Mayo腕关节评分上无统计学差异。两组患者手术恢复了腕关节运动的20%～25%。影像学上,腱固定组维持了舟月角度改善,而关节囊固定组未见改善。但影像学结果似乎与临床症状并不相关,因为很多患者术后还都有明显的疼痛。虽然这些术式是治疗慢性舟月不稳定的常见手段,但这一研究证实它们并非解决这一难题的理想办法。

2. 6　三韧带腱固定术　三韧带腱固定术是Brunelli腱固定术的改进,尝试重建舟大多角小多角关节、背侧舟月和背侧桡三角韧带。这一术式加强了掌侧舟大多角小多角关节复合体,重建了SL IL的背侧部分,减少了舟骨和月骨之间的分离。Garcia2Elias等[ 20 ]为不同的舟月不稳定及其治疗提供了选择标准。标准指出,三韧带腱固定术的最佳适应证是,完全性SL IL损伤,无骨性关节炎征象,有或无可复位的舟骨旋转半脱位。在满足这一标准的38例患者中, 28例(74% )患者随访46个月后无疼痛, 29例(76% )患者回到正常工作。握力为健侧的65% ,屈/伸功能恢复到健侧的74% ～77%。这一结果与Talwalkar等[ 21 ]得出的结论相似,报道了117例患者中的62%在平均随访4年后无疼痛或疼痛缓解,但患者中的43%换为负荷较轻的工作。另外,握力为健侧的80%及屈/伸功能恢复到正常的74%。这一患者群组与Garcia2Elias等[ 20 ]的研究有所不同,含有动态和静态舟月不稳定两种情况,仅其中的1 /3患者进行了随访。三韧带腱固定术对于那些无骨性关节炎、舟骨可复位的静态舟月不稳定是适当的选择。这一术式的结果较Brunelli腱固定术及其多种改进方式为好。

3　结　论

尽管影像学技术不断发展,但关节镜技术仍是诊断舟月不稳定的金标准。关节镜技术还拓展了可用的治疗选择。这些技术的有效性,例如关节镜下热挛缩,随着更长的随访期会更加明确。对于不同形式的舟月不稳的治疗选择还不明确。生物力学和运动学的研究进展会进一步阐明对舟月不稳定机制的理解,为将来能明确解决这一问题提供方向。

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