手术治疗肘关节恐怖三联征28例疗效分析.pdf

625结论渐进性肌肉放松训练配合音乐治疗可更有效改善血透患者的症状，值得推广应用。参考文献：1 Flocco SF,Dellafiore F,Caruso R,et al.Improving health per-ception through a transition care model for adolescents withcongenital heart disease J.Journal of Cardiovascular Medi-cine,2019,20(4):253-260.2 Stremke ER,Trevino L,Doshi S,et al.Postdialysis serumphosphate equilibrium in hemodialysis patients on a controlleddiet and no binders J.Hemodialysis international,2022,26(2):255 263.3 Dipalma G,Inchingolo AD,Mancini A,et al.The C-reactiveprotein level in hemodialysis patients as a predictor factor forcardiovascular diseaseJ.2022,36(2(S3):51-60.4 Haq SZU,Bashir MB,Khan M,et al.Evaluation of Rate andTime to Arteriovenous Fistula Maturation in HemodialysisPatientsJ.Science Publishing Group,2021,10（5):222-226.5 Yao T,Shao Z,Wu L,et al.Long-term persistent immunoge-云南医药2 0 2 4年第45卷第1期nicity after successful standard and triple-dosed hepatitis Bvaccine in hemodialysis patients:A 3-year follow-up studyin ChinaJ.Vaccine,2021,39(18):2537-2544.6 Lhta B,Cmc C,LmL A,Ccta D,et al.Acupressure reducesthe severity of restless legs syndrome in hemodialysis pa-tients:A cluster-randomized crossover pilot study-Science-Direct J.Biomedical Journal,2022,45(3):533-541.7 Chu YT,Hsu PC,Liu CH,et al.Association of HandgripStrength With Mortality in Hemodialysis Patients in Taiwan:AProspective Cohort Study J.Acta nephrologica,2022,36(1):20-29.8 Ki N,Ki S P.The effect of progressive muscle relaxation onsleep quality and fatigue in patients with rheumatoid arthritis:A randomized controlled trial J.International Journal ofNursing Practice,2021,29(3):580-584.9李青,周竹.基于整合医学的慢性肾脏病一体化管理初探J.云南医药,2 0 2 3,44(2):10 0-10 2.10张莉,马迎春,左力.我国成人血液透析患者康复治疗的专家共识J.中国血液净化,2 0 2 1,2 0(11)：7 2 1-7 2 7.临床研究手术治疗肘关节恐怖三联征2 8 例疗效分析段维峰，李祥，钱本俄，吴沅浩，何震南，张世华（曲靖市第一人民医院创伤骨科，云南曲靖6 550 0 0）【摘要目的评估手术治疗肘关节恐怖三联征的临床疗效。方法连续收集本院2 0 2 0 年1月2 0 2 2 年1月收住并接受手术治疗2 8 例肘关节恐怖三联征患者的临床资料，动态随访1年，观察患者的VAS疼痛评分、肘关节屈伸、前臂旋转范围、肘关节功能恢复情况和并发症发生情况。结果2 8 例患者中男性19 例、女性9 例，平均年龄（31.2 8 11.52）岁。尺骨冠状突骨折Regan-MorreyI型5例、II型18 例、II 型5例；桡骨头骨折MasonI型9 例、II型13例、II 型6 例。分别采用不同麻醉方式、手术人路和术式完成骨折内固定和韧带修复，随访结束时2 8 例骨折均骨性愈合（10 0%），发生1例异位骨化（3.57%）被成功纠治（10 0%）。与术前比较，患者术后1年的肘关节疼痛（VAS评分：7.2 12.18 VS2.010.21，P0.001）、肘关节屈伸度（2 9.6 8 16.13VS130.8118.95，P 0.0 0 1）、前臂旋前范围（10.6 38.2 5VS76.352.45，P0.001）、旋后范围（10.2 18.8 9 VS75.323.85，P 0.0 0 1）、肘关节功能（Mayo评分：38.36 18.6 3VS87.4512.38，P 0.0 0 1）均显著改善。结论手术治疗肘关节恐怖三联征疗效显著，选择合适手术人路及手术模式重建肘关节的稳定性、术后早期康复锻炼，是获得满意疗效的关键。【关键词肘关节恐怖三联征；手术方法；临床疗效中图分类号 R687.3Analysis on the curative effect of surgical treatment for 28 casesDUAN Weifeng,LI Xiang,QIAN Bene,WU Yuanhao,HE Zhennan,ZHANG Shihua(Department of Traumatic Orthopedics,Qujing Municipal First Peoples Hospital,Qujing Yunnan 655000,China)Abstract:Objective To evaluate the clinical effect of surgical treatment for terrible triad injury of elbow joint(TTIE).MethodsClinical data of 28 patients with triad injury of elbow joint admitted to our hospital from January 2020 to January 2022 for surgical treatment收稿日期：2 0 2 3-0 8-0 8作者简介：段维峰（19 9 6）男，硕士，医师，从事四肢骨折修复重建工作2 余年。通信作者：张世华，E-mail：z h a n g s h i h u a 36 6 6 16 3.c o m文献标志码 Aof terrible triad injury of elbow joint【文章编号10 0 6-4141(2 0 2 4)0 1-0 0 6 2-0 4云南医药2 0 2 4年第45卷第1期were continuously collected.The patients VAS pain score,elbow joint flexion and extension,forearm pronation and supination range,elbow joint function recovery and incidence of complications were fllowed-up one year and observed.Results Among the 28 patients,there were 19 males and 9 females,with an average age of 31.28 11.52 years.There were 5 cases of Regan-Morrey type I,18 casesof type II,and 5 cases of type II fractures of ulnar coronoid process fractures.There were 9 cases of Mason type I,13 cases of type II and6 cases of type Il of radial head fracture.Dfferent anesthesia methods,surgical approaches and surgical methods were used to completefracture internal fixation and ligament repair,and at the end of the follow-up,28 fractures had bone union(100%),and one case ofectopic ossification(3.57%)was successfully treated(100%).Compared to preoperative,patients elbow pain(VAS score:7.21 2.18 VS 2.01 0.21,P0.01),elbow flexion and extension(29.68 16.13 VS 130.81 18.95,P0.01),forearm pronationrange(10.63 8.25 VS 76.35 2.45,P0.01),supination range(10.21 8.89 VS 75.32 3.85,P0.01)and elbow function(Mayo score:38.36 18.63 VS 87.45 12.38,P0.01)were significantly improved after one year of surgical treatment.ConclusionsSurgical treatment for terrible triad injury of elbow joint has a significant effect.The key to satisfactory efficacy is to choose the appropriatesurgical approach and surgical mode to reconstruct the stability of the elbow joint and early postoperative rehabilitation exercise.Key words:terrible triad of the elbow joint,surgical method,clinical efficacy肘关节恐怖三联征（Terrible triad injury of the el-bow，T T I E）由Hotchkiss于19 9 6 年首次提出，主要是指肘关节后脱位伴桡骨头及尺骨冠状突骨折。肘关节恐怖三联征通常为伸直的肘关节收到轴向的高能量压缩剪切暴力所致，是一种严重的复杂肘关节损伤。手术治疗能够重建肘关节稳定，从而允许进行早期活动及功能锻炼，继而改善患者预后。本文分析了2 0 2 0 年1月2022年1月本院收治的2 8 例肘关节恐怖三联征患者，经手术治疗获得满意的疗效，现报道如下。1资料与方法1.1一般资料本研究一共纳人患者2 8 例，其中男性19 例，女性患者9 例，平均年龄（31.2 8 11.52）岁。尺骨冠状突骨折根据Regan-Morrey分型：I型5例，I型18 例，II型5例；桡骨头骨折根据Mason分型：I型9 例，II型13例，III型6 例；所有患者入院查体可见肘关节局部畸形肿胀，人院后行肘关节屈曲9 0 位石膏外固定术，并完善CT三维成像以评估骨折情况。术前局部冰敷3 4d消肿后行手术治疗。1.2手术方法根据患者具体情况使用全身麻醉或神经阻滞麻醉。于肱骨近端上气压止血带，压力35Kp。2 0 例患者选择肘外侧入路，8 例选择肘外侧联合内侧入路。对于尺骨冠状突骨折，10 例Regan-MorreyI型骨折采用锚钉缝合固定，2 3例ReganM o r r e y II型、型骨折采用克氏针、空心螺钉或微型板固定尺骨冠状突骨折块，其中6例患者进行骨移植术重建冠状突。对于桡骨头骨折，2 2例Masson I型、型患者采用空心螺钉内固定，6 例Masson 型采用微T型板固定。术中检查所有患者均存在外侧副韧带复合体损伤，使用铆钉缝线予以修补外侧副韧带和伸肌总腱起点。在完成骨折及外侧副韧带复合体修复重建后再次检查肘关节稳定性，8 例患者采取联合内侧人路修复内侧副韧带。1.3术后管理术后所有患者使用上肢支具或铰链式外固定架保63护肘关节以避免脱位。予以预防感染及消肿、镇痛等对症支持治疗。术后5d患者在康复治疗师指导下进行功能锻炼。在肘关节屈曲的情况下逐步锻炼前臂的内外旋功能，术后8 周患者可解除支具限制自由锻炼肘关节。1.4疗效评估术后前3月每月随访1次，以后每3月随访1次直至满1年。随访内容包括：（1）肘关节正侧位片（2）V A S疼痛评分（3）肘关节屈伸活动度及前臂的前旋、后旋活动度（4）使用Mayo肘关节功能评分从疼痛、屈伸运动幅度、关节稳定性、日常生活功能四个维度对肘关节功能进行评估。1.5统计方法使用IBMSPSS23.0进行统计分析。计量资料以xs表示，计数资料用n（%）表示。ShapiroWilk检验用于检验数据分布的正态性。采用配对样本t检验（符合正态分布的连续计量资料）或Wilcoxon符号秩检验（不符合正态分布的连续计量资料）比较患者术前及术后1年的相关临床评价指标。对于所有检验，采用双侧检验法，P0.05被认为差异具有统计学意义。2结果所有患者顺利完成手术治疗，在院期间遵医嘱进行康复治疗。出院后对所有患者完成了1年的随访。所有患者肘关节稳定，无二次脱位发生。所有患者肘关节骨折对位对线良好，骨折骨性愈合。随访期间，无患者发生内固定物松动、断裂等不良事件。并发症有异位骨化1例，随访期间并发症发生率为3.57%，该患者发生并发症后经保守治疗后效果欠佳，于术后6个月行异位骨切除及关节松解术，术后肘关节功能恢复良好。采用配对t检验对术前与术后1年时临床评价指标进行比较，发现VAS疼痛评分、肘关节活动度及肘关节功能评分差异有统计学意义（P 50%，肘部将无法稳定5。但是否固定冠状突骨折目前也存在一定争议。Papatheodorou等6 的研究表明在Regan-MorreyI型或型尺骨冠突骨折中，当桡骨头骨折固定及外侧副韧带修补已重建肘关节稳定性时，在不固云南医药2 0 2 4年第45卷第1期表12 8 例患者的临床资料比较（xs，分）术前术后3月7.21 2.183.85 1.6929.68 16.13101.58 9.235.91 3.456.65 2.4510.63 8.2558.65 7.6810.21 8.8955.33 5.1838.36 18.6363.63 9.35术后6 月2.55 1.36115.35 10.238.05 3.4573.56 8.0170.31 6.3280.23 15.69定冠状突骨折情况下仍可获得满意疗效。笔者认为冠状突是上尺桡关节组成部分，在控制肱骨滑车一尺骨鹰嘴关节的绞链连接及旋转活动稳定性中有着重要作用。本研究中对所有尺骨冠突骨折患者进行了固定，6例患者进行骨移植术重建冠状突，术后恢复良好。肘关节恐怖三联征中普遍存在外侧副韧带复合体的损伤，术中外侧副韧带必须修复。部分患者可合并内侧副韧带损伤，而对于其是否需要修补目前尚无明确定论。Hatta T等7 提出内侧副韧带修复对肘关节运动和功能的影响较小，但在未修复内侧副韧带患者中关节炎的发生风险更高。马宁等8 认为内侧副韧带损伤可导致肘关节外翻及内旋不稳定，临床上对肘关节恐怖三联征患者修复内侧副韧带可能会改善肘关节的稳定性。笔者认为不论是内侧或是外侧副韧带对肘关节稳定均有重要作用，在本研究病例中，8 例患者修复外侧副韧带的同时修复了内侧副韧带，均取得较满意的临床疗效。内侧副韧带修复对减少并发症、增加肘关节稳定性及改善术后功能的作用有待更多的研究证明。手术治疗肘关节恐怖三联征的目的在于恢复肘关节稳定性，促进患者早期功能活动锻炼。因此术后的康复功能锻炼也极为重要。本研究2 8 例患者中，术后第二天即指导患者在支具保护下进行张手握拳练习，术后5d指导患者锻炼时松开支具，逐渐进行前臂旋转功能及肘关节屈伸关节功能锻炼。患者出院时嘱患者积极进行肘关节功能锻炼，逐渐增加活动强度与范围。术后随访患者普遍获得较满意疗效。4结论手术治疗肘关节恐怖三联征能够显著减轻患者疼痛，改善患者肘关节活动及功能。术前完善检查，详细评估患者桡骨头及尺骨冠突骨折、韧带损伤情况，选择合适手术入路及手术方式，术中重建肘关节稳定，术后早期康复锻炼，能够获得满意疗效。参考文献：1 Ohl X,Siboni R.Surgical treatment of terrible triad of the el-bowJ.Orthop Traumatol Surg Res,2021;107（1S):102784.2侯召猛，陈彦华.手术治疗肘关节恐怖三联征疗效分析J.中国矫形外科杂志,2 0 19,2 7（9）：8 53-8 55.3 Zwingmann J,Welzel M,Dovi-Akue D,et al.Clinical results术后1年2.01 1.21130.81 18.958.95 1.0576.35 2.4575.32 3.8587.45 12.38P0.010.010.010.010.010.01云南医药2 0 2 4年第45卷第1期after different operative treatment methods of radial head andneck fractures:a systematic review and meta-analysis ofclinical outcome J.Injury,2013;44(11):1540-1550.4 Li XY,Wang YL,Yang S,et al.Radial head arthroplasty vs.open reduction and internal fixation for the treatment of terri-ble triad injury of the elbow:A systematic review and meta-analysis updateJ.Exp Ther Med,2022;24(3):592.5 Giannicola G,Polimanti D,Gumina S,et al.Use of fine-threaded K-wires in the treatment of coronoid fractures incomplex elbow instability J.Orthopedics,2013,36(10):e1233 1238.65.6 Papatheodorou LK,Rubright JH,Heim KA,et al.Terrible tri-ad injuries of the elbow:does the coronoid always need to befixed?J.Clin Orthop Relat Res,2014;472(7):2084-2091.7 Hatta T,Nobuta S,Aizawa T,et al.Comparative Analysis ofSurgical Options for Medial Collateral Ligament Repair inTerrible Triad Injury of the Elbow J.Orthop Rev(Pavia),2016;8(3):6666.8马宁,袁锋，肘关节恐怖三联征的内侧副韧带修复的生物力学研究J.中国骨与关节杂志,2 0 15,4（10）：7 8 5789.临床研究ALBI、NLR、C RP联合诊断肝硬化合并细菌性腹膜炎的临床价值周嘉敏，唐源，李红纳（曲靖市第一人民医院消化医学中心，云南曲靖6 550 0 0）【摘要目的探讨ALBI评分联合NLR、CRP对肝硬化腹水患者合并SBP的诊断价值。方法选取2 0 18 年1月-2 0 2 2 年9月收住曲靖市第一人民医院确诊肝硬化腹水的134例患者，分为SBP与非 SBP2组，患者的临床资料经Logistic回归分析筛选出SBP的独立危险因素，系数法建立联合模型并绘制受试者工作曲线，评估各项指标及联合模型对肝硬化合并SBP的诊断价值。结果ALBI评分、NLR、CRP均是肝硬化患者SBP的独立危险因素。ALBI评分、NLR、CRP以及ALBI-NLR-CRP联合模型诊断SBP的曲线下面积分别为0.7 15（9 5%CI：0.6 2 7 0.8 0 2，P 0.0 5）、0.8 0 8（9 5%C I：0.7 15 0.8 6 6，P 0.0 5）、0.790（9 5%C I;0.7 36 0.8 7 9，P 0.0 5）、0.8 8 0（9 5%C I:0.8 2 0 0.9 40，P 0.0 5），灵敏度分别为6 6.30%、6 5.10%、77.10%、7 7.10%，特异度分别为7 0.6 0%、8 8.2 0%、7 2.50%、9 4.10%。结论ALBI、NLR、C RP都是肝硬化腹水患者继发SBP独立的评价指标，ALBI-NLR-CRP联合模型简便、无创、价廉，用于诊断肝硬化继发SBP有重要推广应用价值。【关键词肝硬化；自发性细菌性腹膜炎；白蛋白胆红素评分；中性粒细胞淋巴细胞比值；C反应蛋白中图分类号R575.2；R57 2.2The clinical value of ALBI score combined with NLR and CRP in the diagnosisof liver cirrhosis complicated with spontaneous bacterial peritonitis(Digestive Medicine Center,Qujing Municipal First Peoples Hospital,Qujing Yunnan 655000,China)Abstract:Objective To investigate the diagnostic value of ALBI score combined with NLR and CRP in patients with liver cirrhosis andascites complicated with spontaneous bacterial peritonitis(SBP).Methods A total of 134 cirrhotic ascites patients admitted to the FirstPeoples Hospital of Qujing City January 2018 to September 2022 were divided into SBP group and non-SBP group.The independent riskfactors of SBP were screened out by Logistic regression analysis of the patients clinical data,and the combined model was established bycoefficient method and the working curve of subjects was drawn to evaluate the diagnostic value of each index and combined model for cirrhosiscomplicated with SBP.Results ALBI score,NLR and CRP were independent risk factors for SBP in patients with liver cirrhosis.The areaunder the curve of ALBI score,NLR,CRP and ALBI-NLR-CRP combined model in the diagnosis of SBP was 0.715(95%CI:0.627-0.802,P0.05)and 0.808(95%CI:0.627-0.802,P0.05)respectively.0.715-0.866,P0.05),0.790(95%CI:0.736-0.879,P 0.05),0.880(95%CI:0.820-0.940,P 0.05),the sensitivity was 66.30%,65.10%,77.10%,77.10%respectively,and the specificity was 70.60%,88.20%,72.50%,94.10%respectively.Conclusions ALBI,NRL and CRP are allindependent evaluation indicators of secondary SBP in patients with liver cirrhosis and ascites.The combined model of ALBI-NLR-CRP issimple,non-invasive and inexpensive,and has important application value in the diagnosis of secondary SBP of cirrhosis.Key words:cirrhosis,spontaneous bacterial peritonitis,albumin-bilirubin score,neutrophil-lymphocyte ratio,C-reactive protein收稿日期：2 0 2 3-0 8-0 8作者简介：周嘉敏（19 9 7）女，在读硕士研究生，研究方向为肝硬化治疗。通信作者：唐源，E-mail：2 32 39 2 2 7 38 q q.c o m。文献标志码 AZOU Jiamin,TANG Yuan,LI Hongna文章编号 10 0 6-4141(2 0 2 4)0 1-0 0 6 5-0 4