1、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61
2、2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
3、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
4、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 wi
5、th 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 long
6、us 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 superf
7、icial 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 syn
8、ovial 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. E
9、vidence 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
10、.,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 long
11、us 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,
12、 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 apon
13、eurosis 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
14、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 co
15、ntrol, 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
16、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 i
17、nto 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.,
