王思成 李全 吳獻民 李廣峰 曹烈虎 曹中華 張鑫 楊國慶張友忠 蘇佳燦

關(guān)節(jié)鏡下清理術(shù)治療創(chuàng)傷后肘關(guān)節(jié)僵硬的臨床研究

王思成1李全2吳獻民1李廣峰1曹烈虎2曹中華1張鑫1楊國慶1張友忠1蘇佳燦2

目的評估關(guān)節(jié)鏡下肘關(guān)節(jié)清理術(shù)治療創(chuàng)傷后肘關(guān)節(jié)僵硬的臨床療效。方法回顧性分析2012年1月至2016年12月上海中冶醫(yī)院收治的42例創(chuàng)傷后肘關(guān)節(jié)僵硬患者，全部給予關(guān)節(jié)鏡下清理術(shù)，術(shù)后第1天即在疼痛控制下進行肘關(guān)節(jié)屈伸功能鍛煉，比較手術(shù)前后肘關(guān)節(jié)主動活動的關(guān)節(jié)活動度（range of motion，ROM），Mayo肘關(guān)節(jié)功能評分（Mayo elbow performance score，MEPS）及疼痛視覺模擬評分（visual analogue scale，VAS）。結(jié)果全部患者獲得隨訪，分別于術(shù)后3、6、12個月進行隨訪。術(shù)后肘關(guān)節(jié)ROM較術(shù)前有明顯改善，差異有統(tǒng)計學意義（P ＜0.05）。術(shù)后3～6個月改善較為明顯，6～12個月改善幅度降低。在MEPS評分方面從術(shù)前的（69.5±15.5）分增加至末次隨訪的（90.4±22.4）分，平均改善了20.9分（P ＜0.001）。術(shù)后MEPS評分結(jié)果為優(yōu)22例，良17例，中3例，優(yōu)良率達92.86%。術(shù)后較術(shù)前VAS均明顯降低（P ＜0.05）。結(jié)論 關(guān)節(jié)鏡下清理術(shù)是治療創(chuàng)傷后肘關(guān)節(jié)僵硬一個很好的治療方式，創(chuàng)傷小，疼痛輕，有利于術(shù)后早期功能鍛煉，能夠改善肘關(guān)節(jié)功能。

肘關(guān)節(jié)； 創(chuàng)傷后關(guān)節(jié)僵硬； 關(guān)節(jié)鏡； 關(guān)節(jié)清理術(shù)

肘關(guān)節(jié)僵硬是肘關(guān)節(jié)創(chuàng)傷或術(shù)后一種常見的難以處理的并發(fā)癥，會嚴重干擾患者的活動和生活質(zhì)量［1］，發(fā)病率超過5%［2］。創(chuàng)傷后肘關(guān)節(jié)僵硬的病因可以是關(guān)節(jié)內(nèi)因素，也可以是關(guān)節(jié)外因素。關(guān)節(jié)內(nèi)因素常見骨贅增生、骨軟骨炎、滑膜炎、關(guān)節(jié)不對稱或關(guān)節(jié)內(nèi)游離體等。而關(guān)節(jié)外因素常見異位骨化、關(guān)節(jié)囊攣縮、韌帶損傷、筋膜炎和皮膚組織疾患等。這些因素改變正常的肘關(guān)節(jié)運動導致關(guān)節(jié)僵硬。關(guān)節(jié)內(nèi)與關(guān)節(jié)外因素混合出現(xiàn)也很常見［3-4］。保守治療失敗的患者是手術(shù)治療的明確指征。目前有許多開放式外科手術(shù)用來治療肘關(guān)節(jié)創(chuàng)傷后僵硬。然而，傳統(tǒng)的開放手術(shù)創(chuàng)傷大，手術(shù)路徑可能造成額外的組織損傷，增加軟組織的攣縮復發(fā)風險，容易產(chǎn)生異位骨化，而且因為疼痛難以實施早期康復功能訓練［5］。因此考慮到肘關(guān)節(jié)僵硬的諸多因素，開放手術(shù)存在明顯的限制和風險。隨著手術(shù)技術(shù)和醫(yī)療設備的發(fā)展，關(guān)節(jié)鏡下清理松解技術(shù)有了顯著的提高。它可以很好的觀察處理關(guān)節(jié)內(nèi)、外的各種問題，同時大大減少手術(shù)創(chuàng)傷，減輕疼痛，有利于開始早期康復訓練。但是，關(guān)節(jié)鏡下肘關(guān)節(jié)清理術(shù)是具有挑戰(zhàn)性的，因為神經(jīng)血管結(jié)構(gòu)接近手術(shù)切口，并且工作空間有限，容易引起并發(fā)癥［6］。本研究的目的是評估關(guān)節(jié)鏡下肘關(guān)節(jié)清理術(shù)治療創(chuàng)傷后肘關(guān)節(jié)僵硬的療效，介紹這項外科手術(shù)技術(shù)，討論可能存在的困難和風險。

資料與方法

一、一般資料

2012年1月至2016年12月上海中冶醫(yī)院收治的42例創(chuàng)傷后肘關(guān)節(jié)僵硬患者，其中男24例、女18例，平均年齡42.3歲（21～59歲），左肘18例、右肘24例。全部患者的癥狀主要為關(guān)節(jié)活動受限伴疼痛，術(shù)前進行X線片和計算機斷層掃描（CT）檢查，評估關(guān)節(jié)僵硬的原因。其中骨贅增生及異位骨化32例，關(guān)節(jié)內(nèi)游離體28例。42例患者中31例有手術(shù)史。

二、納入及排除標準

納入標準：（1）肘關(guān)節(jié)活動度不能達到30～130°；（2）患者接受非手術(shù)治療6個月以上，肘關(guān)節(jié)活動度無明顯改善；（3）有或沒有骨贅形成，X射線顯示肘關(guān)節(jié)間隙仍然存在，沒有連續(xù)性的骨痂通過關(guān)節(jié)。

排除標準：（1）肘關(guān)節(jié)的骨性畸形明顯，需要進行矯正手術(shù)；（2）原發(fā)性退行性或炎性肘關(guān)節(jié)炎的患者；（3）術(shù)后無法配合進行主、被動功能訓練者；（4）肘關(guān)節(jié)周圍皮膚感染或燒傷引起的疤痕攣縮；（5）肘關(guān)節(jié)骨化性肌炎；（6）肘關(guān)節(jié)關(guān)節(jié)間隙幾乎消失，如關(guān)節(jié)骨性強直；（7）尺神經(jīng)手術(shù)史或多次肘關(guān)節(jié)手術(shù)史尺神經(jīng)位置不明。

三、手術(shù)方法

手術(shù)在臂叢麻醉或者全麻下進行，患者取側(cè)臥位，肩關(guān)節(jié)外展90°，肘關(guān)節(jié)屈曲90°，于上臂上止血帶止血。術(shù)前在皮膚上繪制體表解剖標識，將尺神經(jīng)的行走路徑特別標記。利用表面標識，經(jīng)軟點注入20 ml生理鹽水擴張關(guān)節(jié)腔，便于關(guān)節(jié)鏡置入。于肱骨外上髁近端2 cm，前方1 cm處，切開皮膚，鈍性分離組織，置入關(guān)節(jié)鏡設備，建立第一個工作通道—近端外側(cè)入路。然后，透過從近端外側(cè)肘關(guān)節(jié)入路進入的關(guān)節(jié)鏡到達對側(cè)皮下組織，于肱骨內(nèi)上髁遠端2 cm，前方2 cm處建立近端內(nèi)側(cè)入路。通過這兩個入路處理肘關(guān)節(jié)前室。于尺骨鷹嘴近端3 cm，沿肱骨外上髁嵴進入肘后關(guān)節(jié)腔，建立后外側(cè)入路，于后外側(cè)入路內(nèi)側(cè)2 cm處建立后正中入路，處理肘關(guān)節(jié)后室。通過手術(shù)入路，關(guān)節(jié)鏡的監(jiān)控及操作下，使用3.5 mm磨鉆去除所有的影響關(guān)節(jié)功能的骨贅和異位骨化，磨除部分冠狀突、尺骨鷹嘴；用異物鉗取出關(guān)節(jié)內(nèi)游離體；用刨刀及射頻清除滑膜，纖維組織等，對肘關(guān)節(jié)前方病灶清除需要對冠突窩進行清理，對于肘關(guān)節(jié)后方的病灶需要清理鷹嘴窩。然后，松解攣縮的關(guān)節(jié)囊。小心地保持刨刀的鈍邊朝向尺神經(jīng)及內(nèi)側(cè)關(guān)節(jié)囊。避免損傷尺神經(jīng)。之后，再次采用手法松解以獲得滿意的肘關(guān)節(jié)功能，根據(jù)術(shù)前肘關(guān)節(jié)功能障礙情況將肘關(guān)節(jié)固定在伸直或屈曲位矯形器。術(shù)后應用吲哚美辛栓防止異位骨化。

四、術(shù)后處理

術(shù)后第1天開始在靜脈鎮(zhèn)痛泵的鎮(zhèn)痛下進行無痛持續(xù)被動運動（continuous passive motion，CPM）。CPM功能訓練4次/d，20 min/次，功能訓練遵循動靜結(jié)合的原則。每天鍛煉后使用上肢矯形器維持肘關(guān)節(jié)已經(jīng)改善了的關(guān)節(jié)活動度（range of motion，ROM），每天可以拆卸下來進行4～6次肘關(guān)節(jié)運動訓練，該矯形器應使用至少6周，大概每天有1～2 h的訓練時間，訓練結(jié)束后再用矯形器固定。術(shù)后2～4 d開始進行主動功能訓練，6周后逐漸進行抗阻訓練，用以增強肌肉力量。主動及被動訓練應持續(xù)不少于6個月。功能訓練過程中注意控制疼痛和水腫。

五、療效評價

分別于術(shù)后3,6及12個月進行隨訪，手術(shù)前后采用Mayo肘關(guān)節(jié)功能評分（Mayo elbow performance score，MEPS）及疼痛視覺模擬評分（visual analogue scale，VAS）對患者進行評估，并測量肘關(guān)節(jié)主動活動的ROM。

六、統(tǒng)計學分析

采用SPSS17.0統(tǒng)計軟件進行分析。所有的計量數(shù)據(jù)均以 x-±s表示，術(shù)前和術(shù)后3、6、12個月ROM、MEPS 評分及 VAS 評分比較采用配對t檢驗，P＜0.05為差異有統(tǒng)計學意義。

結(jié) 果

全部患者獲得隨訪，沒有患者轉(zhuǎn)換為開放性手術(shù)或需要二次手術(shù)治療?；颊邆笃骄中g(shù)時間為17個月（11～47個月）。術(shù)后肘關(guān)節(jié)ROM較術(shù)前有明顯改善，從術(shù)前的（50.7±18.3）°增加到（119.7±23.6）°，平均增加了69°，差異有統(tǒng)計學意義（P ＜0.001）。術(shù)后3和6個月時改善較為明顯，6和12個月時改善幅度降低，說明早期的功能鍛煉意義較大。在MEPS評分方面從手術(shù)前的（69.5±15.5）分，增加至末次隨訪的（90.4±22.4）分，平均改善了20.9分（P ＜0.001）。術(shù)前MEPS評分優(yōu)0例，良 6例，中 25例，差11例。術(shù)后MEPS評分結(jié)果為優(yōu)22例，良17例，中3例，差0例，優(yōu)良率達92.86%。術(shù)后疼痛VAS評分均較術(shù)前明顯降低（P ＜0.05），見表1。

在隨訪過程中，1例患者出現(xiàn)異位骨化，這例患者術(shù)前即存在異位骨化現(xiàn)象，給予吲哚美辛治療后異位骨化程度較術(shù)前輕，術(shù)后最終ROM達到了95°。術(shù)后4例患者出現(xiàn)尺神經(jīng)支配區(qū)麻木，經(jīng)保守治療6個月內(nèi)全部恢復。全部病例無感染出現(xiàn)。

表1 手術(shù)前后肘關(guān)節(jié)ROM、MEPS評分及VAS評分比較（n=42, x-±s）

討 論

創(chuàng)傷后肘關(guān)節(jié)僵硬治療方案的選擇可分為保守治療和手術(shù)治療。保守治療包括物理治療、動態(tài)夾板、靜態(tài)漸進式夾板和麻醉下手法松解，并應持續(xù)至少6個月［7-9］。保守治療失敗后，建議采取手術(shù)治療［10］?；顒幽┢诘奶弁矗P(guān)節(jié)僵硬，形成骨刺和關(guān)節(jié)內(nèi)游離體是最常見的手術(shù)指征［11-13］。一些文獻已經(jīng)描述了開放手術(shù)和關(guān)節(jié)鏡技術(shù)治療創(chuàng)傷后肘關(guān)節(jié)僵硬的情況［14-19］，在改善肘關(guān)節(jié)ROM和減輕患者疼痛等方面，關(guān)節(jié)鏡提供了良好的滿意結(jié)果［20-21］。另外是否采用關(guān)節(jié)鏡手術(shù)，還取決于外科醫(yī)師對肘關(guān)節(jié)鏡的專業(yè)知識技能水平、尺神經(jīng)的狀態(tài)、異位骨化的形態(tài)和位置、關(guān)節(jié)攣縮程度及關(guān)節(jié)面損傷的情況等［14］。

本組患者術(shù)前肘關(guān)節(jié)ROM有中度僵硬的占41%，重度僵硬的占21%。在末次隨訪評估中，91.2%的患者肘關(guān)節(jié)ROM為輕度受限或無僵硬，僅4%有嚴重的僵硬。肘關(guān)節(jié)ROM平均改善為69°，與最近的文獻報道中增加的情況一致［7，13，17，20-21］。在臨床評分方面，平均改善20.7分，VAS評分改善明顯，這些結(jié)果與Kim等報道結(jié)果類似［12，15-16］。

目前，關(guān)節(jié)鏡下松解治療創(chuàng)傷后肘關(guān)節(jié)僵硬已經(jīng)被認為是一個安全的手術(shù)操作，并發(fā)癥發(fā)生率低［12］。Pederzini等［22］對關(guān)節(jié)鏡手術(shù)治療243例創(chuàng)傷后或退行性肘關(guān)節(jié)僵硬患者進行評價，結(jié)果術(shù)后肘關(guān)節(jié)功能改善顯著。Phillips等［23］對25例患者進行了關(guān)節(jié)鏡手術(shù)，其中15例為創(chuàng)傷后關(guān)節(jié)粘連，10例為退行性骨關(guān)節(jié)炎所造成關(guān)節(jié)攣縮，平均隨訪18個月，術(shù)后平均屈伸活動度改善了41°，肘關(guān)節(jié)ROM取得了明顯的改善，其中創(chuàng)傷后關(guān)節(jié)僵硬的患者表現(xiàn)出更大的改善。Kim等［24］描述了63例肘關(guān)節(jié)攣縮患者行關(guān)節(jié)鏡手術(shù)治療的情況，這些患者癥狀持續(xù)時間小于1年，術(shù)后取得滿意的臨床結(jié)果，肘關(guān)節(jié)ROM平均增加 49°。Kelly等［25］發(fā)現(xiàn)25例肘關(guān)節(jié)僵直患者中的24例治療效果在術(shù)后2年中呈現(xiàn)“好的”或“更好的”結(jié)果。Cefo等［14］的研究探討肘關(guān)節(jié)鏡對創(chuàng)傷后肘關(guān)節(jié)僵硬的療效，他們表示，關(guān)節(jié)鏡下松解對患者創(chuàng)傷后肘關(guān)節(jié)攣縮癥是一種安全可靠的治療方法，優(yōu)點包括手術(shù)創(chuàng)傷小、手術(shù)疤痕小、能改善關(guān)節(jié)的外觀、減少疼痛、加速康復、縮短住院時間等。

本研究最重要的發(fā)現(xiàn)是關(guān)節(jié)鏡下關(guān)節(jié)清理治療肘關(guān)節(jié)僵硬是創(chuàng)傷后肘關(guān)節(jié)僵硬的一個很好的治療選擇，它能夠改善肘關(guān)節(jié)功能。并且術(shù)后的早期主/被動術(shù)后康復對患者康復是非常必要的。關(guān)節(jié)鏡下松解術(shù)最常見的并發(fā)癥是持續(xù)ROM丟失，因此需要再次手術(shù)進行松解。良好的ROM通常可以在手術(shù)中獲得，但隨著時間的推移，沒有有效的鍛煉的情況下改進的ROM不能保持。因此，在最終的隨訪中，臨床結(jié)果往往令人失望。在這項研究中，術(shù)后第1天即開始鼓勵患者進行無痛下的主動和被動肘關(guān)節(jié)運動，目的是為了獲得一個更好的ROM。在最后的隨訪中，結(jié)果39例均為優(yōu)良，3例為中，沒有患者表現(xiàn)出較差的結(jié)果，優(yōu)良率達到92.86%。

無論是開放手術(shù)還是關(guān)節(jié)鏡手術(shù)，血管神經(jīng)并發(fā)癥的報道都有，但關(guān)節(jié)鏡手術(shù)似乎更多見［25］。為了避免這些問題，規(guī)范的操作技術(shù)顯得非常重要，并應該被嚴格遵循。本研究并沒有出現(xiàn)類似的并發(fā)癥是因為嚴格按照操作規(guī)范進行手術(shù)，并由經(jīng)驗豐富的醫(yī)師完成。同時必須強調(diào)對于有多次手術(shù)史，尺神經(jīng)位置不明確的患者，是不能行關(guān)節(jié)鏡手術(shù)的。

肘關(guān)節(jié)鏡手術(shù)是微創(chuàng)手術(shù)，它提供了完整的和準確的關(guān)節(jié)表面的可視化，確?？焖倩謴停啾乳_放技術(shù)具有較低的并發(fā)癥的風險［26］。然而，本研究仍存在幾個局限性：首先，病例數(shù)較少；第二，沒有設置開放手術(shù)或保守治療的對照組；第三，隨訪時間短，難以客觀地評價遠期臨床結(jié)果。因此，未來需要大規(guī)模的、多中心的及長期隨訪的病例對照研究。

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Su Jiacan, Email:drsujiacan@163.com

Efficacy of arthroscopic debridement for treatment of post-traumatic elbow stiffness

Wang Sicheng1, Li Quan2, Wu Xianmin1, Li Guangfeng1, Cao Liehu2, Cao Zhonghua1, Zhang Xin1, Yang Guoqing1, Zhang Youzhong1, Su Jiacan2.1Department of Orthopedic Surgery, Shanghai Zhongye Hospital Shanghai 200941, China;2Department of Orthopedics Trauma, Changhai Hospital of Second Military Medical University, Shanghai 200433, China

BackgroundWith over 5% of morbidity, elbow stiffness is a common and difficult complication after elbow trauma or surgery, which can severely interfere with the daily activities and life quality of patient. The post-traumatic elbow stiffness may be caused by intraarticular or extra-articular factors. The common intra-articular factors include osteophytosis,osteochondritis, synovitis, joint asymmetry and loose bodies, while the common extra-articular factors include heterotopic ossification, joint capsule contracture, ligament injury, fasciitis and skin diseases. These factors result in joint stiffness by altering normal elbow motions. The mixed presence of intra-articular and extra-articular factors is also common. The failure of conservative treatment is a definite indication of surgical treatment. Currently, there are many options of open surgery for the treatment of post-traumatic elbow stiffness. However, the large trauma of traditional open surgery and the additional soft tissue damage possibly caused by surgical approach increase the risk of relapse of soft tissue contracture and the chance of heterotopic ossification occurrence. Furthermore, it is difficult to perform early functional rehabilitation because of pain. Therefore, considering the several factors of elbow stiffness, the open surgery has obvious limitations and risks. With the development of surgical technique and medical equipment, the technique of debridement and arthrolysis under arthroscopy has been remarkably improved, which observes and deals with various intra-articular and extra-articular problems well. At the same time, this technique is beneficial to the initiation of early functional rehabilitation by reducing the operation trauma and relieving the pain. However, the arthroscopic elbow debridement is challenging because of the limitation of working space, the proximity between surgical incision and neurovascular structure and the easiness of triggering complication. The purposes of this study are to evaluate the efficacy of arthroscopic debridement for the treatment of post-traumatic elbow stiffness, to introduce this surgical technique and to discuss the possible difficulties and risks.Methods（1）General information. From January 2012 to December 2016, 42 patients （24 males and 18 females） with post-traumatic elbow stiffness were treated in Shanghai Hospital of metallurgical corporation of China LTD（MCC）.The age ranged from 21 to 59 years with an average of 42.3 years. 18 cases had the left side affected, and 24 cases had the right side affected. The symptoms of all patients were mainly limited joint motion and pain. The causes of joint stiffness were evaluated by preoperative X-ray films and computed tomography （CT）, which included osteophytosis and heterotopic ossification for 32 cases and loose bodies for 28 cases. Of the 42 patients, 31 cases had the history of surgery.（2）Inclusion and exclusion criteria. Inclusion criteria:① The range of elbow motion cannot reach 30-130°; ② The patient receives conservative treatment for more than 6 months, while the range of elbow motion does not improve obviously; ③ With or without the formation of osteophyte, elbow joint space still exists under fluoroscopy, and no successive bone callus passes through joint. Exclusion criteria: ① The bony deformity of elbow joint is obvious and requires corrective surgery; ② The patient with primary or inflammatory elbow arthritis;③The patient who cannot cooperate with postoperative active and passive functional trainings; ④ The skin infection around elbow or the scar contracture caused by burn; ⑤ Myositis ossificans of elbow joint;⑥ Elbow joint space almost disappears, such as joint ankylosis;⑦ The location of ulnar nerve is unknown because the patient had ulnar nerve surgery or elbow surgery for multiple times before.（3）Operative methods. The operation was performed under brachial plexus block or general aesthesia. The patient was in lateral position with shoulder abduction of 90° and elbow flexion of 90°, and the upper arm was tied with tourniquet. The anatomic landmarks of body surface were drawn on the skin preoperatively, and the pathway of ulnar nerve was marked specially. Based on the surface landmarks, the expansion of joint cavity was achieved by injecting 20 ml of saline via soft point, which facilitated the insertion of arthroscopy. The skin was cut open at 2 cm proximal to the humeral supracondylar and 1 cm ahead, and the soft tissue was bluntly separated for the insertion of arthroscopy. In this way, the first working path-proximal lateral approach was established. Then, the arthroscopy from proximal lateral elbow approach reached the contralateral subcutaneous tissue to establish proximal medial approach at 2 cm distal to the condylus medialis humeri and 2 cm ahead. The anterior compartment of elbow joint was debrided via these two approaches. At 3 cm proximal to the olecranon, the arthroscopy entered posterior joint cavity along the humeral supracondylar ridge to establish posterolateral approach. Posterior median approach was established at 2 cm medial to the posterolateral approach. The posterior compartment of elbow joint was debrided via the posterolateral and posterior median approaches. Under the monitoring and operation of arthroscopy, a 3.5 cm power drill was used to remove all the osteophyte and heterotopic ossification that affected joint function and part of coronoid process and olecranon through the approaches mentioned above. Intra-articular loose bodies were taken out with foreign-body forceps. synovial membrane and fibrous tissue were removed with planer and Radiofrequency.The debridement of coronoid fossa was required for the removal of the anterior lesion of elbow joint, while the debridement of olecranon fossa was required for the removal of the posterior lesion of elbow joint. Then, the contractural joint capsule was loosened. To avoid the injury of ulnar nerve, the blunt edge of planer was carefully kept toward the ulnar nerve and medial capsule. Afterward, the manual loosening was applied again to obtain satisfactory elbow joint function. According to the preoperative dysfunction, the elbow joint was fixed in extension or flexion orthosis. Indomethacin suppository was used postoperatively to prevent heterotopic ossification.（4）Postoperative management.Started from the 1st postoperative day, continuous passive motion （CPM） was carried out under the analgesia of intravenous analgesic pump. The CPM functional training was performed 4 times per day and 20 minutes per time, which followed the principles of combination of static and dynamic. Upper limb orthosis was used to maintain the improved ROM of elbow joint after training every day, which can be disassembled to carry out elbow joint exercise for 4-6 times per day. The orthosis should be used for at least 6 weeks with 1-2 hours of training per day. Active functional training was started 2-4 days after operation. 6 weeks later, resistance exercise was gradually carried out to enhance muscle strength. Active and passive training should last no less than 6 months. During the process of functional training,attention should be paid to control pain and edema.（5）Curative effect evaluation.Follow up was carried out at the 3rd, 6th and 12th months. Mayo elbow performance score （MEPS） and visual analogue scale （VAS） were used for patient evaluation before and after operation, and the active range of motion （ROM） of elbow joint was measured. （6）Statistical analysis. The SPSS17.0 statistical software was used for analysis. All the measured data were expressed as . The ROM of elbow, MEPS and VAS were compared in the 3rd, 6th and 12th months before and after the operation were compared using paired t test, and P ＜0.05 was considered statistical difference.Results All patients were followed up, and no patient was converted to open surgery or required secondary procedure. The mean time from injury to operation was 17 months （11-47 months）.The ROM of elbow joint improved significantly after operation, which increased from （50.7±18.3）°to （119.7±23.6）° with an average increment of 69°. The difference was statistically significant（P ＜0.001）. After operation, the improvement was obvious at the 3rd and 6th months and reduced at the 6th and 12th months. This indicated that early functional exercise was of great significance.The MEPS increased from preoperative （69.5±15.5） points to （90.4±22.4）points during the last follow up, and the mean improved score was 20.9 points （P ＜0.01）. According to MEPS, the preoperative function was excellent in 0 case, good in 6 cases, moderate in 25 cases and poor in 11 cases. The outcome of postoperative MEPS showed 22 cases of excellence, 17 cases of good and 3 cases of moderate. The good and excellent rate was 92.86%. The postoperative VAS scores all decreased remarkably compared to those before operation （P ＜0.05）. During the follow-up, 1 patient who was found to have heterotopic ossification before operation turned less severe with indomethacin for treatment. The final ROM of this patient reached 95°. After operation, 4 patients presented with the numbness in ulnar nerve innervation area and recovered in 6 months with conservative treatment. No infection occurred in all cases.ConclusionsArthroscopic debridement is a great option for the treatment of post-traumatic elbow stiffness. This strategy achieves minimal invasion, small scar, little pain and short hospital stay to allow postoperative early functional training and to improve the appearance and function of elbow joint.

Elbow joint; Post-traumatic stiffness; Arthroscopy; Debridement

10.3877/cma.j.issn.2095-5790.2017.03.009

國家自然國際合作基金（8141101156）；上海市科委生物醫(yī)藥專項（154119500600）；上海市衛(wèi)計委科研課題面上項目（201640156）

200941上海中冶醫(yī)院骨外科1；200433上海，第二軍醫(yī)大學附屬長海醫(yī)院創(chuàng)傷骨科2

蘇佳燦， Email:drsujiacan@163.com

2016-10-13）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

王思成,李全,吳獻民,等. 關(guān)節(jié)鏡下清理術(shù)治療創(chuàng)傷后肘關(guān)節(jié)僵硬的臨床研究［J/CD］.中華肩肘外科電子雜志,2017,5（3）：207-212.