双侧等长指浅屈肌腱外侧腱束治疗纽扣指畸形

双侧等长指浅屈肌腱外侧腱束治疗纽扣指畸形

江起庭李智余红王志钢方威李涛

本文来源：《中华整形外科杂志》2023年2月第39卷第2期

DOI:10. 3760 / cma.j.cn114453-20220718-00222

作者单位：南京江北医院手足显微外科，南京210048

通信作者：江起庭，Email：13856568108@163.com

引用本文

江起庭, 李智, 余红, 等. 双侧等长指浅屈肌腱外侧腱束治疗纽扣指畸形 [J] . 中华整形外科杂志, 2023, 39(3) : 278-284. DOI: 10.3760/cma.j.cn114453-20220718-00222.

【摘要】

目的探讨应用双侧等长指浅屈肌腱外侧腱束转至指背侧治疗纽扣指畸形的临床效果。

方法回顾性分析2021年2月至2022年5月，南京江北医院手足显微外科收治的纽扣指畸形患者的临床资料。将指浅屈肌腱外侧近止点处向近端各劈出1束，形成双侧等长外侧腱束，于中节指骨基底部钻孔，再将双侧等长外侧腱束经骨孔转至背侧，与伸肌腱中央腱近断端编织缝合。术后用支具将患指伸直位固定4周，逐步加强患指近指间关节伸屈运动。术后随访观察近指间关节主、被动伸屈活动，参照美国手外科协会总主动活动度(TAM)系统评定手指功能。

结果共纳入7例(7指)患者，男5例5指，女2例2指；年龄22~64岁，平均42岁。受伤指别：示指1例，中指2例，环指2例，小指2例。所有病例均获随访6~8个月，平均7个月，术后7例(7指)切口均无感染，一期愈合，纽扣指畸形均完全矫正。末次随访时患指近指间关节均能主动屈曲、伸直，近指间关节、远指间关节伸直均达至正常范围，患指近指间关节主动活动度平均为92.4°，患指TAM平均为271.3°。参照TAM功能评定法进行评价：优6指，良1指。

结论应用双侧等长指浅屈肌腱外侧腱束转至背侧编织缝合能有效治疗纽扣指畸形，临床效果满意，是一种安全、行之有效的新方法。

【关键词】指；纽扣畸形；肌腱修复；外科手术

The correction of boutonniere deformity by tenodesis of the bilateral slips of the flexor digitorum superficialis tendon

Jiang Qiting, Li Zhi, Yu Hong, Wang Zhigang, Fang Wei, Li Tao

Department of Hand and Foot Microsurgery of Nanjing Jiangbei Hospital, Nanjing 210048, China

Corresponding author: Jiang Qiting, Email: 13856568108@163.com

【Abstract】

Objective To evaluate the clinical efficacy of the treatment of boutonniere deformity by tenodesis of the bilateral slips of the flexor digitorum superficialis (FDS) tendon.

Methods From February 2021 to May 2022, the boutonniere deformity was retrospectively analyzed, by tenodesis of the bilateral slips of the FDS in the Department of Hand and Foot Microsurgery of Nanjing Jiangbei Hospital.During the operation, the lateral side of the bilateral FDS was split at the distal end separately. Then the two bundles were tunneled through the bone of the middle phalanx and weaved with the central band of the extensor tendon. The involved finger was stabilized in extension with splinting for 4 weeks after surgery. Extension and flexion of the proximal interphalangeal joint(PIPJ) of the finger should be gradually strengthened. Finger function was evaluated according to the total action movement (TAM) system of the American Association of Hand Surgeons.

Results A total of 7 patients (7 digits) were enrolled, including 5 males and 2 females, and the age ranged from 22 to 64 years old, with an average age of 42 years old. The injured included 1 index finger, 2 middle fingers, 2 ring fingers, and 2 little fingers. These patients were follow-up for 6 to 8 months with an average of 7 months. All wounds healed by primary intention. This operation can obtain the complete correction of the boutonniere deformity. The PIPJ was stable and capable of active flexion and straightness. The straightness of PIPJ and distal interphalangeal joint was improved. The mean active motion of the PIPJ of the affected finger was 92.4°, and the mean TAM of the affected finger was 271.3°. According to TAM system assessment criteria: excellent in 6 patients, good in 1 patient.

Conclusion It is a safe and effective new method for the correction of boutonniere deformity, which can be effectively treated with tenodesis of the bilateral slips of the FDS.

【Key words】Finger; Boutonniere deformity; Tendon repair; Surgery

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

伸指肌腱中央腱束的断裂或撕脱，是常见的伸肌腱Ⅱ区损伤，导致近节指骨头从断裂的中央腱束中突出，如同从纽孔中突出一样，形成纽扣指畸形[1,2]。既往修复方法有侧腱束交叉缝合术法、抽出钢丝法、锚钉重建法、克氏针横锁掌长肌腱重建法等，有伸指力弱、易伤血管神经、排异反应及纽扣指畸形复发等并发症，疗效均不满意[3,4,5,6]。指浅屈肌腱单侧腱束转位修复中央腱束，虽获得较好的临床报道，但因修复中央腱束强度及力度较差，缝合面过小及掌侧近指间关节松弛，故其应用受限制[7,8]。目前双侧指浅屈肌腱内侧腱束修复伸指肌腱中央腱束，虽也获得了较好临床疗效，但未能加固包绕近指间关节，导致其稳定性下降[9,10,11]。我们在此基础上将双侧指浅屈肌腱内侧腱束转变成双侧外侧腱束，分别从尺桡侧两边包绕近指间关节，加强近指间关节的稳定性，增加了缝合面积、强度及力度，重建中央腱束止点，采用改进的方法治疗纽扣指畸形，获得了较好的临床效果。

资料与方法

一、资料选择

回顾性分析2021年2月至2022年5月，南京江北医院手足显微外科采用双侧等长指浅屈肌腱外侧腱束转至指背侧治疗纽扣指畸形的患者临床资料。纳入标准：(1)患指近指间关节主动伸展受限，被动伸直可；(2)术前CT或X线片检查患指末节指骨基底部背侧无撕脱骨片或骨折；(3)受伤时间在3周内的闭合性纽扣指。排除标准：(1)随访资料不全或随访时间<6个月；(2)依从性差，失访。

本研究已参考赫尔辛基宣言，所有患者均对本研究知情同意并签署知情同意书。

二、手术方法

采用臂丛神经阻滞麻醉，患肢外展90°于手术台上。手术分4部分完成：(1)于指背侧行中轴正中切口，暴露伸指肌腱中央腱损伤断裂处，再将中央腱松解游离后，加以修剪，备用。(2)掌侧沿近指间关节到掌指关节做Bruner切口，充分暴露指浅屈肌腱，同时向近端适当延长。用尖刀片先将一侧指浅屈肌腱外侧剖开1束，约占该侧指浅屈肌腱横断面积的1/2，游离至Camper腱交叉后，长度约3.2 cm，再将指浅屈肌腱外侧一半从近端切断，形成单侧指浅肌腱的外侧腱束；用同样的方法将另一侧指浅屈肌腱外侧剖开并切断，形成长约3.2 cm的外侧腱束，两边的外侧腱束组合形成双侧等长指浅屈肌腱外侧腱束，由近向远掀起。(3)将双侧等长指浅屈肌腱外侧腱束分别从近指间关节两边包绕，以备收紧加固指间关节的稳定性。(4)用直径约2.0 mm克氏针，在中节指骨的基底部，中央腱止点与指浅屈肌腱止点之间，自掌侧垂直穿透至背侧，制作骨孔，再将先前制成的双侧等长指浅屈肌腱外侧腱束，从近指间关节两边分别用3-0缝线缝合肌腱至便于牵引，然后将原肌腱缝线的弧形缝针变成直形穿过骨孔，将双侧的外侧腱束从掌侧分别引至背侧。(5)将原备用缝合的中央腱断端，看成横断面尺、桡侧的两等分，调节张力后，与双侧等长指浅屈肌腱外侧腱束分别编织缝合，至此纽扣指畸形矫正，患指近指间关节处于伸直位，关闭创面，无菌包扎(图1)。

三、术后处理

术后患指采用伸直位支具外固定，术后2周拆线，4周去除外固定。

四、疗效评定

随访观察患指近指间关节主动活动度。采用门诊复查、电话及网络联系等方式进行随访，至少随访至术后6个月以上。末次随访采用美国手外科协会手指总主动活动度(total action movement，TAM)系统评定[12]手指功能，由同一位主刀的副主任医师对患指的近指间关节主动活动度及患指TAM进行评估测量。

TAM＝各关节屈曲度之和－各关节伸直受限之和患侧与健侧比较，将手部功能分为4级：优，关节活动范围正常；良，TAM>75%健侧；可，TAM>50%健侧；差，TAM<50%健侧[13]。

结果

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