Extensor Tendon Rupture in Rheumatoid Arthritis-Surgical Strategies and Results

伸指肌腱斷裂在類風濕性關節炎的外科治療對策與成果

賴志昇(Chih-Sheng Lai) ； 陳伊呈(I-Chen Chen) ； 簡文祥(Wen-Hsiang Chin) ； 林雍球(Yung-Chiou Lin) ； 顏榮信(Jung-Hsing Yen) ； 宋定宇(Ding-Yu Song) ； 唐友文(Yu-Wen Tang)

《臺灣整形外科醫學會雜誌》 20卷1期 (2011/03) Pp. 19-30

https://doi.org/10.7096/TJTSPS.201103.0019

摘要

背景：
類風濕性關節炎造成的伸指肌腱斷裂，將導致手部的手指伸展遲滯與握力減弱。手術重建斷裂的肌腱，應著重於恢復肌腱的活動度與治療其局部致病因子。
目的及目標：
本篇研究使用肌腱移植、肌腱轉移、或結合移植和轉移合併術式，以修復類風濕性關節炎造成的伸指肌腱斷裂。亦強調導致肌腱斷裂的腕部病變的治療。
病患及方法：
自2001年10月至2008年5月，共有15位類風濕性關節炎病人因自發性伸指肌腱斷裂，自免疫風濕科醫師轉來做手術重建。15例患者接受手術治療，共17支手，總共有52伸肌腱斷裂。手術方法爲修復伸肌腱斷裂，分爲三類有肌腱移植，肌腱轉移，或結合兩類手術。手指的掌指關節的活動範圍，在術前、術後都需紀錄。由最終掌指關節屈曲和伸展所增加的平均活動範圍結果，來分等級。平均淨增加超過30度表示掌指關節結果優異。平均淨增加10至30度爲良好結果，增加小於10度爲尚可，結果爲差表示沒有改善或甚至惡化。
結果：
在9次肌腱移植手術中，有4個優異和3良好的結果。在6次肌腱轉移手術中，有1個優異和3良好的結果。在2次結合肌腱移植和轉移手術中，有一個良好的結果。有5次重建手術，在整個研究中結果爲尚可或差，這是由於後續肌腱再次斷裂，粘連，與類風濕疾病沒有控制得宜。手指伸展遲滯在肌腱移植手術後，已經有所減少，掌指關節由術前平均54度（35-80度）到術後平均19.5度（5-65度）。手指伸展遲滯在肌腱轉移手術後，掌指關節由術前平均40.2度（0-80度）到術後平均8.8度（0-25度）。手指伸展遲滯在結合肌腱移植和轉移手術後，掌指關節由術前平均51.6度（40-68度）到術後平均37度（15-60度）。此外，遠端橈尺關節囊背側有一明顯破洞，導致伸指肌肌腱在侵蝕的骨表面受到磨損。此現象在所有同時進行肌腱重建和手腕滑膜切除的病人中，都可觀察到。在17次肌腱重建手術中，共有16次有做腕背關節與遠端橈尺關節滑膜切除、尺骨頭部清創手術與以伸肌支持帶皮瓣修復關節囊。
結論：
肌腱移植或肌腱轉移手術，使得類風濕患者在伸肌腱重建上提供了手部功能的改善。外科手術不僅只恢復手指伸肌功能，並且根絕其局部致病因素，以防止進一步肌腱的破壞。

並列摘要

Background:
Rupture of extensor tendons in rheumatoid arthritic hands results in extension lag of fingers and weakens grip power that affects the function of the involved hands. Surgical reconstruction of ruptured tendons should be aimed at both restoration of tendon motion and treatment local causative factors.
Aim and Objectives:
This study reports the results of surgical repair of extensor tendon rupture in rheumatoid hands using tendon graft, tendon transfer or combination of both techniques. The importance of treating wrist pathologies that cause tendon rupture is also emphasized.
Patients and Methods:
From October 2001 to May 2008, 15 rheumatoid arthritis patients presenting with spontaneous rupture of extensor tendons of the hands were referred from rheumatologist for surgical reconstruction. A total of 52 ruptured extensor tendons underwent surgical intervention in 17 hands of these 15 patients. The surgical techniques for repair of ruptured extensor tendons were categorized into three groups as tendon graft, tendon transfer, or a combination of both procedures. The range of motion at metacarpophalangeal (MCP) joints of involved fingers were recorded preoperatively and postoperatively. The results were graded by average net gain in range of motion of MCP joints at the end of follow-up. An average net gain of more than 30 degrees in MCP range of motion is classified as excellent result. A good indicates gain between 10 and 30 degrees. While a fair result is defined as less than 10 degrees in gain, a poor result indicates no improvement or even worse.
Results:
In the three groups of surgical interventions, there are 4 excellent and 3 good results in 9 primary tendon graft procedures, one excellent and 3 good results in 6 primary tendon transfer procedures, and one good result in 2 combined tendon graft and transfer procedures, five reconstruction procedures in the whole series were graded with fair to poor results due to re-rupture of tendon, adhesion, and failed medical control of rheumatoid disease. The extension lag at the MCP joint decreased from a preoperative mean of 54 degrees (range, 35 degrees-80 degrees) to a postoperative mean of 19.5 degrees (range, 5 degrees-65 degrees) in primary tendon graft procedures. The extension lag at the MCP joint decreased from a preoperative mean of 40.2 degrees (range, 0 degree-80 degrees) to a postoperative mean of 8.8 degrees (range, 0 degree-25 degrees) in primary tendon transfer procedures. The extension lag at the MCP joint decreased from a preoperative mean of 51.6 degrees (range, 40 degrees-68 degrees) to a postoperative mean of 37 degrees (range, 15 degrees-60 degrees) in combined tendon graft and transfer procedures. Also, a gross perforation on the dorsal capsule of the distal radioulnar joint (DRUJ) that causes attrition of the extensor tendons over the eroded bony surface was observed in all cases underwent simultaneous tendon reconstruction and wrist synovectomy procedures. 16 of 17 primary tendon reconstruction procedures were combined with dorsal wrist and DRUJ synovectomy, ulnar head debridement procedures, and capsule repair with retinacular flap.
Conclusion:
Extensor tendon reconstruction in the hand with tendon graft or tendon transfer provides a functional benefit for rheumatoid patients. Surgical intervention is aimed not only at restoring extensor function but also eradicating local causative factors and preventing further damage of tendon.

並列關鍵字

extensor tendon ； rheumatoid arthritis ； tendon graft ； tendon transfer ； dorsal wrist and distal radioulnar joint DRUJ synovectomy