【摘要】 目的探讨局部小剂量单次放射治疗(放疗)加口服吲哚美辛与单用口服吲哚美辛对预防肘关节异位骨化切除术后复发的效果差异。方法 2009年1月至2011年12月间对134例肘关节创伤后僵硬并肘关节异位骨化患者于肘关节松解同时行异位骨化切除。显露及切除异位骨化,于深部组织皆采用内、外侧双入路,于内侧显露并保护尺神经,之后去除内侧关节囊;近端于肱肌和肱三头肌之间进入,去除后部内侧异位骨化、后关节囊;远端于尺侧腕屈肌尺骨头与肱骨头之间去除异位骨化。外侧近端于肱三头肌下方去除后方异位骨化,于肱桡肌下方显露并去除前方异位骨化,外侧远端于肱肌下方显露并去除异位骨化。如需改善前臂旋转功能,则需将上尺桡周围异位骨化及增生瘢痕切除,术中视情况决定尺神经是否前移。其中78例患者,于异位骨化切除术前4小时内行肘关节周围局部小剂量单次放疗,放疗剂量为6~7 Gy,术后口服吲哚美辛每日3次,每次25 mg,6周,术后康复以主动锻炼及主动辅助锻炼为主。78例患者中,男46例,女32例,平均年龄35.8岁(16~65岁)。按Hastings-Graham分型,术前肘关节异位骨化ⅡA型56例,ⅡB型5例,ⅡC型6例,Ⅲ型11例。另56例患者,异位骨化切除术前未行局部小剂量单次放疗,术后口服吲哚美辛。56例患者中,男34例,女22例,平均年龄34.7岁(15~60岁)。按Hastings-Graham分型,术前肘关节异位骨化ⅡA型43例,ⅡB型5例,ⅡC型3例,Ⅲ型5例。结果术后随访平均26个月(24~36个月),134例患者肘关节功能改善。加用放疗的患者中,除1例患者外,肘关节正、侧位X线片均未见明显异位骨化复发。此例患者术后2年随访时X线片显示异位骨化较明显,但功能正常。未加用放疗的患者中,有2例异位骨化复发,其中1例为Ⅰ型,另1例ⅡB型。经过比较,两组患者异位骨化复发率差异无显著性。结论口服吲哚美辛对于预防肘关节异位骨化切除术后复发有意义,加用局部小剂量单次放疗似非必需。更多还原

【Abstract】 Objective To compare the effect of single low dose local radiotherapy and indomethacin together with indomethacin alone in the prevention of recurrence of ectopic ossification around the elbow after resection. Method From Jun. 2009 to Dec. 2011, we performed excision of ectopic ossification around the elbow in 134 stiff elbows. For each case, we used both medial and lateral approach, and we performed both anterior and posterior capsulectomies and removal of ectopic ossification. In the lateral approach, we start proximally,the lateral supracondylar ridge of the humerus is exposed from the interval between extensor carpi radialis longus(ECRL) and triceps, and then continued distally passes the interval between ECRL and extensor carpi radialis brevis(ECRB). With the medial approach, after releasing the ulnar nerve, the pronator teres muscle origin is reflected from the medial epicondyle, and then the common flexor-pronator tendon is split longitudinally distally and the brachalis and the anterior portion of the flexor-pronator group are dissected off the anterior humerus. If there is forearm rotation dysfunction, we use extensive lateral approach, the anconeus muscle is reflected from the ulna and the scar tissue and ectopic ossification around the proximal radioulnar joint are resected. The important structures, such as the lateral ulnar collateral ligament(LUCL) and the anterior part of the medial collateral ligament(AMCL), should be carefully protected, because they are important for the elbow stability. Anterior transposition of the ulnar nerve depends on patients’ condition. For 78 patients, we performed low dose radiotherapy 4 hours before operation, and we used indomethacin for 6 weeks after operation. In these patients, there are 46 males and 32 females averaged 35.8 years(16~65 years). According to Hastings-Graham classification, there are 56 ⅡA, 5 ⅡB, 6 ⅡC and 11 Ⅲ before operation. For another 56 patients, we didn’t perform radiotherapy and used indomethacin after operation. In these patients, there are 34 males and 22 females averaged 34.7 years(15~60 years). According to Hastings-Graham classification, there are 43 ⅡA, 5 ⅡB, 3 ⅡC and 5 Ⅲ before operation. Result We followed up these patients for 26 months in average(24~36 months), all patients improved their elbow function. In the radiotherapy group, only 1 recurrence of ectopic ossification. For this patient, his elbow function is excellent, and according to Hastings-Graham classification, his ectopic ossification is type I. In the other group, there are 2 recurrence of ectopic ossification, 1 is type Ⅰ, another is ⅡB. There are no significant statistic difference between the recurrence rate of these 2 groups.Conclusion Indomethacin is effective in the prevention of recurrence of ectopic ossification around the elbow after excision, single low dose local radiotherapy seems not necessary.更多还原