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Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2022 May;36(5):587–591. [Article in Chinese] doi: 10.7507/1002-1892.202201048

关节盘复位锚固术在下颌骨髁突囊内骨折伴关节盘移位治疗中的应用研究

Clinical application of disc reduction and anchorage for diacapitular condylar fracture with disc displacement

Liangying GUO 1, Xianbin MENG 1, Zhigang WU 1,*
PMCID: PMC9108650  PMID: 35570633

Abstract

Objective

To investigate the effectiveness of disc reduction and anchorage in treatment of diacapitular condylar fracture with disc displacement.

Methods

Between June 2019 and June 2021, 20 patients (27 sides) with diacapitular condylar fractures with disc displacement were treated with disc reduction and anchorage combined with internal fixation. There were 15 males and 5 females with a median age of 40 years (range, 8-65 years). The fractures were caused by falling from height in 3 cases, traffic accident in 3 cases, and falling in 14 cases. Among them, there were 13 cases of unilateral fracture and 7 cases of bilateral fractures. Five sides were type A fractures and 22 sides were type B. There were 14 simple diacapitular condylar fractures, 12 diacapitular condylar fractures combined with mandibular chin fractures, and 1 diacapitular condylar fracture combined with mandibular angle fracture. The maximum opening was 5-20 mm (mean, 9.7 mm). The time from injury to operation was 4-20 days, with an average of 11.6 days. The postoperative imaging examination was performed to evaluate the reduction of fracture and disc. The maximum opening at 6 months after operation was recorded, and the clinical dysfunction index (Di) of Helkimo index was used to evaluate the temporomandibular joint function.

Results

All incisions healed by first intention. All 20 patients were followed up 6-10 months (mean, 8 months). Postoperative imaging examination showed that 27 fractures were well reduced, of which 26 were anatomically reduced and 1 was basically reduced; the reduction of the temporomandibular joint disc was excellent in 25 sides, good in 1 side, and poor in 1 side, and the effective rate of disc reduction and anchorage was 96.3%. The occlusion relationship of the patient was stable and basically reached the pre-injury level, the incision scar was hidden, and the mouth opening significantly improved when compared with the preoperative level. The maximum mouth opening was 32-40 mm (mean, 36.8 mm) at 6 months after operation. Maximum opening was more than 35 mm in 17 cases. At last follow-up, joint function reached Di 0 grade in 8 sides, DiⅠ grade in 18 sides, and DiⅡ grade in 1 side. After operation, 2 cases of opening deviation, 1 case of joint click, and 2 cases of temporary disappearance of frontal striae on affected side occurred, which recovered to normal after symptomatic treatment.

Conclusion

For diacapitular condylar fractures with disc displacement, it is necessary to adopt disc reduction and anchorage at the same time of fracture reduction and internal fixation, which can achieve good clinical results.

Keywords: Mandible, diacapitular condylar fracture, disc reduction and anchorage, fracture reduction, internal fixation

下颌骨髁突囊内骨折是髁突骨折的常见类型，约占髁突骨折的65%[1]。该类型骨折保守治疗存在下颌升支高度降低、关节盘移位、关节弹响、开口受限、开口偏斜、咬合关系紊乱和颞下颌关节强直等并发症[2]，因此越来越多医生倾向于手术治疗，以期恢复下颌升支高度和髁突解剖形态。此外，由于髁突囊内骨折伴有软组织损伤，尤其是关节盘前移位[3]，而颞下颌关节正常功能依赖于良好盘髁关系，所以要实现髁突囊内骨折良好治疗效果不能单纯行骨折复位固定，还需要复位修复关节盘等软组织。2019年6月—2021年6月，我们采用关节盘复位锚固术联合骨折内固定术治疗下颌骨髁突囊内骨折伴关节盘移位20例（27侧），取得良好效果。报告如下。

1. 临床资料

1.1. 一般资料

本组男15例，女5例；年龄8～65岁，中位年龄40岁。致伤原因：高空坠落伤3例，交通事故伤 3例，摔伤14例。术前经全景X线片及颌面部CT检查，确诊为髁突囊内骨折；颞下颌关节MRI检查示关节盘前移位。其中，单侧骨折13例，双侧骨折7 例；根据髁突囊内骨折分型标准[4]：A型5侧，B型22侧。单纯髁突囊内骨折14侧，髁突囊内骨折伴下颌颏部骨折12侧、下颌角骨折1侧。患者均存在咬合关系紊乱、患区疼痛不适，不同程度张口受限，最大开口度5～20 mm，平均9.7 mm。受伤至手术时间4～20 d，平均11.6 d。

1.2. 手术方法

1.2.1. 骨折复位与固定

患区耳周备皮四横指，患者取平卧位，全身麻醉鼻插管后，垫肩，头偏向健侧，常规消毒铺巾。采用1%利多卡因肾上腺素（1∶200 000）行患区耳颞部局部浸润麻醉，采用改良耳轮缘拐杖形切口入路，向下不超过耳垂，向上在耳轮脚处转向发际，发际内长度可以根据需要确定，本组发际内长度约2 cm。切开皮肤及皮下组织直达腮腺咬肌筋膜，再沿颞浅静脉向下分离切开腮腺，弧形切开颞深筋膜及颧弓骨膜层，沿关节囊和咬肌表面向前分离，T形切开关节囊，保留外侧囊和韧带，钝性分离暴露骨折断端及关节腔。使用剥离器置于下颌骨乙状切迹牵拉，使关节间隙增大，以充分暴露骨折区域，寻找前内侧移位的骨折断端并适度松解复位，此时注意保护翼外肌的附着，防止骨折块游离复位；仔细复位骨折断端，使用2枚长15 mm的拉力螺钉（Biomet Microfixation公司，美国）固定。

1.2.2. 关节盘复位与锚固

① 关节盘复位：松解关节盘前附着，去除关节粘连，使关节盘复位并覆盖髁突表面，为了抵消锚固线松弛，必要时关节盘复位可以矫枉过正，一般右侧关节复位至髁突1点钟方向，左侧关节复位至髁突11点钟方向[5]。术中见本组关节盘前移位27侧，盘后区穿孔17侧，关节囊破裂11侧。

② 锚固钉植入：暴露髁突后斜面骨质，在后斜面远离骨折线的位置稍偏向外侧植入1枚直径2.0 mm、长7.0 mm的锚固钉（上海捷迈医疗国际贸易有限公司），注意锚固钉避开髁突头，防止损伤髁突软骨；术中固定骨折使用的拉力螺钉位置合适时，可兼用作关节盘复位锚固术的锚固钉。本组20侧植入1枚锚固钉，7侧使用拉力螺钉。

③ 关节盘锚固：于关节盘后带与双板区的交界处进针，采用水平褥式缝合，由内向外缝合2针，最后将锚固线打结固定于锚固钉上，一般打5～6个结。对盘后区穿孔及关节囊破裂进行缝合处理。仔细冲洗创腔，止血，放置负压引流，分层缝合创面。见图1。

图 1.

Schematic diagram of surgical operation

手术操作示意图

a. 改良耳轮缘拐杖形切口； b. 钝性分离至关节囊；c. 骨折复位与固定　箭头示髁突； d. 关节盘复位　箭头示关节盘； e. 关节盘锚固　箭头示锚固钉； f. 分层缝合创面

a. Modified ear-rim crutch-shaped incision; b. Blunt separation to joint capsule; c. Reduction and fixation of fracture　Arrow showed the condyle; d. Reduction of the disc　Arrow showed the disc; e. Anchoring of the disc Arrow showed the anchor nail; f. Stratified suture of the wound

图 1

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1.3. 术后处理

术后常规使用抗生素3 d预防感染，对术区进行加压固定，减少出血。术后颌间弹性牵引1～2周，无需放置颌垫。嘱咐患者2周内全流质，之后开始开口锻炼。

1.4. 疗效评价指标

① 术后摄全景X线片、颌面部CT扫描及三维重建，检查髁突囊内骨折复位情况。

② 术后1周颞下颌关节MRI检查关节盘复位锚固术有效性[6]。具体评价标准：选取髁突矢状位外、中、内3个层面观察关节盘是否在位，3个层面均可见关节盘记为优，2个层面可见记为良，仅1个层面可见记为差。关节盘复位达良及以上，判定为关节盘复位锚固术有效。

③ 术后6个月测量患者最大开口度，依据何冬梅等[7]提出的髁突骨折治疗成功标准（最大开口度≥35 mm）评价治疗效果。

④ 末次随访时，记录Helkimo指数中的临床功能障碍指数（clinical dysfunction index，Di）[8]，评价颞下颌关节功能。Di包括下颌运动受限指数、关节功能障碍指数、肌肉触痛指数、关节疼痛指数、下颌运动疼痛指数5个方面，每项0～20分；计算各项评分总分。根据总分分级， 0分Di 0级，1～4分Di Ⅰ级，5～9分Di Ⅱ级，10～25分Di Ⅲ级；级别越高，颞下颌关节功能障碍越严重。

2. 结果

术后切口均Ⅰ期愈合。20例患者均获随访，随访时间6～10个月，平均8个月。术后全景X线片及颌面部CT检查示27侧骨折复位良好，其中26侧达解剖复位、1侧达基本复位。术后1周颞下颌关节MRI复查示，关节盘复位达优25侧、良1侧、差1侧，关节盘复位锚固术有效率达96.3%（26/27）。患者咬合关系稳定程度基本达到伤前水平，切口瘢痕隐蔽。开口度较术前明显改善，术后6个月最大开口度达32～40 mm，平均36.8 mm；17例最大开口度≥35 mm。末次随访，Helkimo指数中Di评分为0～6分，平均1.0分；其中Di 0 级 8侧、DiⅠ级18侧、DiⅡ级1侧。术后出现2例开口偏斜、1例关节弹响、2例暂时性患侧额纹消失，嘱患者行相关锻炼并服用营养神经药物后恢复正常。见图2。

图 2.

A 57-year-old female patient with bilateral diacapitular condylar fractures (type A)

患者，女，57岁，双侧下颌骨髁突囊内骨折（A型）

a. 术前全景X线片；b. 术前颌面部CT；c. 术前颞下颌关节MRI示关节盘移位（箭头）；d. 术后1周颞下颌关节MRI示关节盘复位（箭头）； e. 术后6个月全景X线片；f. 术后6个月颌面部CT

a. Preoperative panoramic radiography; b. Preoperative maxillofacial CT; c. Preoperative MRI of temporomandibular joint showed disc displacement (arrow); d. MRI of temporomandibular joint at 1 week after operation showed disc reduction (arrow); e. Panoramic radiography at 6 months after operation; f. Maxillofacial CT at 6 months after operation

图 2

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3. 讨论

近年来，随着MRI技术在颞下颌关节检查的应用，学者们发现髁突囊内骨折会伴发重要软组织损伤，据报道98.0%患者伴颞下颌关节盘移位、盘后区撕裂、关节囊损伤、关节腔积液，其中关节盘前移位最常见[4]。髁突囊内骨折后软组织损伤如不予处理或者处理不当，可能导致术后并发症[5]。Neff等[9]远期随访发现30%髁突囊内骨折患者出现张口受限。曾文丽等[10]发现髁突囊内骨折后如关节盘等软组织未能复位，可能发生关节弹响、疼痛等。Zhang等[11]认为创伤性颞下颌关节强直可能是髁突囊内骨折伴关节盘移位所致。颞下颌关节强直是髁突囊内骨折最严重并发症，而关节盘移位是其发生的重要因素之一[12]。缺少关节盘的阻挡作用，骨折残端与关节窝直接接触，关节强直风险增加。因此，对于伴关节盘移位的髁突囊内骨折患者应进行关节盘复位。

关节盘复位锚固术是由Annandale[13]首次提出，McCarty等[14]将其用于治疗颞下颌关节紊乱病的关节盘移位，取得较好临床效果；任荣等[5，15]用于治疗髁突囊内骨折伴关节盘移位，术后关节盘复位有效率达92%，关节盘趋于正常，盘髁关系稳定；曾文丽等[10]用其治疗36例髁突囊内骨折，术后患者颞下颌关节功能均得到有效改善；Yan等[16]用其治疗双侧髁突粉碎性囊内骨折，术后患者开口度、前伸及侧方运动恢复正常，有效避免了关节强直的发生。上述研究结果均表明关节盘复位锚固术可用于髁突囊内骨折治疗。

本组将关节盘复位锚固术与骨折内固定术结合，兼顾骨组织复位及软组织修复，整体恢复颞下颌关节功能。此外，本组并非所有患者均植入锚固钉，一些患者由于固定骨折的拉力螺钉位置较合适，可以直接用于锚固，既减少了锚固钉的使用，又能达到关节盘复位的效果。临床上对于髁突囊内骨折术后效果的评价多集中于骨折复位情况，而关节盘复位效果缺乏影像学评价。因此，本研究通过MRI 检查选取矢状位3个层面对关节盘复位锚固术有效性进行评价，结果显示关节盘复位锚固术有效率达96.3%，提示通过该术式可有效复位关节盘，为关节功能恢复奠定良好基础。

目前，颞下颌关节功能主要通过比较开口度、下颌侧方或者前伸运动距离来评价。本组术后17例最大开口度≥35 mm，达到何冬梅等[7]提出的髁突骨折治疗成功标准。但上述指标属于单项定量指标，缺乏对颞下颌关节功能全面评价[17]。故本研究同时采用Helkimo指数中的Di，从下颌运动受限指数、关节功能障碍指数、肌肉触痛指数、关节疼痛指数、下颌运动疼痛指数5个方面，综合评价颞下颌关节功能，末次随访显示无明显功能异常者（Di 0级和DiⅠ级）共26侧（96.3%），说明关节盘复位锚固术联合骨折内固定术治疗可有效恢复颞下颌关节功能。

髁突囊内骨折由于手术视野有限，关节盘复位锚固及骨折内固定操作难度大，为达到满意效果，术中需注意以下几点[5, 18-21]：① 骨折断端避免游离复位，以减少对翼外肌的损伤，从而减少术后髁突吸收及下颌运动障碍的发生；② 术中注意保护髁突软骨及关节窝软骨；③ 术后锚固线可能会随着关节运动发生松弛，因此必要时术中关节盘复位可作一定程度过度矫正；④ 锚固钉植入位置应远离骨折块，仔细检查防止松动；⑤ 术后颌间牵引时间一般为1～2周；⑥ 注意术后早期功能训练。

综上述，将颞下颌关节看作一功能整体，在髁突囊内骨折治疗时采用关节盘复位锚固术同期恢复软组织解剖位置，可取得较好疗效。但本组随访时间有限，远期疗效还需进一步随访观察。

利益冲突　在课题研究和文章撰写过程中不存在利益冲突

伦理声明　研究方案经蚌埠医学院第一附属医院临床技术应用伦理委员会批准（2021154）

作者贡献声明　郭梁影：起草文章、数据收集整理及统计分析；孟献斌：数据收集整理；吴志刚：研究设计及实施、对文章的知识性内容作批评性审阅

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

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