摘要
目的探讨交锁髓内钉与锁定钢板治疗肱骨近端骨折的疗效对比。方法将2015年5月至10月第二军医大学附属长海医院创伤骨科收治的51例肱骨近端骨折患者按手术方式分为髓内钉组(n=25)及锁定钢板组(n=26)。记录患者平均手术时间、术中出血量、住院时间、骨折愈合时间、术后并发症的发生情况,采用肩关节Neer评分法和美国肩与肘协会评分系统(American shoulder elbow surgeons'form,ASES)综合评估肩关节功能。结果髓内钉组患者各项手术指标显著优于锁定钢板组(P<0.05)。髓内钉组术后并发症发生率为4.00%,锁定钢板组术后并发症发生率为23.08%,髓内钉组术后并发症发生率低于锁定钢板组。两组患者术后5个月肩关节功能优良率分别为96.00%、88.46%,髓内钉组肩关节功能优良率明显高于锁定钢板组(P<0.05)。结论交锁髓内钉用于治疗肱骨近端骨折,能缩短手术时间、住院时间,减少出血量,在固定骨折稳定性方面与锁定钢板固定相比并没有明显的差异,在手术并发症方面也较锁定钢板固定更具优势,值得临床推广。
Background Proximal humerus fracture accounts for 5%of limb fractures,and the incidence affects 105-342/10 000 people per year.While non-displaced fractures are usually treated conservatively,displaced fractures are treated by surgery.As elderly patients with osteoporosis usually suffer from low energy injury that causes stable or slightly displaced fractures,most of them can obtain the recovery of shoulder joint function with conservative treatment with only about 20%of patients required for surgery.It is generally accepted that surgical treatment should be considered if the displacement of head and shaft is over 50%of shaft diameter,or the angle of varus or valgus is 20°greater than the normal head-shaft angle.Operative treatment methods include transosseous suture fixation,Kirschner wire fixation,intramedullary nail fixation and locking plate fixation.Intramedullary nail fixation and locking plate fixation are more applicable clinically.Intramedullary nailing is indicated for minimally displaced Part-3 and Part-4 fractures that involve humeral metaphyseal or shaft,while open reduction and interal plate fixation is indicated for Part-2,Part-3 and Part-4 fractures that involve greater and lesser tuberosity or humeral head.It is widely accepted that better anatomic reduction can be obtained by open fixation,but the rate of operative complications is higher.Intramedullary nailing is less traumatic,but its fixation stability is inferior to that of locking plate.Thus,the choice of operative methods is still controversial.Studies have shown that intramedullary nailing is superior to plate and has lower complication rate.However,another multicenter study shows that there is no significant difference in curative effect and the incidence of complications between two methods after long-term follow-ups.Intramedullary nail fixation leads to a higher rate of iatrogenic rotator cuff injury which requires further arthroscopic treatment.Therefore,there is still not enough clear guideline or evidence to guide the clinical treatment of proximal humeral fractures.As a relatively common type of fracture,it is seldomly studied by any randomized controlled study.Since the treatment method varies from multiple fracture types,it is difficult to carry out studies.Furthermore,there is no unified standard or guideline for the comparison of results among groups in various studies.In order to provide certain reference for the clinical treatment of proximal humeral fractures,51 patients were treated with locking plate or intramedullary nail respectively from May to October in 2015 for study and comparison of these two fixation methods.Methods(1)General Information.From May 2015 to October,51 patients with proximal humeral fractures were treated.According to the Neer classification,30 cases of Part-2 fracture and 31 cases of Part-3 fracture were included.Patients were divided into two groups based on operative methods.25 cases belonged to the intramedullary nailing group,including 12 males and 13 females;the age ranged from 35 to 67 years with an average of(46.46±5.78)years.26 cases belonged to the locking plate group,including 15 males and 11 females;the age ranged from 30 to 65 years with an average of(43.45±6.34)years.There was no statistical difference in age,gender and fracture classificati on between two groups(P>0.05).The operation was performed by the deputy chief physician trained for professional shoulder and elbow surgery with the cooperation of the attending physician.(2)Inclusive and exclusive criteria.Inclusion criteria:①age over 18 years without server complication;②Part-2 or Part-3 fracture based on Neer classification;③no obvious neurovascular injury;④operation performed 1-4 days after admission and no serious postoperative complications.Exclusion criteria:①age less than 18 years;②severe neurovascular injuries;③severe multiple injuries;④severe postoperative complications.(3)Treatment methods.Intramedullary nail group:after brachial plexus block or general anesthesia,an oblique incision was made on the anterolateral side of acromion.With the protection of axillary nerve,the deltoid muscle was split along muscle fibers at the 1/3 junction of anterior and middle parts of deltoid muscle.The splitting of deltoid muscle should not exceed the distal of acromion for more than 5 cm,and the rotator cuff was cut open along fibers.Full thickness suture was used to protect rotator cuff from damage during medullar cavity reaming.After traction reduction,the guide pin was inserted into the appropriate pos ition of m arrow cavity.After continuous reaming,the intramedullary nail was screwed in until the tail has been embedded under the articular surface of humeral head.Then,the proximal and distal locking screws were inserted from the front side with the help of external equipment.The rotator cuff was repaired with full-thickness suture under direct vision.Fluoroscopy was used to confirmed reduction and the position and length of screws.Early shoulder joint function exercises were performed postoperatively.Locking plate group:after brachial plexus block or general anesthesia,the proximal humerus was exposed through deltopectoral approach.The fracture ends were made visible by stripping deltoid muscle,and reduction was temporarily fixed with Kirschner wires.After the reduction condition was confirmed by fluoroscopy,the plate was placed on greater tuberosity and temporarily fixed with Kirschner wires.As the plate position was confirmed properly by fluoroscopy,locking screws were inserted into humeral head for fixation.Afterward,1-2 screws were for humeral shaft fixation.The position of screws in articular cartilage and the quality of reduction were confirmed under fluoroscopy.In the end,the fixation screws were inserted under fluoroscopy.Early shoulder joint function exercises were performed after surgery.(4)Evaluation criteria.The operation indexes of two groups were recorded,including average operation duration,intraoperative blood loss,hospitalization time,fracture healing time and postoperative complications.American shoulder and elbow surgeons'form(ASES)was used for shoulder joint function evaluation.Excellent:satisfactory reduction,no fracture malunion,no restriction of shoulder abduction and elbow flexion and extension,normal arm wrestle,full recovery of upper limb function,no pain;Good:satisfactory reduction,no fracture malunion,>140°of active shoulder elevation,normal arm wrestle,mild pain or slight angulation around shoulder;Poor:poor reduction,>1 cm of fracture displacement,>30°of angular deformity,difficulty of fracture healing,nonunion,loosening and breakage of internal fixator,obvious and lasting pain,obviously limited shoulder and elbow movements.(5)Statistical analysis.The SPSS 17.0 software was used for statistical analysis,and the measurement data was expressed as.The t test was used between the groups,and the chi square test was used for enumeration data.The difference was statistically significant if P<0.05.Results(1)Comparison of operative indexes.The mean operation time,intraoperative blood los s,hos pitalization and fracture healing tim e for the intram edullary nail group were significantly better than those for the locking plate group(P<0.05).(2)Comparison of postoperative complications.The two groups were followed up for 5 months after surgery.The postoperative complication rate of intramedullary nail group was 4.00%,which was lower than that of locking plate group(23.08%).(3)Comparison of shoulder function recovery.The good and excellent rates of shoulder function for two groups 5 months after operation were 9 6%a n d 8 8.4 6%r e s p e c t i v e l y,a n d t h e e x c e l l e n t a n d g o o d r a t e o f s h o u l d e r f u n c t i o n f o r intramedullary nail group was significantly higher than that for locking plate group(P<0.05).(4)Contrast of imaging observation.As what can be seen from images,proximal humeral fractures can be well fixed with both intramedullary nail and locking plate.After 3 months of observation,two fixation methods have both achieved good healing.Conclusions Interlocking intramedullary nail for the treatment of proximal humeral fractures can shorten the time of operation and hospitalization and reduce blood loss.There is no obvious difference between two strategies in fixing fracture stability.In terms of s urgical complications,the interlocking intramedullary nail has more advantages compared to locking plates.Especially in the treatment of senile fracture fixation,the interlocking intramedullary nail has broader applications and is worth of cl inical promotion.
作者
周启荣
曹烈虎
翁蔚宗
陈晓
张军
汪林
王尧
苏佳灿
Zhou Qirong;Cao Liehu;Weng Weizong;Chen Xiao;Zhang Jun;Wang Lin;Wang Yao;Su Jiacan(Department of Orthopaedic Surgery,Changhai Hospital,Second Military Medical Univer sity,Shanghai 200433,China)
出处
《中华肩肘外科电子杂志》
2017年第2期84-89,共6页
Chinese Journal of Shoulder and Elbow(Electronic Edition)
基金
国家自然国际合作基金(8141101156)
上海市科委生物医药专项(154119500600)
关键词
肱骨近端骨折
交锁髓内钉
锁定钢板
Proximal humeral fracture
Intramedullary nail
Locking plate
作者简介
通信作者:苏佳灿,Email:drsujiacan@163.com
