徐小東 張殿英 付中國 王天兵 陳建海 楊明 蘆浩

鎖定鋼板與交鎖髓內(nèi)釘治療肱骨近端骨折的療效分析

徐小東 張殿英 付中國 王天兵 陳建海 楊明 蘆浩

目的分析比較鎖定鋼板與交鎖髓內(nèi)釘治療肱骨近端骨折的治療結(jié)果。方法對2012年1月至2013年5月的38例肱骨近端骨折患者進行回顧性分析。根據(jù)治療方法分為鎖定鋼板組(24例)與交鎖髓內(nèi)釘組(14例)。結(jié)果所有患者均獲得隨訪,時間為9～23個月(平均16.1個月)。兩組患者在切口長度、手術(shù)時間和并發(fā)癥發(fā)生率方面差異有統(tǒng)計學(xué)意義(t=8.857、5.323、2.460,P均<0.05),鎖定鋼板組患者并發(fā)癥發(fā)生率低,交鎖髓內(nèi)釘組患者切口小、手術(shù)時間短;兩組患者在頸干角、骨折愈合時間方面差異無統(tǒng)計學(xué)意義(t=0.548、0.459,P均>0.05);鎖定鋼板組患者的前舉范圍、Constant-Murley肩關(guān)節(jié)功能評分、優(yōu)良率均高于交鎖髓內(nèi)釘組,但差異無統(tǒng)計學(xué)意義(t=1.470、0.905、0.133,P均>0.05)。結(jié)論鎖定鋼板和交鎖髓內(nèi)釘治療肱骨近端骨折各有優(yōu)勢,如適應(yīng)證合適,經(jīng)過規(guī)范的手術(shù)治療均可取得良好的治療結(jié)果。

肱骨骨折,近端;交鎖髓內(nèi)釘;鎖定鋼板;治療結(jié)果

肱骨近端骨折常見于老年骨質(zhì)疏松患者,年輕人骨折多見于高能量損傷。對于不穩(wěn)定或者明顯移位骨折常采用手術(shù)治療。切開復(fù)位鎖定鋼板固定和閉合復(fù)位交鎖髓內(nèi)釘固定是治療肱骨近端骨折兩種常見的治療方法[1-3]。本文對采用鎖定鋼板與交鎖髓內(nèi)釘治療肱骨近端骨折的病例進行回顧性分析。

資料與方法

一、一般資料

隨機選取我科2012年1月至2013年5月有完整資料的應(yīng)用鎖定鋼板或交鎖髓內(nèi)釘治療的肱骨近端骨折患者38例,其中男性13例,女性25例。年齡20～86歲,平均(66.5±16.9)歲。所有患者均為單側(cè)閉合性骨折,左側(cè)21例,右側(cè)17例。低能量損傷28例,滑雪、車禍等高能量損傷10例。鎖定鋼板組24例,交鎖髓內(nèi)釘組14例。按Neer分型:鎖定鋼板組中2部分骨折7例,3部分骨折11例,4部分骨折6例;交鎖髓內(nèi)釘組中2部分骨折8例,3部分骨折5例,4部分骨折1例;按AO分型:鎖定鋼板組中11-A型4例,11-B型14例,11-C型6例;交鎖髓內(nèi)釘組中11-A型7例,11-B型6例,11-C型1例(表1,2)。術(shù)中使用Synthes公司的PHILOS鋼板和Smith&Nephew公司的TRIGEN髓內(nèi)釘。

表1 兩組患者的一般情況統(tǒng)計

表2 兩組患者的骨折分型及術(shù)中情況

二、手術(shù)方法

患者麻醉后取沙灘椅位。鎖定鋼板組:采用三角肌 胸大肌間隙入路,暴露骨折端后,清理關(guān)節(jié)囊積血,將骨折塊復(fù)位,克氏針臨時固定,C臂X線機輔助復(fù)位滿意后放置鋼板固定,對于3部分和4部分骨折,縫合固定大小結(jié)節(jié)并注意植骨。交鎖髓內(nèi)釘組:行肩峰前外側(cè)切口,縱行劈開肩袖,保護肩袖后顯露肱骨頭。在透視引導(dǎo)下行手法及克氏針撬撥復(fù)位,選擇結(jié)節(jié)間溝后方肱骨頭和大結(jié)節(jié)交界處為進針點,置入合適髓內(nèi)釘,并盡量使尾端沒入骨質(zhì)內(nèi),近端和遠端鎖定,安裝尾帽,仔細縫合肩袖,縫合包扎傷口[4]。

三、功能鍛煉

術(shù)后吊帶支具固定患肢,根據(jù)全身狀況、骨折類型及手術(shù)固定情況指導(dǎo)術(shù)后康復(fù)鍛煉。術(shù)后第2天或拔除引流管后即開始被動活動鍛煉,包括鐘擺樣運動和被動前屈、外旋鍛煉,并逐漸被動內(nèi)旋、內(nèi)收和外展活動。術(shù)后復(fù)查X線片如見骨痂或骨折愈合后主動活動鍛煉,可加強伸屈、旋轉(zhuǎn)及收展活動鍛煉,約3個月后開始肩部力量鍛煉并加強活動范圍練習(xí)[5]。

四、隨訪及評估

內(nèi)容包括:(1)定期復(fù)查并行Constant-Murley肩關(guān)節(jié)功能評分;(2)影像學(xué)檢查:標準X線片(肩胛骨正側(cè)位、腋位);(3)采用Constant-Murley肩關(guān)節(jié)功能評分評定優(yōu)良率,總分100分,90分以上為優(yōu),80～89分為良,70～79分為可,70分以下為差。優(yōu)良率=優(yōu)良例數(shù)/總例數(shù)×100%。內(nèi)翻畸形愈合標準:肱骨頸干角<120°[6-7]。

五、統(tǒng)計學(xué)分析

計量資料以x-±s表示,應(yīng)用SPSS 13.0統(tǒng)計軟件,兩組比較采用獨立樣本t檢驗,計數(shù)資料采用χ2檢驗,P<0.05為差異有統(tǒng)計學(xué)意義。

結(jié) 果

所有患者均獲隨訪,隨訪時間為9～23個月,平均16.1個月。鎖定鋼板組與交鎖髓內(nèi)釘組的平均手術(shù)時間(小時)分別為89.4±14.8與65.7±10.3(t=5.323,P<0.05),平均切口長度(mm)分別為10.3±3.1與2.7±1.1(t=8.857,P<0.05),差異有統(tǒng)計學(xué)意義。

根據(jù)術(shù)后X線片和Constant-Murley肩關(guān)節(jié)功能評分:鎖定鋼板組與交鎖髓內(nèi)釘組患者的初次頸干角分別為(139.2±6.40)°與(137.9±7.04)°(t=0.644,P>0.05);末次頸干角分別為(134.7±8.0)°與(133.3±6.42)°(t=0.548,P>0.05),平均下降度數(shù)分別為4.5°與4.6°,兩組間差異無統(tǒng)計學(xué)意義;鎖定鋼板組與交鎖髓內(nèi)釘組的前舉范圍為(146.2±25.3)°與(135.7±36.3)°(t=1.470,P>0.05);肩關(guān)節(jié)評分為(82.9±16.7)分與(77.6±19.2)分(t=0.905,P>0.05);優(yōu)良率為83.3%與78.6%,前者優(yōu)于后者,但差異無統(tǒng)計學(xué)意義(χ2=0.133,P>0.05)(表3)。

表3 兩組患者預(yù)后情況統(tǒng)計(±s)

表3 兩組患者預(yù)后情況統(tǒng)計(±s)

注:α為χ2值

組別 愈合時間(月) 初次頸干角 末次頸干角 前舉范圍 肩關(guān)節(jié)評分(分) 優(yōu)良率(%)鎖定鋼板組 3.3±1.2 139.2°±6.40° 134.7°±8.0° 146.2°±25.3° 82.9±16.7 83.3交鎖髓內(nèi)釘組 3.6±1.9 137.9°±7.04° 133.3°±6.42° 135.7°±36.3° 77.6±19.2 78.6t或χ2值 0.459 0.644 0.548 1.470 0.905 0.133α0.649 0.524 0.587 0.150 0.372 0.715P值

鎖定鋼板組并發(fā)癥:內(nèi)翻畸形愈合2例,螺釘切出1例,退釘1例,肩峰撞擊綜合征1例;交鎖髓內(nèi)釘組的并發(fā)癥:內(nèi)翻畸形愈合2例,延遲愈合1例,肩峰撞擊綜合征2例;鎖定鋼板組并發(fā)癥發(fā)生率為20.8%,交鎖髓內(nèi)釘組并發(fā)癥發(fā)生率為35.7%,差異有統(tǒng)計學(xué)意義(χ2=2.46,P<0.05),見表4。其中交鎖髓內(nèi)釘組有1例2部分骨折患者在每月復(fù)查過程中出現(xiàn)頸干角降低后再升高的變化,初次、再次和末次頸干角分別為142.7°、122.8°和130.9°。經(jīng)過吊帶固定后于術(shù)后7個月畸形愈合。

表4 兩組患者并發(fā)癥統(tǒng)計

討 論

肱骨近端骨折的常見手術(shù)治療方法包括鎖定鋼板內(nèi)固定和交鎖髓內(nèi)釘內(nèi)固定[8]。鎖定鋼板的螺釘為鎖定設(shè)計,可提供角穩(wěn)定性;螺釘較多,固定體積相對大而全面;螺釘相互成角,把持力強,抗拔出阻力大;鎖定鋼板有限接觸骨膜組織,一定程度上保護骨折斷端及周圍血運。但鎖定鋼板為髓外偏心固定,固定力臂大,抗內(nèi)收力量差,對某些內(nèi)側(cè)皮質(zhì)粉碎、缺損或復(fù)位不良的患者,術(shù)后可出現(xiàn)內(nèi)翻畸形、螺釘切割甚至穿出肱骨頭的情況[9-10]。

交鎖髓內(nèi)釘為髓內(nèi)中心性固定,固定力臂小,初始穩(wěn)定性強,有良好的抗屈曲和抗旋轉(zhuǎn)特性;閉合復(fù)位,剝離軟組織少,骨折斷端血運破壞小;交鎖髓內(nèi)釘近端可平行或垂直多向鎖定,可避免在固定失敗時螺釘穿入關(guān)節(jié)腔[11-12]。但是交鎖髓內(nèi)釘近端螺釘數(shù)量相對較少,單位體積螺釘數(shù)量少,骨塊把持力下降;進針點處的醫(yī)源性骨折、肩袖撕裂、神經(jīng)血管損傷等也是其缺陷。

交鎖髓內(nèi)釘組患者在切口大小和手術(shù)時間方面具有明顯優(yōu)勢,手術(shù)操作快,皮膚切口小更易被患者接受。任世祥等[13]研究發(fā)現(xiàn),鎖定鋼板和交鎖髓內(nèi)釘治療肱骨近端骨折均可取得較好的效果,并且后者具有切口小、操作簡單的優(yōu)點。

鎖定鋼板組患者平均前臂上舉范圍比交鎖髓內(nèi)釘組大,但差異無統(tǒng)計學(xué)意義,這與交鎖髓內(nèi)釘損傷肩袖有一定關(guān)系,但不起決定性作用。目前采用的交鎖髓內(nèi)釘更直、更細,入釘點對肩袖的損傷明顯減小,如入釘點近內(nèi)側(cè),經(jīng)岡上肌肌腹入針,肩袖損傷減少。同時肩關(guān)節(jié)功能與規(guī)范的術(shù)后康復(fù)功能鍛煉密切相關(guān)[11]。Lekic等[3]研究發(fā)現(xiàn),鎖定鋼板和交鎖髓內(nèi)釘治療的患者術(shù)后6個月的上舉范圍平均達到141°與134°,鎖定鋼板組患者的活動范圍比交鎖髓內(nèi)釘組好,但是兩者之間比較差異無統(tǒng)計學(xué)意義。

鎖定鋼板組患者和交鎖髓內(nèi)釘組在優(yōu)良率和肩關(guān)節(jié)評分方面差異無統(tǒng)計學(xué)意義。影響預(yù)后的因素很多,如年齡、一般狀況、骨折類型、內(nèi)固定方式、術(shù)者熟練程度、康復(fù)功能鍛煉等。Konrad等[1]研究發(fā)現(xiàn),鎖定鋼板和交鎖髓內(nèi)釘?shù)呐R床治療效果類似,手術(shù)技巧和經(jīng)驗是手術(shù)成功的關(guān)鍵。von Rüden等[2]研究發(fā)現(xiàn),不同的骨折類型、年齡和內(nèi)固定物在長期臨床和影像學(xué)隨訪中沒有發(fā)現(xiàn)明顯差異,交鎖髓內(nèi)釘和鎖定鋼板都是較好的肱骨近端骨折治療方法。

頸干角<120°即內(nèi)翻畸形和內(nèi)固定丟失之間有密切聯(lián)系,見于各種內(nèi)固定的肱骨近端骨折術(shù)后[6-7]。本研究中兩組患者初次頸干角均比末次頸干角有一定程度的下降,頸干角大小及隨訪過程中的下降程度差異無統(tǒng)計學(xué)意義。交鎖髓內(nèi)釘組有1例患者:女性,80歲,3部分骨折,出現(xiàn)頸干角波動性變化,可能與交鎖髓內(nèi)釘固定單位面積的螺釘數(shù)量相對少、骨質(zhì)疏松等導(dǎo)致螺釘把持能力下降,固定不牢固,導(dǎo)致復(fù)位丟失有關(guān),此種情況應(yīng)該慎重選擇交鎖髓內(nèi)釘固定。

鎖定鋼板組患者肱骨近端內(nèi)側(cè)皮質(zhì)粉碎,骨塊難以復(fù)位固定,內(nèi)側(cè)皮質(zhì)支撐失敗,造成肱骨頭進行性內(nèi)翻并最終出現(xiàn)內(nèi)翻畸形和螺釘切出[4,14-15],術(shù)中對于肱骨頭內(nèi)翻的復(fù)位和維持內(nèi)側(cè)皮質(zhì)支撐作用是避免術(shù)后內(nèi)翻畸形發(fā)生的關(guān)鍵[6]。交鎖髓內(nèi)釘雖然是髓內(nèi)固定、力臂短、抗屈曲能力強,但是如果患者的骨質(zhì)疏松嚴重,肱骨頭內(nèi)骨質(zhì)空虛,植骨困難,難以維持內(nèi)側(cè)皮質(zhì)支撐;而交鎖髓內(nèi)釘螺釘數(shù)量相對少,對部分骨折塊的把持作用有限,尤其對老年骨質(zhì)疏松性3或4部分骨折,不易穩(wěn)定固定肱骨頭。本次研究中交鎖髓內(nèi)釘組并發(fā)癥的發(fā)生率明顯高于鎖定鋼板組,與這些因素有密切關(guān)系。

肱骨近端骨折為關(guān)節(jié)周圍骨折,應(yīng)該解剖復(fù)位,平整關(guān)節(jié)面,恢復(fù)關(guān)節(jié)及內(nèi)側(cè)皮質(zhì)力線,并堅強固定,以維持肱骨近端的形態(tài)并保護血運,以利于早期功能鍛煉和骨折愈合[6,16]。鎖定鋼板和交鎖髓內(nèi)釘治療都是可行的治療方法,把握各自的適應(yīng)證,是提高手術(shù)療效的重要因素。對于2部分或3部分骨折且無骨質(zhì)疏松的年輕患者,可采用鎖定鋼板或交鎖髓內(nèi)釘固定[17]。對于2部分外科頸和肱骨干骨折,可采用交鎖髓內(nèi)釘固定[18],對于交鎖螺釘難以把持的結(jié)節(jié)骨折以及4部分骨折謹慎采用[19],但最新交鎖髓內(nèi)釘?shù)脑O(shè)計和性能越來越完善,交鎖髓內(nèi)釘固定的適應(yīng)證也將進一步擴展。對骨質(zhì)情況良好的3部分或部分4部分老年骨折患者,可以采取鎖定鋼板固定[18]。對于部分3部分或4部分骨折,尤其是伴有嚴重骨質(zhì)疏松的老年患者,血運破壞非常嚴重,肱骨頭中心骨量很少,螺釘難以把持而且容易出現(xiàn)不穩(wěn)定現(xiàn)象,尤其是內(nèi)側(cè)皮質(zhì)缺損或者復(fù)位困難的患者應(yīng)該選擇肩關(guān)節(jié)置換治療[4,17,20]?？傊?應(yīng)該綜合患者年齡、骨量、骨折類型、粉碎程度、碎片數(shù)量與位置等因素,選擇合適的手術(shù)適應(yīng)證,制定個體化的治療方案,并不斷提高手術(shù)技術(shù)和熟練程度,規(guī)范康復(fù)功能鍛煉,才能不斷提高預(yù)后。

本研究的缺點:分組病例較少,沒有對肱骨近端骨折各個分型的預(yù)后及并發(fā)癥等對比分析。

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Treatment of proximal humeral fractures with interlocking intramedullary nail versus locking plate

Xu Xiaodong,Zhang Dianying,Fu Zhongguo,Wang Tianbing,Chen Jianhai,Yang Ming,Lu Hao.Department of Trauma and Orthopedics,Peking University People’s Hospital,Peking University Traffic Medicine Center,Beijing 100044,China

BackgroundProximal humeral fracture is usually seen in elder citizens with osteoporosis,and such a fracture in younger patients mainly results from high-energy injury.Surgical procedure is often adopted for patients with unstable or obviously displaced fracture.Open reduction and locking plate fixation or closed reduction and interlocking intramedullary nail fixation are two common treatment methods for proximal humeral fracture.In this paper,retrospective analysis was conducted to compare the clinical curative effects between locking plate and intramedullary nail in the treatment of proximal humeral fracture.MethodsGeneral data:From January 2012 to May 2013,38 patients with full information in our department were randomly selected in the retrospective analysis,including 13 male and 25 female,aged from 20 to 86,and the mean age was 66.5±16.9 years.According to the different treatment methods,the patients were divided into the locking plate group(24 cases)and the interlocking intramedullary nail group(14 cases).All patients had unilateral closed fractures treated with locking plate or interlocking intramedullary nail,including 22 cases on the left side and 17 cases on the right side.28 patients were injured from low energy falls and 10 cases were from high energy trauma like skiing,motor accidents,etc.According to Neer classification,7 cases of two-part fracture,11 cases of three-part fracture and 6 cases of four-part fracture were in the locking plate group,and 8 cases of two-part fracture,5 cases of three-part fracture and 1 case of four-part fracture were in the interlocking intramedullary nail group.In the meanwhile,on the basis of AO classification,4 type 11-A cases,14 type 11-B cases and 6 type 11-C cases were in the locking plate group,and 7 type 11-A cases,6 type 11-B cases and 1 type 11-C case were in the interlockingintramedullary group.PHILOS plate of Synthes,Inc.and TRIGEN intramedullary nail of Smith&Nephew,Inc.were used in the operation.Operation methods:After successful anesthesia,the patient was placed in beach chair position.Locking plate group:Deltoid pectoralis major muscle gap approach was applied to expose the fracture end.Clean up the hematocele in the joint capsule,reduce the bone fragments and use Kirschner wire for temporary fixation.Plate fixation was done after successful C-arm fluoroscopy assisted reduction.The greater and lesser tubercles of humerus were sutured with bone graft for three and four-part fracture.Interlocking intramedullary nail group:Anterolateral incision on the acromion was made to split the rotator cuff longitudinally,and then protect the acromion and expose the humeral head.Manual or Kirschner wire poking reduction was done under fluoroscopic guidance.Choose the junction of humeral head behind intertubercular sulcus and the greater tubercles of humerus as the entry point,insert the proper nail and make sure that the nail tail was in the bone before locking the proximal and distal screws.After installing the tail cap,closely suture the rotator cuff and then stitch and bind up the wound.Functional training:The affected limb was fixed with forearm sling brace after operation.Postoperative functional training is guided on the basis of general condition,fracture type and state of surgical fixation.With the drainage tube extracted,passive movement is initiated on the second day after surgery,including pendular movement,passive anteflexion and external rotation,and then gradual passive internal rotation,adduction and abduction.With signs of callus or fracture healing seen on postoperative X-ray films,we should encourage active movement and enhance the exercises of flexion and extension,rotation,adduction and abduction,etc.The training of shoulder strength starts 3 months later,with the intensified exercises for range of motion.Follow-ups and evaluation:The content includes:(1)Regular return visit and evaluation of shoulder function with Constant-Murley score;(2)Imaging examinations:standard X-ray films(anteroposterior view of scapula,axillary view);(3)Excellent rate of shoulder function is assessed with Constant-Murley score.The total score is 100 points,regarding 90 points and above as better,80-89 as good,70-79 as normal and 70 points below as poor.The excellent rate=excellent case number/total case number*100%.The standard of varus malunion:humeral neck shaft angle is smaller than 120°.Statistical analysis Measurement data is expressed asx-±swith SPSS 13.0 statistical software,using independent samples t test.Theχ2 test is adopted for enumeration data.P<0.05 is considered as statistical difference.Results(1)All the patients were followed up for 9-23 months with an average of 16.1 months.The mean operation time(minute)of plate group and intramedullary nail group were 89.4±14.8 and 65.7±10.3(t=5.323,P<0.05).The average length of incisions(mm)were 10.3±3.1 and 2.7±1.1(t=8.857,P<0.05).The two indices above had statistically significant difference.(2)Assessment was based on post-operative X-ray film and Constant-Murley scoring system of shoulder joint function:The initial neck shaft angles in plate group and intramedullary nail group were 139.2°±6.40°and 137.9°±7.04°(t=0.644,P>0.05);the last neck shaft angles in plate group and intramedullary nail group were 134.7°±8°and 133.3°±6.42°(t=0.548,P>0.05)with the average decline degrees respectively 4.5°and 4.6°,and there was no statistical difference between the two groups.The ranges of forward elevation in locking plate group and intramedullary nail group were respectively 146.2°±25.3°and 135.7°±36.3°(t=1.470,P>0.05);the shoulder scores were 82.9±16.7 and 77.6±19.2(t=0.905,P>0.05);the excellent rates were 83.3%and 78.6%with the former better than the latter,but no statistical difference was found(χ2=0.133,P>0.05).(3)Complications of plate group:2 cases of varus malunion,1 case of screw cut-out,1 case of screw withdrawal and 1 case of subacromial impingement syndrome;Complications of intramedullary nail group:2 cases of varus malunion,1 case of delayed union and 2 cases of acromion impingement syndrome;The incidence rate of complications in plate group was 20.8%and that in intramedullary nail group was 35.7%(χ2=2.46,P<0.05)with statistical difference.Details are seen in table 4.In a two-part fracture case of intramedullary nail group,the changes of neck shaft angle appeared as increase after decline during monthly review,and the initial-second-last neck shaft angles were 142.7°,-122.8°,-130.9°.This patient had malunion with the affected arm fixed in a sling for 7months after surgery.ConclusionsBoth the interlocking intramedullary nail fixation and the locking plate fixation have the merits in treatment of proximal humeral fractures.Choosing proper indications,we can get excellent curative outcomes after operation and rehabilitation.

Humeral fractures,proximal;Nail;Plate;Treatment outcome

Zhang Dianying,Email:zdy8016@163.com

2014-03-10)

(本文編輯:李靜)

10.3877/cma.j.issn.2095-5790.2014.04.005

衛(wèi)生公益性行業(yè)科研專項(201002014);教育部創(chuàng)新團隊(IRT1201)

100044 北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

張殿英,Email:zdy8016@163.com

徐小東,張殿英,付中國,等.鎖定鋼板與交鎖髓內(nèi)釘治療肱骨近端骨折的療效分析[J/CD].中華肩肘外科電子雜志,2014,2(4):230-234.