馬明太 付中國 張殿英 陳建海 黃偉 徐海林

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·論著·

ITS肱骨近端鎖定鋼板治療肱骨近端骨折療效觀察

馬明太 付中國 張殿英 陳建海 黃偉 徐海林

目的 探討ITS肱骨近端鎖定鋼板治療肱骨近端骨折的療效。方法 自2012年10月至2013年11月采用ITS肱骨近端鎖定鋼板治療肱骨近端骨折的11例患者，其中男性3例，女性8例；年齡57～86歲，平均80.5歲；骨折按Neer分型：Ⅱ型3例，Ⅲ型6例，Ⅳ型2例。記錄患者手術時間，術中出血量，術中和術后并發(fā)癥發(fā)生情況，術后肩關節(jié)Constant-Murley評分及骨折愈合時間等。分別于術后4、8、12、24和48周預約患者來院復查隨訪，常規(guī)拍攝肩胛骨正側(cè)位片及腋位片。結(jié)果 11例患者均獲隨訪，隨訪時間為11～23個月，平均16個月，均達到骨性愈合，平均愈合時間為12周。根據(jù)肩關節(jié)Constant-Murley評分標準，優(yōu)良率為81.8%。結(jié)論 ITS肱骨近端鎖定鋼板具有穩(wěn)定性可靠，操作簡單、快捷, 并發(fā)癥少等優(yōu)點，用于治療肱骨近端骨折獲得滿意療效。

肱骨近端，骨折；骨折固定術；鎖定鋼板

肱骨近端骨折為臨床常見的骨折類型，約占所有骨折的5%[1]。70%的肱骨近端骨折發(fā)生在60歲以上老年骨質(zhì)疏松人群，由低能量跌倒所致[1-2]。在老年人群中，是繼髖部及橈骨遠端骨折之后最常見的骨折類型[1,3]。此外，肱骨近端骨折也常見于年輕患者的高能量損傷，這類患者常合并其他部位骨折或臟器損傷。根據(jù)Neer分型[4,10]骨折移位超過1 cm或成角超過45°視為移位骨折，約20%的肱骨近端骨折為移位骨折，對于這類骨折手術治療已成為多數(shù)醫(yī)師的共識[1]。治療該骨折有多種內(nèi)固定方式，臨床上常用的有肱骨近端鎖定鋼板。目前，常見的有AO PHILOS、ITS肱骨近端鎖定鋼板、Zimmer、Accumed肱骨近端系列等。有關AO PHILOS鋼板的研究報道較多，查閱相關文獻，未見ITS肱骨近端鎖定鋼板相關報道。2012年10月至2013年11月采用ITS肱骨近端鎖定鋼板手術治療11例肱骨近端骨折患者，療效滿意，現(xiàn)報道如下。

資 料 與 方 法

一、一般資料

2012年10月至2013年11月，我院共對11例肱骨近端骨折患者進行切開復位ITS鋼板內(nèi)固定手術。其中男性3例，女性8例；年齡57～86歲，平均80.5歲；左側(cè)4例，右側(cè)7例；低能量損傷(跌傷)10例，高能量損傷(交通傷)1例；合并內(nèi)科基礎疾病7例，合并其他部位骨折1例；從受傷到手術的時間平均為5.5 d；骨折按Neer分型：Ⅱ型3例，Ⅲ型6例，Ⅳ型2例，均為閉合骨折。

二、手術方法

所有患者均采用全身麻醉，沙灘椅體位。手術取三角肌胸大肌間隙入路，依次切開皮膚、皮下組織，顯露并保護頭靜脈，自兩肌間隙剝離，將頭靜脈連同胸大肌拉向內(nèi)側(cè)，三角肌拉向外側(cè)。切開骨膜并適當剝離，顯露骨折端，將骨塊復位。如大、小結(jié)節(jié)骨折移位明顯，使用愛惜康4843縫線縫合肩袖，牽拉骨塊幫助復位，使用克氏針進行臨時固定。鋼板近端置于大結(jié)節(jié)頂點下方0.8 cm。鋼板側(cè)方與骨干平行，位于結(jié)節(jié)間溝偏背側(cè)0.5～1.0 cm。首先在長結(jié)合孔擰入1枚3.5 mm皮質(zhì)骨螺釘，C臂機透視確認骨折復位滿意及鋼板位置合適后，逐個鉆孔擰入鎖釘。根據(jù)術中所見骨質(zhì)缺損情況，酌情進行植骨。

由于ITS鋼板采用無預設螺紋，螺釘頭部擠壓嵌入鋼板進行鎖定的設計，可以根據(jù)不同骨折固定需要，每顆螺釘滿足±15°任意方向的固定，達到萬向鎖定效果。ITS接骨板近端有5個釘孔，通常都要進行固定，遠端依據(jù)接骨板長度使用3枚左右螺釘。

鎖釘固定后，將肩袖預留縫線固定于鋼板近端縫扎孔進一步復位固定骨塊。活動肩關節(jié)有無摩擦感，透視確認鋼板位置及螺釘長度合適，無螺釘穿出。沖洗傷口并止血，逐層縫合傷口，放置引流管。術前0.5 h及術后24 h內(nèi)使用抗生素，常規(guī)術后2 d拔除引流管。

三、術后功能鍛煉

根據(jù)患者全身狀況及術中固定的牢固程度，指導患者術后功能鍛煉。對于固定可靠者，術后3 d即開始被動功能鍛煉，以肩關節(jié)鐘擺活動和被動功能鍛煉為主。鍛煉間期需使用懸臂吊帶固定。4周后摘掉懸臂吊帶，逐步增加肩關節(jié)各方向的活動練習，此后可依照患者復查情況逐步增加被動的內(nèi)旋、內(nèi)收及外展練習。術后8～12周拍片證實骨折初步愈合后開始力量鍛煉并加強各方向的活動練習。

四、觀察指標及療效評定標準

記錄患者手術時間，術中出血量，術中和術后并發(fā)癥發(fā)生情況、術后肩關節(jié)Constant-Murley評分及骨折愈合時間等。分別于術后4、8、12、24和48周預約患者來院復查隨訪，常規(guī)拍攝肩胛骨正側(cè)位片及腋位片。根據(jù)患者術后疼痛、日常活動能力、患肢活動范圍及肌力進行肩關節(jié)Constant-Murley評分，療效標準為：優(yōu)≥90分，良80～89分，可70～79分，差<70分。

結(jié) 果

手術切口長度5～11 cm，平均為8 cm；手術時間60～115 min，平均80 min；術中出血量100～190 ml，平均150 ml；術后引流量50～120 ml，平均91 ml。11例患者術后隨訪11～23個月，平均16個月。本組患者均達到骨性愈合，骨折愈合時間9～16周，平均12周。所有患者未出現(xiàn)術中、術后并發(fā)癥。根據(jù)患者術后疼痛、日?；顒幽芰?、患肢活動范圍及肌力，進行肩關節(jié)Constant-Murley評分。本組患者優(yōu)6例，良3例，可2例，優(yōu)良率為81.8%。典型病例手術前后X線片和功能相片見圖1。

圖1 患者，女性，80歲，右側(cè)肱骨近端骨折，合并骨質(zhì)疏松。A、B為術前肩關節(jié)正側(cè)位X線片；C、D為術后正側(cè)位X線片；E、F、G為術后1年功能相

討 論

隨著人口老齡化的進程，肱骨近端骨折的發(fā)病率有逐年增加的趨勢。有研究報道老年肱骨近端骨折患者的發(fā)病率在近30年增長了近3倍[5]。該骨折的治療方式通常根據(jù)患者的骨折類型、骨質(zhì)量、年齡及身體一般狀況來制定。約20%的肱骨近端骨折是移位骨折，對于這類骨折，通常需要手術治療[1]。肱骨近端骨折手術治療的目的是：力爭解剖復位、堅強內(nèi)固定、早期功能鍛煉、盡量恢復關節(jié)功能[4,6,8-9]。

肱骨近端骨折手術治療的方式包括非可吸收縫線固定、張力帶固定、空心螺釘固定、普通鋼板固定、解剖型鎖定鋼板固定、髓內(nèi)釘固定及人工肩關節(jié)置換等[1-2,4]。雖然可選擇的固定方式很多，但對于肱骨近端骨折的治療方案至今仍沒有統(tǒng)一的金標準，其治療方式選擇仍存在很多爭議[1-3]。作者認為，在需要手術治療的肱骨近端骨折中，解剖型鎖定鋼板可用于治療大多數(shù)病例。對于肱骨頭關節(jié)面壓縮超過50%、肱骨頭劈裂，尤其是嚴重骨質(zhì)疏松、骨質(zhì)難以承載內(nèi)固定系統(tǒng)的患者，如能耐受手術，我們通常一期行人工半肩關節(jié)置換術。而對于年輕患者(<50歲)仍首選切開復位鋼板內(nèi)固定術。

肱骨近端解剖型鎖定鋼板的優(yōu)點：(1)鋼板外形與肱骨近端匹配，貼服好，無需預彎；(2)鎖定成角穩(wěn)定性通過鋼板螺釘間的牢固鎖定起到內(nèi)支架作用，接骨板和骨面不產(chǎn)生壓力，保留骨折區(qū)的血供；(3)接骨板邊緣的縫合孔可將肩袖進行縫合固定進一步加強骨折復位固定；(4)鋼板近端多個方向螺釘孔的設計保證螺釘把持力更強，尤其適用于骨質(zhì)疏松患者。除以上優(yōu)點外，ITS鋼板釘孔無預設螺紋，由于螺釘為鈦合金材質(zhì)，接骨板鈦純度99.1%，致使螺釘比接骨板質(zhì)地稍硬，螺釘頭部擠壓嵌入并進行鎖定。根據(jù)不同骨折固定需要，每顆螺釘可以滿足±15°任意方向的固定，達到萬向鎖定效果，這樣操作簡單快捷，可節(jié)省手術時間。由于ITS螺釘比接骨板質(zhì)地稍硬，可有效避免出現(xiàn)鎖定螺釘冷焊接效應，此設計可使內(nèi)固定取出更容易。由于ITS接骨板近端釘孔為5孔，釘孔相對較少，對于嚴重骨質(zhì)疏松患者，骨折復位后的把持力可能不夠，因此不建議用于嚴重骨質(zhì)疏松患者。

肱骨近端骨折鋼板內(nèi)固定術后常見并發(fā)癥包括：螺釘穿出、接骨板撞擊肩峰、接骨板斷裂、傷口感染、肱骨頭壞死、肱骨頭內(nèi)翻畸形、延遲愈合等[1]。本組病例未出現(xiàn)此類并發(fā)癥，這可能與我們術后康復鍛煉較為保守以及術中鋼板正確放置有關。Owsley等[7]曾對53例肱骨近端骨折鎖定鋼板固定術后的患者進行了隨訪，認為術后晚期出現(xiàn)的螺釘穿出與肱骨頭初始復位不良以及此后肱骨頭持續(xù)的復位丟失有關。我們放置鋼板時將鋼板近端置于大結(jié)節(jié)頂點下方0.8 cm，這樣既可以保證鋼板螺釘對肱骨頭的支撐同時避免發(fā)生肩峰撞擊。因此，本組患者中未出現(xiàn)接骨板撞擊肩峰現(xiàn)象。

肱骨近端骨折切開復位鋼板內(nèi)固定，術中應盡量達到滿意的骨折復位，尤其近年來國內(nèi)外學者提出內(nèi)側(cè)柱支撐的恢復尤其重要[11-12]。鋼板位置放置合理可以避免鋼板撞擊肩峰的發(fā)生。術后待骨折獲得初步愈合后進行功能鍛煉，可能對減少螺釘穿出有幫助。使用ITS肱骨近端鎖定鋼板治療肱骨近端骨折可獲得滿意療效，其具有穩(wěn)定性可靠，操作簡單、快捷，并發(fā)癥少，可有效避免出現(xiàn)鎖定螺釘冷焊接效應等優(yōu)點。

[1] Schulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal humeral fractures: functional outcomes[J]. J Shoulder Elbow Surg, 2011, 20(8): 1234-1240.

[2] Tepass A, Blumenstock G, Weise K,et al. Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland[J]. J Shoulder Elbow Surg, 2013, 22(1): e8-e14.

[3] Petit CJ, Millett PJ, Endres NK, et al. Management of proximal humeral fractures: surgeons don′t agree[J]. J Shoulder Elbow Surg, 2010, 19(3): 446-451.

[4] Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use[J]. J Shoulder Elbow Surg, 2002, 11(4): 389-400.

[5] Bahrs C, Kuhle L, Blumenstock G, et al. Which parameters affect medium-to long-term results after angular stable plate fixation for proximal humeral fractures?[J]. J Shoulder Elbow Surg,2014,24(5):727-732.

[6] Bigorre N, Talha A, Cronier P, et al. A prospective study of a new locking plate for proximal humeral fracture[J]. Injury, 2009, 40(2): 192-196.

[7] Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures[corrected][J]. J Bone Joint Surg Am,2008, 90(2): 233-240.

[8] 姜保國，張殿英，付中國，等.肱骨近端骨折的治療建議[J].中華創(chuàng)傷骨科雜志，2011，13(1)：55-59.

[9] 姜保國，陳建海.肱骨近端骨折的治療[J].北京大學學報:醫(yī)學版，2012，44(6)：821-823.

[10] 冷昆鵬，張殿英.肱骨近端骨折分型的現(xiàn)狀[J/CD].中華肩肘外科電子雜志，2014,2(2)：111-113.

[11] 白露，張文濤，江長青，等.內(nèi)側(cè)皮質(zhì)缺損對肱骨近端骨折鎖定鋼板內(nèi)固定軸向穩(wěn)定性影響的生物力學研究[J/CD].中華肩肘外科電子雜志，2014,2(2)：75-79.

[12] 馬明太，付中國.肱骨近端骨折內(nèi)固定手術的經(jīng)驗與教訓[J/CD].中華關節(jié)外科雜志(電子版)，2015,9(2)：257-260.

(本文編輯：李靜)

馬明太,付中國,張殿英,等.ITS肱骨近端鎖定鋼板治療肱骨近端骨折療效觀察[J/CD]. 中華肩肘外科電子雜志,2015,3(4):206-210.

Observation of the therapeutic effects of ITS locking proximal humerus plate therapy on proximal humeral fractures

MaMingtai,FuZhongguo,ZhangDianying,ChenJianhai,HuangWei,XuHailin.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

Correspondingauthor：XuHailin，Email:xhl166@sohu.com

Background Proximal humerus fracture is a clinical common fracture type, accounting for 5% of all fracture cases. 70% of proximal humerus fractures occur among the elder population over 60 years old with osteoporosis and are caused by low energy falling. Among the elderly population, proximal humerus fracture is the most common fracture type, only next to distal hip and radial fractures. In addition, proximal humeral fractures are also commonly seen in the high energy injuries to young patients, and such cases are often associated with fractures or organ injuries on other parts. According to Neer fracture classification, if fracture displacement exceeds 1cm or fracture angle exceeds 45°, such case is regarded as displaed fracture. About 20% of proximal humerus fractures are displaced fractures. For such type of factures, operative treatment has become a consensus among majority of physicians. There are many internal fixation modes for treatment of such fracture, and the clinically common modes include locking proximal humerus plate. At present, many companies have released locking proximal humerus plates, and common similar products include AO PHILOS and ITS locking proximal humerus plates as well as Zimmer and Accumed proximal humerus series. There are many research reports related to AO PHILOS plate. By referring to relevant literatures, we have not found relevant report on ITS locking proximal humerus plate. During the period from October 2012 to November 2013, Orthopedic trauma department of Peking University People′s Hospital adopted ITS locking proximal humerus plates in the operative treatment of 11 cases of proximal humerus fractures, and achieved satisfactory therapeutic effects. These cases are reported as follows.Methods Ⅰ.General materials:During the period from October 2012 to November 2013, our hospital conducted open reduction and ITS plate internal fixation operations for 11 proximal humerus fracture cases, including 3 male cases and 8 female cases; aged 57-86 years, with average age of 80.5 years; 4 left side cases, and 7 right side cases; 10 cases of low energy injuries (falling) and 1 case of high energy injury (traffic injury); 7 cases of combined medical underlying diseases, and 1 case of combined with fracture on other sites; the average duration from injury to operation is 5.5 d; Neer fracture classification: 3 cases of type Ⅱ, 6 cases of type Ⅲ, 2 cases of type Ⅳ, all of which are closed fractures.Ⅱ. Operative method:For all the patients, adopt general anesthesia and beach chair position. Adopt the clearance between deltoid and pectoralis major as operative approach, slice through skin and subcutaneous tissues in turn, expose and protect cephalic vein, perform stripping from the intermuscular space between two muscles, pull the cephalic vein in together with musculus pectoralis major inward, and pull the deltoid outward. Perform periosteotomy and appropriate stripping, expose the fracture end and reset the bone block. For obvious lesser tubercle/major tubercle fracture displacement, use Ethicon 4843 suture to stitch rotator cuff, pull the bone block to help bone reduction; use kirschner pin for temporary fixation. Place the proximal end of plate at 0.8 cm below the peak of greater tubercle. The lateral side of plate is parallel with the backbone and is located at 0.5-1.0 cm from dorsal part of the intertubercular sulcus. Firstly, screw in one 3.5 mm cortical bone screw into the long combination hole. After having validated satisfactory fracture reduction and appropriate plate position through C-arm fluoroscopy, drill holes and screw in locking screws one by one. According to the bony defect observed during operation, perform bone grafting. Since ITS plate is so designed that no preset thread is provided and the screw head is extruded and embedded into plate to perform locking, it is feasible to use each screw to perform fixation in any direction of ±15°and realize universal locking effect according to different requirments for fracture fixation. There are 5 screw holes at distal end of ITS bone fracture plate, which generally need fixation. At the distal end, use about screws more or less according to the length of bone fracture plate. After fixation of locking screw, fix the reserved suture in the rotator cuff in the proximal stitching hole of steel plate to further reset and fix the bone blocks. Activate the shoulder joint to determine whether there is friction feeling; Through fluoroscopy, validate whether the position of plate and the length of screw are appropriate, and whether there is screw threading out. Wash the wound and perform haemostasis, stitch the wound layer by layer, and place a drainage tube. In preoperative 0.5 h and postoperative 24 h use antibiotics, and remove the drainage Tube in 2 d after conventional operation.Ⅲ. Postoperative functional exercise:According to the systemic conditions of the patients as well as the firmness of fixation during operation, instruct the patients to perform postoperative functional exercise. In case of reliable fixation, start passive functional exercise on postoperative 3 d, with training exercise mainly including shoulder joint pendulum exercise and passive functional exercise. At the exercise interval, it is necessary to use cantilever suspender for fixation. 4 weeks later, take off the cantilever suspender, gradually increase the active exercise of shoulder joint in various directions. Subsequently, according to the reexamination conditions of the patients, it is feasible to gradually increase the passive internal rotation, adduction and abduction exercises. At postoperative 8-12 weeks, after having validated initial fracture union through X-ray film, start strength exercises and intensify the active exercises in various directions. IV. Observation indices and curative effect evaluation criteria:Record the operation time of the patients, the intraoperatve blood loss, the intraoperative and postoperative occurrence of complications, the postoperative shoulder joint Constant- Murley scoring and fracture union time, etc. Respectively at 4, 8, 12, 24 and 48 weeks after operation, order the patient to receive reexamination and follow-up in hospital, and perform conventional radiography of anterioposterior and lateral film and axillary film. According to the postoperative pain and daily living activity of the patients, the range of activities of affected limbs and muscle force, perform shoulder joint Constant-Murley scoring. The criterion of therapeutic effects: Excellent ≥90 points, good 80-89 points, acceptable 70-79 points, poor <70 points.Results Operative incision has length of 5-11 cm, with average value of 8 cm; the operative time is 60-115 min, with average value of 80 min; the intraoperatve blood loss is 100-190 ml, with average value of 150 ml; the postoperative drainage flow is 50-120 ml, with average value of 91 ml. 11 cases obtained postoperative follow-up for 11-23 months, with average value of 16 months. This group of the patients realized bone union, and the fracture union time is 9-16 weeks, with average value of 12 weeks. All the patients have no intraoperative and postoperative complications. According to the postoperative pain, daily living activity, range of motion of affected limbs and muscle force of the patients, we performed shoulder joint Constant-Murley scoring. This group of the patients include 6 excellent cases, 3 good cases and 2 acceptable cases, with good rate of 81.8%.Conclusion ITS locking proximal humerus plate has such advantages as high stability and reliability, simple and quick operation and less complications, and can achieve satisfactory therapeutic effects in the treatment of proximal humeral fracture.

Humerus fracture,proximal;Fracture internal fixation;Locking plate

10.3877/cma.j.issn.2095-5790.2015.04.

衛(wèi)生公益性行業(yè)科研專項(201002014、201302007)；教育部創(chuàng)新團隊(IRT1201)

100044北京大學人民醫(yī)院創(chuàng)傷骨科 北京大學交通醫(yī)學中心

徐海林,Email：xhl166@sohu.com

2015-02-26)