【摘要】 目的探讨肱骨头骨折块性质与手术方法、预后之间的相关性,并获得支持手术方法选择的相关参数。方法自2013年1月至2015年12月上海交通大学医学院附属新华医院骨科连续收治的49例肱骨近端四部分骨折患者,最终44例获得随访,其中男21例,女23例,年龄范围:58~89岁,平均(78.09±2.52)岁,其中32例行切开复位内固定术(open reduction and internal fixation,ORIF),12例行半肩关节置换术(hemi-arthroplasty,HA)。术前均行肩关节三维CT重建,分别测量出肱骨头骨折块体积与肱骨头的体积,所得的加权比值拟代表肱骨头骨折块的性质。患者术后功能的评价采用美国肩与肘协会评分系统(American shoulder and elbow surgeons’form,ASES)评分,随访时间12~58个月,平均(29.26±2.58)个月。结果行ORIF的32例患者,术后ASES评分40.0~85.0分,平均(66.78±4.51)分,优良率为68.7%(22例);行HA的12例患者,术后ASES评分18.0~88.0分,平均(61.83±12.34)分,优良率为41.6%(5例)。对肱骨头骨折块性质与肩关节功能的相关性分析显示,ORIF后,两者间存在线性关系(P<0.01),而HA后两者间无明显相关性。结论肱骨头骨折块体积比>54.46%的四部分骨折,ORIF较HA功能恢复更佳。肱骨头骨折块体积比<54.46%的四部分骨折,尤其是当患者年龄较大伴骨质疏松时,HA预后较好。更多还原

【Abstract】 Background Proximal humerus fractures account for approximately 5% of all fractures,and 80% of them can achieve satisfactory results with nonoperative methods. However,the conservative treatment for unstable fractures may lead to severe deformity and shoulder dysfunction. There are multiple specific surgical methods,but complications usually happen. The open reduction and internal fixation(ORIF)and hemiarthroplasty(HA)are two effective strategies that are commonly used. Currently,the widely used locking plate can well stabilize the cancellous bone fragment in clinic,and most of the patients achieve good functional recovery. However,the overall treatment outcome is still not satisfactory for complex proximal humeral fractures. HA is generally used in elderly patients with poor bone quality or severe comminution. Although previous reports showed unsatisfactory functional recovery of patients after HA and fewer short-term complication and better function of ORIF compared to HA,some report showed that HA achieves better shoulder mobility than ORIF does. More importantly,the integrity of rotator cuff often plays an important role. In this study,the fragment volume of humeral head was measured based on imaging data in order to obtain the parameters that support the selection of surgical methods and to access the correlation in between. Methods(1) General information. From January 2013 to December 2015,49 patients with comminuted proximal humeral fractures were treated in our hospital. Among them,5 cases lost contact; 2 cases refused to be followed up; 3 cases died because of reasons unrelated to this operation. 21 males and 23 females comprised the other 44 treated cases,and the ages ranged from 58 to 89(78.09±2.52) years. Within the treated group,32 cases received ORIF,and 12 cases received HA. All operations were performed by two associate chief physicians who had sufficient experiences in the shoulder joint surgery. Before the operation,all patients took the routine X-ray film of proximal humerus in anteroposterior lateral views and 3D reconstruction CT. Only the X-ray film of anteroposterior lateral views were taken postoperatively. Patients were followed up for 12-58(29.26±2.58) months.(2)Inclusive and exclusive criteria. Inclusion criteria:(1) acute and closed comminuted proximal humeral fractures(according to Neer classification of 4 parts fractures);(2) over 18 years old;(3) no neurological impairment. Exclusive criteria:(1) pathological or open fractures;(2) combined fractures of other limbs;(3) incomplete articular surface of humeral head fragments.(3) Methods.(1) Measurement and calculation: The data were measured with the Unisight 3.0 software. In order to avoid the impact of individual differences on the test result,the actual measurement of humeral head fracture volume was weighted. The weighted ratio R represented the volume of humeral head.(2) Calculations of volume Vm and weighted R: The fragment section was selected on 3D reconstruction images,and the corresponding selected area Sm was automatically calculated. The cross-sectional area of humeral head fragment was measured respectively to calculate the fragment volume using calculus. Meanwhile,the articular surface of the humeral head and its boundary points were connected on each scanning section,and the volume V of entire humeral head was calculated using the same strategy. R=Vm/V*100%. Vm= Sm1H+Sm2H+Sm3H+Sm4H+…+Smn H=H∑sm1smn. V=S1H+S2H+S3H+S4H+…+Sn H=H∑s1sn. Vm: volume of humeral head fragment; Sm: sectional area of fracture fragment; V: volume of humeral head; S: sectional area of humeral head; H: thickness of CT layer; n: number of scanning layer.(4) Operative methods and postoperative rehabilitation exercises.(1) ORIF(PHILOS?):All patients were applied with general anesthesia and put in beach chair position. The standard deltopectoral approach was taken,and the suture technique was used to strengthen fixation. The affected arm was suspended postoperatively using forearm sling. The wrist and elbow joint were allowed with active movements starting from the first day after operation; the shrug and pendular exercises were allowed starting from the second day after operation(after the removal of drainage tube); the passive movements were introduced 3 weeks after operation,including anteflexion,extension,adduction,abduction,internal rotation and external rotation; the strength and compliance exercises around shoulder muscles started once the obvious callus formation was found under fluoroscopy 6 weeks after operation.(2) HA(ZIMMER?):The operation position and approach were same as those of ORIF,which were operated based on the ZIMMER?. After the operation,the shoulder joint was placed in rotating neutral position with 45° of abduction. The isometric muscle contraction of affected limb began right after surgery; the shrug and pendular exercises were allowed starting from the second day after operation(after the removal of drainage tube); passive anteflexion,extension,adduction,abduction,internal rotation and external rotation were introduced 3 weeks after operation(the same as ORIF group); the gradual active exercises with increasing shoulder joint mobility began once the callus formation between nodules were found under fluoroscopy 6 weeks after operation; the shoulder traction and resistance training were started 12 weeks after surgery,and the coordination and compliance of muscle groups around the shoulder were enhanced gradually.(5) Functional evaluation. The functional evaluation was based on the ASES score,which consisted of two components: the patient’s pain perception(50%) and the daily functional activity(50%). The total score was 100 points with 0-55 points for bad,55-69 points for middle,70-84 points for good and 85-100 points for excellent.Results(1)AESE scoring results.(1) For 32 patients with the treatment of ORIF,the ASES score ranged from 40.0 to 85.0(66.78±4.51)points,and the excellent and good rate was 68.7%(22 cases); For 12 patients with the treatment of HA,the postoperative ASES score ranged from 18.0 to 88.0(61.83±12.34),and the excellent and good rate was 41.6%(5 cases).(2) Statistical analysis.(1) Statistical analysis of relevant data of patients after ORIF: The weighted value R of humeral head fragment volume and post-operative ASES scores were analyzed using normal test. P >0.01 suggested the fitness for bivariate normal distribution,which indicated the viability of conducting linear correlation analysis. The analysis with SAS software(V9.4) showed that the weighted volume of humeral head fragment and postoperative ASES scores were in a linear relationship with P <0.01. Furthermore,there was a linear relationship between the humeral head fragment volume and ORIF shoulder joint function scores. The regression equation: y = 34.60 + 0.50 x,R~2= 0.82,P <0.01.(2) Statistical analysis of relevant data of patients after HA: The weighted value R of humeral head fragment volume and post-operative ASES scores were analyzed using normal test. P >0.01 suggested the fitness for bivariate normal distribution,which indicated the viability of conducting linear correlation analysis. The analysis with SAS software(V9.4) showed the correlation of the weighted volume of humeral head fragment and postoperative ASES scores to be P=0.032(P >0.01),which meant that there was no liner correlation between humeral head bone quality and shoulder joint function after HA. Thus,it was impossible to conduct linear regression analysis; As the volume and postoperative ASES scores fitted bivariate normal distribution,the average value could be expressed as 61.83±12.35.(3) Complications. No fixation failure,nerve injury or deep infection was found in the ORIF group. Subacromial impingement occurred in one patient due to high position of locking plate. There were 1 case of ischemic necrosis of humeral head,1 case of screw loosening and 2 cases of delayed union(one received surgery and the other obtained bone union); no periprosthetic fracture,heterotopic ossification,nerve injury or deep tissue infection was found in patients of HA group. One patient had artificial prosthesis loosening and did not receive revision surgery. Conclusion The purpose of this study is to provide a theoretical basis for the selection of surgical methods of proximal humerus comminuted fractures. If the volume ratio of fragment>54.46% for the four-part proximal humeral fracture,good clinical results could be achieved by ORIF. Otherwise,HA would be an ideal treatment for the older patient with osteoporosis.更多还原