肱骨髁间骨折术后不愈合的原因分析及治疗

Etiology and treatment of postoperative nonunion of the intercondylar fracture of humerus

目的 探讨肱骨髁间骨折术后不愈合的原因及治疗方法.方法 对2002年11月至2010年1月收治的肱骨髁间骨折术后不愈合经再手术后治愈的26例患者资料进行回顾性分析,其中男14例,女12例;年龄31～86岁,平均46.6岁;左侧15例,右侧11例.原始骨折按照AO分型：C1型3例,C2型14例,C3型9例;开放性骨折10例.此次治疗除4例行全肘关节置换术外,其余22例采用重新内固定＋自体骨植骨,其中4例患者发生再次内固定失效、骨折不愈合,经二次手术治愈.总结并分析骨折术后不愈合的原因和治疗方法.结果 26例患者最终治疗前共进行30次手术（其中有4例患者进行了 2次手术）,其中不稳定固定28次,术后行石膏外固定16例,有明显骨缺损21例.本组患者平均随访11.4个月（4～41个月）.4例行人工全肘关节置换术的患者肘关节平均屈曲112°（90°～130°）,伸直18°（0～35°）;Mayo肘关节功能评分（MEPS）平均85分（80～90分）.其余22例患者骨折均获愈合,此22例患者术前肘关节平均屈伸55.0°±9.0°（40°～80°）,MEPS评分（47.3±7.8）分（35～60分）,其中可4例,差18例;术后平均屈伸66.8°±10.5°（50°～90°）,MEPS评分（81.4±11.1）分（65～100分）,其中优7例,良9例,可6例;术后与术前肘关节平均屈伸和MEPS评分比较,差异均有统计学意义（P＜0.05）.结论 不稳定的固定、石膏外固定所致肘关节僵硬、明显骨缺损是肱骨髁间骨折术后不愈合的最主要原因.双接骨板垂直固定或平行固定是更加稳定的固定,结合结构性植骨,可使骨折获得愈合,但最终的肘关节屈伸范围仍较差.

Objective To investigate the causes and treatment of postoperative nonunion of the intercondylar fracture of humerus. Methods Twenty-six patients suffering from postoperative nonunion of the intercondylar fracture of humerus, 14 males and 12 females, were analyzed in this study. Four cases underwent total elbow arthroplasty（TEA）, and the other 22 received refixation and autografting, 4 of whom healed only after 2 operations. The causes of postoperative nonunion were analyzed. Results This group had 28 unstable fixations, 16 postoperative plaster external fixations and 21 significant bone defects. On average, they had a follow-up of 11.4 months （4 to 41 months）. In the 4 TEA cases, the average flexion was 112° （90° to 130°） and the extension 18° （0 to 35°）. Their average MEPS score was 85（80 to 90 points）. The other 22 cases achieved bone union ultimately, with an average flexion of 97.7°± 10. 0° （70° to 110°）,an average extension of 30. 9°± 12.8°（0 to 60°）, and an average motion arc of 66. 8°± 10. 5° （50° to 90°）.Their average MEPS score was 81.4 ± 11. 1 points （65 to 100 points）. Conclusions Inadequate internal fixation, elbow stiffness due to plaster external fixation and significant bone defects are the main causes for postoperative nonunion of the intercondylar fracture of humerus. 90-90 plate fixation and parallel plate fixation, together with constructive bone grafting, can achieve bone union in most cases, though the motion arc of the elbow is still unsatisfactory.