微创钢板接骨术与肱骨头置换治疗老年Neer四部分骨折

Minimally invasive plate osteosynthesis and humeral head replacement for treatment of elderly patients with Neer four-part fractures

目的通过前瞻性研究探讨微创钢板接骨术（minimallyinvasiveplateosteosynthesis，MIPO）与肱骨头置换治疗老年Neer四部分骨折的疗效。方法胸大肌三角肌间隙入路，采用锁定钢板结合MIPO技术治疗老年新鲜Neer四部分骨折28例（A组），行人工肱骨头置换治疗相同骨折27例（B组），应用Neer评分、Constant—Murley评分以及简明肩关节问卷（simpleshouldertest，SST）等评估治疗结果。结果A组平均随访32．1个月，2例螺钉进入关节间隙，1例大结节向后上移位，肱骨头缺血性坏死1例。平均疼痛视觉模拟评分（visualanalogscale，VAS）、平均肩关节Neer评分和平均Constant—Murley评分分别为2．2分、88．6分和86．5分。SST中回答“是”的问题平均为9．0个。B组平均随访34．6个月，4例出现肩关节脱位或者半脱位，8例出现大结节移位或过度复位问题。平均VAS评分、平均Neer评分和平均Constant—Murley评分分别为2．4分、78．9分和77．3分。SST问卷中回答“是”的问题平均为8．0个。两组VAS评分比较差异无统计学意义，而并发症、Neer评分、Constant—Murley评分及SST评分结果比较差异有统计学意义，A组优于B组。结论对于大多数老年Neer四部分骨折，在严格掌握手术适应证及手术技巧的前提下，应用MIPO可以获得满意的结果，而人工肱骨头置换术仍存在较多尚未解决的问题，选择时需慎重。

Objective To identify the curative effect of minimally invasive plate osteosynthesis （MIPO） and humeral head replacement in treatment of elderly patients with Neer four-part fractures. Methods Using the deltoid pectoral approach, 28 patients with fresh Neer four-part fractures were treated by the locking plate combined with MIPO （Group A ） and 27 by the humeral head replacement （Group B）. Neer score, Constant-Murley score and simple shoulder test （SST） questionnaire were adopted for assessing the treatment outcome. Results Group A was followed up for mean 32.1 months, which showed screws protruding into the joint space in two patients, tuberosity upward and backward displacement in one and femoral head ischemic necrosis in one. The mean visual analog scale （VAS） score, the mean Neer score and the mean Constant-Murley score were 2.2 points, 88.6 points and 86.5 points respectively. There were average 9.0 answers for ＂yes＂ in the SST questionnaire. Group B were followed up for mean 34.6 months, which showed shoulder dislocation or subluxation in four patients, tuberosity displacement or excessive reduction in eight. The mean VAS score, the mean Neer score and the mean Constant-Mudey score were 2.4 points, 78.9 points and 77.3 points respectively. The mean number of answer for ＂yes＂ in SST questionnaire was 8.0 questions. There showed no statistical difference in VAS score between the two groups. While statistical difference was found in complications, Neer score, Constant-Murley score and SST score between two groups, with Group A superior to Group B. Conclusions For most elderly patients with Neer four-part fractures, MIPO has satisfactory results under strict control of surgical indications and technical tips. The humeral head replacement surgery still has many unresolved problems and needs careful consideration.