髓内钉治疗肱骨近端骨折的临床结果及预后分析

Clinical Results and Risk Factors for Poor Outcome of Intramedullary Nailing in the Treatment of Proximal Humeral Fractures

目的评价髓内钉内固定治疗肱骨近端骨折的临床和影像学结果及不良预后的危险因素。方法将2012年6月至2015年4月我院收取的45例肱骨近端骨折患者纳入研究,进行回顾性分析。其中男性18例,女性27例;年龄56~74岁,平均63.8岁。患者的随访时间为12~14个月,平均13.1个月。术中记录患者的手术时间及术中出血量。术后1、3、6、12个月门诊复查并记录患者的肩关节功能,影像学评估包括前后位和肩胛骨轴面X线片。采用主观满意度量表,美国肩肘外科协会评分、Constant评分、视觉模拟评分(visual analogue scale,VAS)以及DASH评分对不同Neer分型骨折的预后情况进行评价。采用Logistic回归分析年龄、性别、高血压等因素与不良预后之间的相关性。结果 45例患者均顺利完成手术,患者的平均手术时间为(126.8±17.2)min;平均术中出血量为(173.9±22.1)mL,91.1%的患者对治疗满意。术后影像学显示,患者的骨折愈合率为95.6%,2例患者出现假关节。末次随访时患者的VAS评分(1.6±0.3)分;美国肩肘外科协会评分(85.7±6.0)分;Constant评分(70.8±4.6)分;DASH评分(15.0±0.9)分;肩关节前屈上举(147.6±11.3)°;体侧外旋(33.0±3.2)°;外展外旋(28.4±1.8)°。Neer两部分骨折与三部分骨折患者相比,各项指标均差异无统计学意义(P>0.05)。60岁以下与60岁以上患者相比,Constant评分具有显著差异(P<0.05)。16例患者出现内翻畸形愈合(35.6%)且与正常愈合患者相比存在功能学差异。年龄、高血压与骨质疏松是影响不良预后的独立危险因素。结论髓内钉治疗肱骨近端骨折疗效优良,手术时间短,切口小,软组织损伤少,出血量少,并发症少,是治疗肱骨近端骨折的一种有效方法。而治疗的不良结局可能是年龄、高血压与骨质疏松等因素导致的。

Objective To assess the clinical and radiological results of fractures of the proximal humerus treated with intramedullary nail fixation and analyze the risk factors associated with a poor outcome.Methods 45 cases of pa-tients with proximal humeral fractures in our hospital from June 2012 to April 2015 were selected as study objects.Pa-tients were analyzed retrospectively with a minimum follow-up of 12~14 months （average 13.1 months）.Of all the pa-tients,18 were male and 27 were female.Their age were between 56~74 years old （average 63.8 years）.Parameters in-cluding operative time and blood loss were recorded.At 1,3,6,12 months after operation,the radiological assessment included AP and axial X-rays in the scapular plane were recorded.Functional outcome of different Neer type fracture were evaluated using the rating scale of the American Shoulder and Elbow Surgeons （ASES）,Constant Score,Visual Analogue Scale （VAS）scores and DASH scores.Logistic regression analysis was used to analyze the association be-tween poor outcomes and age,gender,hypertension and other factors.Results All patients completed the follow-up, mean operation time was （126.8±17.2）min and mean blood loss was （173.9±22.1）mL.91.1% of patients were satis-fied with treatment.X-rays showed a healing rate of 95.6%,with two cases of pseudarthrosis.At last follow up,the VAS score was （1.6±0.3）,ASES score was （85.7±6.0）and Constant Score was （70.8±4.6）,DASH score was （15.0 ±0.9）.Mean mobility was （147.6±11.3）°of fiexion,（33.0±3.2）°of lateral and （28.4±1.8）°of medial rotation.Sig-nificant differences were found in the Constant score in individuals under 60 years of age （P〈0.05）.Varus healing was observed in 16 patients （35.6%）.Functional differences were found when patients with varus healing were compared with those who had anatomical healing.Age,hypertension and osteoporosis were independent risk factors for adverse outcomes.Conclusion The intramedullary nail fixation is an effective implant for stabilization of displaced proximal humeral fracture with a good functional outcome.Its advantages are short operation time,small incision,less trauma,less blood supply and less complications.Age,hypertension and osteoporosis and other factors may lead to adverse outcomes.