关节镜下中空螺钉和（或）锚钉缝线桥技术固定肱骨大结节骨折

Short-term functional outcome of arthroscopic reduction and fixation with cannulated screws and/or suture-bridge technique with double-row suture anchor for fractures of greater tuberosity

目的探讨关节镜下中空螺钉和（或）锚钉缝线桥技术固定治疗肱骨大结节骨折的早期疗效。方法回顾性分析2012年5月至2016年12月关节镜下治疗25例肱骨大结节患者资料，男12例，女13例；年龄22-69岁，平均44．8岁：左肩7例，有肩18例；新鲜骨折21例，陈旧性骨折4例（受伤至手术时间超过3周）。X线片示肱骨大结节骨折移位5～12mm，平均5．8mm；合并肩盂骨折11例。25例肱骨大结节骨折均在肩关节镜下治疗，其中5例采用中空螺钉固定，12例采用锚钉缝线桥技术固定，8例采用中空螺钉结合锚钉缝线桥技术固定。镜下发现Bankan损伤9例，SLAP损伤1例，肩袖损伤8例，均采用金属或可吸收锚钉固定修复。末次随访时采用视觉模拟评分（visual analogue scale，VAS）评价疼痛，采用美国肩肘外科（American Shoulder＆Elbow Surgeons，ASES）评分、Constant—Murley评分评价肩关节功能。结果切口均一期愈合，无一例发生感染。25例患者均获得随访，随访时间6～38个月，平均21．3个月。术后2～4个月，X线片示肱骨大结节骨折及合并的肩盂骨折均愈合，愈合时间平均3．4个月。无一例发生骨折块移位、吸收。末次随访时，5例使用中空螺钉固定患者平均前屈上举为175．0°±6．3°、体侧外旋57．5°±13．0°、VAS评分（0．3±0．4）分、ASES评分（98．0±1．6）分、Constant－Murlev评分（96．5±2．3）分；12例使用缝线桥技术固定患者前屈上举平均为170．0°±9．5°、体侧外旋56．1°±14．5°、VAS评分（0．8±1．1）分、ASES评分（95．6±4．0）分、Constant—Mudey评分（95．0±4．3）分；8例采用中空螺钊‘结合锚钉缝线桥技术固定患者平均前屈上举为160．6°±27．4°、体侧外旋53．1°±11．2°、VAS评分（1．1±1．4）分、ASES评分（93．3±7．5）分、Constant—Murley评分（92．0±9．2）分。术后6个月，6例出现肩关常外展外旋活动轻度受限，经加强被动外展、外旋训练后好转。术后1周，1例出现外排锚钉松动移位，使用肩关节外展包保护患肢，并延缓功能锻炼，未作进一步治疗，肩关节功能较差（ASES评分75分，Constant—Murley评分69分，VAS评分3分），其余患者均未出现内固定失效、骨折移位、神经血管损伤等并发症。结论关节镜下使用中空螺钉和（或）缝合锚钉缝线桥技术固定肱骨大结节骨折临床疗效好，是一种安全有效的治疗方法。

Objective To evaluate the short-term functional outcome of arthroscopic reduction and fixation for fractures of greater tuberosity of humerus. Methods From May 2012 to December 2016, data of 25 eases with fractures of greater tuberosity of humerus who were treated by reduction and fixation under arthroscopy were retrospectively analyzed. There were 12 males and 13 females, with an average age of 44.8 years （22-69 years）, including 7 cases of left shoulder, and 18 cases of right shoulder. X-ray examinations revealed that the displacement of the greater tuberosity was 5-12 mm, with an average of 5.8 ram. There were 21 cases of fresh fractures and 4 cases of old fraetures （more than 3 weeks from injury to operation）. 5 patients were treated only using cannulated screw fixation（Group one）, while 12 patients only using suture-bridge anchor fixation（Group two） and another 8 patients were treated using combination technique with cannulated screw and suture anchor fixation（Group three）. There were glenoid fractures in 11 cases before surgery, and 9 cases were found with Bankart lesion, 1 ease SLAP injury, 8 eases rotator cuff tear found under arthroseopic examinations. At the last visit, visual analogue scale （VAS） pain score, American Shoulder ＆ Elbow Surgeons （ASES） score and Constant-Murley score were collected to evaluate the recovery of shoulder function. Results All the incision healed primary, and no infection occurred. All 25 patients were tbllowed up for an average period of 21.3 months （6-38 months）. The X-ray showed that the fractures of the great tuberosity of humerus and the glenoid healed 2-4 months after operation,with an average time of 3.4 months. No fracture displacement and absorption were observed. At the final follow-up, the average functions of shoulder were 175.0°±6.3°. 170.0°±9.5° and 160.6°±27.4° in group one, two and three respectively for forward flexion; 57.5°± 13.0°, 56.1° ± 14.5° and 53.1 °±11.2° for lateral external rotation in group one, two and three respectively; 0.3±0.4, 0.8± 1.1 and 1.1±1.4 points for VAS in group one, two and three respectively; 98±1.6, 95.6±4.0 and 93.3-＋7.5 points for ASES in group one, two and three respectively; and 96.5±2.3, 95.0±4.3 and 92.0±9.2 points for the Constant-Murley scoring system in group one, two and three respectively. The displacement of the lateral anchor occurred in 1 patient （75 points for ASES, 69 points for Constant -Murley and 3 points for VAS）; and no complications such as internal fixation failure, fracture displacement and neurovascular injury occurred in the remaining patients. Conclusion It is a safe and effective method to treat the fractures of great tuberosity of humerus by reduction and fixation under the arthroscope using cannulated screws and/or suture anchors.