锁定钢板结合异体腓骨治疗头内翻型肱骨近端骨折

Locking plate fixation with allogeneic fibula graft for treatment of varus impacted proximal humeral fractures

目的探讨锁定钢板结合异体腓骨治疗头内翻型肱骨近端骨折的临床疗效。方法回顾性分析2013年6月至2015年6月安徽医科大学第二附属医院采用PHILOS锁定钢板固定治疗35例头内翻型肱骨近端骨折患者资料(术前颈干角<130°),按术中是否采用异体腓骨来加强内侧支撑分为两组,锁定钢板结合异体腓骨组与单纯锁定钢板组。锁定钢板结合异体腓骨组共11例,男6例、女5例,年龄为(60.27±12.32)岁;单纯锁定钢板组共24例,男10例、女14例,年龄为(50.21±17.60)岁。两组患者资料在基线水平差异均无统计学意义(P>0.05)。根据术后影像学资料评估颈干角,并计算术后1年与术后第1天颈干角的差值,应用术后1年随访时Constant-Murley评分及臂、肩、手功能障碍评分(disabilities of the arm,shoulder and hand score,DASH)评估患者肩关节功能。应用统计学比较两组术前基线水平(年龄、性别、骨折分型、是否抽烟、优势手及内侧柱是否粉碎)是否有差异,再比较术后1年两组颈干角差值及Constant-Murley评分是否有差异。结果术后1年锁定钢板结合异体腓骨组颈干角改变(-1.36±2.58)°,单纯锁定钢板组改变(-7.21±8.06)°,差异具有统计学意义(P=0.003)。术后1年锁定钢板结合异体腓骨组Constant-Murley评分(76.82±6.11)分,单纯锁定钢板组为(64.29±9.15)分,差异具有统计学意义(P=0.0002)。锁定钢板结合异体腓骨组DASH评分(15.55±2.98)分,单纯锁定钢板组为(25.96±9.35)分,差异具有统计学意义(P=0.001)。其中锁定钢板结合异体腓骨组有1例患者出现术后切口感染;单纯锁定钢板组有3例患者出现螺钉穿出,1例患者出现肱骨头缺血坏死。结论在治疗头内翻型肱骨近端骨折方面,锁定钢板结合异体腓骨能有效地增加术后骨折块的稳定性,减少术后颈干角的改变,提高术后的肩关节功能。

Background Proximal humeral fractures account for about4%-5%of allfractures in the whole body,and are only next to the distal radial fractures in the upper limbfractures.Thereinto,approximately80%of proximal humeral fractures have slight displacementand can be treated conservatively,while the other20%of them have obvious displacement whichrequires surgical interventions.The varus impacted proximal humeral fractures account for10%of all proximal humeral fractures,and the efficacy of conservative treatment is unsatisfactory assimple application of locking plate is easy to produce a series of postoperative complications suchas loss of reduction,varus impaction,plate fixation failure,screw piercing,fracture nonunion,humeral head necrosis,etc.The implantation of allogeneic fibula into proximal humeral intramedullary provides effective medial support,and combined with locking plate,it has been widely used inthe treatment of comminuted metaphyseal fractures of proximal humerus,which has achieved satisfactory curativeeffect.However,there are still no reports about the clinical efficacy of locking plate combined with allogeneic fibulain the treatment of varus impacted proximal humeral fractures.Methods(1)General information.From June2013to June2015,a total of35patients with varus impacted proximal humeral fractures treated in our hospitalwere included in this study.Thereinto,11cases were treated with locking plate and allogeneic fibula fixation,while the other24cases were treated with simple locking plate fixation.The group of locking plate combinedwith allogeneic fibula included6males and5females with an average age of(60.27±12.32)years.The group oflocking plate fixation included10males and14females with an average age of(50.21±17.60)years.There wasno statistical difference between the two groups at the baseline level(P>0.05).(2)Inclusive and exclusivecriteria.Inclusive criteria:①18years of age or older;②acute varus impacted proximal humeral fractures(within3weeks and neck-shaft angle<130°)treated by locking plate fixation with or without allogeneicfibular graft;③follow-up time≥1year with complete data.Exclusive criteria:①pathological fracture,open fractures or multiple fractures;②combination of neurovascular injuries;③medical history that affectsshoulder function,such as previous trauma history of ipsilateral limb,chronic arthritis,etc.(3)Treatmentmethods.All the enrolled patients completed the relevant examinations after admission,and were treatedwith open reduction and internal fixation.The patients in the experimental group were treated by lockingplate fixation combined with allogeneic fibular graft,while the patients in the control group were simplytreated with locking plate.After brachial plexus block or general anesthesia,the patient was in beach chairposition during the operation.Through the deltoid-pectoralis approach,the soft tissue was softly separatedto minimize periosteal dissection.After the exposure of fracture ends,the greater and lesser tuberositieswere lifted by pulling the rotator cuff insertions with sutures and the humeral head was reduced.Then theallogeneic fibula was reversely inserted into the medullary cavity of humeral shaft.With the confirmation andadjustment of the fibular length(usually4-6cm),the proximal fibula was under the cartilage of humeralhead.The greater and lesser tuberosities were reduced with sutures and temporarily fixed with Kirschnerwires.As the fracture reduction was satisfactory under fluoroscopy,the locking plate was used for fixation withsutures knotted through the suture holes on the plate.With satisfactory position of fracture fragments,plateand screws under fluoroscopy,the wound was irrigated and closed after hemostasis.The allogeneic fibulargraft was saved in the control group,and all the locking plates used in the two groups were PHILOS plates.All the procedures were performed by3attending surgeons or higher ranks.All the patients followed the samerehabilitation programme:the affected limb was suspended for4weeks before starting passive movements,andactive movements were allowed8weeks later.All the patients were followed up in the1st,3rd,6th and12thmonths with anteroposterior and lateral X-ray films of shoulder joint taken every time.The data of all patientswere collected,including general information,preoperative X-ray films,CT scans,X-ray films on the1stpostoperative day,X-ray films taken in each follow up and functional scores(Constant-Murley scores andDASH scores).The neck-shaft angles were measured on the shoulder radiographs of anteroposterior viewto calculate the difference between values between the1st postoperative day and the12th month afteroperation.(4)Statistical analysis.The SPSS20.0software was adopted for statistical analysis.The ages,neckshaftangels and functional scores were considered as quantitative data,while the gender,fracture types,smokingor not,dominant hand or not and comminution of medial column or not were considered as qualitative data.Allthe quantitative data were tested by the normality test and described as mean value±standard deviation,and theindependent sample t test was used to analyze whether the difference was statistically significant.The qualitativedata was described as constituent ratio,and chi square test was used to analyze whether the difference wasstatistically significant.When P<0.05,the difference was considered statistically significant.Results Thefractures healed in two groups after1year.The change of neck-shaft angles was(-1.36±2.58)°in the groupof locking plate combined with allogeneic fibula while the angle was(-7.21±8.06)°in the simple plate group,and the difference was statistically significant(P=0.003).The Constant-Murley score was(76.82±6.11)pointsin the group of locking plate combined with allogeneic fibula while it was(64.29±9.15)points in the simpleplate group,and the difference was statistically significant(P=0.0002).The DASH score was(15.55±2.98)points in the group of locking plate combined with allogeneic fibula while it was(25.96±9.35)points in thesimple plate group,and the difference was statistically significant(P=0.001).In the respect of postoperativecomplications,1case in the group of locking plate combined with allogeneic fibula had wound infection2weeks after operation,and the patient achieved wound healing with positive disinfection and wound redressing.There were3cases of screw piercing in the simple locking plate group.Thereinto,1patient without obvioussymptoms was given no treatment while the other2patients received secondary procedures to replace lockingscrews.Ischemic necrosis of humeral head occurred in1patient,which was type II of Cruss classification,and the patient was given conservative treatment.Conclusion Regarding the treatment of varus impactedproximal humeral head fractures,locking plate with allogeneic fibula can effectively increase the stabilityof fracture fragments,decrease the changes of neck-shaft angle,reduce the postoperative complication rateand improve the shoulder joint function.In addition,prospective randomized controlled trials are expected tofurther validate the relevant results.