微创钢板内固定术中两种入路方式对肱骨干中段骨折患者骨代谢活性与桡神经损伤的影响

Effect of minimally invasive plate osteosynthesis through two approaches on bone metabolic activity and radial nerve injury in patients with humeral midshaft fracture

目的:比较外侧入路与前侧入路两种不同入路方式在肱骨干中段骨折微创钢板内固定(minimally inva-sive plate osteosynthesis,MIPO)术中的应用,并分析其对患者骨代谢活性与桡神经损伤的影响.方法:自2014年4月至2017年5月采用MIPO术治疗肱骨干中段骨折患者76例,分为前侧入路组(A组)和外侧入路组(B组).A组38例,男22例,女16例;年龄18~74(48.21±5.79)岁;交通事故伤24例,重物压砸伤6例,高处坠落8例;左侧18例,右侧20例;AO分型:A型15例,B型17例,C型6例;采用前侧入路方式进行微创MIPO术治疗.B组38例,其中男23例,女15例;年龄20~73(48.40±5.81)岁;交通事故伤26例,重物压砸伤5例,高处坠落伤7例;左侧17例,右侧21例;AO分型:A型15例,B型18例,C型5例;采用外侧入路方式进行微创MIPO术治疗.比较两组患者的术中出血量、手术时间、住院时间、骨折愈合时间,检测并比较手术前后血清骨钙素(bone gla protein,BGP),胶原C端肽(collagen C-terminal peptide,CTX)及护骨因子(osteoprotegerin,OPG)变化,并观察术后桡神经损伤发生情况.结果:所有患者获得随访,时间12~18(15.4±2.1)个月.两组患者手术时间、术中出血量比较差异无统计学意义(P>0.5);A组住院时间、骨折愈合时间分别为(6.52±1.81)d、(13.27±3.01)周,B组分别为(9.61±1.99)d、(14.83±3.08)周,两组比较差异有统计学意义(P<0.05).两组术前BGP、OPG、CTX比较差异无统计学意义,A组术后1个月BGP、OPG水平分别为(7.10±0.58) ng/ml、(173.67±9.12) pg/ml,高于B组的(6.63±0.62) ng/ml、(152.80±9.23) pg/ml,而A组的CTX水平(224.52±12.67)μg/ml,低于B组(259.13±13.54)μg/ml(P<0.05).A组术后未出现桡神经损伤,B组术后4例出现桡神经损伤,差异有统计学意义(x2=4.220,P<0.05).结论:相较于外侧入路,前侧入路在肱骨干中段骨折微创MIPO术中的应用效果更为显著,可改善骨代谢活性,降低桡神经损伤发生风险.

Objective:To compare application of minimally invasive plate osteosynthesis(MIPO)through two approaches for patients with humeral midshaft fracture,and analyzes the effect on bone metabolic activity and radial nerve injury.Methods:From April 2014 to May 2017,76 patients with humeral midshaft fracture treated by MIPO were selected and randomly divided into group A(anterior approache group)and group B(lateral approach group)according to random number stable.In group A,there were 38 patients including 22 males and 16 females,aged from 18 to 74 years old with an average age of(48.21±5.79)years old;24 patients were caused by traffic accidents,6 patients were caused by heavy object crushing,8 patients were caused by falling down;20 patient were on the right side,18 patients were on the left side;15 patients were type A,17 patients were type B,6 patients were type C according to AO classification;the patients were treated by MIPO through anterior approach.In group B,there were 38 patients including 23 males and 15 females,aged from 20 to 73 years old with an average age of(48.40±5.81)years old;26 patients were caused by traffic accidents,5 patients were caused by heavy object crushing,7 patients were caused by falling down;17 patients were on the right side,21 patients were on the left side;15 patients were type A,18 cases were type B,5 cases were type C according to AO classification;the patients were treated by MIPO through lateral approach.Intraoperative blood loss,operative time,hospital stays,fracture healing time between two groups were compared.between two groups.Hospital stays,fracture healing time in group A were(6.52±1.81)d,(13.27±3.01)weeks respectively,while in group B were(9.61±1.99)d,(14.83±3.08)weeks;and had differences between two groups.There were no differences in BGP,OPG and CTX,BGP between two groups and OPG in group A at 1 month after operation were(7.10±0.58)ng/ml,(173.67±9.12)pg/ml and higher than that of group B(6.63±0.62)ng/ml,(152.80±9.23)μg/ml;while CTX in group A(224.52±12.67)μg/ml was lower than that of group B(259.13±13.54)μg/ml(P<0.05).No patient occurred radial nerve injury in group A,4 patients occurred radial nerve injury in group B,and had statistical differences between two groups(χ2=4.220,P<0.05).Conclusion:Compared with lateral approach,anterior approach has much more effective in minimally invasive MIPO for humeral shaft fractures,which could improve bone metabolism and reduce risk of radial nerve injury.