采用微创技术治疗Neer 2、3部分肱骨近端骨折的疗效观察

Short-term clinical outcome of the minimally invasive technique in the treatment for Neer 2,3 part proximal humeral fractures

目的评价采用Philos钢板与Multiloc髓内钉微创治疗肱骨近端Neer2、3部分肱骨近端骨折的临床疗效。方法回顾性分析从2014年2月至2016年6月成都第一骨科医院骨科和四川省骨科医院骨科采用Philos钢板与Multiloc髓内钉治疗肱骨近端2、3部分肱骨近端骨折患者,并获得完整随访共47例。Philos钢板组24例,其中男9例(37.5%),女15例(62.5%);Multiloc髓内钉组23例,其中男9例(39.1%),女14例(60.9%)。随访时间为1、3、6、9、12个月及>12个月,拍摄正、侧位肩关节X线片。比较两组性别、年龄、手术时间、视觉模拟疼痛评分(VAS)、美国肩肘外科医师评分(ASES)、Constant-Murley评分、骨折愈合时间、肩关节活动范围。结果随访1年共获得47例完整病例纳入研究。钢板组无骨折延迟愈合及不愈合,骨折愈合时间1.5~3.0(2.4±0.6)个月;髓内钉组无骨折延迟愈合及不愈合,骨折愈合时间为1.5~3.0(2.3±0.5)个月。本研究中47例患者术后5例出现轻微疼痛,其中钢板组3例,髓内钉组2例,均口服塞来昔布后疼痛缓解。随访结果显示,钢板组手术时间为(122.3±32.7)min,髓内钉组为(154.9±35.8)min,两者差异有统计学意义(P=0.002)。在2部分骨折中,髓内钉外展角度(158.0°±14.1°)比钢板组外展角度(129.6°±30.2°)高,显示2部分骨折髓内钉治疗有优势。3部分骨折中, Philos钢板组手术时间为(130.4±35.3)min,Multiloc髓内钉组为(161.5±29.2)min,(P=0.024)。未出现骨折不愈合,切口感染及延迟愈合、肩袖损伤及腋神经损伤等并发症。结论在肱骨近端骨折的治疗中,采用Philos锁定钢板与Multiloc髓内钉,并结合微创理念与技术,两者均能取得良好的疗效。对于2部分肱骨近端骨折,采用髓内钉治疗比采用钢板治疗有明显的优势。成熟的手术技术是手术成功的根本保证,对于复杂的肱骨近端骨折需要有经验的医生去处理,方能获得良好的效果。

Objective To evaluate the clinical effect of the minimally invasive technique in treatment of the Neer 2 and 3-part proximal humeral fractures. Methods The data of 47 patients with Neer 2,3-part proximal humerus fractures treated with Philos plate(Group A, n=24) and Multiloc intramedullary nail(Group B,n=23) admitted in Department of Orthopaedics, Chengdu 1 st Orthopedics Hospital and Department of Orthopaedics,Sichuan Orthopedics Hospital from February 2014 to June 2016, were analyzed retrospectively. Anteroposterior and lateral X-ray films in neutral position and external rotation of shoulder joint were used postoperatively after 1,3,6, 9,12 months and longer, and last follow-up. At the last visit, the pain score of visual analogue scale(VAS), American Shoulder and Elbow Surgeons(ASES) score and Constant-Murley score were used to evaluate the recovery of shoulder function. Results All 47 patients completed the operation successfully. Non-fracture healing delayed and nonunion. Fracture healing time was 1.5-3.0(2.4±0.6) months in Group A,and 1.5-3.0(2.4±0.6) months in Group B. There were 5 patients who feeled pain in the 47 patients, including 3 patients in Group A and 2 in group B. The operation time of the Group B was longer than the Group A and the difference was statistically significant(P=0.002). In the 2-parts of the fracture, the abduction angle of Group B(158.0°± 14.1°) was higher than the Group A(129.6°± 30.2°),(P<0.05). In the treatment 2-part proximal humerul fracutres,the Multiloc nail had an advantage. In the 3-parts of the fracture, for the operation time,the Group B was longer than the Group A, and the difference was statistically significant(130.4±35.3) min vs.(161.6±29.2),(P=0.024). There was no nonunion of fracture, wound infection and delayed union, rotator cuff injury and axillary nerve injury. Conclusions Same results could be achieved in treatment of proximal humeral fractures with Philos plate and Multiloc nailing based on the skilled hand and forcusing on the importance of rehabilitation, but the Multiloc nailing group had achieved superior outcomes in the abduction than Philos plate in treatment of the 2-part proximal humeral fractures. An experienced surgical technique is the key for these fractures. Complex proximal humeral fractures need to be treated by experienced doctors to achieve good results.