肩关节外侧入路与胸大肌三角肌入路锁定加压接骨板内固定治疗老年肱骨近端骨折的对比研究

A comparative study of locking compression plate internal fixation through shoulder lateral approach versus ectopectoralis-deltoid approach for treatment of proximal humeral fractures in the aged

目的:比较肩关节外侧入路与胸大肌三角肌入路锁定加压接骨板内固定治疗老年肱骨近端骨折的临床疗效及安全性。方法:回顾性分析80例老年肱骨近端骨折患者的病例资料,其中采用肩关节外侧入路锁定加压接骨板内固定治疗40例(肩关节外侧入路组),采用胸大肌三角肌入路锁定加压接骨板内固定治疗40例(胸大肌三角肌入路组)。男49例,女31例。年龄62~74岁,中位数68岁。按照肱骨近端骨折的Neer分型标准,二部分骨折24例、三部分骨折41例、四部分骨折15例。受伤至手术时间3~19 h,中位数11 h。比较2组患者的切口长度、术中出血量、手术时间、Constant-Murley肩关节功能评分及并发症发生情况,并采用Neer肩关节评分标准评价综合疗效。结果:肩关节外侧入路组的切口长度及手术时间均短于胸大肌三角肌入路组[(6.94±1.28)cm,(13.94±2.67)cm,t=14.952,P=0.000;(66.73±17.45)min,(91.14±20.62)min,t=5.715,P=0.000],术中出血量少于胸大肌三角肌入路组[(124.54±50.37)mL,(303.41±66.21)mL,t=13.598,P=0.000]。术前2组患者的Constant-Murley肩关节功能评分比较,差异无统计学意义(t=0.286,P=0.776);术后3个月,2组患者的Constant-Murley肩关节功能评分均较术前增高[(40.64±5.38)分,(82.66±6.45)分,t=31.641,P=0.000;(40.98±5.26)分,(75.52±5.67)分,t=28.245,P=0.000],且肩关节外侧入路组的Constant-Murley肩关节功能评分高于胸大肌三角肌入路组(t=5.258,P=0.000)。术后6个月,肩关节外侧入路组综合疗效优28例、良9例、可3例,胸大肌三角肌入路组综合疗效优19例、良8例、可10例、差3例,肩关节外侧入路组的综合疗效优于胸大肌三角肌入路组(Z=-2.511,P=0.012)。肩关节外侧入路组1例出现切口感染,胸大肌三角肌入路组5例出现切口感染、3例出现肱骨头无菌性坏死、1例出现螺钉松动,肩关节外侧入路组的并发症发生率低于胸大肌三角肌入路组(χ^2=7.314,P=0.007)。结论:采用肩关节外侧入路锁定加压接骨板内固定治疗老年肱骨近端骨折,比采用胸大肌三角肌入路的切口长度及手术时间短、术中出血量少、肩关节功能及综合疗效好、安全性高。

Objective:To compare the clinical curative effects and safety of locking compression plate internal fixation through shoulder lateral approach versus ectopectoralis-deltoid approach for treatment of proximal humeral fractures in the aged.Methods:The medical records of 80 aged patients with proximal humeral fractures were analyzed retrospectively.Forty patients were treated with locking compression plate internal fixation through shoulder lateral approach(group A),while the others were treated with locking compression plate internal fixation through ectopectoralis-deltoid approach(group B).The patients consisted of 49 males and 31 females and ranged in age from 62 to 74 years(Median=68 yrs)and in disease course from 3 to 19 hours(Median=11 hours).According to Neer classification standard of proximal humeral fracture,the fractures belonged to Neer 2-part(24),3-part(41)and 4-part(15)proximal humeral fractures.The incision length,intraoperative blood loss,operative time,Constant-Murley shoulder function scores and complications were compared between the 2 groups,and the total clinical curative effects were evaluated by using the Neer shoulder scoring standards.Results:The incision length and operative time were shorter,and the intraoperative blood loss were less in group A compared to group B(6.94+/-1.28 vs 13.94+/-2.67 cm,t=14.952,P=0.000;66.73+/-17.45 vs 91.14+/-20.62 min,t=5.715,P=0.000;124.54+/-50.37 vs 303.41+/-66.21 mL,t=13.598,P=0.000).There was no statistical difference in Constant-Murley shoulder function scores between the 2 groups before the surgery(t=0.286,P=0.776).The Constant-Murley shoulder function scores increased in the 2 groups at 3 months after the surgery compared to pre-surgery(40.64+/-5.38 vs 82.66+/-6.45 points,t=31.641,P=0.000;40.98+/-5.26 vs 75.52+/-5.67 points,t=28.245,P=0.000),and were higher in in group A compared to group B(t=5.258,P=0.000).The total clinical curative effects were evaluated at 6 months after the surgery,28 patients obtained an excellent result,9 good and 3 fair in group A;while 19 patients obtained an excellent result,8 good,10 fair and 3 poor in group B.The group A surpassed the group B in the total clinical curative effects(Z=-2.511,P=0.012).The incision infection was found in 1 patient in group A and 5 patients in group B,and aseptic necrosis of head of humerus(3)and screw loosening(1)was found in group B.The postoperative complication incidence rate was lower in group A compared to group B(χ^2=7.314,P=0.007).Conclusion:Locking compression plate internal fixation through shoulder lateral approach has the advantages of shorter incision length and operative time,less intraoperative blood loss,better shoulder function and total clinical curative effects and higher safety compared to locking compression plate internal fixation through ectopectoralis-deltoid approach in treatment of proximal humeral fractures in the aged.