锁定钢板与髓内钉治疗复杂肱骨近端骨折临床疗效分析

Clinical outcomes for nail versus plate fixation of complex proximal humeral fractures

目的比较锁定钢板与髓内钉治疗复杂肱骨近端骨折患者的疗效,为精准化治疗复杂肱骨近端骨折提供一定的参考。方法收集自2012年6月至2017年6月期间在本院行手术治疗的复杂肱骨近端骨折68例患者的资料。其中,男21例,女47例;平均年龄66.5岁;Neer 3部分为43例,Neer 4部分25例;根据损伤机制分型:内翻型38例,外翻型30例。35例行切开复位钢板螺钉内固定术,33例行有限切开复位肱骨近端锁定型髓内钉内固定术,评估锁定钢板与髓内钉治疗肱骨近端骨折后各项围手术期指标、术后肱骨近端形态学参数及肩关节功能评分等。结果所有患者均获随访,平均随访时间为17.8个月。锁定钢板组与交锁髓内钉组的平均手术时间分别为(95.3±12.5)min与(75.9±10.3)min,平均切口长度分别为(11.8±2.6)cm与(7.6±2.2)cm,差异都有具有统计学意义(P<0.05)。肱骨近端形态学评估方面,锁定钢板组与交锁髓内钉组患者的初次颈干角分别为(137.5±7.8)°与(136.4±6.9)°,末次颈干角分别为(133.3±6.13)°与(134.5±7.21)°,两组间差异无统计学意义(P>0.05);锁定钢板组与交锁髓内钉组患者的前举范围为(143.9±20.36)°与(139.6±21.23)°,差异无统计学意义(P>0.05);肩关节评分锁定钢板组平均为(79.8±8.1)分,交锁髓内钉组(81.9±7.6)分(P>0.05)。锁定钢板组并发症发生率为22.8%,交锁髓内钉组并发症发生率为15.1%,差异有统计学意义(P<0.05)。结论钢板与髓内钉治疗复杂肱骨近端骨折有各自优势,对于内翻型复杂肱骨近端骨折类型,力学上髓内钉相对于钢板更有优势,外翻型复杂肱骨近端骨折类型大部分伴有大结节粉碎骨折,锁定钢板对于大结节固定相对更有优势。外科医师需熟练掌握2种手术技术,避免并发症。

Objective To compare the clinical and radiologic outcomes of plate versus nail fixation in treating complex proximal humeral fractures. Methods Sixty-eight patients with proximal humeral fractures were treated with ORIF using locking plates or proximal humeral intramedullary nail from June 2012 to June 2017 were included in the present study.The patient series included 21 males and 47 females, with an average age of 66.5 years. According to the Neer classification system, there were 43 patients with 3-part fractures, 25 patients with 4-part fractures. Thirty-eight cases belonged to varus fracture and 30 cases belonged to valgus fracture. Thirty-five cases were treated using locking plates, and 33 patients using proximal humeral nails. Clinical outcome, radiological results, and postoperative function of shoulder were compared. Results All the patients were followed up, and the average time was 17.8 months. The mean operation time were(95.3±12.5) min in plate group and(75.9±10.3) min in nail group. The mean lengths of incision were(11.8±2.6) cm in plate group and(7.6±2.2) cm in nail group. There were significant differences in operation time and incision length(P<0.05). The average immediately postoperatively neck-shaft angle in the locking plate group was(137.5±7.8) ° and(133.3±6.13) ° 1 year after surgery, respectively. In contrast, the average neck-shaft angle was(136.4±6.9) ° and(134.5±7.21) ° in the interlocking intramedullary nail group. The scope of anterior shoulder stretch was(143.9±20.36) °and(139.6±21.23) °in the locking plate group and intramedullary nail group,respectively. The mean Constant-Murley scores of shoulder were(79.8±8.1) in the plate group and(81.9±7.6) in the nail group. There were no significant differences in humerus neck-shaft angle(immediately postoperatively and 1 year after surgery) and ConstantMurley scores(P>0.05). The complication rate in locking plate group was 22.8%, compared to 15.1% in the nail group(P<0.05). Conclusion Plate and intramedullary nailing for treating humerus proximal complicated fractures have their respective advantages. Intramedullary nail has the edge on mechanics for varus humerus proximal complicated fracture type. Plate have more advantage of fixing the greater tuberosity for eversion proximal humerus complicated fracture mostly accompaning with comminuted greater tuberosity. It is necessary that surgeons master two kinds of surgical technique, to avoid complications.