交锁髓内钉与锁定接骨板治疗老年内翻型肱骨近端骨折的疗效比较

Efficacy comparison of interlocking intramedullary nail and locking plate in the treatment of varus proximal humeral fractures in the elderly

目的比较交锁髓内钉与锁定接骨板治疗老年内翻型肱骨近端骨折的效果。方法采用回顾性病例对照研究分析2016年6月至2019年1月解放军中部战区总医院收治的46例老年内翻型肱骨近端骨折患者临床资料,其中男27例,女19例;年龄60~84岁[(71.9±5.7)岁]。均为新鲜骨折。25例采用闭合复位交锁髓内钉固定(髓内钉组),21例采用切开复位锁定接骨板固定(接骨板组)。比较两组切口长度、手术时间、术中出血量及骨折愈合时间。术后1周及1个月采用视觉模拟评分(VAS)评价疼痛缓解程度,术后1,3个月及1年采用Constant-Murley评分评价肩关节功能恢复情况。记录术后2 d及1年的颈干角,判断有无颈干角丢失。观察并发症发生情况。结果患者均获随访12~32个月[(19.7±6.6)个月]。髓内钉组切口长度[(7.1±0.6)cm]、手术时间[(60.8±5.2)min]、术中出血量[(64.4±8.4)ml]及骨折愈合时间[(10.0±1.0)周]均显著短于或少于接骨板组[(13.6±0.9)cm、(80.2±8.1)min、(151.0±15.2)ml、(11.0±1.5)周](P<0.05)。随术后时间延长,两组VAS均显著降低,Constant-Murley评分均显著增加(P<0.05)。术后1周及1个月髓内钉组VAS[(2.8±0.2)分、(1.1±0.2)分]均显著低于接骨板组[(4.0±0.2)分、(1.5±0.1)分](P<0.05);术后1,3个月髓内钉组Constant-Murley评分[(59.9±6.9)分、(79.1±6.8)分]均高于接骨板组[(50.1±8.5)分、(73.6±8.4)分](P<0.05),但术后1年髓内钉组Constant-Murley评分[(89.1±5.3)分]与接骨板组[(86.4±6.4)分]差异无统计学意义(P>0.05)。术后1年髓内钉组Constant-Murley评分优10例,良15例,优良率为100%;接骨板组优8例,良11例,可2例,优良率为91%(P>0.05)。髓内钉组术后2 d及1年颈干角[(140.2±2.9)°、(139.6±2.3)°]与接骨板组[(139.6±3.2)°、(138.8±3.3)°]差异无统计学意义(P<0.05);组内术后1年颈干角均较术后2 d略有丢失,但差异无统计学意义(P>0.05)。髓内钉组1例肩峰下撞击,并发症发生率为4%(1/25);接骨板组1例出现螺钉切出,2例肩峰下撞击,2例骨折延迟愈合,并发症发生率为24%(5/21)(P<0.05)。结论与锁钉接骨板相比,交锁髓内钉治疗老年内翻型肱骨近端骨折具有创伤小、骨折愈合时间快、疼痛减轻、功能恢复快、并发症少等优点。

Objective To compare the effect of interlocking intramedullary nail and locking plate in the treatment of varus proximal humeral fractures in the elderly.Method A retrospective case-control study was conducted to analyze the clinical data of 46 elderly patients with varus proximal humeral fractures treated in Central Theater General Hospital of PLA from June 2016 to January 2019,including 27 males and 19 females,at age of 60-84 years[(71.9±5.7)years].All fractures were fresh.Overall 25 patients were treated with interlocking intramedullary nail(intramedullary nail group),and 21 patients were treated with locking plate(bone plate group).The incision length,operation time,intraoperative bleeding and fracture healing time were compared between the two groups.Visual analogue scale(VAS)was used to evaluate the degree of pain relief at 1 week and 1 month after operation,and Constant-Murley score was used to evaluate the recovery of shoulder function at 1 month,3 months and 1 year after operation.The cervical trunk angle was recorded at 2 days and 1 year after operation to judge whether there was a loss of cervical trunk angle.Postoperative complications were observed.Results All patients were followed up for 12-32 months[(19.7±6.6)months].The incision length[(7.1±0.6)cm],operation time[(60.8±5.2)minutes],intraoperative bleeding[(64.4±8.4)ml]and fracture healing time[(10.0±1.0)weeks]in intramedullary nail group were significantly less than those in bone plate group[(13.6±0.9)cm,(80.2±8.1)minutes,(151.0±15.2)ml,(11.0±1.5)weeks](P<0.05).In both groups,the VAS decreased significantly over time,and markedly increased Constant-Murley score was detected as well(P<0.05).The VAS in intramedullary nail group[(2.8±0.2)points,(1.1±0.2)points]was significantly lower than that in bone plate group[(4.0±0.2)points,(1.5±0.1)points]at 1 week and 1 month after operation(P<0.05).The Constant-Murley score in intramedullary nail group[(59.9±6.9)points,(79.1±6.8)points]was higher than that in bone plate group[(50.1±8.5)points,(73.6±8.4)points]at 1 month and 3 months after operation(P<0.05),but the score showed no significant difference between intramedullary nail group[(89.1±5.3)points]and bone plate group[(86.4±6.4)points]at 1 year after operation(P>0.05).According to Constant-Murley score,10 patients were evaluated as excellent and 15 patients as good in intramedullary nail group at 1 year after operation,with the excellent and good rate of 100%,while 8 patients were evaluated as excellent,11 patients as good and 2 patients as fair in bone plate group at 1 year after operation,with the excellent and good rate of 91%(P>0.05).The cervical trunk angle in intramedullary nail group[(140.2±2.9)°,(139.6±2.3)°]had significant difference from that in bone plate group[(139.6±3.2)°,(138.8±3.3)°]at 2 days and 1 year after operation(P<0.05).In both groups,the cervical trunk angle had slight lost at 1 year after operation compared with that at 2 days after operation,but the difference was not statistically significant(P>0.05).In intramedullary nail group,1 patient had subacromial impact.In bone plate group,1 patient had screw cutting,2 patients subacromial impact,and 2 patients delayed fracture healing.The incidence of complications in intramedullary nail group was 4%(1/25),lower than 24%(5/21)in bone plate group(P<0.05).Conclusion Compared with locking nail plate,interlocking intramedullary nail in the treatment of senile varus proximal humeral fracture has the advantages of small trauma,early fracture healing,less pain,early function recovery and less complications.