反肩与半肩关节置换术治疗老年肱骨近端三或四部分骨折的临床疗效比较

Comparison of reverse shoulder arthroplasty and hemiarthroplasty in the treatment of three- or four-part fractures of proximal humeral in the elderly

目的比较反肩关节置换与半肩关节置换治疗老年肱骨近端三或四部分骨折的临床疗效。方法回顾性分析2014年6月至2020年6月采用半肩关节置换或反肩关节置换治疗并获得随访的58例老年肱骨近端Neer三或四部分骨折患者资料,其中46例来自四川省骨科医院(半肩关节置换22例、反肩关节置换24例)、12例来自天津市天津医院(半肩关节置换5例、反肩关节置换7例)。半肩关节置换组27例,男7例、女20例;年龄(70.29±6.81)岁(范围61~87岁);三部分骨折10例、四部分骨折17例。反肩关节置换组31例,男9例、女22例;年龄(75.06±4.25)岁(范围67~86岁);三部分骨折9例、四部分骨折22例。术后根据视觉模拟评分(visual analogue scale,VAS)评估疼痛,根据肩关节活动度、假体是否上移、大结节愈合、肩胛盂切迹及美国肩肘外科协会(American Shoulder and Elbow Surgeons,ASES)评分、Constant-Murley评分评估疗效。结果半肩关节置换组随访时间(50.63±16.02)个月(范围24~75个月),反肩关节置换组(28.32±11.93)个月(范围14~56个月)。反肩关节置换组患者前屈上举活动度118.22°±27.22°,半肩关节置换组为102.77°±25.88°,差异有统计学意义(t=2.21,P=0.032);体侧外旋活动度和内旋摸背分级两组结果相似,差异无统计学意义(外旋:t=0.57,P=0.616;内旋:χ^(2)=2.61,P=0.273);半肩关节置换组的大结节完全愈合率为52%(14/27),反肩关节置换组为71%(22/31),差异无统计学意义;反肩关节置换组的Constant-Murley和ASES评分[(71.54±27.31)分和(72.76±17.34)分]均高于半肩关节置换组[(53.03±30.36)分和(61.07±18.99)分],差异均有统计学意义(t=2.43和2.44,P=0.019和0.018);半肩关节置换组和反肩关节置换组的总体并发症发生率分别为37%(10/27)和13%(4/31),差异有统计学意义(χ^(2)=4.59,P=0.032)。半肩关节组中6例出现假体上移、2例肩盂侧磨损,反肩关节置换组中1例出现肩胛盂切迹(Sirveaux 1级)。结论老年肱骨近端Neer三或四部分骨折,相对于半肩关节置换术,反肩关节置换术能获得更好的前屈上举活动度及肩关节功能。

Objective To compare the clinical effects of reverse shoulder arthroplasty and hemiarthroplasty in the treatment of three-or four-part proximal humeral fractures in the elderly.Methods The clinical data of 58 elderly patients with three-or four-part proximal humeral fractures treated with hemiarthroplasty or reverse shoulder arthroplasty from June 2014 to June 2020 were retrospectively analyzed.Among them,46 cases were from Sichuan Provincial Orthopaedic Hospital(22 cases of hemiarthroplasty and 24 cases of reverse shoulder arthroplasty),and 12 cases were from Tianjin Hospital(5 cases of hemiarthroplasty and 7 cases of reverse shoulder arthroplasty).In the hemiarthroplasty group,there were 27 patients,including 7 males and 20 females,with an average age of 70.29±6.81 years(range,61-87 years),and there were 10 cases of 3-part fractures and 17 cases of 4-part fractures.In the reverse shoulder arthroplasty group,including 9 males and 22 females,with an average age of 75.06±4.25 years(range,67-86 years),and there were 9 cases of 3-part fractures and 22 cases of 4-part fractures.The postoperative efficacy evaluation indexes included visual analogue scale(VAS),range of motion(ROM),prosthesis upward displacement,healing of greater tuberosity,scapular glenoid notch,American Shoulder and Elbow Surgeons(ASES)and Constant-Murley score.Results The average follow-up was 50.63±16.02 months(range,24-75 months)in the hemiarthroplasty group and 28.32±11.93 months(range,14-56 months)in the reverse shoulder arthroplasty group.The anterior elevation in the reverse shoulder arthroplasty group was 118.22°±27.22°,and those in the hemiarthroplasty group was 102.77°±25.88°,which was significant difference(t=2.21,P=0.032);the results of external rotation(ER)and internal rotation(IR)in two groups were similar,and no significant difference(ER:t=0.57,P=0.616;IR:χ^(2)=2.61,P=0.273);the average Constant-Murley and ASES in the reverse shoulder arthroplasty group were significantly better than those in the hemiarthroplasty group(P=0.019 and 0.018);the complication rates of hemiarthroplasty group and reverse shoulder arthroplasty group were 37%(10/27)and 13%(4/31),respectively(χ^(2)=4.59,P=0.032).In the hemiarthroplasty group,6 patients had upward movements of the prosthesis and 2 patients had wear of the glenoid side;notching(sirveaux grade 1)was noted in 1 patient in the reverse shoulder arthroplasty group.Conclusion In the treatment of three-or four-part proximal humeral fractures in the elderly,reverse shoulder arthroplasty achieves significantly better functional results compared to hemiarthroplasty.