两种内固定对中老年肱骨近端合并肱骨干骨折的疗效及功能预后:前瞻性队列研究

Efficacy and functional outcome of two types of internal fixation in middle-aged and elderly patients with proximal humeral shaft fractures:a prospective cohort study

目的比较长型PHILOS钢板和长型MultiLoc髓内钉对中老年患者肱骨近端合并肱骨干骨折的安全性、疗效及功能预后。方法本研究为前瞻性队列研究,将2017年6月至2019年8月本科收治的肱骨近端合并肱骨干骨折的中老年患者作为研究对象,根据其入组顺序,依次纳入钢板组(长型PHILOS钢板)和髓内钉组(长型MultiLoc髓内钉),比较两组患者的围手术期指标、并发症、骨折愈合时间、肱骨颈干角、视觉模拟评分(visual analogue scale,VAS)、预后的Constant肩关节评分、Mayo肘关节评分(Mayo elbow performance score,MEPS)、肩关节活动度(range of motion,ROM)及肩袖抗阻试验阳性率。随访终点为术后1年。结果钢板组(n=16)平均随访(12.4±2.5)个月,髓内钉组(n=14)平均随访(12.7±1.9)个月。髓内钉组的住院天数(P=0.045)、术中出血量(P=0.002)、手术时间(P=0.036)均低于钢板组;两组骨折愈合时间、VAS、肱骨颈干角,及随访1年时的Constant肩关节评分、MEPS评分、肩袖抗阻试验阳性率差异无统计学意义(P>0.05);髓内钉组术后1年的肩外展角度大于钢板组(P=0.033)。结论对中老年患者而言,两种内固定治疗肱骨近端合并肱骨干骨折后的骨折愈合疗效相同,但髓内钉的围手术期安全性更高,术后早期恢复更快,预后的ROM范围更大,更适用于老年患者。

Background Proximal humerus fracture combined with humeral shaft fracture is a particular type of fracture in middle-aged and older adults.It has an extensive fracture range,great surgical difficulty,and perioperative complications,which is a great challenge to postoperative rehabilitation and the functional prognosis of patients.The long PHILOS plate and the MultiLoc intramedullary nail are the surgical methods for treating proximal humeral fracture with the humeral shaft in recent years.They have different advantages and characteristics.The former is reliable,less invasive,and does not hurt the rotator cuff.At the same time,the latter is a micro-motion internal fixation,which is conducive to early functional exercise after surgery.There is limited experience in treating proximal humeral fracture with the humeral shaft,and there is a lack of systematic comparison of different internal fixation methods.It is unclear that the best internal fixation method for middle-aged and elderly patients with the proximal humeral fracture combined with the humeral shaft is still unclear.Objective To compare the safety,efficacy,and functional outcome of long PHILOS plate and long MultiLoc intramedullary nail in middle-aged and elderly patients with proximal humerus fractures combined with humeral shaft fractures.Methods This is a prospective cohort study.Middle-aged and elderly patients with proximal humeral fracture combined with humeral shaft fracture admitted into our department from June 2017 to August 2019 were enrolled in the study.According to the inclusive criteria,they were divided into the plate group(long PHILOS plate)and the intramedullary nail group(long MultiLoc intramedullary nail).The perioperative indicators,complications,fracture healing time,humeral neck-shaft angle,and VAS score were compared between the two groups.The Constant-Murley score,Mayo elbow performance score(MEPS),range of motion(ROM),and positive rate of rotator cuff resistance test were analyzed.The endpoint of follow-up was one year after surgery.Results The mean follow-up was(12.4±2.5)months in the plate group(n=16)and(12.7±1.9)months in the intramedullary nail group(n=14).The length of hospital stay(P=0.045),intraoperative blood loss(P=0.002),and operation time(P=0.036)in the intramedullary nail group were lower than those in the plate group.There were no significant differences in fracture healing time,VAS score,humeral neck-shaft angle,Constant shoulder score,MEPS elbow score,and rotator cuff resistance test positive rate at one-year follow-up between the two groups(P>0.05).The shoulder abduction angle in the intramedullary nail group was significantly higher than in the plate group(P=0.033).Conclusion For middle-aged and elderly patients,the two types of internal fixation have the same effect on fracture healing after proximal humeral fracture.However,the intramedullary nail has higher perioperative safety,faster early postoperative recovery,and a more comprehensive prognosis range of shoulder ROM,which is more suitable for elderly patients.