基于"悬臂-杠杆重建-不稳定"理论的老年肱骨近端粉碎骨折术后康复策略探讨

Rehabilitation strategy of proximal humerus comminuted fracture in elderly patients based on the theory of"cantilever-lever reconstruction-instability"

目的探究不同的康复方案对于高龄人群肱骨近端骨折术后的疗效,选择最适宜高龄患者的术后康复理念及方法。方法回顾性对照研究北京市隆福医院骨科从2019年1月至2021年6月因Neer分型三、四部分的肱骨近端骨折行PHILOS钢板内固定的患者共31例,将符合入组标准的60岁以上的肱骨近端骨折患者分为两组:活动组和制动组。分别于术前、术后3个月和术后12个月采用Constant-Murley评分量表、上肢功能评定量表(disabilities of the arm,shoulder and hand,DASH)、疼痛视觉模拟评分(visual analogue scale,VAS)、生命质量SF-12量表评估患者术后肩关节功能及生活质量,测量术后12个月时X线肱骨颈干角,与术后结果对比,比较这两种康复方法的优劣性。结果入组患者31例,其中24例为合并骨质疏松的高龄患者,其中活动组为15例、制动组为16例。术后3个月时、12个月时活动组与制动组Constant评分改善量差异有统计学意义(P<0.001),制动组改善更明显。住院时长差异有统计学意义(P=0.016),制动组(12.0±5.6)d比活动组(7.3±1.3)d的住院时间更长。而DASH评分、VAS评分、SF-12评分在两组间未能体现出明显差异。制动组12个月时颈干角变化值(2.8°±0.9°)较活动组(3.9°±1.1°)更少。结论对于60岁以上的肱骨近端骨折患者应选择一种更保守的术后康复方案,术后早期不宜进行肩关节活动度锻炼,不但可以保证关节活动度不受影响,还能有效改善患者术后的Constant评分。

Background Proximal humeral fractures are a common limb fracture in the elderly,accounting for 4%-9%of total body fractures.Surgical treatment is the preferred treatment for proximal humeral fractures with apparent displacement.The proximal humeral internal fixation locking system for Neer III and IV fractures is relatively mature and practical,but screw cutting and internal fixation failure are still complications.For elderly patients with osteoporosis,although internal fixation materials and surgical techniques have become increasingly complete,there is still a lack of systematic and targeted postoperative rehabilitation programs.The theory of"cantilever-lever reconstruction-instability"indicates that premature postoperative exercise may lead to internal fixation failure,fracture nonunion,and other postoperative complications,so selecting an appropriate rehabilitation program is particularly important.Objective Based on the cantilever-lever reconstruction-instability theory,this study retrospectively analyzed the efficacy of different rehabilitation programs for elderly patients with proximal humerus fractures after surgery.It explored the most appropriate postoperative rehabilitation concepts and methods for elderly patients.Methods A retrospective case-control study was conducted on 31 patients who underwent PHILOS plate internal fixation for Neer type III and IV proximal humeral fractures in the Department of Orthopedics of Beijing Longfu Hospital from January 2019 to June 2021.PHFs patients over 60 who met the inclusion criteria were divided into the active group and the immobilization group.Postoperative shoulder function and quality of life were evaluated by Constant-murley scale,disabilities of the arm,shoulder and hand(DASH),visual analogue scale(VAS),and quality of life(SF-12)before,3,and 12 months after surgery,respectively.The neck-shaft angle of the humerus was measured by X-ray 12 months after the operation and compared with the postoperative results to compare the advantages and disadvantages of the two rehabilitation methods.Results Among the enrolled patients,24 were aged(>60 years)with osteoporosis.There were 15 cases in the active group and 16 in the immobilization group.There was a statistical difference in Constant score improvement between the active and braking groups at 3 and 12 months after surgery(P<0.001),and the progress was more evident in the braking group.The length of hospital stay was statistically significant(P=0.016),and the length of hospital stay was longer in the immobilization group than in the activity group.There were no significant differences between the two groups in DASH,VAS,and SF-12 scores.At 12 months,the neck-shaft angle of the immobilization group(2.8°±0.9°)was less than that of the active group(3.9°±1.1°).Conclusions For PHFs patients over 60 years old,a more conservative postoperative rehabilitation program should be selected,and shoulder range of motion exercise should not be carried out in the early postoperative period,which can not only ensure that the range of motion is not affected but also effectively improve the postoperative Constant score of patients.