自体腓骨段结构移植与肩袖缝合悬吊技术在Neer Ⅳ型肱骨近端骨折内固定术中的应用

Autologous fibular segmental structure graft and rotator cuff suture suspension technique in internal fixation of Neer type IV proximal humerus fractures

目的 评估自体腓骨结构移植重建肱骨距与肩袖缝合悬吊技术在NeerⅣ型肱骨近端骨折锁定钢板内固定术中的应用价值,并总结治疗经验。方法 回顾性分析自2018-10—2021-06采用切开复位锁定钢板内固定治疗的34例NeerⅣ型肱骨近端骨折,显露骨折端后清除周围血肿和嵌入组织,确定所需结构移植的腓骨段长度,取同侧中上段腓骨(长度5~8 cm)插入肱骨髓腔并使其尽量靠近肱骨内侧。根据骨折情况将5号不可吸收缝线预置于冈上肌腱、冈下肌腱、肩胛下肌腱靠近肌腱止点处。肱骨近端骨折解剖复位后,将肩袖缝线穿过钢板头部缝合孔打结,钢板在腋神经下方向远端滑动至适当深度,钢板侧方与骨干平行,钢板远端长结合孔中置入1枚直径3.5 mm皮质骨螺钉,牵引收紧缝线并逐一置入锁钉,置入肱骨距螺钉,透视确认螺钉长度合适后将缝线收紧打结。结果 34例均获得随访,随访时间平均24.6(12~38)个月。术后无腋神经损伤、肱骨头内翻畸形、肱骨头缺血性坏死、螺钉切出等并发症发生。术后第3天X线片测量颈干角为135°~142°,平均138.9°;术后3个月颈干角为130°~139°,平均134.1°;末次随访时颈干角为128°~138°,平均133.1°。末次随访时肩关节功能Constant-Murley评分为80~86分,平均83.9分。结论 将自体腓骨段结构移植与肩袖缝合悬吊技术应用于NeerⅣ型肱骨近端骨折锁定钢板内固定术中可获得稳定的内侧支撑与内固定强度,有利于患者肩关节功能恢复,减少术后并发症发生。

Objective To evaluate the value of autologous fibular structure graft reconstruction of the humeral spur with rotator cuff suture suspension technique in locking plate internal fixation of Neer type Ⅳ proximal humeral fracture and to summarize the treatment experience.Methods Retrospective analysis of 34 cases of Neer type Ⅳ proximal humerus fractures treated with internal fixation using incisional repositioning locking plate from October 2018 to June 2021 was performed. The surrounding hematoma and embedded tissue were removed after the fracture end was exposed. The length of the fibular segment to be structurally grafted was determined, and the ipsilateral mid-superior fibula(length 5-8 cm) was taken and inserted into the humeral medullary cavity as close to the humerus as possible medially. A No. 5 nonabsorbable suture was prepositioned on the supraspinatus tendon, infraspinatus tendon, and subscapularis tendon near the tendon stop according to the fractures. After anatomical repositioning of the proximal humeral fractures, the rotator cuff suture was tied through the suture hole at the head of the plate,the plate was slid distally to the appropriate depth under the axillary nerve, the plate was laterally parallel to the backbone, one3.5 mm diameter cortical bone screw was placed in the long union hole at the distal end of the plate, the suture was traction tightened and the locking screws was placed one by one, the humeral distance screw was placed, and the suture was tightened and tied after fluoroscopic confirmation of the appropriate screw length.Results All 34 cases were followed up for 12 to 38 months,with a mean of 24.6 months. There were no postoperative complications such as axillary nerve injury, humeral head inversion deformity, ischemic necrosis of the humeral head, or screw cut-out. The cervical stem angle measured by X-ray on postoperative day 3 ranged from 135° to 142°, with an average of 138.9°;3 months after surgery, the cervical stem angle ranged from 130° to139°, with an average of 134.1°;at the last follow-up, the cervical stem angle ranged from 128° to 138°, with an average of133.1°. The Constant-Murley score of shoulder function at the last follow-up was 80-86, with a mean score of 83.9.Conclusion The application of autologous fibular segmental grafting and rotator cuff suture suspension technique in the internal fixation of Neer Ⅳ proximal humeral fracture with locking plate can obtain stable medial support and internal fixation strength, which can facilitate the functional recovery of the patient’s shoulder joint and reduce the occurrence of postoperative complications.