经三角肌微创入路与胸大肌三角肌入路肱骨近端锁定内固定系统治疗肱骨近端骨折的效果比较

Comparison of deltoid split versus deltopectoral approaches in locking plate fixation for proximal humerus fracture

目的比较经三角肌微创入路与胸大肌三角肌入路肱骨近端锁定内固定系统(PHILOS)治疗肱骨近端骨折的中长期疗效。方法回顾性分析2018年1月至2020年12月南通大学附属南通第三医院骨科行手术治疗的65例肱骨近端骨折患者资料。男20例,女45例;年龄(64.6±9.2)岁。根据手术入路不同分为微创组(34例,采用经三角肌微创入路PHILOS固定)与标准组(31例,采用胸大肌三角肌入路PHILOS固定)。比较两组患者的一般资料、手术时间、术中出血量、术后住院时间、骨折愈合时间、术中透视次数、术后2年影像学评分及末次随访时肩关节Constant-Murley评分。结果两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。微创组患者的术中出血量(97.9±16.6)mL显著少于标准组的患者(155.8±27.4)mL,术中透视次数(12.0±1.8)次显著多于标准组患者的(6.7±1.8)次,差异均有统计学意义(P<0.05);两组患者的手术时间、术后住院时间、骨折愈合时间比较差异均无统计学意义(P>0.05)。所有患者术后获(43.9±5.5)个月随访。两组患者术后2年影像学评分比较差异均无统计学意义(P>0.05)。与标准组患者比较,微创组患者肩关节Constant-Murley评分的力量评分显著较低,Neer分型四部分骨折Constant-Murley评分显著较低,差异均有统计学意义(P<0.05)。术后微创组与标准组均有1例螺钉穿出,均有1例患者出现完全缺血性坏死,分别有1、3例患者出现部分缺血性坏死。结论与胸大肌三角肌入路相比,经三角肌微创入路具有软组织损伤小、术中出血量少、肱骨头血供破坏少等优势。但对于Neer四部分骨折,可能更适合采用胸大肌三角肌入路治疗。

Objective To compare the medium and long-term efficacy between the deltoid split approach and the conventional deltopectoral approach in locking plate fixation for proximal humerus fractures.Methods A retrospective study was performed in the 65 patients with proximal humerus fracture who had been operatively treated at Department of Orthopedics,The Third People's Hospital of Nantong from January 2018 to December 2020.They were 20 males and 45 females with an age of(64.6±9.2)years.Of them,34 were assigned to fixation with proximal humerus internal locking system(PHILOS)through the deltoid split approach(minimally invasive group),and 31 to PHILOS fixation through the deltopectoral approach(conventional group).The 2 groups were compared in terms of general data,operation time,intraoperative blood loss,hospital stay,fracture union time,intraoperative fluoroscopy,postoperative 2-year imaging scores,and Constant-Murley shoulder score at the last follow-up.Results There was no significant difference in the preoperative general data between the 2 groups,showing comparability(P>0.05).In the minimally invasive group and the conventional group,respectively,the intraoperative blood loss was(97.9±16.6)mL and(155.8±27.4)mL,and the frequency of intraoperative fluoroscopy(12.0±1.8)times and(6.7±1.8)times,both showing a statistically significant difference(P<0.05).There was no significant difference in operation time,hospital stay,or fracture union time(P>0.05).All patients were followed up for(43.9±5.5)months.There was no statistically significant difference between the 2 groups in postoperative 2-year imaging scores(P>0.05).Compared with the conventional group,patients in the minimally invasive group had significantly lower Constant-Murley strength scores and significantly lower Constant-Murley scores for the Neer four-part fractures(P<0.05).Postoperatively,one case of screw protrusion and one case of complete ischemic necrosis occurred in both groups while one case of partial ischemic necrosis was observed in the minimally invasive group and 3 cases of partial ischemic necrosis were observed in the conventional group.Conclusions In locking plate fixation for proximal humerus fractures,compared with the deltopectoral approach,the deltoid split approach shows advantages of less soft tissue damage,less intraoperative bleeding,and less destruction of the blood supply to the humeral head.However,the deltopectoral approach may be more appropriate for the Neer four-part fractures.