肱骨近端骨折钢板内固定术后发生肱骨头内翻的影响因素及术中颈干角对疗效的影响

Influencing factors of humeral head varus following plate internal fixation of proximal humeral fractures and the clinical effect of intraoperative neck-shaft angle

目的探究术中颈干角(NSA)对钢板内固定术(PIF)后肱骨近端骨折(PHF)患者发生肱骨头内翻的影响。方法回顾性分析2020年1月—2023年1月于泸州市中医医院骨伤科行PIF治疗的155例PHF患者,男性88例,女性67例;年龄26~65岁,平均47.1岁;致伤原因:道路交通伤73例,摔伤58例,高处坠落伤15例,其他伤9例。根据肱骨头内翻判定标准,分为内翻组(38例)和未内翻组(117例);根据术中肱骨NSA,分为<125°组(30例),125°~145°组(110例)和>145°组(15例)。收集患者的临床资料,包括年龄、性别、肩关节活动度、功能评分、VAS、术后并发症等。采用多因素Logistic回归分析危险因素。采用广义线性混合效应模型(GLMM)与限制性立方样条法(RCS)分析术中肱骨NSA与术后肱骨头内翻关联强度的剂量-反应关系。结果肩关节受伤机制、骨密度(BMD)、肱骨距置入螺钉、术中肱骨NSA、内侧骨皮质缺损以及复位质量,均是PHF患者术后肱骨头内翻发生的影响因素(P<0.05)。根据多因素GLMM模型(模型3)调整一系列指标(年龄、性别、伤侧等)后,术中肱骨NSA<125°和>145°组术后肱骨头内翻发生风险分别是125°~145°组的2.244、1.499倍(P<0.05)。RCS分析结果显示,术中肱骨NSA连续变化与术后肱骨头内翻的关联强度呈非线性剂量-反应关系(χ2=14.178,P<0.001)。不同术中肱骨NSA组患者的肩关节活动度(前屈上举、外展、外旋)、功能评分(疼痛、日常活动、运动范围、总分)以及VAS比较差异均有统计学意义(P<0.05)。不同术中肱骨NSA患者的术后并发症发生率比较差异无统计学意义(P>0.05)。结论术中肱骨NSA<125°或>145°是PHF患者术后肱骨头内翻发生的独立影响因素。术中肱骨NSA对PHF患者术后肩关节功能恢复存在一定程度的影响,临床医师尤其应注意术中肱骨NSA<125°的PHF患者,术中应尽量解剖复位、内固定以降低术后肱骨头内翻发生率。

Objective To explore the influencing factors of humeral head varus in proximal humeral fractures(PHF)patients afteRplate internal fixation,and to investigate the clinical effect of intraoperative neck-shaft angle(NSA).Methods This retrospective study was conducted on 155 PHF patients managed in Luzhou Traditional Chinese Medicine Hospital from Jan.2020 to Jan.2023.There were 88 males and 67 females aged 26-65(mean 47.1)years,with 73 road traffic injuries,58 ground-level falls,15 falls from height,and 9 others.Based on whetheRhumeral head varus occurred,patients were divided into varus group(n=38)and non-varus group(n=117).The intraoperative humeral NSA was furtheRanalyzed,with all patients divided into anotheR3 groups of<125°NSA group(n=30),125°-145°NSA group(n=110),and>145°NSA group(n=15).Clinical data of patients were collected,including age,gender,shouldeRrange of motion,functional score,VAS,postoperative complications,etc.Multiple logistic regression analysis was used to identify the risk factors.Generalized lineaRmixed models(GLMM)and restricted cubic splines(RCS)were used to analyze the dose-response relationship between intraoperative humeral NSA and postoperative humeral head varus.Results The injury mechanism,bone mineral density,placement of screws in the humeral talus,intraoperative humeral NSA,medial cortical bone defect,and reduction quality were independent influencing factors foRpostoperative humeral head varus in PHF patients(P<0.05).The multifactoRGLMM model(Model 3),afteRadjusting a series of indicators of age,gender,injury side,etc.,showed that the risks of postoperative humeral head varus in the<125°and>145°NSA groups were respectively 2.244 and 1.499 times higheRthan that in the 125°-145°NSA group(P<0.05).RCS analysis results showed a non-lineaRdose-response relationship between intraoperative humeral NSA and postoperative humeral head varus(χ2=14.178,P<0.001).Compared with the otheRtwo groups,the 125°-145°NSA group showed the largest should range of motion(forward bending and upward lifting,abduction,and outward rotation),highest functional score(pain,daily activities,range of motion,total score)and least VAS(P<0.05),but the incidence of postoperative complications revealed no significant difference(P>0.05).Conclusion Intraoperative humeral NSA is one of the independent influencing factors foRpostoperative humeral head varus in PHF patients,which can affect the functional recovery of the shouldeRjoint.Clinicians should pay special attention to PHF patients with a humeral NSA<125°,and try theiRbest to achieve anatomical reduction to reduce the incidence of humeral head varus.