同期修复肩袖撕裂结合锁定钢板治疗老年肱骨近端骨折的特点及疗效分析

Characteristics and efficacy of simultaneous repair of rotator cuff tear combined with locking plate in the treatment of elderly proximal humeral fractures

目的研究同期修复肩袖撕裂结合锁定钢板螺钉治疗老年肱骨近端骨折的特点,并评价其功能。方法自2015年7月至2018年6月收治69例老年肱骨近端骨折患者行手术治疗。A组:手术前MRI并且术中探查存在肩袖损伤患者26例;B组:其他肱骨近端骨折患者43例。手术中应用缝线缝合18例,锚钉结合缝线修复8例。骨折固定采用Phlios钢板固定。所有患者术后均外展支具保护4周,并接受标准康复计划。记录两组患者手术时间、术中出血量和术后并发症,术后12周和末次随访时采用视觉模拟评分(visual analogue scale,VAS)、美国肩肘外科协会(rating scale of the American shoulder and elbow surgeons,ASES)评分及Constant评分评估肩关节功能,对以上指标进行比较。结果69例患者获得随访,时间12~21个月,平均13个月。全部骨折均获得愈合,A组术后伤口感染1例,脂肪液化1例,螺钉突出肱骨头1例,肩峰撞击症1例;B组伤口脂肪液化1例,螺钉突出肱骨头2例,肩峰撞击症2例,未出现神经损伤、钢板螺钉断裂、肩关节脱位以及肱骨头坏死等其他并发症。肩袖损伤组术后12周随访VAS评分更低(P<0.001),差异有统计学意义,两组患者手术时间、出血量、术后24 h及术后12个月VAS评分、术后12周及12个月ASES评分、Constent评分比较,差异无统计学意义。结论对于诊断老年肱骨近端骨折合并肩袖损伤的患者,建议采用锁定钢板结合缝合修复肩袖同时恢复肱骨近端骨性及软组织解剖关系,为肩关节功能康复提供了先决条件和有利保证。

Background Proximal humerus fracture is more common in clinical practice.Its incidence accounts for 5%of total body fractures,especially in elderly patients over 60 years old.The incidence accounts for the third place in the incidence of all fractures in the body,second only to distal radius fracture and elderly hip fracture.Proximal humerus fractures are often combined with shoulder subluxation,dislocation,rotator cuff,and nerve injury,and the supraspinatus muscle is the most common injury in the rotator cuff.MRI identified the suspected rotator cuff injury.The rotator cuff is composed of the supraspinatus muscle,infraspinatus muscle,subscapularis muscle,and teres minor muscle wrapped around the head of the humerus,a set of tendon complex,to help complete the shoulder joint lift,rotation,rotation,and other movements.At the same time,the rotator cuff is also an essential structure for stabilizing the shoulder joint.Currently,there are many types of rotator cuffs,which can be divided into complete and partial cuffs,depending on the depth of the tear in the clinic.According to tear length,full-layer tears can be divided into mild tears(tear length of<1 cm),moderate tears(tear length 1-3 cm),severe tears(tear length of>3-5 cm),and colossal tears(tear length of>5 cm).For patients with shoulder joint trauma,the purpose of treatment of proximal humerus fracture is to restore the integrity of the shoulder joint,and the purpose of treatment of rotator cuff injury is to maintain the stability of the original shoulder joint.In order to obtain satisfactory shoulder joint function,anatomic reduction and firm internal fixation are required.Currently,treating proximal humerus fractures accompanied by rotator cuff injury is controversial.However,more and more clinicians have begun to investigate the integrity of rotator cuff tissue and repair it before and during surgery,but there are few clinical studies on proximal humerus fracture combined with rotator cuff injury in China.Objective To study the characteristics and function of simultaneous repair of rotator cuff tear combined with locking plate screw in the treatment of elderly proximal humerus fractures.Methods From July 2015 to June 2018,69 elderly patients with proximal humerus fractures were treated with surgery.Group A:26 patients with rotator cuff injury with MRI before operation and intraoperative exploration;Group B:patients with other proximal humerus fractures;Sutures were used in 18 cases and anchors combined with sutures in 8 cases.The fracture was fixed with the PHILOS plate.All patients were protected by the outreach branch for four weeks and received a standard rehabilitation program.The two groups'operative time,intraoperative blood loss,and postoperative complications were recorded.The shoulder joint function was evaluated using the VAS pain score,ASES score,and Constant score 12 weeks after surgery and the last follow-up.The above indexes were compared.Results Sixty-nine patients were followed for 12 to 21 months,averaging 13 months.All fractures were healed.In group A,wound infection occurred in 1 case,fat liquefaction occurred in 1 case,screw protrusion occurred in 1 case,and acromial impingement occurred in 1 case;in group B,wound fat liquefaction occurred in 1 case,screw protrusion occurred in 2 cases,and acromial impingement occurred in 2 cases,and no other complications such as nerve injury,plate screw rupture,shoulder dislocation,and necrosis of humerus head occurred.The postoperative VAS score was lower in the rotator cuff injury group at 12 weeks after surgery(P<0.001),and the difference was statistically significant.There was no statistically significant difference between the two groups in operation time,blood loss,VAS scores 24 hours and 12 months after surgery,ASES scores,and Constant scores 12 weeks and 12 months after surgery.Conclusions For the diagnosis of elderly patients with proximal humerus fracture combined with rotator cuff injury,it is recommended to use a locking plate combined with suture to repair the rotator cuff and restore the anatomical relationship between bone and soft tissue of the proximal humerus,which provides a prerequisite and favorable guarantee for the functional rehabilitation of shoulder joint.