外固定支架植骨和有限内固定治疗肱骨中段术后无菌性骨不连

External fixation combined with bone graft and screw fixation for aseptic nonunion on midshaft humeral fractures

背景:单边外固定架和Ilizarov外固定架已经在感染及非感染肱骨骨不连患者中得到广泛运用,但尚无文献单独报道采用外固定架治疗肱骨中段骨折术后骨不连的临床效果。目的目的:探讨外固定支架植骨配合有限内固定治疗肱骨中段术后无菌性骨不连的临床疗效及手术要点。方法方法:2006年1月至2011年11月收治肱骨中段术后无菌性骨不连患者30例,均采取肱骨前外侧或后侧入路,拉力螺钉置入内固定、髂骨移植加外固定架治疗。所有患者随访时间均≥12个月,记录患者一般情况、肩肘关节活动度、骨折愈合情况、并发症及X线片情况,采用Constant肩关节评分及Mayo肘关节功能评分评估肩、肘关节功能。结果结果:30例患者全部获得随访,随访时间为12~36个月,平均(21.1±5.9)个月。所有患者骨折均获愈合(愈合率为100%),影像学愈合时间为3.5~8个月,平均(5.0±1.2)个月。3例患者术后出现针道的浅表性感染,经伤口换药后伤口愈合;1例术后4个月出现外固定架连接杆断裂,X线片提示骨折已愈合,取出外固定架;2例出现桡神经牵拉伤,经静滴及口服营养神经药物4个月后恢复;4例术后出现肩关节周围粘连,外展上举后伸受限,经手法及理疗2周后活动度正常。术后随访患者术肢较健肢平均缩短(1.8±0.6)cm;Constant肩关节评分为66~96分,平均为(85.8±7.0)分;Mayo肘关节评分为78~95分,平均为(90.1±4.5)分。结论结论:外固定支架植骨和有限内固定治疗肱骨中段术后无菌性骨不连的关键是彻底清理骨折断端,加强骨折稳定性,保护骨折端血液供应,充分有效的自体髂骨植骨。该手术方式可以极大提高骨折愈合率,减少并发症发生,并可获得较好的肩肘功能。

Background: Both single external fixator and Ilizarov external fixator has been widely applied in the treatment of humeral nonunion in clinic. But there is not a report on therapeutic effect of external fixation for postoperative aseptic nonunion of midshaft humerus fracture.Objective: To investigate clinical outcome and key points of external fixator with limited internal fixation for postoperative aseptic nonunion of midshaft humerus fracture.Methods: Thirty patients with postoperative aseptic nonunion of midshaft humerus fracture treated between January 2006 and November 2011 were enrolled in this study. Lag screw and autogenous bone were implanted through anterolateral or posterior approach. Meanwhile, external fixator was applied. The duration of follow- up was 12 months or more than 12 months in all patients. General state of health, range of motion of the shoulder and elbow, fracture healing, complications and X- ray results were recorded. Shoulder and elbow function were assessed according to Constant shoulder score and Mayo elbow performance score systems.Results: The average duration of follow-up was(21.1±5.9) months(range, 12-36 months). Bony union was observed in all patients(healing rate was 100%), the average radiographic healing time was(5.0±1.2) months(range, 3.5-8 months). Superficial pin tract infection occurred in 3 patients, and the wound healed after change of dressing. The connecting rod of the external fixator broke up in one patient 4 months postoperatively; X-ray showed the fracture had healed and the external fixator was removed. Tension injury of radial nerve was found in 2 patients who recovered by the intravenous drip and oral neurotrophic drugs 4 months later. Shoulder joint adhesion characterized by abductor, lift, extension restriction occurred in 4patients whose range of motion of the shoulder became normal by manipulation and physical therapy 2 weeks later. Affectedlimb was decreased by(1.8±0.6)cm as compared with the healthy side. Constant shoulder score was 85.8±7.0 on average(range, 66-96). Mayo elbow score was 90.1±4.5 on average(range, 78-95).Conclusions: In revision of aseptic nonunion of humeral fracture after surgical failure, the combined treatment of external fixation, bone graft and internal fixation can greatly increase the rate of union and reduce complications to ensure good functional recovery of the upper extremity. The key of the procedure is to completely resect nonunion ends and fibrous tissue,strengthen the stability of fractures, protect blood supply and effectively use autologous bone.