肩峰指数与运用Multiloc髓内钉治疗肱骨近端骨折的临床相关性研究

Correlation studies between acromion index and Multiloc intramedullary nail in the treatment of proximal humeral fracture

目的：评估肩峰指数(acromion index,AI)与 Multiloc 髓内钉治疗肱骨近端骨折的相关性。方法将2014年2月至2015年6月,四川省骨科医院采用 Multiloc 髓内钉治疗17例肱骨近端骨折患者的病例资料纳入研究。其中男6例,女11例；年龄48~67岁,平均61.4岁；AI 为0.69~0.94,平均0.78,其中男0.66,女0.75。根据 Neer 分型,二部分骨折8例(47%),三部分骨折7例(41%),四部分骨折2例(12%),其中合并有鹰嘴骨折、桡骨远端骨折、肩袖损伤及腋神经损伤。所有患者均为闭合性骨折。记录手术时间,出血量,术后1、2、4、6、8、12个月门诊定期复查,X 线检查复位效果及愈合情况,并采用美国肩肘外科协会评分(rating scale of the American shoulder and elbow surgeons,ASES),Constant 评分等指标评价患者肩关节功能。结果17例患者均顺利完成手术,1例术后出现肘关节僵硬,术后并发症发生率为5.8%。ASES 评分中：总分 P =0.670,疼痛 P =0.078,生活功能 P =0.010；Constant 评分中：总分 P =0.019,疼痛 P =0.083,功能活动 P =0.453,肩关节活动度 P =0.007,力量 P =0.869；出血量 P <0.001；骨折愈合时间 P =0.001；手术时间 P =0.866。日常活动中：前屈上举 P =0.012,外展 P =0.010,外旋 P =0.038。6例男性平均 AI 为0.66±0.54,11例女性平均 AI 为0.75±0.40,两者 AI 相比 P =0.218。提示 AI 与患者术中出血量、骨折愈合时间及术后功能活动(特别是前屈上举、外展、外旋)有相关性。结论肱骨近端骨折运用髓内钉治疗时,AI 大小与性别、年龄、手术时间无明显相关性。AI 越小,术中出血量越少,骨折愈合时间越短；AI 越大,术中出血量相对较多,骨折愈合时间稍长。AI 较大的患者,术后 ASES 评分及 Constant 评分较高,术后功能活动(前屈上举、外展及外旋)较好；相反,AI 较小的患者,术后 ASES 评分及Constant 评分相对较低,术后功能活动(前屈上举、外展及外旋)相对较差。在运用 Multiloc 髓内钉治疗肱骨近端骨折时,暂未发现与手术相关并发症,且 AI 的大小与术后并发症的发生无明显相关性。

Background The proximal humeral fracture is a common clinical disease in the department of orthopedics,accounting for 4%-5% of all the fractures. More than 70% of the proximal humeral fractures occur in the elderly patients of over 60 years,and the number will increase year by year with the trend of population aging in China.The majority of proximal humeral fractures obtain good clinical prognosis through conservative treatment,but there are still some complications. The surgical treatment methods include close or open reduction and internal fixation and shoulder joint arthroplasty.The internal fixators are numerous,such as Multiloc intramedullary nail.During the&nbsp;intramedullary nailing treatment,Rispoli,etc.discovered the value of acromion index (AI)had an effect on the surgery,but no domestic literatures are reported at present.So this study assumes that the operation time,intraoperative blood loss,fracture healing time,postoperative functional scores and functional rehabilitation are different as the AI varies during the treatment of proximal humeral fractures with Multiloc intramedullary nail.In this study,seventeen patients of proximal humeral fractures were treated with Multiloc intramedullary nails from February 2014 to June 201 5 in Sichuan provincial orthopedic hospital and the operation time,blood loss,fracture healing time,postoperative functional rehabilitation (anteflexion and uplift,internal and external rotation)and functional scores, etc.were recorded.All the clinical data were retrospectively analyzed to assess the correlation between AI and Multiloc intramedullary nailing in the treatment of proximal humeral fractures.Methods (1)General information.From February 2014 to June 201 5,seventeen patients of proximal humeral fractures, including 6 males and 1 1 females were treated with Multiloc intramedullary nails and followed up for 1 year.The ages ranged from 48 to 67 years with 61.4 years on average.The AI ranged from 0.69 to 0.94 with 0.78 on average.The mean AI were 0.66 in male patients and 0.75 in females.According to Neer classification,there were 8 cases (47%)of 2-part fracture,7 cases (41%)of 3-part fracture and 2 cases (12%)of 4-part fracture,including olecranon fracture,distal radius fracture,rotator cuff tear and axillary nerve injury.8 cases (47%)were injured in the dominant sides and 9 cases (53%) were non-dominant sides.The causes were slips during walking in 9 cases (53%),falls from bicycles in 5 cases (29.4%)and traffic accidents in 3 cases (1 7.6%)and all the injuries were closed fractures. This research was approved by the hospital ethics committee and all the subjects signed the informed consents.(2)Follow-ups and evaluation index.All the operations were performed by physicians of the same group,and the follow-ups and assessments were conducted by another 2 senior orthopedic clinicians in the outpatient department.The postoperative routine visits were in the 1st,2nd,4th, 6th,8th and 12th months and the X-ray radiographs were taken at the same time.The shoulder activity scale,rating scale of the American shoulder and elbow surgeons (AESE)and Constant scoring system were applied in the evaluation of shoulder function.ASES is made by the association of American shoulder and elbow surgeons,including pain (50%)and life function (50%).The total score is 100 points and the higher score indicates the better function.The Constant scoring system is composed of pain (1 5 points),muscle strength (25 points),functional activity (20 points)and range of motion of shoulder joint (40 points),and the total score is 100 points.The higher score reveals the better shoulder function as well. (3 )AI measurement Standard.The X-ray radiographs of anteroposterior view,lateral view and axillary view were taken in all the patients by 1 senior and experienced radiologist with blind method. The respective distances from the lateral margin of acromion and the outer end of humeral head to the glenoid plane were measured by two physicians and the results were the mean values.All the radiographic images were provided by picture archiving and communication systems (PACS)in the hospital to avoid the measurement bias caused by different equipments and technical personnel.(4)Statistical analysis.The SPSS 22.0 statistical software was adopted and the independent samples t test was used in the analysis of patient genders.The linear correlation analysis was applied in shoulder joint function,blood loss,operation time,fracture healing time,ASES scores and Constant scores.Theαvalue of inspection level was 0.05 on double sides and the difference was considered statistically significant with P < 0.05.Results (1 )General results. ASES score:total score P =0.670,pain P =0.078,life function P =0.010;Constant score:total score P =0.01 9,pain P =0.083,functional activity P =0.453,shoulder activity scale P = 0.007, muscle strength P =0.869,blood loss P <0.001,fracture healing time P =0.001,operative time P =0.866.Daily life:anteflexion and uplift P = 0.012,abduction P = 0.010,external rotation P =0.038.The mean AI was 0.66 in 6 males and 0.75 in 1 1 females with the comparison P = 0.218. Five patients had smaller AI (<0.68),including 1 case of 2-part fracture,3 cases of 3-part fracture and 1 case of 4-part fracture.The mean age was 55.8 years (43-69 years)and the mean AI was 0.55 (0.47-0.66);The mean intraoperative blood loss was 1 10 ml (100-1 50 ml);The mean degree of&nbsp;anteflexion and uplift was 146° (120°-1 70°)with 36° of abduction on average (30°-40°)and 88° of external rotation on average (80°-1 10°);The mean ASES score was 83.8 points (80-90 points)and the mean Constant score was 81 points (76-91 points ); The mean fracture healing time was 1.6 months (1.5-2 months).Twelve patients had larger AI (> 0.68 ),including 7 cases of 2-part fracture,4 cases of 3-part fracture and 1 case of 4-part fracture.The mean age was 61.4 years (48-69 years)and the mean AI was 0.78 (0.69-0.94);The mean intraoperative blood loss was 257.5 ml (1 50-300 ml );The mean degree of anteflexion and uplift was 1 61.6° (120°-180°) with 40° of abduction on average (20°-50°)and 106.5° of external rotation on average (85°-1 60°);The mean ASES score was 89.7 points (80-96 points)and the mean Constant score was 87.3 points (79-98 points);the mean fracture healing time was 2.25 months (1.5-3 months ).(2 )Postoperative complications.In the last follow-ups,no iatrogenic neurovascular injury,wound infection,internal fixation failure or humeral head necrosis were found in 1 7 patients.One patient had ipsilateral elbow joint stiffness (1 10°of flexion and 50°of extension)but no muscle strength loss,muscle atrophy or other nerve damages,which was considered to be relevant with the 3 months absence of outpatient follow-ups.The release surgery of elbow joint was performed 1 year after Multiloc intramedullary nail fixation and the functional rehabilitation was acquired after operation (130° of flexion and 10° of extension).There was no obvious correlation between AI and postoperative bleeding complications. Conclusions No obvious correlation was found between the AI and the genders,ages and operation time in the treatment of proximal humeral fractures with intramedullary nails.The smaller AI indicated less intraoperative blood loss and fracture healing time.On the contrary,the larger AI indicated more intraoperative blood loss and fracture healing time.The patients with larger AI obtained higher ASES and Constant scores and better postoperative function (anteflexion,abduction and external rotation).Otherwise the patient with smaller AI acquired less ASES and Constant scores and relatively poor postoperative function.No operative complications occurred in the treatment of proximal fractures with Multiloc intramedullary nail and the AI had no significant correlation with the postoperative complications.