应用Multiloc髓内钉与Phlios钢板治疗老年肱骨近端骨折的疗效对比

应用Multiloc髓内钉与Phlios钢板治疗
老年肱骨近端骨折的疗效对比
王岩松,褚鑫,孙毓,夏天芝,滕鹏
(锦州医科大学附属第一医院骨创伤科,辽宁锦州121000)
摘要:目的　比较Multiloc髓内钉与Phlios钢板治疗老年肱骨近端骨折的临床疗效㊂方法　回顾性分析2017年8月至2019年6月在我院行手术治疗并获得6个月以上随访的49例老年肱骨二㊁三部分近端骨折患者的临床资料㊂其中男11例,女38例,年龄61~83岁㊂根据手术内固定物不同分为Multiloc髓内钉组(23例),Phlios钢板组(26例),比较两组病人手术时间㊁切口长度㊁手术出血量㊁骨折愈合时间㊁Constant-Murley肩关节功能评分及术后并发症的情况㊂结果　49例患者都获随访,随访时间为平均9(6~15)个月㊂两组在㊁术中出血㊁骨折愈合㊁并发症发生率等方面差异无统计学意义(P>0.05)㊂Multiloc髓内钉组Constant-Murley肩关节功能评分优于Phlios钢板组,Multiloc髓内钉组手术切口长度更短,手术时间更短㊂Multiloc髓内钉组㊂结论　Multiloc髓内钉治疗老年肱骨近端骨折手术切口更小,术后肩关节功能恢复佳㊂关键词:锁定钢板;多平面角稳定髓内针;肱骨近端骨折;骨质疏松
中图分类号:R641 文献标志码:A 文章编号:2096-305X(2020)05-0049-05
Comparison ofTherapeutic Effect of Multi-Loc Intramedullary Nails and PHILOS Locking Plate in Treatment of Proximal Humeral Fractures in Elderly Patients
Wang Yansong,Chu Xin,Sun Yu,Xia Tianzhi,Teng Peng (Department of Bone Traumatology,the First Affiliated Hospital of Jinzhou Medical University,Jinzhou121000China) Abstract:Objective　To explore the therapeutic effect of Multi-loc intramedullary nailing and PHILOS locking plate in the treatment of elderly patients with proximal humeral fractures.Methods　The clinical data of49elderly patients with proximal fractures of the second and third humerus who received surgical treatment in our hospital from August2017to June2019and were followed up for more than6months were retrospectively analyzed,with11males and38females,aged61to83.The patients were divided into Multi -loc intramedullary nail group(23cases)and Phlios plate group(26cases)according to different internal fixators.The operation time,incision length,intraoperative blood loss,fracture healing time,Constant-Murley shoulder joint function score and postopera⁃tive complications were compared between the two groups.Results　All of the49patients were followed up for an average of9(6~ 15)months.There was no statistically significant difference in the intraoperative blood loss,fracture healing time,and incidence of postoperative complications between the two groups(P>0.05).The Multi-loc intramedullary nail group owned higher Constant-Mur⁃ley shoulder joint function score,shorter incision length and operation time than PHILOS locking plate group(P<0.05).Conclusion Multi-loc proximal humeral nails has smaller operative incision in the treatment of proximal humerus fractures in elderly patients, which performs better in the recovery of shoulder joint function.
Key words:locking plate;Multi-loc intramedullary nailing;proximal humerus fractures;osteoporosis
肱骨近端骨折的发病率占全身骨折的4%~ 5%,是老年人中第三常见的骨折[1-2],尤其是骨质疏松的老年女性㊂随着我国人口结构的变化,这些骨折的发病率会逐年增加㊂大约80%的肱骨骨折近端是最小或无移位的,可通过保守治疗获得良好的功能结果[3]㊂根据修订的Neer标准,约20%的肱骨近端骨折有手术治疗的指征[4]㊂
治疗肱骨近端骨折最常用的手术方法是锁定钢板内固定,特别是角稳定钢板固定系统Philos可获得良好治疗效果[5]㊂少部分患者在锁定钢板内固定后表现不满意,主要由继发移位引起[6],在骨
质疏松患者更容易出现㊂第三代Multiloc髓内钉强调肱骨内侧距的支撑,最新一些研究显示相较传统肱骨髓内钉及钢板固定均更有优势[7-8]㊂本文通过
94
锦州医科大学学报
J Jinzhou Medical University2020Oct.41(5)
　基金项目:辽宁省科技厅-辽宁医学院联合基金项目,项目编号:201602323㊂
　作者简介:王岩松(1980),男,辽宁兴城人,副主任医师,博士学位,主要研究方向为骨与关节损伤㊂
分析2017年8月至2019年6月在锦州医科大学附属一院行Multiloc 肱骨髓内钉和Phlios 锁定钢板治疗的49例老年肱骨二㊁三部分近端骨折患者的临床资料,比较两组的效果,报道如下㊂1　材料和方法1.1　一般资料
2017年8月至2019年6月在锦州医科大学附
属第一医院行手术治疗患者共49例,根据手术方式不同分为两组:Multiloc 髓内钉组和Phlios 钢板组㊂其中Multiloc 髓内钉组共23例,男6例,女
17例;年龄61~83岁;受伤原因:生活伤19例,交通事故伤4例;骨折根据Neer 分型,二部分骨折12例,三部分骨折11例㊂Phlios 钢板组共26例,男7例,女19例;年龄62~83岁;受伤原因:生活伤23例,交通事故伤3例;骨折根据Neer 分型,二部分骨折11例,三部分骨折15例㊂上述患者入院后行患侧肩关节正侧位X 线片㊁肩关节CT 平扫及三维重建,术前认真行血管㊁神经评估㊂
1.2　纳入标准病历资料完整,
(1)肱骨近端闭合性骨折;
(2)二部分㊁三部分骨折;(3)随访时间>6个月;(4)年龄>60岁㊂
1.3　排除标准(1)肱骨近端病理性骨折;(2)患肢周围有
感染灶;(3)合并患侧其它部位骨折者;(4)血
管神经损伤;(5)合并其他脏器损伤㊂
1.4　手术方法
Multiloc 髓内钉组:全麻后沙滩椅位,常规消
毒㊁铺巾㊂C 臂监视下行闭合复位,复位失败则尝试撬拨复位,复位满意后用克氏针临时固定(避开髓内针通道)㊂取肩关节前外侧入路,切口长约
3cm㊂沿三角肌前外侧肌纤维走形纵行劈开,探查肩袖并纵行劈开,临时缝线保护肩袖,暴露肱骨头顶点,C 臂透视肱骨干正侧位片,确定定位针与肱骨近端的解剖轴线方向一致,扩髓后插入合适直径和长度Multiloc 髓内钉㊂髓内钉尾端需没入肱骨头软骨面下3~4mm,应用导向器依次置入近端及远端锁定螺钉,近端3~4枚螺钉,远端1~2枚螺钉,置入尾帽,仔细缝合肩袖,逐层缝合㊂对于原始骨折为内翻移位或者内侧柱粉碎的骨折类型需要使用肱骨距螺钉;依骨折类型,应用 钉中钉”以增加对肱骨头及肱骨后内侧区域的把持力,见图
1㊂
Phlios 锁定钢板组:全麻后沙滩椅位,常规消毒㊁铺巾㊂取劈三角肌微创入路,切口长约5cm,沿三角肌纤维方向分离,在切口下段缝线固定,以
防止损伤远端的腋神经,暴露肱骨近端,清理骨折端的血肿,C 臂透视复位成功用克氏针临时固定,选择大小合适的锁定钢板插入,透视下确认钢板的位置,标注㊁避开腋神经,在骨干部做两个小切口以利于置入远端锁定螺钉㊂C 臂透视下置入锁钉㊂修复关节囊及损伤的肩袖,关闭切口,见图
2㊂
左:术前X 线片,右:术后X 线片
图1　Multiloc 髓内钉治疗肱骨近端骨折典型病例X 片
05锦州医科大学学报　2020年10月,41(5)
左:术前X线片,右:术后X线片
图2　Phlios钢板治疗肱骨近端骨折典型病例X片
以上患者术后前臂吊带制动患肢1w,根据患者身体情况㊁骨折类型及骨折内固定情况指导康复锻炼㊂术后次日行患肩被动活动,先前屈㊁外旋,再逐渐内旋㊁内收和外展㊂3~4w限制外展在90°以内㊂术后3个月肩部适当力量锻炼并加强活动范围㊂
1.5　观察指标
观察并比较两组患者手术时间㊁切口长度㊁手术出血量㊂术后定期随访,包括:标准肩关节正侧位X线片,骨折愈合时间㊁Constant-Murley肩关节功能评分及术后并发症的情况㊂其中Constant-Murley肩关节功能评分总分为100分,90分及以上为优,80~89分为良,70~79分为可,<70分为差,优良率=(优+良)/总数×100%[9]㊂1.6　统计学方法
采用SPSS17.0软件对数据进行统计学处理,计量资料若符合正态分布,以均数±标准差表示,组间比较采用t检验进行比较;若不符合正态分布,应采用秩和检验㊂计数资料用χ2检验,P< 0.05为差异有统计学意义㊂
2　结 果
2.1　手术情况比较
两组在术中出血㊁术前准备时间差异无统计学意义(P>0.05)㊂与Phlios钢板组比较,Multiloc 髓内钉组手术切口长度更短(P<0.05),手术时间更短(P<0.05),见表1㊂
表1　Multiloc髓内钉组与Phlios锁定钢板组
手术情况比较(⎺x±s)
组别n
手术时间
(min)
切口长度
(cm)
手术出血量
(mL) Multiloc组2379.6±10.33.8±1.295.3±18.6 Phlios组2695.7±12.55.1±1.998.0±15.8
t值8.7576.1041.336
P值0.0090.0430.792 2.2　两组骨折愈合时间及Constant-Murley肩关节功能评分比较
两组在骨折愈合时间差异无统计学意义(P> 0.05)㊂与Phlios钢板组比较,Multiloc髓内钉组Constant-Murley评分优于Phlios钢板组(P< 0.05),见表2㊂Multiloc髓内钉组优良率为87.0%(优5例,良15例,可2例,差1例), Phlios钢板组优良率为82.8%(优6例,良18例,可4例,差1例)㊂
表2　两组骨折愈合时间及Constant-Murley
评分比较(⎺x±s)
组别n
骨折愈合时间
(w)
Constant-Murley评分
(分) Multiloc组2312.2±2.890.6±2.1 Phlios组2612.6±2.584.7±3.4
t值1.0327.019
P值0.8650.032 2.3　术后并发症比较
两组患者都没有出现术区感染㊁血管神经损伤及内植物断裂等并发症㊂Phlios锁定钢板组1例肱骨头螺钉切出并出现畸形愈合,1例肱骨头缺血坏
15
王岩松,等:应用Multiloc髓内钉与Phlios钢板治疗老年肱骨近端骨折的疗效对比
死,1例肩关节僵硬,1例术后肩部疼痛㊂MultiLoc
髓内钉组1例术后存在肩峰下撞击,1例肱骨头缺
血坏死,1例术后肩部疼痛㊂两组患者的并发症发
生率相比较,差异无统计学意义(P>0.05)㊂
3　讨 论
在65岁以上的患者中,肱骨近端骨折是继股
骨近端和桡骨远端骨折之后的第三大最常见的非椎
体骨质疏松性骨折㊂随着我国人口老龄化的加剧,
肱骨近端骨折这一常见的老年骨质疏松性骨折呈逐
年递增趋势[10-11]㊂肱骨近端骨折的危险因素包括骨量低和跌倒风险增加㊂此外,视力低下㊁使用助
听器㊁糖尿病㊁抑郁症㊁饮酒㊁使用抗惊厥药物已
被确认为存在更高的肱骨近端骨折风险[12-14]㊂大多数肱骨近端骨折可采取非手术治疗,然而,最近的一项前瞻性研究表明,即使在非移位的肱骨近端骨折中,也可能出现明显的功能障碍,超过三分之二的患者患有慢性疼痛[15]㊂随着患者对生活质量要求的提高,手术治疗比例逐年增加㊂Phlios钢板相对体积较大,术中剥离软组织的范围大一些,可能破坏血运,术后可能出现肱骨头缺血性坏死㊁骨折不愈合等并发症㊂Multiloc髓内钉理论上可以减少对骨折周围血运破坏,但入针点可能损伤肩袖及关节软骨,导致术后疼痛及肩关节功能障碍㊂Phlios肱骨近端锁定钢板可实现多角度支撑肱骨头,提高骨折复位稳定性,对大多数骨质疏松患者也能取得良好效果㊂由于大㊁小结节骨块骨质疏松,点式复位钳复位可能夹碎骨块,需利用缝线牵拉法复位,在冈上肌㊁肩胛下肌肌腱止点腱骨结合处缝置不可吸收风线,牵拉辅助骨块复位[16]㊂复位后采用克氏针临时固定,克氏针的位置不能阻挡钢板放置的位置㊂多角度透视,确定解剖正常关系已经恢复㊂钢板的长轴要与肱骨干长轴一致,其最高点位于大结节顶点下方5~8mm,钢板边缘位于结节间沟后方2~4mm㊂术中透视确认钢板高度,因为钢板过高术后将出现肩峰撞击[17-20]㊂同时透视确定螺钉没有穿出肱骨头,内侧结构不稳定时需置入肱骨距螺钉固定[21]㊂骨折固定完成后,将大㊁小结节固定于钢板缝合孔上,中和肌力,避免肌肉直接牵拉骨折块,减轻疼痛[22]㊂本研究中,29例Phlios钢板组治疗的患者,1例肱骨头螺钉切出并出现畸形愈合(考虑为患者体型小,内侧粉碎,而肱骨距螺钉无法打入),1例肱骨头缺血坏死,1例肩关节僵硬(术后康复锻炼时患者依从性差), 1例术后肩部疼痛㊂
Multiloc髓内钉在治疗老年骨质疏松性中肱骨近端骨折具有理论上的生物力学优势,以在手术创伤最小的情况下实现稳定[23]㊂Multiloc髓内钉的主要适应症是移位的两部分外科颈骨折,特别是延伸到肱骨干的骨折,以及三部分骨折[24-26]㊂术前建议将对侧未受伤肩部的影像作为骨折固定的模板[27]㊂手术关键是骨折实现满意复位后,在维持复位的位置获得进入肱骨头的最佳通道㊂入针点位于肱骨头最高点[28]㊂本文所用的直钉通过肩袖肌腱交界处的裂口进入肱骨头关节面㊂直钉会将冈上肌腱交界处更内侧劈开,从而避免损伤肩袖,可有效减少术后肩袖疼痛和肩关节功能障碍㊂肩峰下囊部分切除后,暴露冈上肌腱㊂肱二头肌腱是帮助骨折复位和建立近端入针点的关键标志㊂一旦获得足够的骨折复位,在冈上肌腱的肌腱连接处的水平切开㊂肌腱边缘用不可吸收的缝合线标记,在手术期间应小心保护㊂不可吸收缝线缝合肩袖的骨腱连接处对于处理移位的结节㊁获得暂时稳定以及对最终构造提供结构加固很有意义[29]㊂本研究中,23例Multiloc髓内钉治疗的患者,1例出现了肩峰撞击, 1例术后肩部疼痛,早期开展手术时对肩袖损伤较大导致㊂
研究显示,Multiloc髓内钉与Phlios钢板在治疗老年肱骨近端二部分骨折时,如果能实现解剖复位并正确放置内固定物则均可获得满意疗效[8]30533-30537㊂但在较复杂的三部分骨折时,Multi⁃loc髓内钉治疗优于Phlios钢板,如可减少术中出血量㊁缩短手术时间及骨折愈合时间,降低肱骨头坏死风险等[30]㊂本研究比较Multiloc髓内钉与Phlios钢板治疗老年肱骨近端骨折的临床疗效,两组在术中出血㊁骨折愈合㊁并发症发生率等方面差异无统计学意义,Multiloc髓内钉组手术切口长度更短,手术时间更短㊂今后,以上治疗方案的长期效果和并发症还需大样本的临床数据证实㊂
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收稿日期:2020-06-11
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王岩松,等:应用Multiloc髓内钉与Phlios钢板治疗老年肱骨近端骨折的疗效对比。