同种异体骨移植在骨质疏松性肱骨近端骨折中的临床应用研究

同种异体骨移植在骨质疏松性肱骨近端骨折中的临床应用研究
曹烈虎　翁蔚宗　陈晓　周启荣　张军　汪琳　王尧　纪方　苏佳灿
【摘要】　目的　探讨采用同种异体骨移植在骨质疏松性肱骨近端不同类型骨折中的应用价值。

方法　回顾性分析2007年5月至2013年6月，第二军医大学附属长海医院创伤骨科收治的36例患者，其中男17例，女19例，年龄65~82岁，平均（71.5±5.5）岁；致伤原因：摔伤25例，车祸外伤7例，运动伤4例。

合并肩关节脱位4例，肋骨骨折3例，锁骨骨折1例。

根据Neer 分型：外科颈或解剖颈二部分骨折14例，三部分骨折13例，四部分骨折9例。

所有患者均采用切开复位锁定钢板内固定治疗联合同种异体骨植入。

术后采用Constant 评分、加利福尼亚大学洛杉矶分校（University of California，Los Angeles，UCLA）肩关节评分、视觉模拟评分（visual analogue scale，VAS）以及相关并发症进行评价和影像学评价。

结果　所有患者术后获6~36个月（平均31.6个月）随访，34例患者获骨性愈合，骨折愈合时间（5.5±0.7）个月（3~9个月），未出现同种异体骨排异反应。

术后1年末次随访，二、三、四部分颈干角分别为129°±5°（121~135°）、128°±3°（111~140°）、121°±4°（110~134°），四部分骨折颈干角明显低于二、三部分骨折，差异具有统计学意义（P <0.01）；二、三、四部分肱骨头高度分别丢失（1.7±0.4）mm（1.2~2.7 mm）、（1.8±0.3） mm（1.3~3.1 mm）、（1.9±0.5）mm （1.4~3.5 mm），三组之间差异无统计学意义（P >0.05）；二、三、四部分疼痛VAS 评分分别为（1.7±0.8）分（1~3分）、（1.5±0.5）分（1~3分）、（1.4±0.3）分（1~3分），三组之间差异无统计学意义（P >0.05）；但二、三、四部分功能Constant 评分分别为（82.0±4.2）分 （52~90） 分、（78.0±3.6）分 （57~91分）、（63.0±3.8）分 （55~89分），UCLA 评分分别为（31.3±2.1）分（27~35分）、（30.2±1.5）分（26~33分）、（27.6±1.6）分（23~31分），二、三部分肩关节功能明显优于四部分骨折，差异有统计学意义（P <0.01）。

7例患者出现相关并发症，并发症发生率19.4%。

结论　同种异体骨移植治疗骨质疏松性肱骨近端二、三部分骨折，使肱骨头得到有效的支撑，可以达到良好的骨折愈合，使肩关节的功能得到明显改善，但在四部分骨折方面，临床效果较差，并发症发生率较高。

【关键词】　骨折；　肱骨近端；　内固定；　同种异体松质骨
DOI :10.3877/cma.j.issn.2095-5790.2018.01.003
基金项目：上海市自然科学基金（15ZR1412500）;国家自然国际合作基金（8141101156）;上海市科委生物医药专项（154119500600）
作者单位: 200433　上海，第二军医大学附属长海医院创伤骨科 通信作者:苏佳灿，Email:drsujiacan@
Clinical research on allograft bone transplantation in the treatment of osteoporotic proximal humeral fracture
Cao Liehu, Weng Weizong, Chen Xiao, Zhou Qirong, Zhang Jun, Wang Lin, Wang Yao, Ji Fang, Su Jiacan.Department of Orthopedics and Traumatology, Changhai Hospital of Second Military Medical University of Chinese PLA, Shanghai 200433, China
Corresponding author: Su Jiacan, Email:drsujiacan@
【Abstract 】
Background Accounting for 5% of all fractures, proximal humerus fracture is one of the most common fractures for osteoporotic group with an incidence of 90.9/100 000 per year. Its incidence rate increases with age, and approximately 70% of proximal humeral fractures occur in patients over 60 years old. Female accounts for the majority of the affected elderly over 80 years old, as the ratio between men and women is 3:7. With obvious displacement and osteoporosis, bone
·论著·
compression and loss are easily formed after fracture, which result in the loss of the unique anatomical mark of humeral neck. The therapeutic effect of conservative treatment for displaced fracture is unsatisfactory. The displacement even causes great difficulty in plate fixation during surgery, which easily triggers complications such as loss of reduction, ischemic necrosis, screw piercing, etc. For osteoporotic proximal humeral fracture, locking plate fixation has the advantages of multi-angle and stable fixation, which can significantly improve postoperative function and reduce complications. However, the complications caused by locking plate still happen. According to the literature, the rate of humeral head bone loss and screw piercing is still as high as 29% with the bone loss of about 6 mm. Allograft bone transplantation can provide good support for humeral head and promote fracture healing, and the clinical effect is satisfactory. Although locking plate fixation with allogeneic bone graft has been applied for the treatment of senile osteoporotic proximal humeral fracture, the clinical efficacy evaluation and imaging data analysis of different types have been barely reported. Therefore, this article aims to explore the application value of allograft bone transplantation in different types of osteoporotic proximal humerus fracture. Methods（1） General information. A total of 36 patients （17 males and 19 females）were included in this study, and the age ranged from 65 to 82 years with an average of （71.5±5.5） years. The causes of injury include 25 cases of fall damage, 7 cases of traffic accident and 4 cases of sports injury. According to Neer classification, there were 14 cases of surgical neck or anatomic neck part-2 fracture, 13 cases of part-3 fracture and 9 cases of part-4 fracture. Furthermore, there were 4 cases combined with shoulder joint dislocation, 3 cases combined with rib fracture and 1 case combined with clavicular fracture. All patients were treated with open reduction and locking plate internal fixation.（2） Inclusive and exclusive criteria. Inclusive criteria: ① osteoporosis with dual energy x-ray absorptiometry （DXA） T value <-2.5 SD （according to the diagnostic criteria of WHO, DXA T value<-2.5 SD is regarded as osteoporosis）;② unilateral proximal fracture with displacement ＞ 1 cm and angulation＞ 45º; ③ Neer part-2, part-3 and part-4 impacted fracture，s with humeral head bone loss; ④ age over 60 years; ⑤ follow-up time ≥1 year. Exclusive criteria: ① pathological fracture or open fracture; ② combined with neurovascular injury ; ③history of diseases that affects limb function, such as previous operation, chronic arthritis, etc. （3） Surgical procedures. The patients were operated under brachial plexus block or general anesthesia. Deltoid-pectoralis approach was used in 26 cases，while deltoid-splitting approach was used in 10 cases. The removal of periosteum and surrounding soft tissue was minimized during the operation. For simple fracture, the intraoperative traction of affected limb should be conducted appropriately by assistants based on the specific conditions. Meanwhile, the affected limb was operated with internal or external rotation if necessary. The humeral head was raised and applied with 2 Kirschner wires of 2.5 mm above the greater tuberosity. The rotation and displacement of humeral head were controlled by Kirschner manipulation lever to assist with reduction. For complex fracture （especially the comminuted fracture with split greater tuberosity and displaced lesser tuberosity）, the insertions of subscapularis, supraspinatus and infraspinatus were penetrated respectively with 2 non-absorbable sutures, and the fragments of greater or lesser tuberosities were indirectly reduced by the traction of these sutures. According to the displacement direction of humeral head, the reduction was achieved through proper pulling, internal or external rotation of humeral shaft and simultaneous poking of humeral head. When the fracture was reduced with satisfactory shape of humeral head, the sutures could be intersected and knotted temporarily to fix the fracture fragments, and the humeral head was percutaneously placed with 2 Kirschner wires above greater tuberosity. With satisfactory reduction of the inferomedial area of bone cortex, 2 Kirschner wires were inserted percutaneously and obliquely upward from the posterior humeral shaft to the inferomedial area of humeral head for temporary fixation. With satisfactory reduction of fracture under fluoroscopy, the metaphysis defect was evaluated under direct vision. The defect over 5 mm was regarded as the standard for bone graft. A moderate amount of allograft bone was transplanted into the gap between fracture end and humeral head. As satisfactory reduction was confirmed under fluoroscopy once again, the fracture was ultimately fixed with locking plate that was placed 5 mm lateral to the intertubercular sulcus and 5-8 mm
inferior to the apex of greater tuberosity. When locking screws were pierced proximally, the depth of drilling was controlled carefully. The screws of proper length were selected based on fluoroscopy, that was, the screws reached to the subchondral bone of humeral head （approximately 6 mm from the articular surface）. The inferomedial area of humeral head was inserted with another oblique screw to protect the humeral head from collapse. The suture holes on plate were penetrated with 3 No.2 non-absorbable sutures before placement. After the plate and screws were fixed, the insertions of subscapularis, supraspinatus, infraspinatus and teres minor were penetrated with non-absorbable suture with the knot tightened. For combined lesser tuberosity fracture, one hollow screw of 3.5 mm was used for fixation. After internal fixation, radiographic examination was performed in multiple perspectives including anteroposterior view and auxiliary view to confirm that the screw was not in joint cavity. Afterward, the incision was irrigated and closed. In this study, proximal humeral internal locking system （PHILOS plate, Synthes, Switzerland） was used in 16 cases; locking proximal humeral plate （LPHP, Zimmer, USA） was used in 14 cases; proximal humeral locking plate （Double medical technology Inc., Xiamen） was used in 6 cases. The drainage tube was routinely placed and removed within 24 hours after operation.（4）Postoperative rehabilitation.The active movements of interphalangeal joints and wrist were encouraged on the 1st postoperative day. The flexion and extension of elbow joint and the shoulder abduction of < 90º were conducted 1 week later. The climbing exercises of upper limb was carried out 2 weeks after operation. The shoulder joint was suspended for immobilization at the position of internal rotation and slight anteflexion and abduction within 4 weeks. The isometric exercises of the rotator cuff started at the 6th week, and gradually transferred to the active exercises.（5） Follow-up evaluation. The postoperative follow ups were conducted at the 2nd week, 1st, 2nd, and 3rd months. The radiographic examination was performed every 2 months in the outpatient visit till the fracture was healed. According to the imaging assessment of fracture healing, the neck-shaft angle and the height of humeral head （the distance between the two parallel lines that were respectively over the superior edge of plate and the top of humeral head and vertical to the humeral shaft） were recorded. One year after operation, the curative effect was evaluated by Constant score, UCLA scoring system and visual ana1ogue scale （VAS）. In the meanwhile, the shoulder joint function and postoperative complications in the last follow up were recorded as well, including internal fixation failure, screw cutting-out, humeral head necrosis, infection, etc. Results All patients were followed up for 6 to 36 months with an average of 31.6 months, and 34 patients acquired bone healing. The healing time was （5.5±0.7） months （3-9 months）, and no allograft rejection occurred. Follow up was carried out 1 year after operation. During the last follow up, the neck-shaft angles of part-2, part-3 and part-4 fractures were 129°±5°（121-135°）, 128°±3°（111-140°）and 121°±4°（110-134°） respectively. The neck-shaft angle of part-4 fracture was remarkably lower than those of part-2 and part-3 fractures, and the difference is statistical significant （P <0.01）. The humeral head height losses of part-2, part-3 and part-4 fractures were （1.7±0.4） mm （1.2-2.7 mm）, （1.8±0.3） mm （1.3-3.1 mm） and （1.9±0.5） mm （1.4-3.5 mm） respectively, and no significant difference was observed among three groups （P＞0.05）. The VAS scores of part-2, part-3 and part-4 fractures were （1.7±0.8） points （1-3 points）, （1.5±0.5） points （1-3 points） and （1.4±0.3） points （1-3 points）respectively, and the difference between groups did not show statistical significance （P＞0.05）. On the other hand , the Constant scores of part-2, part-3 and part-4 fractures were （82.0±4.2） points （52-90 points）, （78.0±3.6） points （57-91 points） and （63.0±3.8） points （55-89 points） respectively, and the UCLA scores were （31.3±2.1） points （27-35 points）, （30.2±1.5） points （26-33 points） and （27.6±1.6） points （23-31 points） respectively. The shoulder joint functions of part-2 and part-3 fractures were remarkably superior to that of part-4 fracture, and the difference had statistical significance （P <0.01）. Seven cases had complications, and the complication rate was 19.4%. The complication rate of part-4 fracture was up to 44%, which was obviously higher than those of part-2 fracture （7.6%） and part-3 fracture （14.2%）. One patient of part-2 fracture had subacromial impingement syndrome, and the function was acceptable. One patient of part-3 fracture had subacromial impingement syndrome as well, and the pain was still tolerable. Another case had the loss of reduction, and the fracture healed 3 months after revision
肱骨近端骨折是骨质疏松人群中比较常见的一种骨折，其发病率每年约为90.9/100 000［1］，约占全身骨折的5％［2］。

随着年龄的增长，其发生率也随之增高，且多见于老年人，约70％的肱骨近端骨折患者年龄＞60岁［3-4］，且大部分发生于女性，尤其是大于80岁以上的高龄老人，男女比例为3：7。

明显移位以及骨质疏松的患者，骨折后易形成骨质压缩及丢失，致使肱骨颈部丧失其特有解剖对位标志，保守治疗对移位的骨折疗效较差，即使进行手术治疗，也给钢板固定造成极大困难，手术后容易发生复位丢失、缺血性坏死、螺钉穿出等并发症［5］。

对于骨质疏松性肱骨近端骨折，锁定钢板治疗老年骨质疏松患者具有多角度固定、固定稳定的优势，能明显改善患者的术后功能，减少并发症的产生。

但锁定钢板带来的并发症仍不少见，据文献报道，肱骨头骨量丢失和螺钉穿出率仍然高达29%，丢失约为6 mm［6-7］。

同种异体骨移植明显可以使肱骨头获得良好的支撑，促进骨折愈合，临床效果满意［8］。

运用锁定钢板结合异体骨移植治疗老年骨质疏松肱骨近端骨折已有相关文献报道［9］，但对不同的骨折类型进行临床疗效评判和影像资料分析，尚没有文献报道。

因此，本文的目的在于探讨采用同种异体骨移植在骨质疏松性肱骨近端不同类型骨折中的应用价值。

资料与方法
一、一般资料
本研究共纳入患者36例，其中男17例，女19例，年龄65~82岁，平均（71.5±5.5）岁；致伤原因：摔伤25例，车祸外伤7例，运动伤4例。

骨折根据Neer分型：外科颈或解剖颈二部分骨折14例，三部分骨折13例，四部分骨折9例。

合并肩关节脱位4例，肋骨骨折3例，锁骨骨折1例。

所有患者均采用切开复位锁定钢板内固定治疗。

二、纳入及排除标准
纳入标准：①患有骨质疏松症，双能X线骨密度T值<-2.5 SD（依据WHO推荐诊断标准，DXA测定 T <-2.5 SD 为骨质疏松）；②单侧肱骨近端骨折患者，骨折移位超过1 cm和成角大于45º；③骨折类型为Neer二部分、三部分和四部分骨折，且肱骨头与肱骨干嵌插、伴有肱骨头骨量丢失；④年龄≥60岁；⑤随访时间≥1年。

排除标准：①病理性骨折、开放性骨折；②合并有神经、血管损伤；③伤前上肢有手术史或慢性关节炎等影响肢体功能的疾病史。

三、手术方法
采用臂丛神经麻醉或全身麻醉，采用肩关节三角肌与胸大肌入路26例，三角肌劈开入路10例。

术中尽量减少骨膜及周围软组织的剥离。

对于简单骨折，助手根据术中骨折的具体情况适当牵引患肢，同时辅以内旋或外旋。

抬升肱骨头，采用2枚2.5 mm 克氏针大结节上方置入肱骨头，通过克氏针操纵杆作用控制肱骨头的旋转、移位，从而辅助复位。

对于复杂骨折，特别是大结节劈裂、小结节移位的粉碎性骨折，首先用2根不可吸收缝线分别穿过肩胛下肌止点、冈上肌和冈下肌止点，通过牵拉缝线来间接复位小结节或大结节骨折块。

根据肱骨头移位的方向，适当牵引、内旋或外旋肱骨干，同时撬拨复位肱骨头。

当骨折复位、肱骨头外形满意时，缝线可相互交叉打结临时固定骨折块，并于大结节后上方经皮将2枚克氏针置入肱骨头。

确定内下区皮质复位满意后，同时，用2枚克氏针从肱骨干偏后方经皮斜向上置入肱骨头内下区，临时固定肱骨干与肱骨头。

透视骨折复位大致满意后，直视下评估干骺端的缺损［10］。

将准
surgery. One case of part-4 fracture was discovered with the penetration of screw into joint cavity, and the screw was removed later. Two cases underwent hemiarthroplasty due to humeral head necrosis. Humeral head collapse occurred in 1 patient, and his family refused reoperation because of the advanced age. Conclusions The treatment of osteoporotic proximal humeral fracture with allograft bone transplantation can provide effective support to humeral head, reduce loss of humeral head height and lower related complications. Therefore, the patient can carry out training early and thus acquire the function level closed to preinjury. For part-4 fracture, however, the clinical effect was poor with high rate of complication. The defect of this article is that this research is a simple retrospective study with limited cases. Expansion of sample size, prolonged follow-up and randomized trial are required for further validation of our conclusion.
【Key words】ɔ　Fracture;　Proximal humerus;　Internal fixation;　Allogeneic cancellous bone
备好适量的同种异体骨植入在骨折端与肱骨头空隙内，再次透视确认骨折复位满意后，采用钢板进行最终固定；钢板放置于结节间沟外侧约5 mm、大结节顶点下5~8 mm处。

近端置入锁定螺钉时，控制钻孔深度，经透视选择长度合适的螺钉，即达到肱骨头软骨下骨（距关节面6 mm左右）。

再于肱骨头内下区植入1枚内下斜向锁定螺钉，支撑肱骨头，防止肱骨头塌陷。

放置钢板前于钢板缝合孔穿入3根2号不可吸收缝线，当钢板螺钉固定后，用不可吸收缝线穿过肩胛下肌、冈上肌、冈下肌和小圆肌止点并收紧打结。

对于合并的小结节骨折，另采用1枚3.5 mm空心钉固定。

内固定结束后反复经C臂正侧位、腋位透视多角度透视确认螺钉不在关节腔内，确认无误后，再冲洗关闭伤口。

本研究16例采用肱骨近端内固定锁定系统（proximal humeral internal locking system，PHILOS）钢板（Synthes公司，瑞士）固定，14例患者采用肱骨近端锁定钢板（1ocking proximal humeral plate，LPHP）（捷迈公司，美国）固定，6例采用国产肱骨近端锁定钢板（厦门大博器械有限公司）固定。

术毕常规放置引流管，留置24 h内拔除引流管。

四、术后康复
术后第1天进行指间关节、腕关节的主动活动，术后1周进行肘关节的伸屈活动，肩关节小于90º外展活动，术后2周进行患侧上肢的爬墙练习。

术后4周内予肩关节内旋及轻度前屈外展位悬吊固定。

术后6周起进行肩袖肌群的等长收缩训练并逐渐过渡到肩关节主动锻炼。

五、随访评估指标
术后2周、1个月、2个月、3个月，然后每2个月进行门诊拍片，直至骨折愈合。

根据影像学评估骨折愈合情况，记录术后颈干角，肱骨头高度（过钢板上缘和肱骨头顶点并垂直肱骨干纵轴的两条平行线间的距离）。

术后1年应用Constant评分、加利福尼亚大学洛杉矶分校（University of California，Los Angeles，UCLA）肩关节评分、、疼痛视觉模拟评分（visual ana1ogue scale，VAS）评估患者疗效。

同时记录末次随访患肩关节活动功能及术后相关并发症，如内固定失败、螺钉切出、肱骨头坏死、感染等。

结 果
所有患者术后获6~36个月（平均31.6个月）随访，34例患者获骨性愈合，骨折愈合时间（5.5±0.7）个月（3~9个月），未出现同种异体骨排异反应。

术后1年时末次随访，二、三、四部分颈干角分别为129°±5°（121~135°）、128°±3°（111~140°）、121°±4°（110~134°），四部分骨折颈干角明显低于二、三部分骨折，差异具有统计学意义（P <0.01）；二、三、四部分肱骨头高度分别丢失（1.7±0.4）mm（1.2~2.7 mm）、（1.8±0.3） mm （1.3~3.1 mm）、（1.9±0.5）mm（1.4~3.5 mm），三组之间差异无统计学意义（P >0.05）；二、三、四部分疼痛VAS评分分别为（1.7±0.8）分（1~3分）、（1.5±0.5）分（1~3分）、（1.4±0.3）分（1~3分），三组之间差异无统计学意义（P >0.05）；但二、三、四部分功能Constant评分分别为（82.0±4.2）分（52~90分）、（78.0±3.6）分 （57~91分）、（63.0±3.8）分（55~89分），UCLA评分分别为（31.3±2.1）分（27~35分）、（30.2±1.5）分（26~33分）、（27.6±1.6）分（23~31分），二、三部分肩关节功能明显优于四部分骨折，差异有统计学意义（P <0.01）（表1）。

7例患者出现相关并发症，并发症发生率19.4%，四部分骨折并发症发生率高达44.4%，明显高于二部分骨折7.6%，三部分骨折14.2%（表2）。

二部分骨折1例出现肩峰撞击征，功能尚可，三部分骨折1例出现肩峰撞击征，疼痛尚可忍受，另外1例复位丢失，再次行翻修手术后3个月骨折愈合，四部分骨折1例患者螺钉穿出，予以取出突入关节内螺钉，2例患者出现肱骨头坏死，行半肩置换术，1例患者出现肱骨头塌陷，年龄较大，家属拒绝再次手术。

典型病例见图1、2。

表1　不同类型骨折患者末次随访评估情况（x-±s）
分型
例
数
颈干角
（°）
高度丢
失（mm）
Constant
（分）
UCLA
（分）
VAS
（分）二部分骨折13129±5 1.7±0.482.0±4.231.3±2.1 1.7±0.8三部分骨折14128±3 1.8±0.378.0±3.630.2±1.5 1.5±0.5四部分骨折9121±4 1.9±0.563.0±3.827.6±1.6 1.4±0.3检验值F=11.42F=0.7133F=68.45F=11.96F=0.7534
P值0.00020.4974<0.01<0.010.4787 注：UCLA为加利福尼亚大学洛杉矶分校；VAS为视觉模拟评分表2　不同类型骨折患者出现并发症情况分型
例
数
螺钉
穿出
肩峰
撞击
缺血性
坏死
大结节
移位
复位
丢失
肩关节
僵硬
并发症发
生率（%）二部分骨折13０1００００7.6
三部分骨折14０1０００114.2
四部分骨折91０2０1０44.4
讨 论
肱骨近端骨折多发生于≥65岁的老年人群，成为威胁老年人的第三大骨折。

而且大部分老年人合并骨质疏松，骨质疏松是与年龄相关的一种全身性疾病，以低骨量和骨的微结构破坏为特征，导致骨强度降低，骨脆性增加，容易骨折。

老年人因肱骨外科颈部骨质严重疏松、皮质骨变薄及髓腔骨质稀疏，使肱骨头颈部呈蛋壳样结构［11］。

锁定钢板是治疗骨质疏松性肱骨近端骨折的金标准，可有效复位肱骨头的解剖性和连续性，但由于肱骨头内骨质压缩与丢失，遗留较大空腔，导致肱骨头与肱骨干缺乏有效支撑，螺钉的把持力下降［12］。

据目前文献报道，锁定钢板带来的并发症发生率高达49%，包括肱骨头塌陷、螺钉穿出关节腔、内固定失败、缺血性坏死、畸形愈合等并发症［13-15］。

Owsley等［16］发现在大于60岁以上老年患者当中，锁定钢板带来很高的螺钉穿出关节腔和手术再翻修率。

其中骨质的低密度和内侧结构缺乏支撑是影响
锁定钢板的重要因素，Krappinger等［17］报道证实低骨密度将会是加剧内固定失败和复位丢失的重要因素。

因此，骨质疏松性肱骨近端骨折进行有效的结构植骨可使肱骨头得到有效的支撑，从而降低肱骨头塌陷，降低螺钉穿出关节腔的发生概率。

同种异体骨植入可有效提高锁定钢板的稳定性，防止肱骨头塌陷，功能活动良好［18］。

因此，本次研究运用锁定钢板结合异体骨植骨治疗老年骨质疏松性肱骨近端骨折，由于锁定钢板螺钉的把持固定和肱骨头受到同种异体骨的支撑，末次随访肱骨近端二、三部分骨折影像结果和临床效果满意。

但在四部分骨折方面，肱骨头高度分别丢失（1.9±0.5）mm、颈干角121°±4°、Constant评分（63.0±3.8）分，UCLA评分（27.6±1.6）分，1例患者螺钉穿出，2例患者出现肱骨头坏死,1例患者复位丢失、内翻塌陷，并发症发生率高达44.4%，临床效果较差。

与二、三部分骨折存在明显的统计学差异，这与四部分骨折损伤较为严重，加上患者合并骨质疏松，骨折块难以维持复位以及血运破坏密切相关。

因此，近年来有学者运用锁定钢板联合
A B C
图1　患者，女，74岁，摔伤致右肱骨近端骨折（Neer 三部分骨折）　图A为术前X线片显示患者肱骨近端外翻压缩，蛋壳样结构；图B为术后即刻; 图C为术后1年X线片示肱骨高度明显恢复，内侧皮质复位
A B C D
图2　患者，男，84岁，车祸致右肱骨近端骨折（Neer 四部分骨折）　图A为术前X线片显示患者肱骨近端外翻伴骨折肱骨头脱位；图B为术前平扫CT; 图C为术后即刻; 图D为术后2个月X线片示肱骨头塌陷
同种异体腓骨段重建内侧柱，术后相关并发症明显降低，可有效改善肱骨近端四部分骨折的术后功能，临床效果满意［19-20］。

临床中对于植骨材料的选择，有自体骨、骨水泥、人工骨、同种异体骨等植骨材料。

自体骨具有良好的骨传导、骨诱导和骨生成作用，是最理想的骨移植材料，但自体骨来源有限，并且取自体骨有血肿、感染、取区疼痛等并发症 ，很少在肱骨近端骨折采用。

骨水泥聚甲基丙烯酸甲酯具有良好的生物力学特性，有学者通过尸体试验将甲基丙烯酸甲酯骨水泥固化骨质疏松性肱骨骨折螺钉头部来增强钢板稳定性，并通过生物力学试验证实其有增加螺钉的把持力［21-23］。

其想法主要基于早期骨水泥强化主要用脊柱骨质疏松骨折椎弓根螺钉领域。

通过骨水泥经螺钉中空流出通道，通过螺钉尖端侧孔弥散于骨小梁中，形成“螺钉-骨水泥-骨小梁”复合体，使螺钉固定于椎体中，从而提高了内固定的稳定性［24］，但骨水泥散热带来对局部骨折和软骨的损伤可能会引起股骨头坏死，是不可忽视的问题。

Lazejak等［25］体外实验研究表示加入0.5 ml 聚甲基丙烯酸甲酯骨水泥螺钉周围软骨下和 关节面的温度分别为43.5º和38.6º，另外，仍然存在骨水泥渗漏、体内不能生物降解及不具生物相容性等问题。

因此，聚甲基丙烯酸甲酯骨水泥并不能将其作为一个常规的手段。

磷酸钙骨水泥具有可注射性、生物活性、可生物降解等优点，在近年来用在肱骨近端骨折中较多。

Robinson等［26］首次报道了将螺钉钢板结合可注射性硫酸钙治疗25例肱骨近端骨折患者，取得良好的效果。

Egol等［27］通过病例对照研究，将92例肱骨近端骨折患者分成三组：磷酸钙骨水泥组、松质骨组和对照组，随访1年时间，结果硫酸钙组骨水泥较其他两组能明显降低骨折沉降和减少螺钉穿出率。

Somasundaram等［28］报道运用硫酸钙结合锁定钢板21例患者（22处肱骨近端骨折），通过2年的随访，骨折都完全愈合，无股骨头坏死和螺钉穿出，人工骨6个月完全吸收。

但其价格昂贵、固化时间较快、降解速度较慢，以及有出现排异反应，限制了其在临床中的广泛运用。

同种异体骨来源广泛，与自体骨相同的结构，具有一定的支撑力，异体冻干小块骨成为骨移植常用植骨材料，为骨再生提供并维持一个生长空间，且同种异体松质骨有成骨细胞容易黏附和增殖的界面，以及利于营养成分渗透的三维多孔结构，可为骨髓细胞提供良好的载体和吸附材料，其生物相容性好，能提供机械性结构支持，且人体易吸收［29］。

因此，作者采用单皮质的同种异体髂骨植骨治疗塌陷型肱骨近端骨折，既避免了取自体骨引起的供区并发症，又比人工具有更好的生物相容性与术后早期的力学支撑。

本研究采用锁定钢板联合同种异体骨治疗骨质疏松性肱骨近端骨折，末次随访研究发现二、三部分肱骨近端骨折中，肱骨头得到有效的支撑，骨折达到良好的愈合，肩关节的功能得到明显改善。

综上所述，同种异体骨植骨治疗骨质疏松性肱骨近端骨折可以使肱骨头得到有效的支撑，减少肱骨头高度的丢失和相关并发症。

因此患者术后能够及早地进行功能锻炼，从而获得接近伤前的功能水平，但在四部分骨折方面，临床效果较差，并发症发生率较高。

本文缺陷是单纯的病例回顾性研究，且病例数有限，有待扩大病例样本量、延长随访周期以及开展随机试验进一步验证。

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（收稿日期：2016-10-13）（本文编辑：李静；英文编辑：陈建海、张晓萌、张立佳）
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