锁定钢板结合异体腓骨治疗老年肱骨近端粉碎性骨折的中远期疗效观察
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摘要
目的探讨锁定钢板结合异体腓骨髓内支撑(locking compression plate with fibular allograft,F-LCP)治疗老年肱骨近端粉碎性骨折的中远期临床疗效及并发症。方法回顾性分析2013年1月-2015年12月我院104例老年肱骨近端三部分或四部分骨折患者资料,其中采用单纯锁定钢板内固定术(locking compression plate,LCP)治疗61例为Ⅰ组,锁定钢板结合异体腓骨髓内支撑治疗43例为Ⅱ组。评估术后随访1年时两组临床疗效,包括Constant-Murley评分(CMS)、肩-手功能障碍评分(disabilities of the arm,shoulder and hand score,DASH)、加利福尼亚大学洛杉矶分校(University of California Los Angeles,UCLA)肩关节评分、肩关节活动范围评分(range of motion,ROM)、疼痛视觉模拟评分(visual analogue scale,VAS)及术后影像学资料。结果两组基线资料的差异均无统计学意义(P均> 0.05)。术后骨折愈合时间,Ⅰ组(4.72±0.93)个月,Ⅱ组(4.77±0.90)个月,差异无统计学意义(P=0.801)。术后1年复查X线片,Ⅰ组肱骨头高度丢失(4.48±2.06) mm,显著高于Ⅱ组的(2.19±1.58) mm (P <0.001);颈干角差值大于Ⅱ组[(8.56±4.96)°vs (3.17±2.93)°,P <0.001];Ⅰ组11例发生肱骨头内翻畸形(颈干角<110°),8例发生螺钉切出,2例发生肱骨头坏死,并发症发生率为34.43%;Ⅱ组2例发生肱骨头内翻畸形,1例发生螺钉切出,2例发生肱骨头坏死,并发症发生率为11.63%,差异有统计学意义(P=0.008)。术后1年Ⅱ组各项功能评估均优于Ⅰ组:CMS[(75.42±4.77) vs (62.89±8.25)],DASH[(16.09±2.87) vs (31.15±9.55)],UCLA肩关节评分[(31.40±1.50) vs(28.97±1.61)],ROM[(25.77±3.84) vs(18.34±4.43)](P均<0.05);两组VAS评分差异无统计学意义[Ⅰ组(1.57±0.62) vsⅡ组(1.42±0.55),P=0.189)。结论本研究中锁定钢板结合异体腓骨髓内支撑治疗老年肱骨近端骨折效果优于单纯锁定钢板内固定,功能结局更优,并发症发生率低。
Objective To compare the clinical outcomes and complications between locking compression plate(LCP) and LCP with ?bular allograft(F-LCP) in the treatment of older patients with displaced proximal humerus fracture(PHF). Methods From January 2013 to December 2015, a total of 104 older patients with displaced PHF including three-part or four-part fracture treated in Chinese PLA General Hospital were included in this study. Of the 104 cases, 61 cases were treated with simple LCP ?xation as group Ⅰ, while the other 43 cases were treated with LCP combined with allogeneic ?bula as group Ⅱ. Group Ⅰ included 14 males and 47 females with an average age of(72.02±8.90) years, and group Ⅱ included 9 males and 34 females with an average age of(72.95±7.76) years. The radiographic indicators and functional outcomes(Constant-Murley scores, DASH scores, UCLA scores,ROM scores and VAS scores) were collected and compared between the two groups before and after surgery. Results There was no statistically signi?cant difference in general data between the two groups at baseline. The fractures healing time was(4.72±0.93)months in group Ⅰ, and(4.77±0.90) months in group Ⅱ, without statistically signi?cant difference. The height loss of humeral heads was(4.48±2.06) mm in group Ⅰ, signi?cantly higher than(2.19±1.58) mm in group Ⅱ(P < 0.001). The change of neckshaft angles in group Ⅰ was also greater than that in group Ⅱ [(8.56±4.96)° vs(3.17±2.93)°, P < 0.001). In group Ⅰ, 11 cases developed varus malunion(neck-shaft angle < 110°), 8 cases had screw perforation, and 2 cases had avascular necrosis(AVN). In group Ⅱ, 1 case had screw perforation, 2 cases had avascular necrosis(AVN) and 2 cases had varus malunion. The difference of complication incidence in two groups was statistically signi?cant(34.43% vs 11.63%, P=0.008). There were signi?cant differences in Constant-Murley score, DASH score, UCLA score and ROM score between group Ⅰ and group Ⅱ [(62.89±8.25) vs(75.42±4.77),(31.15±9.55) vs(16.09±2.87),(28.97±1.61) vs(31.40±1.50),(18.34±4.43) vs(25.77±3.84), all P < 0.05]. However, no significant difference was found in VAS score between two groups [(1.57±0.62) vs(1.42±0.55), P =0.189]. Conclusion The present study indicates that LCP with ?bular allograft has a better functional outcome and a lower complication rate compared to LCP alone for older patients with displaced proximal humerus fractures.
Objective To compare the clinical outcomes and complications between locking compression plate(LCP) and LCP with ?bular allograft(F-LCP) in the treatment of older patients with displaced proximal humerus fracture(PHF). Methods From January 2013 to December 2015, a total of 104 older patients with displaced PHF including three-part or four-part fracture treated in Chinese PLA General Hospital were included in this study. Of the 104 cases, 61 cases were treated with simple LCP ?xation as group Ⅰ, while the other 43 cases were treated with LCP combined with allogeneic ?bula as group Ⅱ. Group Ⅰ included 14 males and 47 females with an average age of(72.02±8.90) years, and group Ⅱ included 9 males and 34 females with an average age of(72.95±7.76) years. The radiographic indicators and functional outcomes(Constant-Murley scores, DASH scores, UCLA scores,ROM scores and VAS scores) were collected and compared between the two groups before and after surgery. Results There was no statistically signi?cant difference in general data between the two groups at baseline. The fractures healing time was(4.72±0.93)months in group Ⅰ, and(4.77±0.90) months in group Ⅱ, without statistically signi?cant difference. The height loss of humeral heads was(4.48±2.06) mm in group Ⅰ, signi?cantly higher than(2.19±1.58) mm in group Ⅱ(P < 0.001). The change of neckshaft angles in group Ⅰ was also greater than that in group Ⅱ [(8.56±4.96)° vs(3.17±2.93)°, P < 0.001). In group Ⅰ, 11 cases developed varus malunion(neck-shaft angle < 110°), 8 cases had screw perforation, and 2 cases had avascular necrosis(AVN). In group Ⅱ, 1 case had screw perforation, 2 cases had avascular necrosis(AVN) and 2 cases had varus malunion. The difference of complication incidence in two groups was statistically signi?cant(34.43% vs 11.63%, P=0.008). There were signi?cant differences in Constant-Murley score, DASH score, UCLA score and ROM score between group Ⅰ and group Ⅱ [(62.89±8.25) vs(75.42±4.77),(31.15±9.55) vs(16.09±2.87),(28.97±1.61) vs(31.40±1.50),(18.34±4.43) vs(25.77±3.84), all P < 0.05]. However, no significant difference was found in VAS score between two groups [(1.57±0.62) vs(1.42±0.55), P =0.189]. Conclusion The present study indicates that LCP with ?bular allograft has a better functional outcome and a lower complication rate compared to LCP alone for older patients with displaced proximal humerus fractures.
引文
1 Jo MJ,Gardner MJ.Proximal humerus fractures[J].Curr Rev Musculoskelet Med,2012,5(3):192-198.
2 Konrad G,Bayer J,Hepp P,et al.Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate.Surgical technique[J].J Bone Joint Surg Am,2010,92(Suppl 1 Pt 1):85-95.
3朱正国,齐红哲,常祖豪,等.成人肱骨近端骨折手术治疗进展[J].解放军医学院学报,2017,38(12):1178-1181.
4 Vachtsevanos L,Hayden L,Desai AS,et al.Management of proximal humerus fractures in adults[J].World J Orthop,2014,5(5):685-693.
5 Agudelo J,Schürmann M,Stahel P,et al.Analysis of efficacy and failure in proximal humerus fractures treated with locking plates[J].J Orthop Trauma,2007,21(10):676-681.
6 Launonen AP,Lepola V,Flinkkil?T,et al.Treatment of proximal humerus fractures in the elderly:a systemic review of 409 patients[J].Acta Orthop,2015,86(3):280-285.
7 Dai J,Chai Y,Wang C,et al.Meta-analysis comparing locking plate fixation with hemiarthroplasty for complex proximal humeral fractures[J].Eur J Orthop Surg Traumatol,2014,24(3):305-313.
8 Chen H,Ji X,Gao Y,et al.Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemiarthroplasty for repair of osteoporotic four-part proximal humerus fracture:Consecutive,prospective,controlled,and comparative study[J].Orthop Traumatol Surg Res,2016,102(3):287-292.
9 G?n?U,Atabek M,Teker K,et al.Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures[J].Acta Orthop Traumatol Turc,2017,51(1):17-22.
10 Gracitelli ME,Malavolta EA,Assun??o JH,et al.Locking intramedullary nails compared with locking plates for two-and three-part proximal humeral surgical neck fractures:a randomized controlled trial[J].J Shoulder Elbow Surg,2016,25(5):695-703.
11 Sproul RC,Iyengar JJ,Devcic Z,et al.A systematic review of locking plate fixation of proximal humerus fractures[J].Injury,2011,42(4):408-413.
12 Hertel R.Fractures of the proximal humerus in osteoporotic bone[J].Osteoporos Int,2005,16(Suppl 2):S65-S72.
13 Padegimas EM,Zmistowski B,Lawrence C,et al.Defining optimal calcar screw positioning in proximal humerus fracture fixation[J].JShoulder Elbow Surg,2017,26(11):1931-1937.
14 Katthagen JC,Schwarze M,Meyer-Kobbe J,et al.Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures[J].Clin Biomech(Bristol,Avon),2014,29(7):735-741.
15 Somasundaram K,Huber CP,Babu V,et al.Proximal humeral fractures:the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates[J].Injury,2013,44(4):481-487.
16 Schliemann B,W?hnert D,Theisen C,et al.How to enhance the stability of locking plate fixation of proximal humerus fractures?An overview of current biomechanical and clinical data[J].Injury,2015,46(7):1207-1214.
17 He Y,He J,Wang F,et al.Application of Additional Medial Plate in Treatment of Proximal Humeral Fractures With Unstable Medial Column:A Finite Element Study and Clinical Practice[J].Medicine(Baltimore),2015,94(41):e1775.
18 Zhu L,Liu Y,Yang Z,et al.Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture[J].Chin Med J(Engl),2014,127(9):1672-1676.
19 Namdari S,Voleti PB,Mehta S.Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment[J].J Shoulder Elbow Surg,2012,21(12):1787-1795.
20 Bae JH,Oh JK,Chon CS,et al.The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus[J].J Bone Joint Surg Br,2011,93(7):937-941.
21 Chow RM,Begum F,Beaupre LA,et al.Proximal humeral fracture fixation:locking plate construct+/-intramedullary fibular allograft[J].J Shoulder Elbow Surg,2012,21(7):894-901.
22 Mathison C,Chaudhary R,Beaupre L,et al.Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft[J].Clin Biomech(Bristol,Avon),2010,25(7):642-646.
23 Osterhoff G,Baumgartner D,Favre P,et al.Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures:an in vitro study with synthetic bone[J].J Shoulder Elbow Surg,2011,20(5):740-746.
24 Chen H,Ji X,Zhang Q,et al.Clinical outcomes of allograft with locking compression plates for elderly four-part proximal humerus fractures[J].J Orthop Surg Res,2015,10:114.
25朱正国,齐红哲,常祖豪,等.解剖型异体腓骨髓内支撑钢板内固定术治疗老年肱骨近端粉碎性骨折疗效观察[J].解放军医学院学报,2018,39(2):91-94.
26高远,陈雪梅,陈玉娥,等.新型上肢贴胸固定悬吊装置的设计及其在救治上肢军事训练伤中的应用效果[J].解放军护理杂志,2016,33(17):68-71.
27 Gardner MJ,Collinge C.Management principles of osteoporotic fractures[J].Injury,2016,47(Suppl 2):S33-S35.
28 Wu ZX,Gao MX,Sang HX,et al.Surgical treatment of osteoporotic thoracolumbar compressive fractures with open vertebral cement augmentation of expandable pedicle screw fixation:a biomechanical study and a 2-year follow-up of 20 patients[J].J Surg Res,2012,173(1):91-98.
2 Konrad G,Bayer J,Hepp P,et al.Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate.Surgical technique[J].J Bone Joint Surg Am,2010,92(Suppl 1 Pt 1):85-95.
3朱正国,齐红哲,常祖豪,等.成人肱骨近端骨折手术治疗进展[J].解放军医学院学报,2017,38(12):1178-1181.
4 Vachtsevanos L,Hayden L,Desai AS,et al.Management of proximal humerus fractures in adults[J].World J Orthop,2014,5(5):685-693.
5 Agudelo J,Schürmann M,Stahel P,et al.Analysis of efficacy and failure in proximal humerus fractures treated with locking plates[J].J Orthop Trauma,2007,21(10):676-681.
6 Launonen AP,Lepola V,Flinkkil?T,et al.Treatment of proximal humerus fractures in the elderly:a systemic review of 409 patients[J].Acta Orthop,2015,86(3):280-285.
7 Dai J,Chai Y,Wang C,et al.Meta-analysis comparing locking plate fixation with hemiarthroplasty for complex proximal humeral fractures[J].Eur J Orthop Surg Traumatol,2014,24(3):305-313.
8 Chen H,Ji X,Gao Y,et al.Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemiarthroplasty for repair of osteoporotic four-part proximal humerus fracture:Consecutive,prospective,controlled,and comparative study[J].Orthop Traumatol Surg Res,2016,102(3):287-292.
9 G?n?U,Atabek M,Teker K,et al.Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures[J].Acta Orthop Traumatol Turc,2017,51(1):17-22.
10 Gracitelli ME,Malavolta EA,Assun??o JH,et al.Locking intramedullary nails compared with locking plates for two-and three-part proximal humeral surgical neck fractures:a randomized controlled trial[J].J Shoulder Elbow Surg,2016,25(5):695-703.
11 Sproul RC,Iyengar JJ,Devcic Z,et al.A systematic review of locking plate fixation of proximal humerus fractures[J].Injury,2011,42(4):408-413.
12 Hertel R.Fractures of the proximal humerus in osteoporotic bone[J].Osteoporos Int,2005,16(Suppl 2):S65-S72.
13 Padegimas EM,Zmistowski B,Lawrence C,et al.Defining optimal calcar screw positioning in proximal humerus fracture fixation[J].JShoulder Elbow Surg,2017,26(11):1931-1937.
14 Katthagen JC,Schwarze M,Meyer-Kobbe J,et al.Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures[J].Clin Biomech(Bristol,Avon),2014,29(7):735-741.
15 Somasundaram K,Huber CP,Babu V,et al.Proximal humeral fractures:the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates[J].Injury,2013,44(4):481-487.
16 Schliemann B,W?hnert D,Theisen C,et al.How to enhance the stability of locking plate fixation of proximal humerus fractures?An overview of current biomechanical and clinical data[J].Injury,2015,46(7):1207-1214.
17 He Y,He J,Wang F,et al.Application of Additional Medial Plate in Treatment of Proximal Humeral Fractures With Unstable Medial Column:A Finite Element Study and Clinical Practice[J].Medicine(Baltimore),2015,94(41):e1775.
18 Zhu L,Liu Y,Yang Z,et al.Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture[J].Chin Med J(Engl),2014,127(9):1672-1676.
19 Namdari S,Voleti PB,Mehta S.Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment[J].J Shoulder Elbow Surg,2012,21(12):1787-1795.
20 Bae JH,Oh JK,Chon CS,et al.The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus[J].J Bone Joint Surg Br,2011,93(7):937-941.
21 Chow RM,Begum F,Beaupre LA,et al.Proximal humeral fracture fixation:locking plate construct+/-intramedullary fibular allograft[J].J Shoulder Elbow Surg,2012,21(7):894-901.
22 Mathison C,Chaudhary R,Beaupre L,et al.Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft[J].Clin Biomech(Bristol,Avon),2010,25(7):642-646.
23 Osterhoff G,Baumgartner D,Favre P,et al.Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures:an in vitro study with synthetic bone[J].J Shoulder Elbow Surg,2011,20(5):740-746.
24 Chen H,Ji X,Zhang Q,et al.Clinical outcomes of allograft with locking compression plates for elderly four-part proximal humerus fractures[J].J Orthop Surg Res,2015,10:114.
25朱正国,齐红哲,常祖豪,等.解剖型异体腓骨髓内支撑钢板内固定术治疗老年肱骨近端粉碎性骨折疗效观察[J].解放军医学院学报,2018,39(2):91-94.
26高远,陈雪梅,陈玉娥,等.新型上肢贴胸固定悬吊装置的设计及其在救治上肢军事训练伤中的应用效果[J].解放军护理杂志,2016,33(17):68-71.
27 Gardner MJ,Collinge C.Management principles of osteoporotic fractures[J].Injury,2016,47(Suppl 2):S33-S35.
28 Wu ZX,Gao MX,Sang HX,et al.Surgical treatment of osteoporotic thoracolumbar compressive fractures with open vertebral cement augmentation of expandable pedicle screw fixation:a biomechanical study and a 2-year follow-up of 20 patients[J].J Surg Res,2012,173(1):91-98.