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中华肩肘外科电子杂志

中华肩肘外科电子杂志 ›› 2021, Vol. 09 ›› Issue (04) : 310 -317. doi: 10.3877/cma.j.issn.2095-5790.2021.04.005

论著

杠杆重建平衡理论分析锁骨骨折术后内固定失效的原因
张一翀1, 王艳华1, 张立佳2, 张晓萌1, 郁凯3, 陈小锋4, 熊晨4, 姬云4, 张殿英5,†()   
  1. 1. 100044　北京大学人民医院创伤骨科；100044　北京，国家创伤医学中心；100044　北京，"创伤救治与神经再生"教育部重点实验室
    2. 100730　北京协和医学院
    3. 300450　天津，北京大学滨海医院骨科
    4. 100044　北京大学人民医院创伤骨科
    5. 100044　北京大学人民医院创伤骨科；100044　北京，国家创伤医学中心；100044　北京，"创伤救治与神经再生"　教育部重点实验室；300450　天津，北京大学滨海医院骨科
  • 收稿日期:2021-09-15 出版日期:2021-11-05
  • 通信作者: 张殿英
  • 基金资助:
    教育部创新团队项目(IRT_16R01); 北京大学医学部学院建设项目（2020）——国家创伤医学中心(BMU2020XY005-01); 北京大学医学部学院建设项目（2020）——创伤救治与神经再生教育部重点实验室(BMU2020XY005-03)

Analysis of the internal fixation failure after clavicular fractures by lever reconstruction balance theory

Yichong Zhang1, Yanhua Wang1, Lijia Zhang2, Xiaomeng Zhang1, Kai Yu3, Xiaofeng Chen4, Chen Xiong4, Yun Ji4, Dianying Zhang5,†()   

  1. 1. Dpepartment of Orthopaedics and Traumatology, Peking University People's Hospital, Beijing 100044, China; National Center for Trauma Medicine, Beijing 100044, China; Key Laboratory of Ministry of Education for Trauma Treatment and Nerve Regeneration, Beijing 100044, China
    2. Department of Orthopaedics, Peking Union Medical College Hospital, Beijing 100730, China
    3. Department of Orthopaedics, Tianjin Fifth Central Hospital, Tianjin 300450, China
    4. Dpepartment of Orthopaedics and Traumatology, Peking University People's Hospital, Beijing 100044, China
    5. Dpepartment of Orthopaedics and Traumatology, Peking University People's Hospital, Beijing 100044, China; National Center for Trauma Medicine, Beijing 100044, China; Key Laboratory of Ministry of Education for Trauma Treatment and Nerve Regeneration, Beijing 100044, China; Department of Orthopaedics, Tianjin Fifth Central Hospital, Tianjin 300450, China
  • Received:2021-09-15 Published:2021-11-05
  • Corresponding author: Dianying Zhang
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引用本文：

张一翀, 王艳华, 张立佳, 张晓萌, 郁凯, 陈小锋, 熊晨, 姬云, 张殿英. 杠杆重建平衡理论分析锁骨骨折术后内固定失效的原因[J]. 中华肩肘外科电子杂志, 2021, 09(04): 310-317.

Yichong Zhang, Yanhua Wang, Lijia Zhang, Xiaomeng Zhang, Kai Yu, Xiaofeng Chen, Chen Xiong, Yun Ji, Dianying Zhang. Analysis of the internal fixation failure after clavicular fractures by lever reconstruction balance theory[J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2021, 09(04): 310-317.

目的

基于Medline、万方等数据库，对锁骨骨折内固定失效的可能原因进行分析，为未来治疗提供参考。

方法

对Medline、Embase、Pubmed、PQDT、万方、中国知网、维普等数据库进行手工检索，获得锁骨骨折内固定失效的相关文献。研究对象为国内、外自2001年1月至2021年1月已发表的锁骨骨折内固定术后并发症的个案报道、论著和综述，对数据筛选提炼，将符合纳入及排除标准者作为研究对象。观察终点为锁骨骨折术后内固定断裂、畸形、松动或穿出。根据文献提供的文字描述或图片，记录观察指标并进行描述性统计分析。

结果

本研究共纳入17篇文献，65例患者符合纳入与排除标准，其中43例采用钢板螺钉、22例采用弹性髓内钉固定，有25例患者出现内固定松动（38.5%）、11例发生内固定穿出（16.9%）、33例发生内固定形变或断裂（50.8%）；在观察终点，有31例发生骨折再移位（47.7%）、26例骨折不愈合（40%）、2例形成假关节（3%）。

结论

经过对上述结果的分析比较，结合杠杆重建平衡理论，笔者认为锁骨骨折内固定后重建了新的杠杆系统，多数锁骨骨折可以采用保守治疗。对于移位较大或粉碎严重的骨折，仍需手术治疗，内固定长度选择应依据骨折线位置而定，使支点两端内固定长度相同，动力臂与阻力臂相等，达到杠杆远端、近端及支点的三点平衡。同时术后应尽量避免过早康复运动，防止并发症的发生。该理论可以指导未来骨折治疗的原则、内植物的选择研发、康复方案，并有效减少临床并发症，为锁骨骨折乃至全身其他部位骨折的治疗提供了新思路、新方向。

关键词: 锁骨骨折, 内固定, 失效, 并发症, 杠杆重建平衡
Background

Clavicular fractures are common, accounting for 2.6%-10% of all adult fractures. Approximately 80% of the fractures were located in the middle shaft of the clavicle, among which 48% were associated with displacement, and 19% were associated with comminution. Generally, clavicular fractures are treated conservatively, but for displaced or severely comminuted fractures, surgery should be considered. The traditional surgical treatment method is mainly plate fixation, and locking plate is widely used with good functional result. However, postoperative internal fixation failure includes loosening, deformation, fracture, etc., and the postoperative revision rate reached 6.9%-16.7%, especially for wedge or comminution fractures that directly affects the stability of internal fixation. Currently, intramedullary nail has been gradually recognized in the treatment of clavicle fracture, with the advantages such as small incision and good blood supply protection. However, some studies have reported related complications, in which the incidences of fracture, deformation or displacement of intramedullary nailing reached 5%-10%. As far as we know, there are no specific studies on the mechanism and biomechanical causes of such complications, as well as relevant theories to guide the selection of internal fixator type and length.

Objective

To investigate and analyze the causes of internal fixation failure after clavicular fractures by lever reconstruction balance theory.

Methods

This study conducted a manual search on MEDLINE, EMBASE, PubMed, PQDT, Wanfangdata, CNKI, QCVIP and other databases, and the research objects were domestic and foreign case reports, publications and reviews of complications after internal fixation of clavicular fracture published from January 2001 to January 2021, and those who met the inclusive and exclusive criteria were selected. The end points were plate fracture, deformity, loosening or perforation after internal fixation of clavicle fractures. The observation indicators were recorded according to the text description or pictures provided by the literatures.

Results

A total of 17 literatures were included in this study, among which 65 cases met the inclusive criteria, with 43 cases fixed with plates and 22 cases fixed with elastic intramedullary nails. There were 25 patients of internal fixation loosening (38.5%) , 11 patients of internal fixation penetration (16.9%) , and 33 patients of internal fixation deformation or fracture (50.8%) . At the end point, 31 cases (47.7%) had fracture redisplacement, 26 cases (40%) had nonunion, and 2 cases (3%) had pseudo-articulation.

Conclusion

A new lever system was reconstructed after internal fixation of clavicular fracture, and the selection of internal fixation length should be determined according to the position of fracture line. The internal fixation length at both ends of fulcrum should be the same with equal power arm and resistance arm, so as to achieve a three-point balance of distal clavicle, fulcrum and proximal clavicle. In the meanwhile, early rehabilitation exercise should be avoided as far as possible to prevent the occurrence of complications. This theory can guide the principle of clavicular fracture treatment, the selection and development of internal fixators, and rehabilitation programs, and effectively reduce clinical complications, providing a new idea and direction for the treatment of clavicle fracture and even other parts of the body fractures in the future.

Key words: Clavicular fracture, Internal fixation, Failure, Complications, Lever reconstruction balance theory
图1 Pubmed检索策略
表1 符合纳入与排除标准的文献病例
作者 时间（年） 题目 例数 并发症时间（月） 年龄（岁） 性别 内固定种类 内固定失效的并发症
松动 穿出 断裂（变形） 断端移位 骨折不愈合 假关节形成
Huang等[12] 2020 Clavicle nonunion and plate breakage after locking compression plate fixation of displaced midshaft clavicular fractures 4 3~6 N/A 男 钢板 3   4 4 4  
Batash等[13] 2019 Mechanical failure of plate breakage after open reduction and plate fixation of displaced midshaft clavicle fracture—— a possible new risk factor: a case report 1 1.25 35 男 钢板     √ √ √  
Fang等[14] 2020 Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates—— a propensity score matched retrospective cohort study of 106 patients 2 3 N/A N/A 钢板     2 2 1  
Shin等[15] 2012 Risk factors for postoperative complications of displaced clavicular midshaft fractures 10 5.3 44.7 7:3 钢板 4   6 6 10 1
Marinescu等[16] 2017 Clavicle anatomical osteosynthesis plate breakage—— failure analysis report based on patient morphological parameters 1 1.5 28 男 钢板       √    
Meeuwis等[7] 2017 Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures 18 1.3 N/A 女 钢板 13   5 5 3  
Largo等[17] 2011 Anatomic reconstruction of unstable lateral clavicular fractures 1 4 N/A N/A 钢板/线缆     √ √ √ √
Millett等[11] 2011 Complications of clavicle fractures treated with intramedullary fixation 2 0.5 N/A N/A TEN     2      
Kleweno等[18] 2011 Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation 1 4 N/A N/A TEN   √        
1 11 N/A N/A 钢板     √ √ √  
Payne等[19] 2011 Outcome of intramedullary fixation of clavicular fractures 4 3 N/A N/A TEN 1 1 2 3 2  
Lee等[20] 2008 Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails 2   N/A N/A TEN     2      
Strauss等[21] 2007 Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures 2 2 25 男 TEN   2        
Frigg等[22] 2009 Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications   3 N/A N/A TEN   7 1 1    
Ogawa等[23] 2021 A multicentric study on the newly developed reconstruction locking plate for midshaft clavicular fracture   1 69 男 钢板 √     √    
吴树华等[24] 2010 钛制弹性髓内钉微创治疗锁骨骨折临床疗效分析   2 N/A N/A TEN     2 2    
张晓萌等[25] 2017 锁骨骨折患者并发症的原因分析与对策   4.1 42.6 4:2 钢板 2   4 5 3  
曾伟坤等[26] 2014 微创弹性髓内钉手术治疗锁骨骨折的疗效观察   3 N/A N/A TEN √          
图2 典型病例[12]　图A：急诊平片提示锁骨中段骨折（白色箭头）；图B：切开复位钢板内固定术后2 d平片；图C：切开复位术后4个月，骨折不愈合、钢板断裂（白色箭头）
图3 锁骨术后运动内固定受力改变示意图　图A：当做上提动作时，锁骨远端抬高，此时钢板远端螺钉受牵张应力（红色箭头），近端螺钉受支撑应力（绿色箭头）；图B：当做下压动作时，锁骨远端降低，此时钢板远端螺钉受支撑应力（绿色箭头），近端螺钉受牵张应力（红色箭头）
图4 弹性髓内钉并发症　图A：内侧穿出;图B：外侧穿出；图C：断裂；图D：尾帽脱位[22]
图5 锁骨中段骨折　图A：术后复位良好，钢板螺钉内固定；图B：术后过早功能锻炼造成螺钉松动，内固定失效，骨折移位[7]
图6 锁骨中段骨折内固定放置位置示意图　图A：支点两侧动力臂大于阻力臂，L1>L2，此时钢板近端阻力F2增大，易发生螺钉切出；图B：钢板固定后形成新的杠杆系统，支点两侧动力臂小于阻力臂，L1<L2，此时杠杆近端阻力F2降低，但支点处分担应力增加，易发生钢板断裂；图C：钢板固定后形成新的杠杆系统，支点两侧动力臂与阻力臂相等，L1=L2，此时杠杆远、近端及支点处受力平衡
图7 典型病例[14]　图A：锁骨中远端骨折；图B：由锁定重建加压钢板治疗；图C：术后3个月发生内固定支点处断裂，患者自述持续疼痛及异响；图D：术后10个月再次进行手术，骨折愈合
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