两种手术方法治疗Neer Ⅲ型肱骨近端骨折的临床研究

doi:10.3877/cma.j.issn.2095-5790.2021.04.009

目的

观察比较采用单纯外侧PHILOS钢板和外侧PHILOS钢板结合内侧支撑钢板治疗NeerⅢ型肱骨近端骨折的临床疗效。

方法

2015年1月至2020年1月本科室收治的NeerⅢ型肱骨近端骨折患者65例，其中32例采用单纯外侧PHILOS钢板治疗（单钢板组），另33例采用PHILOS钢板结合内侧支撑钢板治疗（双钢板组）。对比两组的手术时间、术中出血量、骨折愈合时间、术后第12个月肱骨颈干角、术后6个月和12个月的Neer评分及Constant评分等相关指标。

结果

两组患者术中均无神经血管损伤情况发生，伤口均I期愈合。所有患者均获得随访12个月。双钢板组在手术时间、术中出血量、骨折愈合时间明显大于单钢板组（P<0.01）。双钢板组在术后第6个月和第12个月Neer评分和Constant肩关节评分系统的评分明显高于单钢板组（P<0.01）。在术后第12个月末次随访时，双钢板组的肱骨颈干角较单钢板组更加接近正常值（P<0.01）。

结论

对于NeerⅢ型肱骨近端骨折合并内侧柱损伤的患者来说，采用外侧PHILOS钢板结合内侧支撑钢板治疗,可以提高肱骨近端内侧稳定性及肱骨近端整体牢固性,降低术后骨折复位丢失、肱骨头内翻、内固定失效等并发症的发生率,可以早日行肩关节康复功能锻炼，恢复肩关节功能。

关键词: 肱骨近端骨折, NeerⅢ型, PHILOS钢板, 支撑钢板

Background

With the continuous progress of domestic aging, the occurrence of proximal humeral fractures is second only to distal radius fractures and hip fractures, ranking third with an incidence of approximately 4%-5%. The first choice for the treatment of patients with Neer type III or IV proximal humeral fractures is the locking plate technique. With the increasing number of proximal humerus fractures in recent years, the postoperative complications of locking plate technique alone have been increasingly concerned. Relevant studies in recent years have found that the poor quality of proximal humerus and the loss of medial column are the main reasons for postoperative complications. In this study, a buttress plate was placed on the inner side of the proximal humerus to enhance the overall stability and firmness of proximal humerus and reduce postoperative complications.

Objective

To observe and compare the clinical efficacy of the simple lateral PHILOS plate and the lateral PHILOS plate combined with the medial buttress plate in the treatment of Neer type Ⅲ proximal humeral fractures.

Methods

From January 2015 to January 2020, 65 patients with Neer type Ⅲ proximal humeral fractures were admitted into our department. Among them, 32 cases were treated with lateral PHILOS plate, and the other 33 cases were treated with PHILOS plate combined with medial buttress plate. The operation time, intraoperative blood loss, fracture healing time, humeral neck shaft angle in the 12th month after operation, Neer score and Constant score in the 6th and 12th months after operation were compared between the two groups.

Results

No neurovascular injury occurred in the two groups of patients during the operation, and the wounds healed at first stage. All patients were followed up for 12 months. The operation time, intraoperative blood loss, and fracture healing time of the double-plate group were significantly longer than those of the single-plate group (P<0.01) . The Neer score and Constant score of the double-plate group in the 6th and 12th months after surgery were significantly higher than those of the single-plate group (P<0.01) . At the last follow-up in the 12th month after surgery, the humeral neck shaft angle of the double-plate group was closer to the normal angle than that of the single-plate group (P<0.01) .

Conclusion

For patients with Neer type Ⅲ proximal humeral fractures combined with medial column injury, treatment with lateral PHILOS plate combined with medial buttress plate can improve the medial stability and overall firmness of proximal humerus, and reduce the incidence of reduction loss, humeral head varus, fixation failure, etc, which is helpful for early shoulder rehabilitation and shoulder function restoration.

Key words: Proximal humeral fracture, Neer type Ⅲ, PHILOS plate, Buttress plate

图1 肱骨颈干角的测量方法注：ab线为肱骨头基底部最长径；cd线垂直于ab线；ef线平行于肱骨干；cd线和ef线所形成的夹角α角即为肱骨干颈干角

表1 两组患者手术情况相关指标对比表（±s）

组别	例数	手术时间（min）	术中出血量（ml）	骨折愈合时间（周）	术后第12月肱骨颈干角（°）	并发症（例）
单钢板组	32	87.09±12.47	128.49±29.62	12.21±3.99	115.93±4.68	6
双钢板组	33	119.17±10.37	167.81±31.67	10.32±3.61	135.15±3.61	0
t值		7.281	7.386	3.193	8.918	0
P值		<0.001	<0.001	<0.001	<0.001	<0.001

表1 两组患者手术情况相关指标对比表（±s）

组别	例数	手术时间（min）	术中出血量（ml）	骨折愈合时间（周）	术后第12月肱骨颈干角（°）	并发症（例）
单钢板组	32	87.09±12.47	128.49±29.62	12.21±3.99	115.93±4.68	6
双钢板组	33	119.17±10.37	167.81±31.67	10.32±3.61	135.15±3.61	0
t值		7.281	7.386	3.193	8.918	0
P值		<0.001	<0.001	<0.001	<0.001	<0.001

表2 两组患者术后第6个月和第12个月的Neer和Constant评分对比表（分，±s）

组别	例数	Neer评分		Constant评分
组别	例数	术后6个月	术后12个月	术后6个月	术后12个月
单钢板组	32	73.19±6.93	79.38±7.91	86.06±5.73	92.15±2.93
双钢板组	33	74.51±6.72	80.14±8.63	87.38±4.51	93.01±3.17
t值		1.602	1.312	1.636	1.358
P值		<0.001	<0.001	<0.001	<0.001

表2 两组患者术后第6个月和第12个月的Neer和Constant评分对比表（分，±s）

组别	例数	Neer评分		Constant评分
组别	例数	术后6个月	术后12个月	术后6个月	术后12个月
单钢板组	32	73.19±6.93	79.38±7.91	86.06±5.73	92.15±2.93
双钢板组	33	74.51±6.72	80.14±8.63	87.38±4.51	93.01±3.17
t值		1.602	1.312	1.636	1.358
P值		<0.001	<0.001	<0.001	<0.001

图2 患者，女性，69岁，左肱骨近端骨折（NeerⅢ型），行单纯PHILOS钢板固定治疗　图A-B：术前X线片及CT层扫断面片；图C：患者术后6个月复查平片示骨折解剖复位，内固定在位牢固，骨折线模糊，愈合良好；图D：患者术后12个月去除内固定后的X线片

图3 患者，女性，63岁，左肱骨近端骨折（NeerⅢ型），行PHILOS钢板结合内侧3.0锁定支撑钢板固定治疗　图A-B：术前X线片及CT层扫断面片；图C：患者术后6个月复查平片示骨折解剖复位，内固定在位牢固，骨折线模糊，愈合良好；图D：患者术后12个月去除内固定后的X线片

[1]	陈德健，邱福平，卞健,等.锁定接骨板联合内侧普通钢板治疗肱骨近端NeerⅢ、Ⅳ型骨折[J].中国矫形外科杂志,2019,27(24):2233-2237.
[2]	向明，胡晓川，姜春岩．重视整体观念，提高肱骨近端骨折诊治水平[J].中华骨科杂志，2017,37(27):1313-1317．
[3]	张玉富，米萌，张健,等.肱骨近端骨折合并肩袖损伤情况初步调查[J].中华创伤骨科杂志，2018,20(11):975-979．
[4]	强华，孙建锋，马永安,等.自体髂骨条植骨联合锁定钢板治疗肱骨近端Neer3/4型骨折的疗效分析[J].中国医师杂志,2020,22(7):1065-1068.
[5]	柯铁，张永发，许志贤，等.肩峰下前外侧入路复位锁定钢板内固定治疗肱骨近端骨折的疗效[J].中华创伤杂志，2019,35(11):1017-1023.
[6]	王礼宁，王强，沈婧鈺,等. 三种手术方式治疗NeerⅢ-Ⅳ部分肱骨近端骨折的比较[J].中国矫形外科杂志,2018,26(22):2038-2043.
[7]	Boesmueller S, Wech M, Gregori M, et al. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures[J]. Injury, 2016,47(2):350-355.
[8]	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.
[9]	Gardner MJ, Weil Y, Barker JU，et al．The importance of medial support in locked plating of proximal humerus fractures[J]． J Orthop Trauma，2007,21(3) : 185-191．
[10]	宛磊，张晓光，代彭威,等.内侧柱支撑重建与常规内固定治疗老年肱骨近端骨折的疗效比较[J].临床骨科学杂志，2019,22(2):211-213.
[11]	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):1178-1181,1185．
[12]	Klug A, Gramlich Y, Wincheringer D，et al．Trends in surgical management of proximal humeral fractures in adults: A nationwide study of records in Germany from 2007 to 2016[J]. Arch Orthop Trauma Surg，2019,139(12):1713-1721．
[13]	Plath JE, Kerschbaum C, Seebauer T，et al．Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: A prospective randomised controlled trial[J]. BMC Musculoskelet Disord，2019,20(1):20．
[14]	Gonc U, Atabek M, Teker K，et al．Minimally invasive plate osteo-synthesis with PHILOS plate for proximal humerus fractures[J]. Acta Orthop Traumatol Turc，2017,51(1): 17-22．
[15]	陆伟成，罗振东，张建明,等.锁定钢板结合重建肱骨近端内侧支撑治疗成人肱骨近端骨折[J]. 生物骨科材料与临床研究,2016,13(6):20-24.
[16]	陈德健，邱福平，卞健,等.锁定接骨板联合内侧普通钢板治疗肱骨近端NeerⅢ、Ⅳ型骨折[J]. 中国矫形外科杂志,2019,27(24):2233-2237.
[17]	Brorson S, Frich LH, Winther A，et al．Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus[J]. Acta Orthop，2011,82(4):475-481．
[18]	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.
[19]	徐鹏，苏萍，李雪栋,等.锁定接骨板治疗累及肱骨距的肱骨近端骨折：有效支撑、发症和功能恢复[J]. 中国组织工程研究,2020,24(12):1949-1956.
[20]	Kavuri V, Bowden B, Kumar N，et al．Complications associated with locking plate of proximal humerus fractures[J]. Indian J Orthop，2018,52(2):108-116．
[21]	di Tullio PO, Giordano V, Souto E，et al．Biomechanical behavior of three types of fixation in the two-part proximal humerus fracture without medial cortical support[J]．PLoS One,2019,14(7):e0220523．
[22]	Ponce BA,，Whitcomb J．Fixation device for proximal humerus fractures: US，10.206.728[P]．2019-02-19.
[23]	沈施耘，李雄峰，吴猛，等.锁定钢板结合不同腓骨植骨方式治疗肱骨近端骨折的生物力学稳定性分析[J]. 中华创伤骨科杂志,2019,21(5):427-431.
[24]	何继业，张家红，蔡贵泉，等.锁定钢板治疗不稳定肱骨近端骨折术后内翻的危险因素分析[J]. 中华创伤杂志,2020,36(5):448-454.
[25]	Lin SJ, Tsai YH, Yang TY，et al. Medial calcar supportand radiographic outcoms of plate fixation for proximal humeral fractures[J]. Bio Med Res Int，2015,2015:170283.
[26]	Oppeboen S, Wikery AK, Fuglesang HF，et al． Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients fol-lowed for a mean of 3 years[J]．J Orthop Surg Res，2018,13(1):197．
[27]	Lee SH, Han SS, Yoo BM, et al. Outcomes of locking plate fixa-tion with fibular allograft augmentation for proximal humeral frac-tures in osteoporotic patients: comparison with locking plate fixa-tion alone[J]. Bone Joint J,2019,101-B(3):260-265.
[28]	Hsiao CK, Tsaj YJ, Yen CY, et al.Intramedullary cortical bone strut improves the cyclic stability of osteoporotic proximal humeral fractures[J]. BMC Musculoskelet Disord, 2017,18(1):64.
[29]	张军，庄云强，李东贞，等.锁定钢板结合异体腓骨支撑治疗老年肱骨近端Neer三、四部分骨折[J]. 中华创伤骨科杂志,2018,20(11):946-952.
[30]	葛鸿庆，郑沐欣，管华，等.锁定钢板联合异体腓骨支撑治疗老年内翻型肱骨近端骨折[J]. 中华创伤骨科杂志,2019,21(5):440-442.
[31]	赵晓东，吴月明，赵志刚,等.单纯锁定钢板与联合植骨治疗肱骨近端Neer三部分骨折的比较[J]. 中国矫形外科杂志,2019,27(22):2050-2054.
[32]	王筠，王利昕，孙军平,等.肱骨近端锁定内固定系统结合同种异体股骨头结构植骨治疗骨质疏松性肱骨近端骨折 [J]. 中华创伤骨科杂志，2018,20(6):541-544.
[33]	Bai L, Fu Z, An S,et al.Effect of alcarscre wusein surgi calneck fractures of the proximal humerus with unstable medial support: abiomechanical study [J]. J Orthop Trauma,2014,28(8):452-457.
[34]	Amtnt MH.Managing the endosteal fibula during arthroplasty for proximal humeral fracture sequelae[J]. J Orthop Trauma, 2019,33 Suppl1:S1-S2.
[35]	Park SG, Ko YJ. Medial buttress plating for humerus fractures with unstable medial column[J]. J Orthop Trauma,2019,33(9):352-359.
[36]	He Y, Zhang Y, Wang Y, et al.Biomechanical evaluation of a novel dualplate fixation method for proximal humeral fractures without medial support[J]. J Orthop Surg Res,2017,12(1):72.

[1]	李立, 王红莉, 常红, 张艳. 肱骨近端骨折术后功能康复策略现状及新理念下的研究进展[J]. 中华肩肘外科电子杂志, 2023, 11(03): 284-287.
[2]	左楠, 刘岩, 孙大辉, 刘哲闻, 杨光. 胸大肌三角肌入路与经三角肌外侧入路治疗肱骨近端骨折的疗效分析[J]. 中华肩肘外科电子杂志, 2023, 11(03): 252-257.
[3]	宗宇宁, 薛海鹏, 韩天宇, 张昊, 王帅, 马翔宇, 纪振钢, 周大鹏. 解剖状骨水泥占位器在治疗内侧柱缺失型肱骨近端骨折中的实用性的有限元分析[J]. 中华肩肘外科电子杂志, 2023, 11(03): 242-251.
[4]	车娟, 刘俊阳. 肱骨近端骨折围手术期深静脉血栓发生因素分析[J]. 中华肩肘外科电子杂志, 2023, 11(02): 146-149.
[5]	张晓萌, 杨杰, 刘海, 王艳华, 张一翀, 张立佳, 熊晨, 唐缪田, 张殿英. 科研创新就在我们身边[J]. 中华肩肘外科电子杂志, 2023, 11(01): 1-6.
[6]	刘兵, 马翔宇, 杨超, 周大鹏. 应用Philos钢板联合个体化髓内解剖型骨水泥占位器治疗老年骨质疏松性肱骨近端骨折的临床疗效[J]. 中华肩肘外科电子杂志, 2022, 10(04): 293-299.
[7]	丁小方, 杨黎黎, 周海涛, 纪坤羽, 杨鹏杰, 杨坤, 吕昊润, 王元利, 付中国. 基于"悬臂-杠杆重建-不稳定"理论的老年肱骨近端粉碎骨折术后康复策略探讨[J]. 中华肩肘外科电子杂志, 2022, 10(03): 232-238.
[8]	张伟, 成冬冬, 崔胜宇, 徐又佳, 刘巍, 丁一, 朱新辉. 两种内固定对中老年肱骨近端合并肱骨干骨折的疗效及功能预后：前瞻性队列研究[J]. 中华肩肘外科电子杂志, 2022, 10(03): 207-213.
[9]	祝相如, 张聿达, 李绪文, 刘国明, 梁承志, 扈延龄. 自体髂骨块植骨结合Calcar螺钉重建内侧柱治疗复杂肱骨近端骨折[J]. 中华肩肘外科电子杂志, 2021, 09(03): 244-248.
[10]	徐小东, 王颜华, 刘洋, 杨雨润, 朱前拯, 杨欢, 陈星佐, 王立强, 陈瀛, 林朋. 老年肱骨近端骨折患者围手术期隐性失血情况分析[J]. 中华肩肘外科电子杂志, 2021, 09(02): 164-168.
[11]	赵彦瑞, 刘洋, 单磊, 周君琳. 锁定钢板结合异体腓骨治疗老年肱骨近端Neer III、IV型骨折的疗效分析[J]. 中华肩肘外科电子杂志, 2021, 09(02): 159-163.
[12]	张晓萌, 陈征, 陈杰, 张殿英, 熊建. 如何使用术中超声探测肱骨近端板钉固定后的螺钉穿透：一项初步尸体研究[J]. 中华肩肘外科电子杂志, 2021, 09(01): 48-54.
[13]	金万通, 薛海鹏, 周大鹏, 刘兵, 纪振钢, 马翔宇, 杨超, 张昊, 韩宁, 宗宇宁, 张咏晧, 马泽方. 3D打印结合PMMA骨水泥髓内支撑技术在老年肱骨近端骨质疏松性骨折中的应用[J]. 中华老年骨科与康复电子杂志, 2022, 08(05): 276-284.
[14]	杨良栋, 张华泽, 何举仁, 高艳刚, 李栋. 锁定钢板与交锁髓内钉固定治疗老年Neer分型2、3部分肱骨近端骨折的疗效比较[J]. 中华老年骨科与康复电子杂志, 2022, 08(02): 96-103.
[15]	赵阔, 王忠正, 王宇钏, 张浚哲, 郭家良, 郑占乐, 陈伟, 张英泽. 双反牵引复位器联合MIPO技术治疗肱骨近端骨折的初步应用[J]. 中华老年骨科与康复电子杂志, 2021, 07(06): 321-325.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Clinical study of two surgical methods for the treatment of Neer typeⅢ proximal humeral fractures

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Clinical study of two surgical methods for the treatment of Neer typeⅢ proximal humeral fractures