切换至 "中华医学电子期刊资源库"
高级检索
中华肩肘外科电子杂志

中华肩肘外科电子杂志 ›› 2022, Vol. 10 ›› Issue (03) : 207 -213. doi: 10.3877/cma.j.issn.2095-5790.2022.03.004

论著

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
张伟1, 成冬冬1, 崔胜宇1, 徐又佳2, 刘巍1, 丁一3, 朱新辉1,†()   
  1. 1. 226001　南通市第一人民医院南通大学第二附属医院骨科
    2. 215000　苏州大学附属第二医院骨科
    3. 100191　北京大学第三医院运动医学研究所
  • 收稿日期:2022-05-24 出版日期:2022-08-05
  • 通信作者: 朱新辉
  • 基金资助:
    国家自然科学基金面上项目(82072474); 南通市卫健委青年医学重点人才资助项目(20211030)

Efficacy and functional outcome of two types of internal fixation in middle-aged and elderly patients with proximal humeral shaft fractures: a prospective cohort study

Wei Zhang1, Dongdong Cheng1, Shengyu Cui1, Youjia Xu2, Wei Liu1, Yi Ding3, Xinhui Zhu1,†()   

  1. 1. Department of Orthopedics, the First People’s Hospital of Nantong City, the Second Affiliated Hospital of Nantong University, Nantong 226001, China
    2. Department of Orthopedics, the Second Affiliated Hospital of Suzhou University, Suzhou 215000, China
    3. Institute of Sports Medicine, Peking University Third Hospital, Beijing 100191, China
  • Received:2022-05-24 Published:2022-08-05
  • Corresponding author: Xinhui Zhu
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

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.

Wei Zhang, Dongdong Cheng, Shengyu Cui, Youjia Xu, Wei Liu, Yi Ding, Xinhui Zhu. Efficacy and functional outcome of two types of internal fixation in middle-aged and elderly patients with proximal humeral shaft fractures: a prospective cohort study[J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2022, 10(03): 207-213.

目的

比较长型PHILOS钢板和长型MultiLoc髓内钉对中老年患者肱骨近端合并肱骨干骨折的安全性、疗效及功能预后。

方法

本研究为前瞻性队列研究，将2017年6月至2019年8月本科收治的肱骨近端合并肱骨干骨折的中老年患者作为研究对象，根据其入组顺序，依次纳入钢板组（长型PHILOS钢板）和髓内钉组（长型MultiLoc髓内钉），比较两组患者的围手术期指标、并发症、骨折愈合时间、肱骨颈干角、视觉模拟评分（visual analogue scale,VAS）、预后的Constant肩关节评分、Mayo肘关节评分（Mayo elbow performance score, MEPS）、肩关节活动度（range of motion，ROM）及肩袖抗阻试验阳性率。随访终点为术后1年。

结果

钢板组（n=16）平均随访（12.4±2.5）个月，髓内钉组（n=14）平均随访（12.7±1.9）个月。髓内钉组的住院天数（P=0.045）、术中出血量（P=0.002）、手术时间（P=0.036）均低于钢板组；两组骨折愈合时间、VAS、肱骨颈干角，及随访1年时的Constant肩关节评分、MEPS评分、肩袖抗阻试验阳性率差异无统计学意义（P>0.05）；髓内钉组术后1年的肩外展角度大于钢板组（P=0.033）。

结论

对中老年患者而言，两种内固定治疗肱骨近端合并肱骨干骨折后的骨折愈合疗效相同，但髓内钉的围手术期安全性更高，术后早期恢复更快，预后的ROM范围更大，更适用于老年患者。

关键词: 中老年骨折, 肱骨近端合并肱骨干骨折, PHILOS钢板, MultiLoc髓内钉, 肩关节功能, 关节活动度
Background

Proximal humerus fracture combined with humeral shaft fracture is a particular type of fracture in middle-aged and older adults. It has an extensive fracture range, great surgical difficulty, and perioperative complications, which is a great challenge to postoperative rehabilitation and the functional prognosis of patients. The long PHILOS plate and the MultiLoc intramedullary nail are the surgical methods for treating proximal humeral fracture with the humeral shaft in recent years. They have different advantages and characteristics. The former is reliable, less invasive, and does not hurt the rotator cuff. At the same time, the latter is a micro-motion internal fixation, which is conducive to early functional exercise after surgery. There is limited experience in treating proximal humeral fracture with the humeral shaft, and there is a lack of systematic comparison of different internal fixation methods. It is unclear that the best internal fixation method for middle-aged and elderly patients with the proximal humeral fracture combined with the humeral shaft is still unclear.

Objective

To compare the safety, efficacy, and functional outcome of long PHILOS plate and long MultiLoc intramedullary nail in middle-aged and elderly patients with proximal humerus fractures combined with humeral shaft fractures.

Methods

This is a prospective cohort study. Middle-aged and elderly patients with proximal humeral fracture combined with humeral shaft fracture admitted into our department from June 2017 to August 2019 were enrolled in the study. According to the inclusive criteria, they were divided into the plate group (long PHILOS plate) and the intramedullary nail group (long MultiLoc intramedullary nail) . The perioperative indicators, complications, fracture healing time, humeral neck-shaft angle, and VAS score were compared between the two groups. The Constant-Murley score, Mayo elbow performance score (MEPS) , range of motion (ROM) , and positive rate of rotator cuff resistance test were analyzed. The endpoint of follow-up was one year after surgery.

Results

The mean follow-up was (12.4±2.5) months in the plate group (n=16) and (12.7±1.9) months in the intramedullary nail group (n=14) . The length of hospital stay (P=0.045) , intraoperative blood loss (P=0.002) , and operation time (P=0.036) in the intramedullary nail group were lower than those in the plate group. There were no significant differences in fracture healing time, VAS score, humeral neck-shaft angle, Constant shoulder score, MEPS elbow score, and rotator cuff resistance test positive rate at one-year follow-up between the two groups (P>0.05) . The shoulder abduction angle in the intramedullary nail group was significantly higher than in the plate group (P=0.033) .

Conclusion

For middle-aged and elderly patients, the two types of internal fixation have the same effect on fracture healing after proximal humeral fracture. However, the intramedullary nail has higher perioperative safety, faster early postoperative recovery, and a more comprehensive prognosis range of shoulder ROM, which is more suitable for elderly patients.

Key words: Fractures in middle and old age, Proximal humeral with shaft fracture, PHILOS plate, MultiLoc intramedullary nail, Shoulder function, Range of motion
图1 长型PHILOS钢板治疗肱骨近端合并肱骨干骨折的术前检查及术后随访　图A：术前X线片示肱骨近端合并肱骨干骨折；图B：术前三维CT重建示，Neer 1部分骨折合并肱骨干短斜形骨折（A型）；图C：第1次随访（术后10周），X线片示长型PHILOS钢板位置正常；图D：X线片示骨折愈合（术后16周），颈干角正常
图2 长型MultiLoc髓内钉治疗肱骨近端合并肱骨干骨折的术前检查及术后随访　图A：术前X线片；图B：术前右肱骨三维重建CT示，右肱骨近端Neer 1部分骨折合并肱骨干短斜形骨折（A型）；图C：术后第1次随访（术后11周），X线片示长型MultiLoc髓内钉固定位置佳；图D：X线片示骨折愈合（术后15周），颈干角正常
表1 两组患者的一般资料结果
组别 例数 年龄（岁，±s） 男/女 肱骨近端骨折（Neer1/2/3部分） 肱骨干骨折AO分型（A/B型） 受伤至手术时间（d，±s） 平均随访时间（月，±s）
钢板组 16 67.8±6.4 6/10 3/7/6 7/9 4.1±0.8 12.4±2.5
髓内钉组 14 64.7±6.8 5/9 4/6/4 5/9 3.6±0.9 12.7±1.9
检验值   t=-1.264 x2=0.010 x2=1.091 x2=0.436 t=-1.139 t=-0.874
P值   0.217 0.779 0.779 0.804 0.341 0.505
表2 两组患者的一般临床资料比较（±s）
组别 例数 住院总天数（d） 术中出血（ml） 手术时间（min） 并发症
钢板组 16 11.4±2.5 291.3±68.5 96.3±20.3 0
髓内钉组 14 9.7±1.9 217.4±43.6 81.8±14.9 0
t值   -2.144 -3.475 -2.198 --
P值   0.045 0.002 0.036 --
表3 两组患者的骨折愈合情况及功能预后的比较（±s）
组别 例数 骨折愈合时间（周） 肱骨颈干角（°） VAS（分）
钢板组 16 15.6±2.2 134.1±2.4 1.2±0.8
髓内钉组 14 14.9±1.8 132.8±3.4 1.4±0.9
t值   -1.024 -1.204 0.782
P值   0.314 0.239 0.441
表4 两组患者的骨折愈合情况及功能预后的比较（±s）
组别 例数 前屈上举（°） 外旋（°） 外展（°） 抱抬抗阻试验 Constant肩关节评分（分） MEPS评分（分）
钢板组 16 143.8±18.6 38.4±4.8 150.2±24.4 1/16 83.6±7.3 98.93±2.1
髓内钉组 14 140.7±17.3 36.1±4.6 163.7±18.2 4/14 82.8±6.3 99.1±2.0
检验值   t=-0.461 t=-1.403 t=-5.266 x2=2.679 t=-1.139 t=-0.874
P值   0.648 0.172 0.033 0.102 0.740 0.861
[1]
Calvo E, Morcillo D, Foruria AM, et al. Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception[J] . J Shoulder Elbow Surg, 2011, 20（5）: 795-801.
[2]
苏文财, 谢卫强, 薛云,等. 肱骨骨折采用钢板固定的相关研究进展[J] . 中国医药, 2020, 15（2）:4.
[3]
苏权, 魏若晔, 赵武杰. 加长型肱骨近端锁定接骨板内固定治疗老年肱骨干合并肱骨近端骨折[J] . 中国骨与关节损伤杂志, 2020, 35（3）:303-305.
[4]
Pantalone A,Vanni D,Guelfi M,et al. From plate to nail: a case-report of proximal humerus nonunion[J] . Injury,2015,46（Suppl 7）: S48.
[5]
宋辉, 贺韬, 张超,等. 长解剖钢板和髓内钉治疗肱骨近端骨折累及肱骨干骨折的疗效比较[J] . 临床骨科杂志, 2018, 21（4）:96-99.
[6]
白晓东, 邢更彦, 姜川,等. 解剖钢板内固定治疗复杂肱骨近端骨折伴肱骨干骨折[J] . 中华创伤杂志, 2017, 33（5）:408-413.
[7]
Lee W, Park JY, Chun YM. Operative treatment of 2 part surgical neck fracture of the humerus: intramedullary nail versus locking compression plate with technical consideration[J] . J Orthop Trauma, 2017,31（9）: e270.
[8]
Shin YJ, Kim WH, Kim SG. Correlations among visual analogue scale, neck disability index, shoulder joint range of motion, and muscle strength in young women with forward head posture[J] . J Exerc Rehabil, 2017, 13（4）：413-417.
[9]
Kawakami J, Gotoh M, Matsuura K, et al. Cut-off values of the Japanese Orthopaedic Association score corresponding to Constant scores for evaluating outcomes in rotator cuff tear[J] . J Orthop Surg （Hong Kong）, 2017, 25（2）: 2309499017720002.
[10]
Morry BF, An KN. Functional evaluation of the elbow //Morry BF. The elbow and its disorders[M] . 3rd ed. Philadephia: WB Sannders, 2000: 74-83.
[11]
王毅焘,孟柏屹,阮如昕,等. PHILOS钛板内固定术与半肩关节置换术治疗老年肱骨近端粉碎性骨折的疗效比较[J] . 中国骨与关节损伤杂志, 2020, 35（9）: 913-916.
[12]
王陶然,高嘉锴,毕龙,等.联合使用氨甲环酸在减少肱骨骨折内固定围术期失血中的作用[J] .创伤外科杂志,2021,23（11）:823-827.
[13]
Stedtfeld HW, Biber R. Proximal third humeral shaft fractures-A fracture entity not fully characterized by conventional AO classification[J] . Injury, 2014, 45: S54-S59.
[14]
余斌峰, 王伟良, 林锡鹏. 加长型肱骨近端内固定锁定系统治疗肱骨干骨折合并同侧肱骨近端骨折[J] . 中医正骨, 2015, 27（8）: 23-25.
[15]
吴永光, 王炯, 邢丹谋. PHILOS钢板内固定治疗肱骨近端并肱骨干中上段长段骨折[J] . 中国骨与关节损伤杂志, 2016, 31（1）:79-80.
[16]
洪亮, 邹华章, 焦根龙, 等. 经皮微创接骨板固定术治疗青壮年肱骨近端Neer三部分骨折[J] . 中华创伤骨科杂志, 2017, 19（8）:714-717.
[17]
李雪飞, 王林祥, 王铁军, 等. 锁定髓内针系统与锁定钢板治疗老年肱骨近端骨折的临床疗效[J] . 中国老年学杂志, 2014, 35（6）: 1681-1682.
[18]
吴晓明, 吴剑宏, 王秋根. 肱骨近端骨折髓内钉治疗的老概念与新方法——第三代肱骨近端髓内钉的设计理念和临床实践[J] . 中华创伤骨科杂志, 2015, 17（10）: 915-920.
[19]
Benninger E, Meier C. Minimally invasive lateral plate placement for metadiaphyseal fractures of the humerus and its implications for the distal deltoid insertion- it is not only about the radial nerve. A cadaveric study[J] . Injury, 2017, 48（3）: 615-620.
[20]
Brunner A, Thormann S, Babst R. Minimally invasive plating osteosynthesis of proximal humeral shaft fractures with long PHILOS plates[J] . Oper Orthop Traumatol, 2012, 24（4-5）: 302-311.
[21]
赵东升, 郑晓勇, 余清文, 等. Multiloc髓内针治疗老年肱骨近端骨折的临床疗效[J] . 实用骨科杂志, 2017, 23（5）: 74-76.
[1] 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.
[2] 新苏雅拉图, 刘峰, 高雨, 高晓宇, 谢迎光. 关节镜松解术治疗肘关节僵硬的疗效观察[J]. 中华肩肘外科电子杂志, 2022, 10(03): 239-243.
[3] 程邦君, 黄燕峰, 罗轶, 何耀华. 两种手术方法治疗Neer Ⅲ型肱骨近端骨折的临床研究[J]. 中华肩肘外科电子杂志, 2021, 09(04): 335-340.
[4] 董志辉, 徐建杰, 季伟, 毕伟东, 李洁冰, 张立兴, 武建忠. 肩关节镜下双排缝合桥技术对巨大肩袖损伤患者术后肩关节功能恢复、疼痛及预后的影响研究[J]. 中华肩肘外科电子杂志, 2021, 09(04): 325-330.
[5] 鲍飞龙, 姬广伟, 亢世杰, 黄东生, 江涛, 吕夫新, 刘涛. MultiLoc髓内钉技术在肱骨近端骨折中的应用和体会[J]. 中华肩肘外科电子杂志, 2021, 09(01): 42-47.
[6] 冷昆鹏, 孟钰童, 周君琳. PHILOS钢板和Multiloc髓内钉治疗老年肱骨近端骨折的显性失血和隐性失血分析[J]. 中华肩肘外科电子杂志, 2020, 08(02): 146-150.
[7] 秦耕, 周君琳. Multiloc髓内钉治疗肱骨近端骨折的临床疗效分析[J]. 中华肩肘外科电子杂志, 2019, 07(04): 314-318.
[8] 何昌军, 马腾, 任程, 李庆达, 路遥, 熊晨, 杨明义, 崔玉, 杨娜, 许毅博, 李明, 李忠, 张堃. 肱骨近端骨折内固定术后影响肩关节功能的因素分析及生活质量的研究[J]. 中华老年骨科与康复电子杂志, 2022, 08(05): 296-303.
[9] 周柏臻, 李春雨, 林绍仪, 刘付滴, 徐万宏. 3D打印技术辅助肩胛骨改良Judet入路手术治疗肩胛骨骨折的疗效[J]. 中华老年骨科与康复电子杂志, 2022, 08(03): 172-176.
[10] 马将, 李红, 史万英, 张玉漫, 汪婷, 赵雅彤. 任务导向性训练对上肢周围神经损伤患者肌电图及手功能的影响[J]. 中华老年骨科与康复电子杂志, 2020, 06(03): 159-164.
[11] 赵树林, 韩坤, 张元昆, 王磊. 肱骨髓内钉固定治疗老年肱骨近端骨折的疗效评价[J]. 中华卫生应急电子杂志, 2020, 06(01): 32-35.
[12] 顾霄鹏, 陆欢, 王奇军, 翁宏军, 顾岳全. 内侧柱植骨结合PHILOS钢板治疗老年肱骨近端内收型骨折的体会[J]. 中华卫生应急电子杂志, 2019, 05(01): 10-14.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号