两种入路手术治疗肱骨近端骨折脱位的比较

Comparison of two surgical approaches for open reduction and internal fixation of proximal humeral fractures complicated with glenohumeral dislocation

摘要:

［目的］比较劈三角肌入路与三角肌胸大肌肌间隙入路开放复位内固定治疗 Neer Ⅲ、Ⅳ型肱骨近端骨折合并肩关节脱位的疗效。［方法］回顾性分析 2014 年 1 月—2020 年 12 月在本院开放复位肱骨近端锁定钢板固定 Neer Ⅲ、Ⅳ型肱骨近端骨折伴盂肱脱位 33 例患者的临床资料。依据术前医患沟通结果，16 例采用劈三角肌入路，17 例采用三角肌-胸大肌肌间隙入路。比较两组的围手术期、随访与影像学资料。［结果］两组均顺利完成手术。劈三角肌组手术切口长度、术中出血量、住院时间显著优于肌间隙组（P<0.05），但前者手术时间显著长于后者（P<0.05），两组恢复主动伤肩活动时间的差异无统计学意义 （P>0.05）。所有患者均获随访 12 个月以上，两组恢复完全负重活动时间的差异无统计学意义 （P>0.05）。术后 3 个月，劈三角肌组 Constant-Murley 评分显著优于肌间隙组 （P<0.05），但术后 12 月，肌间隙组显著优于劈三角肌组（P<0.05）。术后 3 个月时两组在前屈上举和外展上举 ROM 的差异均无统计学意义 （P>0.05），但术后 12 个月，肌间隙组显著优于劈三角肌组 （P< 0.05）。影像方面，肌间隙组的骨折复位质量显著优于劈三角肌组（P<0.05）。至末次随访，两组骨折均愈合，愈合时间差异无统计学意义 （P>0.05）。肌间隙组晚期不良影像表现的发生率显著低于劈三角肌组 （P<0.05）。［结论］ 肌间隙入路较劈三角肌入路治疗<70 岁 NeerⅢ、Ⅳ型肱骨近端骨折脱位，具有骨折复位方便，手术时间短，并发症少等优势。

Abstract:

[Objective] To compare the clinical outcomes of open reduction and internal fixation (ORIF) with proximal humeral locking plate (PHLP) through the anterolateral deltoid-split (DS) approach versus deltopectoral (DP) approach for Neer type Ⅲ and Ⅳ proximal hu- meral fractures with glenohumeral dislocation. [Methods] A retrospective study was conducted on 33 patients who received ORIF with PHLP for Neer type Ⅲ and Ⅳ proximal humeral fractures with glenohumeral dislocation in our department from January 2014 to December 2020. According to preoperative doctor- patient communication, 16 patients were through DS approach, while the other 17 patients were through DP approach. The perioperative period, follow- up and imaging data of the two groups were compared. [Results] Operation were done successfully in both groups. The DS group showed a significant better result in hospital stay and intraoperative blood loss and incision length (P＜0.05) , however, the former had significantly longer operation time than the latter (P＜0.05) . There was no significant difference in active motion time of injured shoulder between the two groups (P＞0.05) . All patients were followed up over 12 months, and there was no sig- nificant difference in the time of full weight-bearing activity between the two groups (P＞0.05) . At 3 months after operation, the DS group was significantly superior to the DP group in Constant-Murley score (P＜0.05) , but the DP group showed a significant better result in Con- stant-Murley score at 12 months postoperatively (P＜0.05) . Although there was no significant difference in forward flexion and lift range of motion (ROM) and abduction and lift ROM between the two groups at 3 months postoperatively (P＞0.05) , the DP group showed a signifi- cant better result in forward flexion and lift ROM and abduction and lift ROM at 12 months postoperatively (P＜0.05) . Radiographically, the DS group was significantly inferior to the DP group in quality of fracture reduction (P＜0.05) . During follow-up, the fractures healed time showed no significant difference between the two groups (P＞0.05) . However, the DS group had significantly higher incidence of late ad- verse imaging findings than the DP group (P＜0.05) . [Conclusion] The deltopectoral approach used for ORIF of Neer type Ⅲ and Ⅳ proxi- mal humeral fractures with glenohumeral dislocation has the advantages of facilitated fracture reduction, short operation time and less com-plications at elderly aged less than 70 years.