内固定与肱骨头置换治疗高龄肱骨近端骨折比较

Comparison of internal fixation with locking proximal humeral plate versus humeral hemiarthroplasty for complex proxi⁃ mal humeral fractures in the elderly

摘要:

［目的］比较切开复位解剖锁定钢板内固定术（locking proximal humeral plate, LPHP）与肱骨头置换（humeral hemiar- throplasty, HHA） 治疗高龄患者复杂肱骨近端骨折的临床疗效。［方法］ 回顾性分析 2015 年 1 月—2018 年 1 月，手术治疗 78 例高龄 （≥80 岁） 复杂肱骨近端骨折 （Neer 三、四部分骨折） 的临床资料。依据术前医患沟通结果，46 例采用 LPHP 内固定 （LPHP 组），32 例采用 HHA （HHA 组）。比较两组临床资料、并发症、肩关节功能 Neer 评分、ASES 评分和 Constant-Murley 评分及影像学资料。［结果］两组均顺利完成手术，无严重术中并发症。HHA 组术中出血量和手术时间显著优于 LPHP 组，差异有明显统计学意义（P<0.05）；两组透视次数、术后输血、住院天数和围术期并发症方面差异无统计学意义（P>0.05）。两组均获得随访 12~18 个月，平均随访 （13.87±2.84） 个月。不良事件，LPHP 组为 14/46 （30.43%），HHA 组为 5/32 （15.63%）， 两组间差异无统计学意义 （P=0.134）。两组主动活动时间、完全负重时间比较差异无统计学意义 （P>0.05）。术后相应时间点，HHA 组的前屈上举 ROM 小于 LPHP 组，而 HHA 组的 Neer、ASES 和 Constant-Murley 评分均高于 LPHP 组，但是两组间上述指标的差异均无统计学意义（P>0.05）。影像方面，与术后即刻相比，末次随访时两组的肩肱间间隙（AHI）和肱骨颈干角 （HNSA） 均无显著改变 （P<0.05），相应时间点，两组间 AHI 的 HNSA 的差异均无统计学意义 （P<0.05）。至末次随访时， LPHP 组 46 例中，9 例内固定螺丝钉松动或穿出，5 例肱骨头缺血坏死，11 例骨折愈合不良，包括骨折未愈合、延迟愈合等。 HHA 组 32 例中，3 例假体周围骨折，2 例肱骨大小结节愈合不良。［结论］两种治疗高龄复杂肱骨近端骨折均可取得较好临床效果，行 HHA 更有利于早期康复功能锻炼，改善肩关节功能。

Abstract:

[Objective] To compare the clinical outcomes of locking proximal humeral plate (LPHP) versus humeral hemiarthroplasty (HHA) for complex proximal humeral fractures in the elderly. [Methods] A retrospective study was done on 78 elderly patients (≥80 years old) who underwent surgical treatment for complex proximal humeral fractures (Neer type III and IV fractures) from January 2015 to Janu- ary 2018. According to the results of preoperative doctor-patient communication, 46 patients received LPHP for open reduction and inter- nal fixation, while the remaining 32 patients had HHA performed. Clinical documents, such as complications, Neer, ASES and ConstantMurley scores, as well as radiographic data were compared between the two groups. [Results] All the patients in both groups were success- fully operated on without serious intraoperative complications. The HHA group had significantly less intraoperative blood loss and operation time than the LPHP group (P＜0.05) , although there were no statistically significant differences in terms of number of fluoroscopy, postoper- ative blood transfusion, hospital stay and perioperative complications between the two groups (P＞0.05) . All patients in both groups were fol- lowed up for 12~18 months, with an average of (13.87±2.84) months. Adverse events were of 14/46 (30.43%) in the LPHP group, 5/32 (15.63%) in the HHA group, which was not statistically significant (P=0.134) . There were no significant differences in terms of time to re- sume active motion and time to recover full weight-bearing activity between the two groups (P＞0.05) . At corresponding postoperative time points, HHA group had less forward extension ROM, while higher Neer, ASES and Constant-Murley scores than LPHP group, despite of the fact that no statistically significant differences were noticed in the abovementioned items between the two groups (P＞0.05) . Radiographical- ly, the acromiohumeral interval (AHI) and humeral neck-shaft angle (HNSA) remained unchanged significantly in the two groups at the lat-est follow-up compared with those immediately after surgery (P＞0.05) , and there was no statistical significance in AHI and HNSA between the two groups at corresponding time points (P＞0.05) . By the time of the latest follow-up, 9 patients presented loosening or perforation of screws, 5 cases had ischemic necrosis of the humeral head, and 11 cases had poor fracture union, including nonunion and delayed fracture union in the LPHP group, whereas 3 patients had periprosthetic fractures and 2 had poor healing of humeral greater trochanter in the HHA group. [Conclusion] Both LPHP and HHA do achieve reasonable clinical outcomes for complex proximal humeral fractures in the elderly. By comparison, the HHA is more conducive to early rehabilitation exercise and improvement of shoulder joint function.