老年肱骨近端骨折小切口与开放复位内固定比较（开放获取）

Comparison of small incision and open reduction internal fixation of proximal humerus fractures in elderly

摘要:

[目的] 前瞻性研究小切口与开放复位内固定治疗老年肱骨近端骨折的临床疗效。[方法] 选取2019 年3 月—2022年3 月本院骨科收治的87 例老年肱骨近端骨折患者，以随机数字表法分为开放组（44 例） 和小切口组（43 例）。比较两组围手术期、随访及影像结果。[结果] 两组患者均顺利完成手术，小切口组的手术时间[(94.3±9.2) min vs (79.1±10.8) min, P＜0.001] 显著长于开放组，但切口长度[(7.4±0.9) cm vs (10.8±1.5) cm, P＜0.001]、术中失血量[(138.6±8.9) ml vs (190.2±13.7) ml, P＜0.001]、主动活动时间[(6.4±1.8) d vs (8.9±1.5) d, P＜0.001] 和住院时间[(8.5±0.7) d vs (9.7±1.1) d, P＜0.001] 均显著少于开放组。术后随时间推移，两组患者VAS 评分、Constant-Murley 评分、前屈上举及外展上举ROM 均显著改善（P＜0.05）。术后3 个月及末次随访时，小切口组VAS 评分[(1.3±0.5) vs (1.6±0.7), P=0.024; (0.8±0.4) vs (1.0±0.5), P=0.042] 均显著优于开放组。术后1、3 个月，小切口组Con-stant-Murley 评分[(70.3±3.2) vs (68.3±3.9), P=0.011; (82.5±5.7) vs (80.1±4.5), P=0.032] 均显著优于开放组。术后相应时间点，小切口组的前屈上举与外展上举ROM 均显著优于开放组（P＜0.05）。影像方面，两组骨折复位质量的差异无统计学意义（P＞0.05）。术后8 周小切口组骨折愈合率[例(%), 34 (77.3) vs 25 (58.1) P=0.028] 显著高于开放组。相应时间点，两组间肩峰下间隙（subacromi-nalinterval, SAI） 的差异无统计学意义（P＞0.05）。[结论] 小切口微创复位内固定和传统开放切口均可用于治疗老年肱骨近端骨折，但小切口微创技术能够有效保护骨折端微循环系统，有利于骨折早期愈合和康复。

Abstract:

[Objective] To prospectively investigate the clinical efficacy of small incision (minimally invasive percutaneous plating os-teosynthesis, MIPPO) versus open reduction and internal fixation (ORIF) in the treatment of proximal humerus fractures in the elderly.[Methods] A total of 87 elderly patients with proximal humerus fracture admitted to our Department of Orthopedics from March 2019 toMarch 2022 were included into this study. The patients were divided into the MIPPO group (44 cases) and the routine ORIF group (43 cases)by random number table method. The documents regarding perioperative period, follow-up and images were compared between the twogroups. [Results] All patients in both group had operation performed successfully. Although the MIPPO consumed significantly longer opera-tion time than the ORIF group [(94.3±9.2) min vs (79.1±10.8) min, P＜0.001], the former proved significantly superior to the ORIF group interms of incision length [(7.4±0.9) cm vs (10.8±1.5) cm, P＜0.001], intraoperative blood loss [(138.6±8.9) ml vs (190.2±13.7) ml, P＜0.001], ac-tive movement time [(6.4±1.8) days vs (8.9±1.5) days, P＜0.001] and hospital stay [(8.5±0.7) days vs (9.7±1.1) days, P＜0.001]. The VASscore, Constant-Murley score, forward flexion-uplift range of motion (ROM) and abduction- uplift ROM significantly improved over time inboth groups (P＜0.05). At 3 months and the last follow-up, the MIPPO group was significantly better than the ORIF group regarding to VASscore [(1.3±0.5) vs (1.6±0.7), P=0.024; (0.8±0.4) vs (1.0±0.5), P=0.042]. In addition, at 1 and 3 months after surgery, the MIPPO group wasalso superior to the ORIF group in Constant-Murley scores [(70.3±3.2) vs (68.3±3.9), P=0.011; (82.5±5.7) vs (80.1±4.5), P=0.032]. At all cor-responding time points after operation, the MIPPO group proved significantly better than the ORIF in ROMs (P＜0.05). As for imaging, therewas no significant difference in fracture reduction quality between the two groups (P＞0.05), while the fracture healing rate 8 weeks after sur-gery in the MIPPO group was better than the ORIF group [cases (%), 34 (77.3) vs 25 (58.1) P=0.028]. There was no significant difference insubacromial interval (SAI) between the two groups at any corresponding time points (P＞0.05). [Conclusion] Both MIPPO and traditional OR-IF can be used in the treatment of proximal humerus fractures in elderly. By comparison, the MIPPO can effectively protect the local bloodcirculation near the fracture ends, which is conducive to early healing and rehabilitation of fractures.