人工肱骨头置换术中大结节不同固定方式的稳定性研究

目的对比人工肱骨头置换术中以解剖方式和以重叠方式对大结节进行固定后的生物力学稳定性。方法取8对(16个)新鲜冷冻肩关节标本,按左右侧配对分为解剖重建组和重叠重建组。通过截骨制作肱骨近端四部分骨折模型,对解剖重建组标本中的大、小结节按解剖位置复位固定;对重叠重建组的标本,在保证大、小结节与肱骨头假体相对位置正常的前提下将大、小结节与肱骨干进行重叠方式固定(重叠5mm)。两组标本使用相同的固定方式。对肩关节不同的外旋和前屈上举角度时大结节与肱骨干之间的相对位移进行测定。结果当肱骨干外旋至中立位时,解剖重建组的平均位移为(1.81±1.75)mm,重叠重建组为(3.23±2.91)mm,差异有统计学意义。当肱骨干前屈至30°和60°时,解剖重建组的位移分别为(4.01±5.00)mm和(5.99±6.97)mm,重叠重建组分别为(3.02±5.27)mm和(6.97±7.00)mm,两组差异均无统计学意义。结论人工肱骨头置换术后肩关节被动外旋至中立位时,解剖重建组的大结节稳定性优于重叠重建组。提示采用重叠方式对大结节进行固定,可能会在抗外旋稳定性上出现损失。即使术后按照标准康复程序进行被动活动,大结节相对于肱骨干的位移还是比较明显。因此,在应用人工肱骨头置换术治疗肱骨近端骨折时应适当推迟术后开始被动功能锻炼的时间。     

半肩置换治疗肱骨近端粉碎性骨折的研究进展

肱骨近端骨折多见于中老年骨质疏松患者,其多采用半肩置换术进行治疗。如果骨折造成肱骨近端的骨性标志破坏、术中假体的高度及后旋角度难以确定、以及术后大小结节未达到解剖复位及骨性愈合等可影响肩关节置换术后的疗效。因此,对于肱骨近端骨折的治疗,需熟练掌握肩关节的解剖关系、力学机制、肩关节特殊的重建技术,并制订周密的术前规划才可以降低并发症的发生率。现就近几年来肩关节置换术治疗肱骨近端骨折的情况予以综述。     

肩关节置换术治疗肱骨近端骨折研究进展

1955年，Neer首次发表肩关节置换术治疗肱骨近端骨折的手术方法，并报告其优良率及满意率均为90％左右00]。但亦有文献报道肩关节置换术治疗肱骨近端骨折的效果较差，术后可出现肩关节僵硬或疼痛。因肱骨近端骨折发生率较低，故临床处理此类骨折的经验不足。骨折造成骨性标志的破坏、术中假体放置高度及后旋角度的不确定性、大、小结节未达到解剖复位等均可影响肩关节置换术后的疗效及预后。本文拟对人工肩关节置换术的相关问题进行综述。[第一段]     

肱骨大结节骨折及治疗的研究进展

肱骨近端骨折是临床常见的骨折,其中包括大结节骨折。但至今为止,大结节骨折的分类尚不完善。在治疗方面,以往对大结节骨折复位的精确度重视不够,骨折块往往不能达解剖复位。愈合后留下一些后遗症,如冈上肌、冈下肌及小圆肌的长度缩短,肌张力下降,收缩力不强,造成肩关节外旋、外展活动受限,同时肩关节外侧间隙变窄,上举时出现肩峰撞击症,影响肩上举运动,造成肩关节功能受限。     

复杂肱骨近端骨折人工肱骨头置换术中肩袖重建的长期疗效观察

目的探讨Neer 3、4部分肱骨近端骨折人工肱骨头置换术中肩袖重建的远期临床效果。方法回顾性分析自2001-01—2012-12采用人工肱骨头置换术治疗的25例Neer 3、4部分肱骨近端骨折。术前测量健侧大结节最低点至肱骨头最高点的距离,术中尽量解剖复位肱骨大、小结节,合理控制假体高度及后倾角度,尽可能修复重建损伤肩袖,术后分阶段康复锻炼。结果本组22例获得有效随访,随访时间平均120(49~190)个月。末次随访时ASES评分为80~92(86.28±3.36)分,肩关节内旋至T10水平,患肢主动前屈上举125°~135°,外旋36°~42°。1例合并臂丛神经损伤者术后肩关节功能恢复满意。结论对于骨折端无法良好复位、肱骨头缺血性坏死可能性大的复杂肱骨近端骨折,人工肱骨头置换同时进行精细的肩袖重建可以获得无痛和良好运动范围的肩关节。     

肩关节置换术治疗肱骨近端骨折

随着肩关节置换术治疗复杂肱骨近端骨折的广泛应用，也出现了许多新的问题，如骨折造成骨性标志的破坏，术中假体放置高度及后旋角度的不确定性，大、小结节未达到解剖复位等，这些都影响了手术的效果和患者的预后。[第一段]     

肩关节置换术中肱骨假体低置的疗效分析

目的探讨肱骨假体低置在肩关节置换术患者中的疗效。方法对12例肱骨近端三、四部骨折的老年患者行半肩关节置换术治疗,术中采用假体低置使肱骨大结节与肱骨近端重叠方式固定,并对其进行5～36个月随访,参照美国肩肘关节医师学会肩关节评分系统（ASES）进行功能评分。结果 12例患者均无明显疼痛,无肩关节脱位或不稳的情况出现,患肩上举、内旋、外旋、外展活动总体满意。ASES功能评分平均为81分,评定为满意。结论肱骨假体低置对肩关节置换术患者的早期功能及稳定性影响不大。     

人工肱骨头置换术治疗复杂性肱骨近端骨折

[目的]探讨人工肱骨头置换术治疗肱骨近端复杂性骨折的临床疗效.[方法]35例肱骨近端复杂性骨折患者施行人工肱骨头置换术,手术全部采用骨水泥型人工肱骨头假体.手术前后均对患者的肩关节功能进行UCLA评分.[结果]35例患者随访31～63个月(平均52个月),UCLA评分优(34～35分)10例,良(28～33分)21例,中(21～27分)4例,无差病例.术后肩关节活动范围上举(90.6±8.3)°,外旋(64.5±6.5)°,内旋(72.5±5.3)°.病人主观均较满意.所有病例大小结节均愈合,未发现假体松动、感染、脱位等并发症.[结论]严格掌握手术适应证,重建肱骨近端正常解剖和实现大、小结节骨折块的坚强固定,规范的肩关节功能康复锻炼,是人工肱骨头置换术获得满意疗效的关键.     

肱骨头置换治疗老年肱骨近端骨折

2016年3月~2017年3月,我科采用肱骨头置换治疗15例老年肱骨近端骨折患者,疗效良好,报道如下。1材料与方法1.1病例资料本组15例,男5例,女10例,年龄70~85岁。均为新鲜骨折。受伤至手术时间为3~10 d。1.2治疗方法全身麻醉或颈丛阻滞麻醉。Thompson入路,用0号线标记肩袖、大小结节,显露肱骨头。取出肱骨头及骨折块,植骨备用,测量肱骨头大小,修整肱骨断面,依次扩髓、试模,确认假体高度及假体后倾角28°~32°,行前后抽屉试验及下方稳定试验,牵拉患肢时肱骨头移动范围不超过肩盂关节面高度的1/2,撤去压力后能自行复位。标记置入深度和方向,取出试模,冲洗髓腔,向肱骨近端髓腔内置入一骨栓以封闭远端髓腔,髓腔内注入骨水泥,置入人工肱骨头假体,待骨水泥固化后复位人工肩关节假体,缝合关节囊,解剖位点修复肩袖及大、小结节,被动活动肩关节,确认活动度在正常范围。术后置引流管24~48 h。术后第3天开始被动活动肩关节,术后1周开始被动外展、前屈、后伸,幅度不宜过大,疼痛在患者耐受范围内;第1~6周患肢悬吊保持中立位,2周内不要内旋,4周后可逐渐在重力辅助下继续钟摆式锻炼。     

闭合复位经皮克氏针内固定治疗儿童严重移位肱骨近端骨折

目的分析闭合复位经皮克氏针内固定治疗儿童严重移位肱骨近端骨折的临床疗效。方法回顾性分析自2017-01—2019-12采用闭合复位经皮克氏针内固定治疗11例儿童严重移位肱骨近端骨折,术中患肢轴向牵引,将骨折远端屈曲、外展、外旋进行复位,复位成功后行经皮克氏针交叉内固定,术后患肢给予悬吊包扎,采用石膏外固定、放置肩关节外展复位枕或肩部外展架进行辅助固定。结果 11例均顺利完成手术,随访时间3～24个月,平均12.6个月。肩关节活动均无受限,未出现神经血管损伤及针道感染。住院时间5～14 d,平均9.1 d。11例均获得解剖复位,骨折均获得骨性愈合,骨折愈合时间4～16周,平均10.2周。末次随访时肩关节功能Neer评分92～100分,平均97.6分。结论闭合复位经皮克氏针内固定治疗儿童严重移位肱骨近端骨折复位效果好,内固定牢固,手术创伤小,骨折愈合快,克氏针易二次取出,患者功能康复良好,疗效满意。     

Humeral head translation during glenohumeral abduction following computer-assisted shoulder hemiarthroplasty

This study compared the effect of a computer-assisted and a traditional surgical technique on the kinematics of the glenohumeral joint during passive abduction after hemiarthroplasty of the shoulder for the treatment of fractures. We used seven pairs of fresh-frozen cadaver shoulders to create simulated four-part fractures of the proximal humerus, which were then reconstructed with hemiarthroplasty and reattachment of the tuberosities. The specimens were randomised, so that one from each pair was repaired using the computer-assisted technique, whereas a traditional hemiarthroplasty without navigation was performed in the contralateral shoulder. Kinematic data were obtained using an electromagnetic tracking device. The traditional technique resulted in posterior and inferior translation of the humeral head. No statistical differences were observed before or after computer-assisted surgery. Although it requires further improvement, the computer-assisted approach appears to allow glenohumeral kinematics to more closely replicate those of the native joint, potentially improving the function of the shoulder and extending the longevity of the prosthesis.     

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.     

Clinical evaluation of a new custom offset shoulder prosthesis for treatment of complex fractures of the proximal humerus

Primary hemiarthroplasty of the shoulder is an accepted procedure to treat complex proximal humeral fractures. The goal of this study was to assess the functional outcome in patients treated with hemiarthroplasty using a custom offset shoulder prosthesis, either for an acute four-part fracture of the proximal humerus or following failed primary treatment of a complex humeral fracture. Thirty seven patients were followed up for a mean of 17 months after shoulder replacement (Group A: four-part-fractures; n = 26, Group B: posttraumatic necrosis/non-union after failed primary treatment; n = 11). The Constant-Murley-Score and radiological score according to Neer's classification were used for postoperative functional and radiological assessment. Following hemiarthroplasty, Group A achieved an average Constant Score of 52 and Group B of 46. The pain relief after hemiarthroplasty was about 53% in Group A and only 33% in Group B. The least satisfying partial function was shoulder mobility in both groups. Radiographic evaluation did not correlate with the Constant Score. Patients secondarily treated with arthroplasty seem to have less chance to achieve a satisfying functional outcome compared to those with immediate hemiarthroplasty. These results emphasise the importance of a careful initial decision to select the most appropriate treatment modality in complex fractures of the proximal humerus.     

肱骨近端锁定接骨板/肱骨近端内锁定系统和人工肱骨头置换治疗成年人肱骨近端骨折的疗效比较

背景:成人肱骨近端骨折,尤其是三、四部分骨折,采用何种治疗方案仍有争论。目的:对采用肱骨近端锁定接骨板/肱骨近端内锁定系统(LPHP/PHILOS)与人工肱骨头置换治疗成年人肱骨近端骨折(proximal humeral fracture,PHF)的临床疗效进行系统评价。方法:检索Ovid Medline和Pub Med(2001年1月至2011年12月)、Embas(e2001年1月至2011年12月)、Cochrane Cen-tral Register of Controlled Trial(s2011年)、中国生物医学文献数据库(CBM,2001年1月至2011年12月)等数据库,搜集全部有关LPHP/PHILOS治疗肱骨近端骨折的各种对照研究,进行系统评价。结果:LPHP/PHILOS与其他内固定治疗成人肱骨近端骨折的系统评价共纳入7个非随机对照试验及1个半随机对照试验,8个研究均为C级。资料分析结果显示:人工肱骨头置换与LPHP/PHILOS比较Neer评分优良率无显著性差异[OR=1.27,95%C(I0.34,4.71),P=0.72];术后其他并发症发生率及二次手术发生率差异无统计学意义。结论:目前认为LPHP/PHILOS与人工肱骨头置换针对特定年龄及特定骨折类型人群各有利弊。对于高龄粉碎性肱骨近端骨折患者(75岁,三/四部分骨折)大部分医生倾向于人工肱骨头关节置换。对于老年骨质疏松性肱骨近端骨折患者,现有文献中没有足够的对照实验证明LPHP/PHILOS相对与人工肱骨头置换的优越性。     

半肩假体置换治疗肱骨近端复杂性骨折的应用研究

目的探讨半肩假体置换治疗肱骨近端NeerⅢ和NeerⅣ骨折的临床疗效及手术要点。方法从2005年9月～2010年10月,本组收治了33例肱骨近端复杂骨折的患者,男14例,女19例;年龄62～80岁,平均73.7岁;左侧11例,右侧22例,NeerⅢ13例,NeerⅣ20例,行LINK半肩假体置换治疗。术后应用改良的半肩关节置换评分系统（scoring system-modification for hemiarthroplasty,SSMH）评分和美国肩肘医师评分（American Shoulder and Elbow Surgeon Score,ASES）评价治疗效果。结果 33例患者中均得到随访,随访时间6～55个月,平均28个月。SSMH评分术后1周平均评分14.5分,末次随访（所有患者随访时间均〉6个月）平均评分25.6分,ASES评分术后1周平均评分45分,末次随访平均为84分。结论半肩关节置换是一种治疗肱骨近端复杂性骨折的有效方法,肩袖重建方式、假体与关节盂吻合度、术后功能锻炼是影响疗效的主要因素。     

Proximal humerus fractures should be treated with a reverse shoulder replacement

Historically, fractures of the proximal humerus not amendable to closed treatment or internal fixation have been treated with hemiarthroplasty. Clinical outcomes following hemiarthroplasty have been variable and difficult to predict. Results are often correlated with increasing age, tuberosity healing, and tuberosity position. Reverse shoulder arthroplasty has demonstrated effectiveness in elderly patients with rotator cuff arthropathy and has been increasingly employed for complex fractures in older patients. Several small trials have compared the reverse arthroplasty and hemiarthroplasty for acute fractures, and reverse shoulder arthroplasty has demonstrated more reproducible results in elderly patients.     

Neurological impairment in proximal humeral fractures-dislocations undergoing shoulder replacement

Abstract The outcome of shoulder replacement for trauma has been studied in large series but not always all factors have been examined for their effects on the final results. One important element not sufficiently considered regards neurological impairment. This complication is reported in 1%–67% of shoulder dislocations and humeral neck fractures. Electromyography has an important role in revealing nerve injuries undetected by clinical examination alone. Three patients with typical neurological impairment complicating proximal humeral fractures are reported. The cases were studied through clinical, radiographical and electromyographical examinations, before and after undergoing shoulder hemiarthroplasty. Only a few reports have described nerve lesions in hemiarthroplasty for proximal humeral fractures, we discuss these typical cases and review the recent literature on the topic.     

Reverse shoulder arthoplasty as treatment for comminuted proximal humeral fractures in elderly patients

The results of hemiarthroplasty as treatment for comminuted humerus fractures are poor in elderly patients. While hemiarthroplasty is also an unreliable treatment for rotator cuff tear arthropathy, reverse shoulder arthroplasty (RSA) has been a reliable salvage procedure. The present study examines the result of RSA as treatment for comminuted proximal humeral fractures in elderly patients. Thirteen elderly patients underwent RSA for comminuted proximal humeral fractures. Follow-up ranged from 8 months to 46 months. Patients were assessed retrospectively for Constant-Murley score, rate of complications, and postoperative radiographic review, and data were compared to historical controls. Mean Constant-Murley score was 67 points (range, 45-77 points). No dislocations occurred. Two patients sustained a postinjury auxiliary nerve palsy, one of which resolved only partially. One patient sustained a postinjury radial nerve palsy that resolved. One patient underwent evacuation of a postoperative wound hematoma. No shoulder needed revision. RSA should be considered a salvage procedure, whether performed for cuff tear arthropathy or severe proximal humerus fracture. Even so, RSA can provide immediate shoulder stability for elderly patients with severe shoulder injuries, and results compare favorably to historical controls for hemiarthroplasty in these patients.     

锁定钢板与半肩关节置换治疗肱骨近端骨折临床疗效系统评价

目的通过文献系统综述,比较切开复位锁定钢板内固定与半肩关节置换治疗严重肱骨近端骨折后临床疗效及常见并发症方面的差异,以评价两种治疗方法的优劣。方法计算机检索Pubmed、Embase、Cochrane数据库2010年10月31以前有关锁定钢板及半肩关节置换治疗肱骨近端骨折的前瞻性或回顾性临床研究文献。阅读评价文献质量并提取有效数据,采用SPSS17.0软件进行描述性统计分析。结果37篇文献纳入系统评价,共2089例患者。平均Constant-Murley功能评分,锁定钢板组为72.37(SD=6.68),半肩关节置换组为52.43(SD=7.64),但锁定钢板组平均Constant-Murley评分高于半肩关节置换组之差异,可能与选择偏倚和评估偏倚相关。锁定钢板组总并发症发生率变异较大,最低为6.2%,最高达61.7%。锁定钢板组常见并发症有螺钉穿出(7.5%,n=87)、肩峰撞击(2.8%,n=33)、肱骨头缺血坏死(7%,n=81)、骨折不愈合(1.2%,n=14)及内固定失效(4.6%,n=53),其中14%需要二次手术处理。半肩关节置换术后常见并发症有假体松动及错位(5.1%,n=48)、大结节异常(25.3%,n=235)、严重疼痛(2.8%,n=26)。结论目前缺乏有说服力的临床证据证明锁定钢板与半肩关节置换治疗严重肱骨近端骨折的优劣差异,应针对不同患者的具体情况采取个体化治疗策略。仍需要更多大样本、多中心、高质量的临床随机对照研究进一步验证。