肱骨头置换治疗肱骨近端粉碎性骨折中期疗效分折

目的探讨肱骨头置换治疗肱骨近端粉碎性骨折的临床疗效。方法对2001年7月～2006年12月采用肱骨头置换治疗的55例肱骨近端粉碎性骨折患者临床资料进行回顾性分析，根据Neer分类：三部分骨折39例，四部分骨折16例，均为新鲜骨折，所有假体均采用单极骨水泥型假体。结果55例关节活动度：外展平均100°（90°～110°），前屈95°（80°～100°），外旋35°（30°～40°），内旋L2水平（L1-～L3）。采用半关节成形改良评分系统（SSMH）对患肩进行综合评分，本组评定结果平均26.2分（23～28分），优（27分以上）41例，良（24-27分）7例，优良率达87．3％。无假体松动、下沉或断柄，无肩袖功能不全、关节不稳、异位骨化、脱位等并发症。结论肱骨头置换对于肱骨近端粉碎性骨折是一种行之有效的治疗方法，慎重选择适应证和假体、精细的手术操作和完善的术后功能锻炼是治疗成功与否的关键。     

Shoulder hemiarthroplasty for fractures of the proximal humerus

Proximal humeral fractures were managed with primary hemiarthroplasty in 57 patients, 53 women (93%) and 4 men (7%) aged 51-87 years (mean 72.2). The mean follow-up period was 52 months (range 12-98), and the mean Constant score was 59.2 (range 38-76). Patients were very satisfied (n = 19); satisfied (n = 32) or dissatisfied with the outcome (n = 5). One patient required early revision surgery. Surgical treatment of three- and four-part fractures of the proximal humerus with hemiarthroplasty is a safe and effective approach, the outcome of which appears to be related to the quality of the anatomical reconstruction of the tuberosities.     

Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up

Significant discrepancy in the functional outcome of hemiarthroplasty for proximal humerus fractures has been reported with short or mid-term follow-up. This study reports the long-term results and rate of complications of shoulder arthroplasty in the treatment of proximal humerus fractures. The review comprised 57 patients (44 women, 13 men) who underwent hemiarthroplasty between 1976 and 1996 as treatment of a proximal humerus fracture and who had a minimum 5-year follow-up (mean, 10.3 years). The mean patient age was 66 years at the time of surgery (range, 23-89 years). According to a modified Neer result rating system, results were satisfactory in 27 patients and unsatisfactory in 30. The mean active elevation was 100 degrees (range, 20 degrees -180 degrees ) and external rotation was 30 degrees (range, 0 degrees -90 degrees ). At the most recent follow-up, 9 patients (16%) had moderate or severe pain and 2 required implant revision or removal. The study data suggest that patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. In view of these results, current indications, surgical technique, and postoperative treatment may need to be revisited.     

Outcomes of hemiarthroplasty for fractures of the proximal humerus

We reviewed 80 shoulders (72 shoulders in 71 patients) treated with hemiarthroplasty. At follow-up, 66 patients (93%) were pain-free and satisfied with their results; the mean American Shoulder and Elbow Surgeons score was 76.6, the mean Simple Shoulder Test score was 7.5, the average forward flexion was 128 degrees, external rotation was 43 degrees, and internal rotation was to L2. Radiographic analyses revealed nearly anatomic tuberosity reconstruction in 58 shoulders, heterotopic ossification in 18, pseudosubluxation in 10, and superior migration in 15. Patients with superior migration had statistically lower mean American Shoulder and Elbow Surgeons scores, mean Simple Shoulder Test scores, and decreased forward flexion. Tuberosity complications occurred in 16 shoulders. Malunion of the greater tuberosity was the most common complication. Healing of the greater tuberosity more than 2 cm below the humeral head correlated with a worse functional result. Hemiarthroplasty for indicated fractures of the proximal humerus results in shoulder-level function and reproducible pain relief.     

Shoulder hemiarthroplasty for the treatment of complex proximal humeral fractures

Objective: To investigate the indication, perioperative announcements, selection of prosthesis and clinical results of shoulder hemiarthroplasty for the treatment of complex proximal humeral fractures.Methods: A total of 55 patients who suffered from com-plex proximal humeral fractures were treated by shoulder hemiarthroplasty. The mean age was 55.6 years and mean follow-up period was 25.1 months. The scoring system modi-fication for hemiarthroplasty (SSMH) had been adopted for evaluation at the latest follow-up.Results: The pain was obviously relieved in all patients. Fifty patients were painless and 5 patients had slight pain. The mean range of motion was 100°(90°-110°) in abduction, 95°(80°-100°) in forward flexion, 35°(30°-40°) in extemal rotation and internal rotation was confined at L2 level (L1-L3). The mean SSMH score was 27.9 (24-29). Fifty patients (90.1%) were satisfied with the clinical outcome.Conclusions: Shoulder hemiarthroplasty is an effective method to treat complex proximal humeral fractures. The proper selection of patients and prosthesis, good operation skill and enough functional exercise are the key points of successful treatment.     

半肩关节置换术治疗肱骨近端复杂骨折疗效分析

[目的]评估半肩关节置换治疗肱骨近端复杂骨折的疗效并对其影响因素予以分析.[方法]2006年1月～2009年6月,对36例肱骨近端3部分、4部分骨折以半肩关节置换术进行治疗.采用Neer评分和Constant-Murley评分作为术后肩关节功能临床评估标准.以术后真实前后位等比例X线平片上肱骨大结节重建位置、假体位置、肩峰、喙突之间的关系作为影像学评估参数.[结果]所有患者均获随访,平均随访时间18个月(13～38个月).35例(97%)术后肩关节活动时无疼痛或仪有轻度疼痛.末次随访时肩关节平均前屈126°,平均外旋40°,平均内旋至L<,3>椎体水平.根据Neer评分,18例患者对手术结果非常满意,10例对手术结果满意,8例对手术结果不满意.Constant-Murley评分为(68±20)分(20～97分).骨折后1周内手术病例的Neer评分优于1周后进行手术的病例.术后Constant-Mur]ey评分与肱骨偏心星巨呈正相关,与头结节间距(head to tuberosity distance,HTD)呈负相关.[结论]骨折后早期手术有利于术后肩关节功能的恢复.肱骨偏心距和头结节间距是影响半肩置换术后肩关节功能的重要因素.     

Modular hemiarthroplasty for fractures of the proximal part of the humerus.

A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in twenty-two shoulders in twenty-two patients. The fractures were classified according to the Neer system; there were thirteen four-part, five three-part, and four head-splitting fractures. There were fifteen women and seven men, and the mean age was seventy years (range, forty-nine to eighty-seven years). The hemiarthroplasty was performed an average of eleven days (range, one to forty-five days) after the injury. The deltopectoral interval was used in all patients, and the prosthesis was implanted with cement in twenty of the shoulders. All of the patients participated in a supervised program of rehabilitation. The patients were followed for an average of thirty-six months (range, twenty-six to forty-nine months). Twenty of the twenty-two patients had a good or excellent result. The active forward elevation averaged 119 degrees; external rotation, 40 degrees; and internal rotation, to the twelfth thoracic vertebra. All of the patients except for the two who had a poor result had satisfactory relief of pain. The two patients who had a poor result had a successful revision with a modular prosthesis of the same design. The modular head could be removed, enabling the surgeon to gain access to the glenoid and to adjust the soft tissues. The over-all scores correlated inversely with the age of the patients and the interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

肱骨近端骨折肱骨头置换假体高度的控制

目的:评估利用大结节骨折片复位的方法,确定肱骨近端骨折肱骨头置换假体高度的临床疗效。方法:回顾性研究2015年1月至2019年12月收治并获得随访的肱骨近端骨折患者,符合肱骨头置换指征19例,男7例,女12例;左侧8例,右侧11例;年龄58~84(71.5±5.8)岁;受伤至手术时间3~18(7.9±4.3) d。根据Neer分型,3部分骨折伴脱位2例,4部分骨折17例,其中伴肱骨头脱位6例,肱骨头劈裂2例。19例采用组配式肱骨头假体,在手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离作为假体高度的标准。术后1年采用Constant-Murley评分,美国加州大学洛杉矶分校(University of California,Los Angeles,UCLA)肩关节评分评价肩关节功能状况及患者满意度。结果:19例均获随访,时间12~58(31.9±14.2)个月。测量手术后上臂长度26~32 cm,双侧比较误差<0.5 cm。术后3个月肩关节正侧位X线片示骨折均愈合。术后1年Constant-Murley评分(80.8±8.9)分,UCLA评分(27.9±4.8)分。术后1年患者满意度89.5%(17/19)。结论:肱骨近端骨折肱骨头假体置换手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离确定假体高度,方法简单准确,临床效果良好。     

人工肱骨头置换治疗肱骨近端三、四部分骨折

目的探讨人工肱骨头置换治疗肱骨近端骨折,术中应注意的关键问题. 方法采用Thompson入路行人工肱骨头置换术23例. 术后随访6～36个月,平均随访21.1个月.用ASES评分对患肩进行术后功能评估.结果医师客观评定:全部患者肩关节活动明显改善,肌力恢复良好,肩关节稳定,5例轻压痛,1例发生撞击.患者主观评定:疼痛平均102分,肩关节稳定平均106分,完成10个日常生活动作22例,完成7个日常生活动作1例.复查X线片显示人工肱骨头位置良好,无假体松动,肱骨大、小结节骨折愈合. 结论术中肩周软组织保护及修复,人工肱骨头假体安装和肱骨大、小结节解剖重建是提高人工肱骨头置换术疗效的关键技术.     

Shoulder hemiarthroplasty for the treatment of three and four part fractures of the proximal humerus using Comprehensive? Fracture stem

We looked at the functional outcome of 32 consecutive patients with proximal humeral fractures that required hemiarthroplasty. Functional status was assessed using University of California Los Angeles (UCLA) shoulder end result assessment, simple shoulder test (SST) and American Shoulder and Elbow Society (ASES) shoulder index. Mean age of the patients was 72.2 years and the mean follow-up was 25.3 months. The mean score on UCLA shoulder end result assessment was 24.8, the mean SST score was 7.4 and the mean ASES shoulder index was 67.2. Mean active forward elevation was 85.1°. Patient satisfaction was around 81%. Radiologically, no dislocation, loosening or greater tuberosity pull off was seen. Superior migration of the humeral head was seen in 11 patients (34%). There was no significant difference seen in functional outcome among different genders, age and those who had radiological superior migration of the prosthesis. However, there was a significant statistical difference seen in the functional outcome between patients who had a deficient or a good quality cuff showing that quality of the rotator cuff is an important predicator of functional outcome.     

The continuing role of hemiarthroplasty in the treatment of proximal humerus fractures

Three- and four-part proximal humerus fractures may be successfully managed with non-operative or operative treatment. When surgery is indicated, younger patients with proximal humerus fractures commonly undergo open reduction and internal fixation, while older patients are often treated with reverse shoulder arthroplasty. However, for the active, older patient with a fracture that cannot be reliably reconstructed, hemiarthroplasty remains a viable treatment option. The orthopedic surgeon must carefully review each patient’s overall clinical picture and select the treatment technique with the most advantageous risk/benefit profile for that individual.     

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.     

Treatment of comminuted proximal humerus fractures with shoulder hemiarthroplasty in elderly patients

This retrospective study was done to find out the outcome of hemiarthroplasty of the shoulder following comminuted proximal humeral fractures in 20 elderly patients. Their average age was 77.6 years. The average follow-up was 33 months. All patients were reviewed in the outpatient clinic using the Constant Score. The median Constant Score was 47.5. None of the patients had severe pain. Four had moderate and 16 had no or mild pain. Range of movement was not good. The activities of daily living were significantly reduced in patients with moderate shoulder pain. Sixteen patients (80%) were satisfied with the outcome of the management of their shoulder injury. Radiological assessment showed malrotation of the prosthesis and ectopic ossification in one patient each. Osteolysis around the greater tuberosity was noted with three isoelastic prostheses. Seven patients showed proximal migration of the prosthesis although there was no significant difference in functional results. Complications included fatal pulmonary embolism in one patient. Overall, hemiarthroplasty of the shoulder gave good pain relief but there was only moderate functional improvement.     

单纯人工肱骨头置换术治疗肱骨近端粉碎性骨折

目的探讨单纯人工肱骨头置换术治疗肱骨近端严重3～4部分骨折的方法及其效果。方法对本组12例肱骨近端粉碎性骨折患者进行了单纯人工肱骨头置换术,其中男5例,女7例,年龄42～67岁,平均（54．3±3．4）岁。按AO骨折分类标准,9例B2型骨折,2例B3型骨折,1例c3型骨折。结果术后随访9～36个月,平均17．2个月。采用Neer标准评定患者肩关节功能,其中4例大于90分,其余均在80分以上。结论对于肱骨近端粉碎性骨折而言,单纯人工肱骨头置换术是一种疗效较好的治疗方法,人工肱骨头假体安装和肱骨大、小结节解剖重建是提高人工肱骨头置换术疗效的关键,并且术中注意修复损伤的肩袖。术后需要求患者积极进行康复训练促进功能恢复。     

AO肱骨近端锁定系统在肱骨近端骨折治疗中的应用

肱骨近端骨折(proximal humeral fracture,PHF)占骨折发病总数的5%,而且在老年人骨折发病率中排名第3[1].可用于肱骨近端骨折治疗的传统内固定物包括三叶草钢板、T型钢板、1/3管型钢板等.利用传统钢板内固定治疗肱骨近端骨折的一大缺陷是由于螺钉松脱而导致骨折再次移位,特别是在骨质疏松患者中此比例更是高达16%～27%[2-3].过去针对骨量丢失的肱骨近端三、四部分骨折的治疗方法只有肩关节置换,然而固定后大、小结节的坏死导致预后功能的不确定性也限制了低要求的骨量丢失患者采用半肩关节置换[4-5].