二期反式肩关节置换治疗肱骨近端骨折内固定术后感染

目的总结二期反式肩关节置换治疗肱骨近端骨折内固定术后感染的疗效。方法2014年6月—2018年1月,收治17例肱骨近端骨折内固定术后感染伴肱骨头坏死或骨不连患者。男8例,女9例;年龄52~78岁,平均63.8岁。初次内固定术后19~66个月确诊发生感染,平均34.8个月。关节腔液体微生物培养14例阳性、3例阴性。术前Constant评分为(36.41±8.65)分,美国肩肘外科协会(ASES)评分为(31.06±7.43)分,疼痛视觉模拟评分(VAS)为(7.29±0.99)分。肩关节前屈(45.88±12.46)°,外展(42.18±12.31)°,外旋(16.76±4.92)°,内旋达臀部9例、腰骶关节3例、L35例。一期扩创、内固定物取出及植入抗生素骨水泥占位器,待感染消失后行二期反式肩关节置换。两期手术间隔时间为3.0~6.5个月,平均4.2个月。结果两期手术术后切口均Ⅰ期愈合,均无感染复发、血管神经损伤等并发症发生。患者均获随访,随访时间15~32个月,平均22.0个月。末次随访时,肩关节前屈(109.00±23.66)°、外展(98.53±16.92)°、外旋(41.41±6.82)°,内旋达腰骶关节5例、L38例、T124例,Constant评分为(64.88±8.70)分,ASES评分为(65.18±8.10)分,VAS评分为(2.94±1.25)分,均较术前明显改善(P<0.05)。X线片复查示均无假体松动。结论二期反式肩关节置换治疗肱骨近端骨折内固定术后感染伴肱骨头坏死或骨不连,能有效控制感染复发,改善肩关节功能,近期疗效满意。

Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture

Objective To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture.Methods Between June 2014 and January 2018,17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated.There were 8 males and 9 females,aged from 52 to 78 years(mean,63.8 years).The infection occurred at 19-66 months after the initial internal fixation(mean,34.8 months).Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases.The preoperative Constant score,American shoulder and elbow surgeons(ASES)score,and visual analogue scale(VAS)score were 36.41±8.65,31.06±7.43,and 7.29±0.99,respectively.The preoperative ranges of forward flexion,abduction,external rotation were(45.88±12.46),(42.18±12.31),and(16.76±4.92)°,respectively.The preoperative range of internal rotation was buttock in 9 cases,lumbosacral joint in 3 cases,L3 in 5 cases.At the first-stage surgery,the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation.After the infections disappeared,the two-stage reverse total shoulder arthroplasty was performed.The mean interval between the two procedures was 4.2 months(range,3.0-6.5 months).Results All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred.All patients were followed up 15-32 months(mean,22.0 months).At last follow-up,the ranges of forward flexion,abduction,and external rotation were(109.00±23.66),(98.53±16.92),(41.41±6.82)°,respectively;and the range of internal rotation was lumbosacral joint in 5 cases,L3 in 8 cases,T12 in 4 cases.The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion(P<0.05).The Constant score(64.88±8.70),ASES score(65.18±8.10),and VAS score(2.94±1.25)were significantly superior to the preoperative scores(P<0.05).X-ray films showed that no prosthesis loosening occurred.Conclusion Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture,which has advantages of low risk of infection recurrence,good shoulder function,and satisfactory short-term effectiveness.