成人肱骨远端骨折切开复位内固定术后异位骨化形成的影响因素

目的探讨成人肱骨远端骨折切开复位内固定术后异位骨化形成的影响因素。 方法2014年12月至2017年12月，对138例（139肘）成人肱骨远端骨折切开复位内固定术后患者进行回顾性分析。平均年龄（45.32±15.02）岁（18~69岁）；男56例，平均年龄（39.43±14.46）岁（18~69岁）；女82例，平均年龄（49.07±14.07）岁（18~69岁）。采用AO/OTA分型：B1型5肘；B2型6肘，鹰嘴截骨1肘；B3型48肘，鹰嘴截骨28肘；C1型12肘；C2型37肘，鹰嘴截骨21肘；C3型31肘，鹰嘴截骨31肘。应用X线片评估术后肘关节异位骨化形成情况，采用Mayo肘关节功能评分（Mayo elbow performance score，MEPS）、上肢功能评分表（disability of arm shoulder and hand，DASH）评估肘关节功能。对性别、年龄、损伤侧别、入院时空腹血糖、体重指数、骨折AO/OTA分型、手术中是否采用尺骨鹰嘴截骨及术后是否口服吲哚美辛等可能影响肘关节异位骨化形成的因素进行单因素及多因素Logistic回归分析。 结果术后获随访平均（14.26±3.83）个月（12~25个月）。术后切口均Ⅰ期愈合，无感染及愈合不良。肱骨远端骨折及尺骨鹰嘴截骨均愈合，无延迟愈合、不愈合及内固定物松动。末次随访时，肘关节平均屈伸活动度99.35°±28.72°（135° ~0°），MEPS评分（91.71±9.36）分（60~100分），DASH评分（6.71±8.25）分（2.88~41.66分）。末次随访时，1例患者前臂旋转轻度受限，旋前50°，旋后30°，其余患者前臂旋转功能均正常。单因素Logistic回归分析发现年龄（P=0.009）、空腹血糖（P=0.005）、尺骨鹰嘴截骨（P=0.016）、手术时间（P=0.016）、骨折分型（P=0.049）差异有统计学意义。C3型骨折较其他类型的异位骨化发生率更高（P=0.049）。受伤至手术时间≤6 d与>6 d的差异无统计学意义（P=0.058）。是否口服吲哚美辛差异无统计学意义（P=0.424）。多因素Logistic回归分析发现，是否尺骨鹰嘴截骨和空腹血糖差异有统计学意义（P=0.024,P=0.016）。 结论影响肱骨远端骨折切开复位内固定术后肘关节异位骨化形成的主要因素是尺骨鹰嘴截骨和空腹血糖，吲哚美辛不是主要的影响因素。复杂骨折的创伤更重，手术中常需要尺骨鹰嘴截骨以利于关节面骨折的解剖复位和内固定，异位骨化的发生率较高。

Influence factors of heterotopic ossification formation after open reduction and internal fixation for distal humeral fractures in adults

BackgroundHeterotopic ossification (HO) refers to the pathological process of new bone formation within the soft tissue or outside the intra-articular bone. It commonly occurs in patients with severe trauma or bone morphogenetic protein (BMP) receptor gene mutation.Heterotopic ossification of elbow joint is one of the main reasons for limited elbow function. Distal humeral fracture is a common injury of elbow joint. It has been reported that the incidence of heterotopic ossification after operation of distal humeral fracture is about 45%, and the influence factors are numerous. Which of the many influence factors plays a major role? Whether indomethacin is effective for preventing heterotopic ossification of elbow joint? Currently, there is no consistency among the reported literatures. Objective To investigate the influence factors of heterotopic ossification after open reduction and internal fixation for distal humeral fractures in adults. MethodsFrom December 2014 to December 2017, 138 patients (139 elbows) who underwent open reduction and internal fixation for distal humeral fractures were retrospectively reviewed. The heterotopic ossification was evaluated with X-rays, and the elbow joint function were also assessed using Mayo score and DASH score. Univariate and multivariate Logistic regression analysis were performed for gender, age, injury side, fasting blood glucose on admission, body mass index (BMI) , AO/OTA classification of fracture, whether to perform olecranon osteotomy during operation and whether to take indomethacin after operation. ResultsThe mean age of 138 patients was (45.32±15.02) years (18-69 years) , the mean age of 56 males was (39.43±14.46) years (18-69 years) , and the mean age of 82 females was (49.07±14.07) years (18-69 years) . According to AO/OTA classification, there were 5 cases of type B1 fractures, 6 cases of type B2 fractures with 1 case of olecranon osteotomy included, 48 cases of type B3 fractures with 28 cases of olecranon osteotomy included, 12 cases of type C1 fractures, 37 cases of type C2 fractures with 21 cases of olecranon osteotomy included, and 31 cases of type C3 fractures with 31 cases of olecranon osteotomy included. The mean time from injury to operation was (7.06±5.36) days (2-56 days) , and the mean operation time was (124.94±44.24) minutes (40-280 minutes) . Oral indomethacin was not taken among 50 cases (51 elbows) , but it was taken among 88 cases (88 elbows) . The mean postoperative follow-up time was (14.26±3.83) months (12-25 months) . All the incisions healed in the first stage after operation without infection and poor healing. All the distal humeral fractures as well as olecranon osteotomy healed without delay, nonunion or internal fixation loosening. At the last follow-up, the mean range of elbow flexion and extension was 99.35°±28.72° (135°-0°) , the mean Mayo score was (91.71±9.36) points (60-100 points) , and the mean DASH score was (6.71±8.25) (2.88-41.66 points) . At the last follow-up, one patient's forearm rotation was slightly restricted, with 50°of pronation and 30°of supination. The rest of the patients had normal forearm rotation. Univariate Logistic regression analysis revealed statistical differences in age (P=0.009) , fasting blood glucose on admission (P=0.005) , ulna olecranon osteotomy (P=0.016) , operation time (P=0.016) , and fracture classification (P=0.049) . Type C3 fractures had a higher incidence of heterotopic ossification than other types (P=0.049) . There was statistical difference of time from injury to operation between≤6 d and > 6 d (P=0.058) . There was no significant difference in whether oral indomethacin was taken (P=0.424) . Multivariate Logistic regression analysis revealed that there were statistical differences in whether or not to perform olecranon osteotomy and fasting blood glucose,respectively (P=0.024,P=0.016) . ConclusionsThe main factors causing the formation of heterotopic ossification of elbow joint after open reduction and internal fixation for distal humeral fractures were olecranon osteotomy and fasting blood glucose, while whether or not to take oral indomethacin after operation was not. The trauma of complex fracture is usually severer, and the olecranon osteotomy is often required to facilitate the anatomical reduction and internal fixation of articular surface and thus the incidence of heterotopic ossification is higher.