韓立強(qiáng) 江漢 肖聯(lián)平 楊國(guó)躍 江毅 張殿英

T形切口下微創(chuàng)鎖定鋼板治療肱骨近端骨折療效探討

韓立強(qiáng) 江漢 肖聯(lián)平 楊國(guó)躍 江毅 張殿英

目的回顧性分析T形切口下微創(chuàng)鎖定鋼板治療肱骨近端骨折的療效。方法自2011年1月至2013年8月,我院收治肱骨近端骨折患者35例,分類(lèi)方法采用AO分型,其中11-A2型7例,11-A3型12例,11-B1型8例,11-B2型6例,11-C1型2例,均采用T型切口下鎖定鋼板手術(shù)治療,術(shù)后2～3 d開(kāi)始肩關(guān)節(jié)被動(dòng)活動(dòng)鍛煉,逐漸增加活動(dòng)范圍,術(shù)后2周開(kāi)始肩關(guān)節(jié)擺動(dòng)鍛煉,術(shù)后3周開(kāi)始肩關(guān)節(jié)鍛煉,并采用Neer肩關(guān)節(jié)功能評(píng)分。結(jié)果本組35例患者手術(shù)切口均一期愈合,所有患者均得到隨訪,隨訪時(shí)間5～16個(gè)月,平均13.1個(gè)月,骨折均骨性愈合,術(shù)后未發(fā)現(xiàn)腋神經(jīng)損害表現(xiàn),未發(fā)現(xiàn)退釘、鋼板松動(dòng)。Neer肩關(guān)節(jié)功能評(píng)分:優(yōu)19例,良10例,可6例。結(jié)論T形切口下微創(chuàng)鎖定鋼板治療肱骨近端骨折具有創(chuàng)傷小、功能恢復(fù)快、臨床療效佳的優(yōu)點(diǎn),尤其適于AO分型的A2、A3型和B型骨折的治療。

肱骨骨折,近端;微創(chuàng);鎖定鋼板;切口

在65歲以上的人口中,肱骨近端骨折發(fā)病率排在髖部骨折和Colles骨折之后,處于第三位。隨著社會(huì)人口的老齡化,肱骨近端骨折日益普遍,移位性的肱骨近端骨折往往會(huì)造成長(zhǎng)期的功能障礙。對(duì)不穩(wěn)定并且移位的骨折而言,手術(shù)治療效果最佳。目前鎖定鋼板在肱骨近端骨折的治療中已得到廣泛應(yīng)用,并取得了良好的臨床效果[1]。因傳統(tǒng)的胸大肌-三角肌入路創(chuàng)傷較大,近年來(lái)越來(lái)越多的醫(yī)生嘗試應(yīng)用小切口下微創(chuàng)技術(shù)治療肱骨近端骨折[2]。我院自2011年1月至2013年8月采用T形切口微創(chuàng)鎖定鋼板治療肱骨近端骨折35例,在此作一總結(jié)分析。

資料與方法

一、一般資料

本組病例共35例,男性16例,女性19例,年齡31～72歲,平均年齡56.3歲,左側(cè)15例,右側(cè)20例,均為新鮮骨折。致傷原因:自行摔傷20例,高處墜落傷6例,車(chē)禍傷9例。所有患者術(shù)前均行X線及CT三維重建檢查(圖1,2)。

二、骨折分型

本組病例采用AO分型,其中11-A2型7例,11-A3型12例,11-B1型8例,11-B2型6例,11-C1型2例。

三、手術(shù)方法

患者麻醉后采取沙灘椅位,術(shù)前于體表標(biāo)注手術(shù)切口、肩峰及腋神經(jīng)大致位置,于肩關(guān)節(jié)外側(cè)肩峰下約一橫指處行長(zhǎng)約6 cm橫行切口,切開(kāi)皮下組織后縱行切開(kāi)深筋膜,通過(guò)辨認(rèn)肌腹之間的脂肪纖維紋,找到三角肌前部和中間部肌肉之間的間隙,縱行鈍性劈開(kāi),劈開(kāi)距離不宜超過(guò)6 cm,以免損傷腋神經(jīng)。將劈開(kāi)的三角肌牽向兩側(cè),暴露三角肌下滑囊,將其縱行切開(kāi)暴露肱骨大結(jié)節(jié)及骨折端。在肩關(guān)節(jié)外展?fàn)恳峦ㄟ^(guò)撬撥及手法推壓骨折塊的方法完成復(fù)位,以結(jié)節(jié)間溝、大結(jié)節(jié)作為復(fù)位指標(biāo),復(fù)位滿意后維持肘關(guān)節(jié)屈曲外展,保證30°～40°后傾角,以克氏針臨時(shí)固定,選用長(zhǎng)度合適的鋼板(均選用AO辛迪斯公司的PHILOS鋼板),另于骨折遠(yuǎn)端行長(zhǎng)約3 cm縱行切口(圖3),將鋼板沿骨膜上植入,鋼板放置于距離肱骨大結(jié)節(jié)上緣5～8 mm、結(jié)節(jié)間溝外側(cè)2～4 mm,C臂X線機(jī)透視位置滿意后,近端植入5～9枚鎖定螺釘,遠(yuǎn)端植入3枚雙皮質(zhì)鎖定螺釘(圖4,5),常規(guī)植入引流管。術(shù)后以三角巾懸吊固定3～4周。

結(jié) 果

本組35例患者手術(shù)切口均一期愈合。術(shù)后2～3 d開(kāi)始肩關(guān)節(jié)被動(dòng)活動(dòng)鍛煉,逐漸增加活動(dòng)范圍,術(shù)后2周開(kāi)始肩關(guān)節(jié)擺動(dòng)鍛煉,術(shù)后3周開(kāi)始肩關(guān)節(jié)上舉、外展、后伸及前屈鍛煉。所有患者均獲得隨訪,隨訪時(shí)間5～16個(gè)月,平均13.1個(gè)月,骨折均骨性愈合,未發(fā)現(xiàn)腋神經(jīng)損傷表現(xiàn),未發(fā)現(xiàn)退釘、鋼板松動(dòng)。采用Neer肩關(guān)節(jié)功能評(píng)分[3]:優(yōu)19例,良10例,可6例。

討 論

微創(chuàng)是指以最小的侵襲和最小的生理干擾達(dá)到最佳手術(shù)療效的一種手術(shù)或檢查方式,最主要特征是創(chuàng)傷小。意外創(chuàng)傷對(duì)人體有極大的危害性且難以避免,而外科手術(shù)作為有計(jì)劃的創(chuàng)傷,術(shù)者有必要力求將創(chuàng)傷降到最低限度,即達(dá)到微創(chuàng)的目的。微創(chuàng)手術(shù)理念目前在骨科各個(gè)領(lǐng)域均獲得了較大的發(fā)展,其致力于軟組織的保護(hù)、獲得更好的預(yù)后功能的理念已逐漸成為共識(shí),并為臨床療效所證實(shí)。

圖1～5 患者,女,62歲,自行摔傷,骨折分型為11-C1型。圖1肱骨近端骨折術(shù)前正位X線片;圖2肱骨近端骨折術(shù)前CT三維重建片;圖3術(shù)中手術(shù)切口示意圖;圖4～5肱骨近端骨折術(shù)后正位及穿胸位X線片

一、微創(chuàng)治療適應(yīng)證

鎖定鋼板的出現(xiàn)為肱骨近端骨折微創(chuàng)治療的實(shí)施提供了條件,并且在四肢骨折中的應(yīng)用也取得了良好的臨床效果[4]。但并不是所有的肱骨近端骨折都適于微創(chuàng)治療,嚴(yán)格把握手術(shù)適應(yīng)證才能取得最佳療效,不能一味追求微創(chuàng)而喪失手術(shù)固定的基本原則,良好的復(fù)位、固定仍是手術(shù)成功、獲得良好預(yù)后的重要決定因素。本組病例在手術(shù)適應(yīng)證選擇上根據(jù)閉合復(fù)位的難易程度主要偏重于AO分型的A2、A3型與B型骨折,部分閉合復(fù)位不佳的病例亦可通過(guò)上端橫切口直接復(fù)位,但對(duì)于C型骨折來(lái)說(shuō),技術(shù)性要求較高,若閉合復(fù)位技巧掌握不好,則難以達(dá)到理想的復(fù)位,且T形切口暴露相對(duì)不充分,不利于直視復(fù)位,故仍建議采用傳統(tǒng)的胸大肌-三角肌入路。

二、手術(shù)切口

胸大肌-三角肌入路是治療肱骨近端骨折的傳統(tǒng)手術(shù)入路,其位于肩關(guān)節(jié)前方,可很好地暴露盂肱關(guān)節(jié),但肱骨近端外側(cè)區(qū)域顯露欠佳,鎖定鋼板放置的理想位置位于肱骨側(cè)方,在此入路下鋼板的放置位置顯示困難,同時(shí)因鎖定螺釘由外向內(nèi)的置入方向已固定,故在前方切口內(nèi)完成鉆孔和置釘也較為困難。該入路術(shù)中為充分暴露肱骨頭側(cè)面,通常在肩袖上縫合絲線或在肱骨頭上置入臨時(shí)克氏針作為牽引,維持肱骨頭內(nèi)旋,但在行肱骨頭復(fù)位和鋼板放置時(shí)通常需要內(nèi)旋或外旋前臂,從而導(dǎo)致已復(fù)位的肱骨頭或者位置良好的鋼板出現(xiàn)位置丟失。另外,該手術(shù)入路對(duì)軟組織剝離廣泛,亦有損傷旋肱前動(dòng)脈的潛在風(fēng)險(xiǎn),可能不利于骨折的愈合,并且增加肱骨頭缺血性壞死的可能性。因此,目前鎖定鋼板廣泛應(yīng)用于肱骨近端骨折治療的情況下,胸大肌-三角肌入路并不是最佳的入路選擇。

肩峰前外側(cè)入路,即劈開(kāi)三角肌入路,最早僅適用于局限性手術(shù),用于暴露止于肱骨大結(jié)節(jié)的肌腱和三角肌下的滑囊,但隨著鎖定鋼板技術(shù)的發(fā)展與廣泛應(yīng)用,因其結(jié)合間接復(fù)位技術(shù)對(duì)骨折局部的軟組織破壞少,并使鋼板易于放置于最佳位置,可顯著改善功能預(yù)后,所以該入路又再次受到臨床重視。本組病例采用的手術(shù)切口在此基礎(chǔ)上進(jìn)行了改善,近端皮膚切口未采用縱切口,而采用橫切口,整體呈“T”形切口(圖3),深部組織暴露與其相同,因肩部皮紋為橫行,橫行切口愈后瘢痕相對(duì)較小且更為美觀,患者也更易接受。

肩峰前外側(cè)入路相對(duì)于胸大肌-三角肌入路來(lái)說(shuō),鋼板的放置相對(duì)更容易,T型切口優(yōu)越性顯著,但文獻(xiàn)報(bào)道不多,普及率不高,究其原因主要是解剖不熟悉,難以保證腋神經(jīng)不受損。解剖學(xué)研究顯示腋神經(jīng)自四邊孔穿出后繞行于肱骨外科頸后方,位于三角肌后緣中點(diǎn),其解剖位置位于上肢中立位時(shí)肩峰下緣大約6.5 cm處,由三角肌后緣橫行直至其前緣,沿途分出眾多細(xì)支至肌纖維,由腋神經(jīng)主干發(fā)出的分支走向兩個(gè)肌束毗鄰處,然后發(fā)出分支走向每一肌束,三角肌中部包含有極稠密的神經(jīng)網(wǎng)。根據(jù)腋神經(jīng)的分布情況可以看到,理論上三角肌任何部位的縱行劈開(kāi),一定會(huì)引起腋神經(jīng)損傷。但根據(jù)我們的經(jīng)驗(yàn),術(shù)前仔細(xì)規(guī)劃,將腋神經(jīng)的水平位置在皮膚上進(jìn)行標(biāo)識(shí),術(shù)中經(jīng)三角肌前、中肌間隙縱行劈開(kāi)三角肌,從此間進(jìn)入可很好地避開(kāi)了腋神經(jīng)在三角肌各肌束的入肌點(diǎn),不會(huì)損傷腋神經(jīng)分支,同時(shí)只要劈開(kāi)距離不超過(guò)6 cm,就不會(huì)損傷腋神經(jīng)主干,而且術(shù)中可在接近6 cm處以手指去感受腋神經(jīng),但并不需要徹底游離暴露腋神經(jīng),以免不必要的損傷。許文勝等[5]認(rèn)為腋神經(jīng)前支經(jīng)外科頸水平前行時(shí),與肱骨骨膜關(guān)系并不密切,而是緊貼三角肌底面走形,表面有三角肌束膜包裹,可以經(jīng)此間隙將其連同三角肌一起從骨面推開(kāi)。本組病例采用的即是沿骨膜外剝離肌肉,且6 cm的縱行暴露區(qū)間對(duì)于鋼板置入及顯露骨折端已相當(dāng)充足,若術(shù)野不充分,可在肩峰上切斷部分三角肌擴(kuò)大顯露范圍,在這些措施下腋神經(jīng)損傷的風(fēng)險(xiǎn)極低。

因此,針對(duì)肱骨近端骨折,T型切口肩峰前外側(cè)入路和傳統(tǒng)的胸大肌-三角肌入路相比更符合微創(chuàng)原則,術(shù)后患者疼痛程度明顯減輕,并且可取得相類(lèi)似的功能預(yù)后,而同時(shí)具有傳統(tǒng)胸大肌-三角肌入路不具備的優(yōu)勢(shì),如鋼板植入更方便、軟組織損傷更小等優(yōu)點(diǎn),若術(shù)中全程注意腋神經(jīng)的保護(hù),損傷腋神經(jīng)的風(fēng)險(xiǎn)非常低。但該切口相對(duì)于傳統(tǒng)縱切口來(lái)說(shuō),近端橫切口手術(shù)視野的暴露充分性欠佳,初學(xué)者會(huì)不適應(yīng),但隨著手術(shù)的熟練不適應(yīng)感覺(jué)會(huì)逐漸消失,學(xué)習(xí)曲線相對(duì)較短。

三、肱骨距的復(fù)位與維持

術(shù)中肱骨近端內(nèi)下方(肱骨距)的良好復(fù)位是手術(shù)成功的決定因素,肱骨距的機(jī)械支撐對(duì)于維持骨折復(fù)位很重要,肱骨距完整與否和患者的功能及主觀療效預(yù)后有關(guān),其作為一項(xiàng)簡(jiǎn)便的評(píng)估方法可用于術(shù)后患者臨床療效的預(yù)測(cè)。Bj?rkenheim等[6]發(fā)現(xiàn)使用PHILOS系統(tǒng)具有較高的骨折再移位率(26.4%),這主要是由于復(fù)位時(shí)沒(méi)有強(qiáng)調(diào)頭干角的恢復(fù)和內(nèi)側(cè)皮質(zhì)完整性的重建。Osterhoff等[7]總結(jié)病例后發(fā)現(xiàn)鎖定鋼板單從張力側(cè)并不能支撐肱骨頭、解剖復(fù)位或輕度壓縮性穩(wěn)定復(fù)位,并于近端肱骨塊內(nèi)下方植入斜向上的鎖定釘可以獲得更穩(wěn)定的內(nèi)側(cè)柱支撐,并可更好地維持復(fù)位。不穩(wěn)定肱骨近端骨折由于粉碎及骨量差,常常難以獲得穩(wěn)定固定,可通過(guò)向肱骨頭骨折塊的內(nèi)下方鉆入鎖定螺釘可獲得適當(dāng)?shù)膬?nèi)側(cè)支撐,重建內(nèi)側(cè)肱骨距,若未能建立內(nèi)側(cè)支撐則可能會(huì)導(dǎo)致早期復(fù)位丟失,鎖定釘常常無(wú)法單獨(dú)支撐內(nèi)側(cè)柱,手術(shù)失敗的幾率亦會(huì)大大增加。

本組病例中有9例病例復(fù)位后因內(nèi)側(cè)肱骨距處骨折呈粉碎狀,難以維持穩(wěn)定,因此均于近端肱骨塊內(nèi)下方植入斜向上的鎖定釘以協(xié)助支撐,術(shù)后隨訪至骨折愈合,均未發(fā)生內(nèi)固定失效所致的手術(shù)失敗。

四、螺釘數(shù)量

肱骨以承受高旋轉(zhuǎn)扭力為主,在骨折遠(yuǎn)端應(yīng)至少使用3～4枚雙皮質(zhì)固定螺釘以減少松動(dòng)及退釘已基本達(dá)到共識(shí),但對(duì)于骨折近端以幾枚螺釘固定最佳尚無(wú)臨床相關(guān)報(bào)道。Erhardt等[8]在體外力學(xué)研究后建議對(duì)于肱骨近端骨折至少運(yùn)用5枚螺釘對(duì)肱骨頭進(jìn)行固定,此時(shí)螺釘失效幾率最低,同時(shí)如果內(nèi)側(cè)無(wú)法依靠復(fù)位獲得支撐則有必要使用一枚內(nèi)下支撐螺釘。但該研究?jī)H限于體外實(shí)驗(yàn)研究,尚沒(méi)有進(jìn)一步的臨床療效證實(shí)。本組病例均選取PHILOS鋼板,保證肱骨頭內(nèi)至少有5枚螺釘進(jìn)行固定,對(duì)于骨質(zhì)疏松患者,則盡量將近端9枚螺釘全部植入,本組所有病例均未出現(xiàn)螺釘松動(dòng)、退釘?shù)炔l(fā)癥。

針對(duì)肱骨近端骨折,在嚴(yán)格把握手術(shù)適應(yīng)證的條件下,T形切口下微創(chuàng)鎖定鋼板治療方式具有創(chuàng)傷小、恢復(fù)快、臨床療效佳的優(yōu)點(diǎn),尤其適于AO分型的A2、A3型與B型骨折的治療。但本組病例缺乏對(duì)于有關(guān)三角肌損傷程度的相關(guān)支持研究及與胸大肌-三角肌傳統(tǒng)入路的對(duì)比研究,若能在術(shù)后隨訪中檢測(cè)三角肌的神經(jīng)肌電圖,明確損傷程度,并設(shè)立傳統(tǒng)的胸大肌-三角肌入路對(duì)照組,則會(huì)更有臨床說(shuō)服力。

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[5] 許文勝,周君琳,劉清和,等.經(jīng)肩峰外側(cè)小切口治療肱骨近端骨折的相關(guān)解剖學(xué)研究[J].第三軍醫(yī)大學(xué)學(xué)報(bào),2011,33(6):648-650.

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Operative treatment of proximal humeral fractures with T incision and MIPPO locking compression plate

Han Liqiang,Jiang Han,Xiao Lianping,Yang Guoyue,Jiang Yi.Department of Orthopedics,Tianjin Third Central Hospital,Tianjing 300170,China

BackgroundWith the aging of population,the proximal humerus fractures are becoming more and more common.The displaced proximal humeral fractures often result in long-term disability.For the instability and displacement of the fracture,the operation treatment is of the best effect so far.At present,the locking plate has been widely used in the treatment of proximal humerus fractures,and has already achieved good clinical results.This paper retrospectively analysis the functional effect of minimally invasive locking plate in the treatment of proximal humeral fractures in our hospital with T shape incision.MethodsThirty-five cases in our hospital suffered from proximal humeral fractures were included in this study(16 males,19 females,aged 31-72 years old)during the past years.The average age was 56.3 years old.Fifteen cases were injured on the left side,20 cases were injured on the right side.All the fractures were fresh.The cause of injury:20 cases were living accident,6 cases were of high falling injury,9 cases were of traffic accident.All the Patients had undergone X-ray examinations and three-dimensional CT reconstruction before receiving surgery.According to the AO classification,there were 7 cases of type 11-A2,12 cases of type 11-A3,8 cases of type 11-B1,6 cases of type 11-B2 and type 11-C1 in 2 cases.All were treated with locking plates through the type T incision.Patients were in the beach chair position after anesthesia to get operation.Then mark the operating incision,the axillary nerve and the acromion on the surface before surgery.A 6 cm transverse incision was made one finger subacromially in the lateral side of shoulder.The subcutaneous tissue was incised before a longitudinal dissection of the deep fascia.Find the anteriorand middle part of the deltoid muscle by identifying the fat fiber lines between the gap and the muscle belly.Bluntly split it longitudinally,not exceeding 6 cm of the distance in order to avoid the injury of axillary nerve.Stretch the splitted deltoid to the sides,expose deltoid bursa,incise it longitudinally to expose the greater tuberosity of humerus and the fracture.Make the reduction by poking and manual pressing the fracture with the traction of the shoulder in the abduction position.Take the intertubercular sulcus and greater tuberosity as the reduction index,then flex and abduct the elbow after a satisfactory reduction to guarantee the 30-40 degree retroverted angle,fix it with the Kirschner wire temporarily and then select a steel plate with an appropriate length(select AO Synthes,PHILOS steel plate).Then make a 3 cm longitudinal incision on the distal part of the fracture,implant the steel plate along the periosteum,place the plate 5-8 mm upper the greater tuberosity,2-4 mm laterally of the intertubercular sulcus.After an satisfactory position of the C-arm fluoroscopy,implant 5-9 locking screws proximally and 3 bicortical locking screws distally,place a drainage tube conventionally.Sling the arm with a triangular scarf for immobilization for 3 to 4 weeks postoperatively.ResultsThe operation incision of the 35 patients of this group got healed in the first period.They were required to exercise the shoulder joint passively after 2-3 days postoperatively.Increase the range of motion gradually.Then start to do the shoulder swing exercise 2 weeks after operation,try the lift,abduction,posterior extension and flexion exercise 3 weeks after operation.All the patients were followed up from 5 to 16 months,averagely 13.1 months.All the fractures got healed,there was no sign of damage of the axillary nerve.No loosening of the nails and plate were found.For the Neer score:there are 19 cases of excellence,10 cases of good,6 cases of fair.ConclusionsMinimal invasion refers to an operation or a check with less invasion and less physiological disturbance to achieve the best operation effect,the main feature is the micro trauma.Accidental trauma does great harm to the human body,and it is really hard to avoid.But as a planned trauma of surgical operation,surgeons have to try all they can to minimize the trauma,that is to say,to achieve the goal of minimal invasion.This concept has achieved great development now in various fields of orthopedics,it commits to the protection of soft tissue and obtaining better prognosis function,which has gradually become a consensus and been confirmed by clinical effect.When we comes to the fracture of the proximal humerus,in strict confidence condition operation indications,the minimally invasive locking plate treatment under T shaped incision has the advantage of less trauma,quicker recovery and perfect clinical curative effect,which is especially suitable for AO type A2,type A3 and type B fractures.But this group of patients lack the related supportive study for the degree of deltoid muscle damage and the comparison of traditional pectoralis major-deltoid muscle approach,if we can take a detection of deltoid muscle electromyography in the postoperative follow-up to ensure the degree of injury,and then establish a control group of the pectoralis major-deltoid muscle approach,then it would be more clinically convincing.

Humeral fracture,proximal;Minimally invasion;Locking compression plate;Incision

Han Liqiang,Email:liqianghan9809@163.com

2014-05-06)

(本文編輯:李靜)

10.3877/cma.j.issn.2095-5790.2014.04.004

衛(wèi)生公益性行業(yè)科研專(zhuān)項(xiàng)(201002014,201302007);教育部創(chuàng)新團(tuán)隊(duì)(IRT1201)

300170 天津市第三中心醫(yī)院骨科(韓立強(qiáng)、江漢、肖聯(lián)平、楊國(guó)躍、江毅);300450 天津市第五中心醫(yī)院骨科(張殿英)

韓立強(qiáng),Email:liqianghan9809@163.com

韓立強(qiáng),江漢,肖聯(lián)平,等.T形切口下微創(chuàng)鎖定鋼板治療肱骨近端骨折療效探討[J/CD].中華肩肘外科電子雜志,2014,2(4):225-229.