李奉龍 姜春巖

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·論著·

反球型人工肩關(guān)節(jié)置換術(shù)治療肱骨近端陳舊骨折不愈合

李奉龍 姜春巖

目的 評(píng)價(jià)采用反球型人工肩關(guān)節(jié)置換術(shù)治療肱骨近端陳舊骨折不愈合的臨床療效。方法 回顧性研究2010年10月至2013年2月,收治并進(jìn)行反球型人工肩關(guān)節(jié)假體置換手術(shù)的9例肱骨近端陳舊骨折不愈合，均為肱骨近端骨折切開復(fù)位內(nèi)固定術(shù)后患者，其中3例患者為大結(jié)節(jié)不愈合，6例患者為大結(jié)節(jié)及肱骨外科頸不愈合,4例患者合并肱骨頭缺血性壞死。男性3例，女性6例；平均年齡(75.2±8.6)歲(70～86歲)。主力側(cè)受累6例。本次手術(shù)距上次手術(shù)平均時(shí)間為(15±7.3)個(gè)月(10～29個(gè)月)。結(jié)果 9例患者術(shù)后獲(37.9±10.2)個(gè)月(24～52個(gè)月)隨訪。末次隨訪時(shí)患者肩關(guān)節(jié)活動(dòng)度：前屈上舉為131.2°±22.0°，外旋為22.6°±11.2°，內(nèi)旋平均為第3腰椎椎體水平(±3個(gè)椎體)；VAS疼痛評(píng)分為(1.5±1.7)分(0～6分)，ASES評(píng)分為(74.3±15.6)分(48～94分)，Constant評(píng)分為(71.6±10.2)分(44～92分)，UCLA評(píng)分為(27.9±5.6)分(18～34分)。所有患者術(shù)后均無肩峰應(yīng)力骨折、感染、假體松動(dòng)、神經(jīng)血管損傷等并發(fā)癥發(fā)生。結(jié)論 采用反球型人工肩關(guān)節(jié)置換術(shù)治療肱骨近端陳舊骨折不愈合可獲得良好的臨床療效。

肩關(guān)節(jié)；人工關(guān)節(jié)置換術(shù)；肱骨骨折，近端；骨折并發(fā)癥

肱骨近端骨折術(shù)后不愈合的治療是肩關(guān)節(jié)外科的難點(diǎn)之一，此類患者常合并陳舊骨折塊血供差、肩袖功能不良等，若行植骨再固定手術(shù)或人工肱骨頭置換術(shù)，術(shù)后肩關(guān)節(jié)功能恢復(fù)結(jié)果難以預(yù)期[1-6]。近年來，國(guó)外有學(xué)者報(bào)道采用反球型人工肩關(guān)節(jié)假體置換術(shù)治療肱骨近端骨折，并取得了一定療效[7]，但反球型肩關(guān)節(jié)假體在治療肱骨近端陳舊骨折不愈合方面的作用，目前仍缺乏相關(guān)研究報(bào)道。本文通過分析近年來我院采用反球型人工肩關(guān)節(jié)假體置換術(shù)治療肱骨近端陳舊骨折不愈合的臨床結(jié)果，對(duì)此種手術(shù)方法的療效作一初步總結(jié)。

資 料 與 方 法

一、一般資料

病例入選標(biāo)準(zhǔn)：(1)因肱骨近端陳舊骨折不愈合于我院行反球型人工肩關(guān)節(jié)假體置換手術(shù)者，不合并血管神經(jīng)損傷；(2)術(shù)后最短隨訪時(shí)間不低于2年。病例排除標(biāo)準(zhǔn)：(1)合并有血管神經(jīng)損傷；(2)術(shù)后隨訪時(shí)間少于2年。

2010年10月至2013年2月，于我院收治并進(jìn)行反球型人工肩關(guān)節(jié)假體置換手術(shù)的肱骨近端陳舊骨折不愈合患者共9例，男性3例，女性6例；平均年齡(75.2±8.6)歲(70～86歲)。主力側(cè)受累6例。本次手術(shù)距上次手術(shù)平均時(shí)間為(15±7.3)個(gè)月(10～29個(gè)月)。所有患者均為肱骨近端骨折切開復(fù)位內(nèi)固定術(shù)后患者，其中3例患者為大結(jié)節(jié)不愈合，6例患者為大結(jié)節(jié)及肱骨外科頸不愈合；4例患者合并肱骨頭缺血性壞死。9例患者均使用骨小梁金屬(TM)反球型肩關(guān)節(jié)假體(Zimmer)進(jìn)行人工全肩關(guān)節(jié)置換治療。

二、手術(shù)方法

手術(shù)采用沙灘椅位，全身麻醉后，選取三角肌胸肌間入路，分離顯露頭靜脈并加以保護(hù)。術(shù)中應(yīng)特別注意保護(hù)三角肌及其起止點(diǎn)。顯露并辨認(rèn)肱二頭肌長(zhǎng)頭腱以確定大、小結(jié)節(jié)，術(shù)中應(yīng)仔細(xì)探查并明確陳舊骨折塊，確定肱骨近端各個(gè)骨折部分，必要時(shí)需行截骨以利于充分顯露肩盂及后續(xù)重建大小結(jié)節(jié)操作。術(shù)中用較粗的非可吸收線在肩袖止點(diǎn)部位固定陳舊骨折塊，以備牽引復(fù)位之用。

充分顯露肩盂，打磨至軟骨下骨，置入肩盂基座，使其向下方傾斜10°。選取肩盂球并將其置入基座。肱骨側(cè)假體使用骨水泥固定，假體后傾角度確定為5°～10°。在使用骨水泥固定前，應(yīng)采用假體試模仔細(xì)比對(duì)并試行復(fù)位，理想的復(fù)位狀態(tài)是獲得良好的假體盂肱關(guān)節(jié)順應(yīng)性與理想的假體高度以維持適當(dāng)?shù)娜羌『吐?lián)合腱張力。復(fù)位大小結(jié)節(jié)骨折塊，利用取出的肱骨頭在大小結(jié)節(jié)與肱骨干結(jié)合部作松質(zhì)骨植骨，以利骨折愈合。以鈦纜環(huán)抱固定骨折塊，并采用高強(qiáng)度縫合線進(jìn)一步縫合，加固大小結(jié)節(jié)骨折塊。

三、康復(fù)方法

術(shù)后采用肩關(guān)節(jié)外展包支具制動(dòng)6周。手、腕、肘的被動(dòng)功能鍛煉在術(shù)后第1天根據(jù)患者疼痛允許情況下盡快進(jìn)行，術(shù)后3周后進(jìn)行肩關(guān)節(jié)被動(dòng)功能鍛煉，術(shù)后6周后若存在大小結(jié)節(jié)愈合的證據(jù)，則可摘除支具開始主動(dòng)活動(dòng)度練習(xí)，根據(jù)患者具體康復(fù)情況逐步恢復(fù)日常生活活動(dòng)。術(shù)后12周開始肌肉力量練習(xí)。

四、隨訪及評(píng)價(jià)方法

患者術(shù)后3周、6周、12周、6個(gè)月、12個(gè)月以及末次隨訪時(shí)拍攝肩外旋中立位肩關(guān)節(jié)正位、側(cè)位和腋位X線片，以判斷假體位置、大結(jié)節(jié)愈合情況等。末次隨訪時(shí)采用VAS(visual analogue score)疼痛評(píng)分、ASES(American shoulder and elbow surgeons)評(píng)分、Constant評(píng)分及UCLA(university of california los angeles)評(píng)分評(píng)價(jià)肩關(guān)節(jié)功能恢復(fù)情況。

結(jié) 果

9例患者術(shù)后獲平均(37.9±10.2)個(gè)月(24～52個(gè)月)隨訪。末次隨訪時(shí)患者肩關(guān)節(jié)活動(dòng)度：前屈上舉平均為131.2°±22.0°，外旋平均為22.6°±11.2°，內(nèi)旋平均為第3腰椎椎體水平(±3個(gè)椎體)；VAS疼痛評(píng)分平均為(1.5±1.7)分(0～6分)，ASES評(píng)分平均為(74.3±15.6)分(48～94分),Constant評(píng)分平均為(71.6±10.2)分(44～92分)，UCLA評(píng)分平均為(27.9±5.6)分(18～34分)。

所有患者通過肩關(guān)節(jié)正位、側(cè)位和腋位X線片定期復(fù)查，無大小結(jié)節(jié)不愈合發(fā)生；所有患者術(shù)后均無肩峰應(yīng)力骨折、感染、假體松動(dòng)、肩胛骨撞擊、神經(jīng)血管損傷等并發(fā)癥發(fā)生。

討 論

第二代反球型肩關(guān)節(jié)假體最早由Grammont設(shè)計(jì)并提出，此種假體通過反轉(zhuǎn)盂肱關(guān)節(jié)對(duì)位關(guān)系，使盂肱關(guān)節(jié)旋轉(zhuǎn)中心內(nèi)移，進(jìn)而使三角肌在肩關(guān)節(jié)前屈上舉中發(fā)揮主要作用[8]。同時(shí)由于新設(shè)計(jì)使盂肱關(guān)節(jié)旋轉(zhuǎn)中心內(nèi)移至肩盂關(guān)節(jié)面，大大降低了肩盂假體松動(dòng)的幾率。反球型肩關(guān)節(jié)假體在設(shè)計(jì)初始階段，主要用于治療巨大或不可修復(fù)肩袖損傷所引起的關(guān)節(jié)病變，因?yàn)樵诖朔N患者中，肩袖的動(dòng)態(tài)穩(wěn)定機(jī)制已被破壞，三角肌的動(dòng)力難以通過肩袖肌肉轉(zhuǎn)化為肩關(guān)節(jié)上舉的動(dòng)力。而通過反球肩關(guān)節(jié)置換，可以使三角肌作為肩關(guān)節(jié)前屈上舉的動(dòng)力直接發(fā)揮作用，進(jìn)而替代了部分肩袖肌肉(岡上肌)的功能[9-12]。

雖然反球型關(guān)節(jié)置換手術(shù)可以降低患者肩關(guān)節(jié)功能預(yù)后對(duì)于大結(jié)節(jié)愈合的依賴性，但大小結(jié)節(jié)的愈合狀況仍對(duì)患者術(shù)后功能產(chǎn)生一定影響。Sirveaux等[13]通過研究發(fā)現(xiàn)，對(duì)于進(jìn)行反球關(guān)節(jié)置換手術(shù)的患者，術(shù)中重建大小結(jié)節(jié)組的功能優(yōu)于非重建組。因此，在進(jìn)行反球關(guān)節(jié)置換手術(shù)時(shí)要仔細(xì)重建大小結(jié)節(jié)，以促進(jìn)術(shù)后結(jié)節(jié)愈合，最大程度地改善患者術(shù)后肩關(guān)節(jié)功能。

文獻(xiàn)報(bào)道反球型肩關(guān)節(jié)置換術(shù)后的常見并發(fā)癥包括肩胛骨撞擊、關(guān)節(jié)不穩(wěn)或脫位、肩峰應(yīng)力骨折等[14-19]。其中肩胛骨撞擊是指肱骨側(cè)假體在肩關(guān)節(jié)內(nèi)收時(shí)與肩胛頸下緣發(fā)生撞擊，進(jìn)而導(dǎo)致假體松動(dòng)以致失效。本組病例中術(shù)后無肩胛骨撞擊發(fā)生，考慮與隨訪時(shí)間較短有關(guān)。

本研究有一定的局限性。首先，隨訪時(shí)間較短，應(yīng)延長(zhǎng)隨訪時(shí)間以明確反球型肩關(guān)節(jié)置換術(shù)的遠(yuǎn)期療效；其次，本研究為回顧性隨訪研究，將來仍需要設(shè)計(jì)更高等級(jí)的前瞻性隨機(jī)對(duì)照試驗(yàn)或隊(duì)列研究，以論證反球型肩關(guān)節(jié)置換術(shù)在治療肱骨近端陳舊骨折不愈合方面的優(yōu)勢(shì)。

小結(jié)：采用反球型人工肩關(guān)節(jié)置換術(shù)治療肱骨近端陳舊骨折不愈合，術(shù)后療效令人滿意，患者可獲得良好的肩關(guān)節(jié)功能。

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(本文編輯：李靜)

李奉龍，姜春巖.反球型人工肩關(guān)節(jié)置換術(shù)治療肱骨近端陳舊骨折不愈合[J/CD].中華肩肘外科電子雜志,2015,3(2):85-88.

Treatment of old proximal humerus fracture nonunion with reverse total shoulder arthroplasty

LiFenglong,JiangChunyan.

DepartmentofSportsInjuy,BeijingJishuitanHospital,Beijing100035,China

JiangChunyan,Email:chunyanj@hotmail.com

Background The nonunion treatment of proximal humerus fracture is one of the difficulties that the shoulder surgery faces.Usually these patients have old fracture are complicated with poor block blood supply,dysfunction of rotator cuff as well as other unfavorable conditions.If the patients are operated with bone grafting and then fixation,or artificial humeral head arthroplasty,it will be difficult to predict the results of post-operation functional shoulder recovery.During recent years,there have been reports from abroad about adopting reverse total shoulder arthroplasty in treating proximal humerus fracture nonunion which achieved great curative effects.However,reports about adopting reverse total shoulder arthroplasty in treating old proximal humerus fracture nonunion are still rare.This thesis will firstly analyze the clinical effects of adopting reverse total shoulder arthroplasty for treatment of old proximal humerus fracture nonunion in our hospital,and then get preliminary conclusions on the curative effects of this arthroplasty.Methods General data:inclusion criteria of cases:(1) patients who had old proximal humerus fracture nonunion and were given reverse total shoulder arthroplasty in our hospital;(2) no complicated with neurovascular injury;(3) the post-operation visit should be not less than two years.Cases exclusion criteria:(1) complicated with neurovascular injury;(2) the post-operation visit less than two years.From October 2010 to February 2013,our hospital has

nine patients with old proximal humerus fracture nonunion who were performed reverse total shoulder arthroplasty.Three males and six females and their average ages were from 70 to 86 years old (75.2±8.6).Six patients among them got the dominant side affected.The latest operation was about 10 to 29 months (15±7.3) long from last time.All patients had gotten the proximal humerus fracture open reduction and internal fixation operation.Three patients had major tubercle nonunion,six patients had major tubercle and humerus surgical neck fracture nonunion.Four patients were complicated with ischemic necrosis of the humeral head.Nine patients adopted the trabecular metal (TM) reverse total shoulder prosthesis (Zimmer) for the artificial shoulder arthroplasty.Operation methods:During the operation,the beach chair position was adopted,after general anesthesia,the patients were operated from the deltopectoral groove and then the cephalic veins were separated clearly with further protection.The operators should protect the starting and the terminal points of deltoid.Revealed and recognized the long tendon of biceps for confirming the greater tuberosity and lesser tubercles.The operators should check clearly and confirm the old fracture bones,and then determine each fracture parts of the proximal humerus.Osteotomy was necessary when the spinoglenoid ligament need to be revealed and for the continuous operation of greater tuberosity and lesser tubercles.The comparative thick non-absorbable thread was used to fix the old fracture bones at the terminal point of rotator cuff,and for traction and restoration.The spinoglenoid ligament was revealed thoroughly,the subchondral bone was abraded,and the prosthesis was inserted into the base of spinoglenoid ligament and rotated down to the 10°.The spinoglenoid ligament ball was selected and then inserted into the base.The humerus lateral prosthesis was fixed with bone cement,and the prosthesis was rotated to 5° to 10°.Before applying the bone cement,the prosthesis was compared carefully using the prosthesis moulds and try to restore.A perfect restore state helps the compliance of prosthesis glenohumeral joint and an ideal prosthesis height helps to maintain the tension of deltoid and conjoint tendon.The greater tuberosity and lesser tubercles facture bones were restored,the humerus head was taken out and cancellous bone graft was operated to the joint part of greater tuberosity and lesser tubercles and humerus shaft,so as for better union of the fracture.The fracture bones were surrounded with the titanium cable,and the high-strength suture lines were applied for further suturing and consolidating the greater tuberosity and lesser tubercles fracture bones.Rehabilitation methods:After the operation,the patients should use the shoulder joint outstretch pack for six weeks.On the first day the passive movements of hands,wrists and elbows should be trained according to the patients′ pain condition.The passive movements of shoulder joints should be trained three weeks after the operation.Six weeks after the operation,if any evidences of the union of greater tuberosity and lesser tubercles fracture are found,the pack could be taken away and the patients could start the active movements practice.Patients′ normal daily life could be restored gradually depending on the patients′ rehabilitation conditions.Patients started the muscles strength training twelve weeks after the operation.Follow-up visit and evaluation methods:At the third week,sixth weeks,twelfth week,sixth month,twelfth month after operation as well as the last follow-up visit,patients should be taken X-ray pictures of the shoulder extorsion neutral position,shoulder joint front position,shoulder joint side position,and axilla position,so as to confirm the prosthesis position and the union condition of greater tuberosity.On the last follow-up visit,the visitors should estimate the shoulder joints restoration condition by adopting VAS (Visual Analogue Score),ASES (American Shoulder and Elbow Surgeons),Constant and UCLA(University of California Los Angeles).Results After the operation,nine patients were followed up for 24 to 52 (37.9±10.2) months.In the last follow-up visit,the patients′ shoulder range motion conditions were as follows:the average forward bends and lifts was 131.2°±22.0°,the average extorsion was 22.6°±11.2°,the average internal rotation was the third lumbar vertebrae level (±3 centrums),the average VAS was (1.5±1.7) points (0-6 points),the average ASES was (74.3±15.6) points (48-94 points),the average Constant was (71.6±10.2) points(44-92 points),the average UCLA was (27.9±5.6) points (18-34 points).All patients had periodic X-ray review of the shoulder joint front,shoulder joint sides and axilla,no greater tuberosity nor lesser tubercles nonunion was found.After the operation,no patients were found shoulder peak stress fracture,infection,prosthetic loosening,shoulder blade,neurovascular injury nor other complications.Conclusion The curative effects after adopting reverse total shoulder arthroplasty for treatment of old proximal humerus fracture nonunion is satisfactory,which helps patients to have better shoulder joints functions.

Shoulder joint；Artificial joint replacement；Huneral fractures,proximal；Fracture complications

10.3877/cma.j.issn.2095-5790.2015.02.004

北京市新世紀(jì)百千萬人才工程培養(yǎng)經(jīng)費(fèi)(20111103)；“首都臨床特色應(yīng)用研究”專項(xiàng)資助課題

100035北京積水潭醫(yī)院運(yùn)動(dòng)損傷科

姜春巖,Email:chunyanj@hotmail.com

2015-03-20)

(Z141107002514001)