T形切口下微创锁定钢板治疗肱骨近端骨折疗效探讨

韩立强 江汉 肖联平 杨国跃 江毅 张殿英

T形切口下微创锁定钢板治疗肱骨近端骨折疗效探讨

韩立强 江汉 肖联平 杨国跃 江毅 张殿英

目的回顾性分析T形切口下微创锁定钢板治疗肱骨近端骨折的疗效。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,分类方法采用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型切口下锁定钢板手术治疗,术后2～3 d开始肩关节被动活动锻炼,逐渐增加活动范围,术后2周开始肩关节摆动锻炼,术后3周开始肩关节锻炼,并采用Neer肩关节功能评分。结果本组35例患者手术切口均一期愈合,所有患者均得到随访,随访时间5～16个月,平均13.1个月,骨折均骨性愈合,术后未发现腋神经损害表现,未发现退钉、钢板松动。Neer肩关节功能评分:优19例,良10例,可6例。结论T形切口下微创锁定钢板治疗肱骨近端骨折具有创伤小、功能恢复快、临床疗效佳的优点,尤其适于AO分型的A2、A3型和B型骨折的治疗。

肱骨骨折,近端;微创;锁定钢板;切口

在65岁以上的人口中,肱骨近端骨折发病率排在髋部骨折和Colles骨折之后,处于第三位。随着社会人口的老龄化,肱骨近端骨折日益普遍,移位性的肱骨近端骨折往往会造成长期的功能障碍。对不稳定并且移位的骨折而言,手术治疗效果最佳。目前锁定钢板在肱骨近端骨折的治疗中已得到广泛应用,并取得了良好的临床效果[1]。因传统的胸大肌-三角肌入路创伤较大,近年来越来越多的医生尝试应用小切口下微创技术治疗肱骨近端骨折[2]。我院自2011年1月至2013年8月采用T形切口微创锁定钢板治疗肱骨近端骨折35例,在此作一总结分析。

资料与方法

一、一般资料

本组病例共35例,男性16例,女性19例,年龄31～72岁,平均年龄56.3岁,左侧15例,右侧20例,均为新鲜骨折。致伤原因:自行摔伤20例,高处坠落伤6例,车祸伤9例。所有患者术前均行X线及CT三维重建检查(图1,2)。

二、骨折分型

本组病例采用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、手术方法

患者麻醉后采取沙滩椅位,术前于体表标注手术切口、肩峰及腋神经大致位置,于肩关节外侧肩峰下约一横指处行长约6 cm横行切口,切开皮下组织后纵行切开深筋膜,通过辨认肌腹之间的脂肪纤维纹,找到三角肌前部和中间部肌肉之间的间隙,纵行钝性劈开,劈开距离不宜超过6 cm,以免损伤腋神经。将劈开的三角肌牵向两侧,暴露三角肌下滑囊,将其纵行切开暴露肱骨大结节及骨折端。在肩关节外展牵引下通过撬拨及手法推压骨折块的方法完成复位,以结节间沟、大结节作为复位指标,复位满意后维持肘关节屈曲外展,保证30°～40°后倾角,以克氏针临时固定,选用长度合适的钢板(均选用AO辛迪斯公司的PHILOS钢板),另于骨折远端行长约3 cm纵行切口(图3),将钢板沿骨膜上植入,钢板放置于距离肱骨大结节上缘5～8 mm、结节间沟外侧2～4 mm,C臂X线机透视位置满意后,近端植入5～9枚锁定螺钉,远端植入3枚双皮质锁定螺钉(图4,5),常规植入引流管。术后以三角巾悬吊固定3～4周。

结 果

本组35例患者手术切口均一期愈合。术后2～3 d开始肩关节被动活动锻炼,逐渐增加活动范围,术后2周开始肩关节摆动锻炼,术后3周开始肩关节上举、外展、后伸及前屈锻炼。所有患者均获得随访,随访时间5～16个月,平均13.1个月,骨折均骨性愈合,未发现腋神经损伤表现,未发现退钉、钢板松动。采用Neer肩关节功能评分[3]:优19例,良10例,可6例。

讨 论

微创是指以最小的侵袭和最小的生理干扰达到最佳手术疗效的一种手术或检查方式,最主要特征是创伤小。意外创伤对人体有极大的危害性且难以避免,而外科手术作为有计划的创伤,术者有必要力求将创伤降到最低限度,即达到微创的目的。微创手术理念目前在骨科各个领域均获得了较大的发展,其致力于软组织的保护、获得更好的预后功能的理念已逐渐成为共识,并为临床疗效所证实。

图1～5 患者,女,62岁,自行摔伤,骨折分型为11-C1型。图1肱骨近端骨折术前正位X线片;图2肱骨近端骨折术前CT三维重建片;图3术中手术切口示意图;图4～5肱骨近端骨折术后正位及穿胸位X线片

一、微创治疗适应证

锁定钢板的出现为肱骨近端骨折微创治疗的实施提供了条件,并且在四肢骨折中的应用也取得了良好的临床效果[4]。但并不是所有的肱骨近端骨折都适于微创治疗,严格把握手术适应证才能取得最佳疗效,不能一味追求微创而丧失手术固定的基本原则,良好的复位、固定仍是手术成功、获得良好预后的重要决定因素。本组病例在手术适应证选择上根据闭合复位的难易程度主要偏重于AO分型的A2、A3型与B型骨折,部分闭合复位不佳的病例亦可通过上端横切口直接复位,但对于C型骨折来说,技术性要求较高,若闭合复位技巧掌握不好,则难以达到理想的复位,且T形切口暴露相对不充分,不利于直视复位,故仍建议采用传统的胸大肌-三角肌入路。

二、手术切口

胸大肌-三角肌入路是治疗肱骨近端骨折的传统手术入路,其位于肩关节前方,可很好地暴露盂肱关节,但肱骨近端外侧区域显露欠佳,锁定钢板放置的理想位置位于肱骨侧方,在此入路下钢板的放置位置显示困难,同时因锁定螺钉由外向内的置入方向已固定,故在前方切口内完成钻孔和置钉也较为困难。该入路术中为充分暴露肱骨头侧面,通常在肩袖上缝合丝线或在肱骨头上置入临时克氏针作为牵引,维持肱骨头内旋,但在行肱骨头复位和钢板放置时通常需要内旋或外旋前臂,从而导致已复位的肱骨头或者位置良好的钢板出现位置丢失。另外,该手术入路对软组织剥离广泛,亦有损伤旋肱前动脉的潜在风险,可能不利于骨折的愈合,并且增加肱骨头缺血性坏死的可能性。因此,目前锁定钢板广泛应用于肱骨近端骨折治疗的情况下,胸大肌-三角肌入路并不是最佳的入路选择。

肩峰前外侧入路,即劈开三角肌入路,最早仅适用于局限性手术,用于暴露止于肱骨大结节的肌腱和三角肌下的滑囊,但随着锁定钢板技术的发展与广泛应用,因其结合间接复位技术对骨折局部的软组织破坏少,并使钢板易于放置于最佳位置,可显著改善功能预后,所以该入路又再次受到临床重视。本组病例采用的手术切口在此基础上进行了改善,近端皮肤切口未采用纵切口,而采用横切口,整体呈“T”形切口(图3),深部组织暴露与其相同,因肩部皮纹为横行,横行切口愈后瘢痕相对较小且更为美观,患者也更易接受。

肩峰前外侧入路相对于胸大肌-三角肌入路来说,钢板的放置相对更容易,T型切口优越性显著,但文献报道不多,普及率不高,究其原因主要是解剖不熟悉,难以保证腋神经不受损。解剖学研究显示腋神经自四边孔穿出后绕行于肱骨外科颈后方,位于三角肌后缘中点,其解剖位置位于上肢中立位时肩峰下缘大约6.5 cm处,由三角肌后缘横行直至其前缘,沿途分出众多细支至肌纤维,由腋神经主干发出的分支走向两个肌束毗邻处,然后发出分支走向每一肌束,三角肌中部包含有极稠密的神经网。根据腋神经的分布情况可以看到,理论上三角肌任何部位的纵行劈开,一定会引起腋神经损伤。但根据我们的经验,术前仔细规划,将腋神经的水平位置在皮肤上进行标识,术中经三角肌前、中肌间隙纵行劈开三角肌,从此间进入可很好地避开了腋神经在三角肌各肌束的入肌点,不会损伤腋神经分支,同时只要劈开距离不超过6 cm,就不会损伤腋神经主干,而且术中可在接近6 cm处以手指去感受腋神经,但并不需要彻底游离暴露腋神经,以免不必要的损伤。许文胜等[5]认为腋神经前支经外科颈水平前行时,与肱骨骨膜关系并不密切,而是紧贴三角肌底面走形,表面有三角肌束膜包裹,可以经此间隙将其连同三角肌一起从骨面推开。本组病例采用的即是沿骨膜外剥离肌肉,且6 cm的纵行暴露区间对于钢板置入及显露骨折端已相当充足,若术野不充分,可在肩峰上切断部分三角肌扩大显露范围,在这些措施下腋神经损伤的风险极低。

因此,针对肱骨近端骨折,T型切口肩峰前外侧入路和传统的胸大肌-三角肌入路相比更符合微创原则,术后患者疼痛程度明显减轻,并且可取得相类似的功能预后,而同时具有传统胸大肌-三角肌入路不具备的优势,如钢板植入更方便、软组织损伤更小等优点,若术中全程注意腋神经的保护,损伤腋神经的风险非常低。但该切口相对于传统纵切口来说,近端横切口手术视野的暴露充分性欠佳,初学者会不适应,但随着手术的熟练不适应感觉会逐渐消失,学习曲线相对较短。

三、肱骨距的复位与维持

术中肱骨近端内下方(肱骨距)的良好复位是手术成功的决定因素,肱骨距的机械支撑对于维持骨折复位很重要,肱骨距完整与否和患者的功能及主观疗效预后有关,其作为一项简便的评估方法可用于术后患者临床疗效的预测。Björkenheim等[6]发现使用PHILOS系统具有较高的骨折再移位率(26.4%),这主要是由于复位时没有强调头干角的恢复和内侧皮质完整性的重建。Osterhoff等[7]总结病例后发现锁定钢板单从张力侧并不能支撑肱骨头、解剖复位或轻度压缩性稳定复位,并于近端肱骨块内下方植入斜向上的锁定钉可以获得更稳定的内侧柱支撑,并可更好地维持复位。不稳定肱骨近端骨折由于粉碎及骨量差,常常难以获得稳定固定,可通过向肱骨头骨折块的内下方钻入锁定螺钉可获得适当的内侧支撑,重建内侧肱骨距,若未能建立内侧支撑则可能会导致早期复位丢失,锁定钉常常无法单独支撑内侧柱,手术失败的几率亦会大大增加。

本组病例中有9例病例复位后因内侧肱骨距处骨折呈粉碎状,难以维持稳定,因此均于近端肱骨块内下方植入斜向上的锁定钉以协助支撑,术后随访至骨折愈合,均未发生内固定失效所致的手术失败。

四、螺钉数量

肱骨以承受高旋转扭力为主,在骨折远端应至少使用3～4枚双皮质固定螺钉以减少松动及退钉已基本达到共识,但对于骨折近端以几枚螺钉固定最佳尚无临床相关报道。Erhardt等[8]在体外力学研究后建议对于肱骨近端骨折至少运用5枚螺钉对肱骨头进行固定,此时螺钉失效几率最低,同时如果内侧无法依靠复位获得支撑则有必要使用一枚内下支撑螺钉。但该研究仅限于体外实验研究,尚没有进一步的临床疗效证实。本组病例均选取PHILOS钢板,保证肱骨头内至少有5枚螺钉进行固定,对于骨质疏松患者,则尽量将近端9枚螺钉全部植入,本组所有病例均未出现螺钉松动、退钉等并发症。

针对肱骨近端骨折,在严格把握手术适应证的条件下,T形切口下微创锁定钢板治疗方式具有创伤小、恢复快、临床疗效佳的优点,尤其适于AO分型的A2、A3型与B型骨折的治疗。但本组病例缺乏对于有关三角肌损伤程度的相关支持研究及与胸大肌-三角肌传统入路的对比研究,若能在术后随访中检测三角肌的神经肌电图,明确损伤程度,并设立传统的胸大肌-三角肌入路对照组,则会更有临床说服力。

[1] Hirschmann MT,Fallegger B,Amsler F,et al.Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate(PHILOS)[J].J Orthop Trauma,2011,25(5):286-293.

[2] Röderer G,Erhardt J,Graf M,et al.Clinical results for minimally invasive locked plating of proximal humerus fractures[J].J Orthop Trauma,2010,24(7):400-406.

[3] Neer CS 2nd.Displaced proximal humeral fractures.I.Classification and evaluation[J].J Bone Joint Surg Am,1970,52(6):1077-1089.

[4] 杨运发,侯之启,徐中和,等.微创经皮LCP或LISS内固定治疗膝关节周围骨折[J].临床骨科杂志,2006,9(5):440-441.

[5] 许文胜,周君琳,刘清和,等.经肩峰外侧小切口治疗肱骨近端骨折的相关解剖学研究[J].第三军医大学学报,2011,33(6):648-650.

[6] Björkenheim JM,Pajarinen J,Savolainen V.Internal fixation of proximal humeral fractures with a locking compression plate:a retrospective evaluation of 72 patients followed for a minimum of 1 year[J].Acta Orthop Scand,2004,75(6):741-745.

[7] Osterhoff G,Hoch A,Wanner GA,et al.Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures[J].Injury,2012,43(10):1651-1656.

[8] Erhardt JB,Stoffel K,Kampshoff J,et al.The Position and Number of Screws Influence Screw Perforation of the Humeral Head in Modern Locking Plates:a Cadaver Study[J].J Orthop Trauma,2012,26(10):e188-e192.

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)

(本文编辑:李静)

10.3877/cma.j.issn.2095-5790.2014.04.004

卫生公益性行业科研专项(201002014,201302007);教育部创新团队(IRT1201)

300170 天津市第三中心医院骨科(韩立强、江汉、肖联平、杨国跃、江毅);300450 天津市第五中心医院骨科(张殿英)

韩立强,Email:liqianghan9809@163.com

韩立强,江汉,肖联平,等.T形切口下微创锁定钢板治疗肱骨近端骨折疗效探讨[J/CD].中华肩肘外科电子杂志,2014,2(4):225-229.