雙排錨釘橋式縫合在肱骨大結節骨折中的應用

張少戰 黃長明 傅仰攀 董輝詳 甘志勇

雙排錨釘橋式縫合在肱骨大結節骨折中的應用

張少戰 黃長明 傅仰攀 董輝詳 甘志勇

目的探討雙排錨釘在肱骨大結節骨折有限切開復位內固定中應用的臨床價值。方法自2010年3月至2013年3月，對10例單獨大結節骨折患者通過有限切開復位，雙排錨釘橋式縫合內固定治療肱骨大結節移位骨折。術后隨訪，復查X線片評價復位情況，以Constant評分和UCLA評分評價肩關節功能。結果所有患者術后均獲得解剖復位。在平均12．3個月的隨訪中，X線片顯示復位無丟失，骨折獲得愈合，Constant評分平均90．3分，UCLA評分平均32．2分。結論雙排錨釘內固定治療單純移位的肱骨大結節骨折效果可靠。

肱骨骨折，大結節；錨釘

肱骨近端骨折占全身骨折的5%，其中單獨的肱骨大結節骨折占20%［1］，可伴或不伴盂肱關節脫位，在Neer分型上屬于2部分肱骨近端骨折，在AO分型上為11－A1．2或11－A1．3。自2010年3月至2013年3月對10例肱骨大結節撕脫骨折患者采用雙排錨釘縫合方法進行內固定，取得了較好效果。

材料和方法

一、一般資料

肱骨大結節骨折患者10例，其中男性4例，女性6例，年齡41～63歲，平均48．2歲。致傷原因：摔傷8例，車禍2例，其中伴盂肱關節前脫位3例。傷后肩關節X線片提示肱骨大結節骨折移位均＞0．5cm。

二、方法

盂肱關節脫位患者均急診予局麻下手法復位。所有患者于傷后2～21d，平均10d獲得有限切開復位，雙排錨釘內固定手術。具體術式為：肩關節前外側縱向經三角肌入路，切口避免超過肩峰遠側5cm，以免造成腋神經損傷。通過旋轉肩關節充分暴露大結節骨塊及骨折床，清理骨床，臨時復位骨折塊，選擇置釘點，于骨床近端偏前、后側接近肱骨頭關節面分別擰入Twinfix錨釘2枚作為內側錨釘，通過縫針或過線器將縫線帶過骨折塊近端附著之肩袖組織，打結固定，于骨床遠端內外側擰入footprint錨釘作為外側錨釘，將內側錨釘之尾線成編織狀覆蓋卡入footprint錨釘內（圖1、2）。術后予頸腕吊帶懸吊固定2周，期間開始肩關節被動鐘擺練習。6周后開始外展、前屈過90°練習。

圖1 內排錨釘置入后準備裝入Footprint錨釘

圖2 外排Footprint置入

三、隨訪及評價方法

本組所有患者均獲得門診隨訪，術后隨訪時間7～18個月，平均12．3個月。術后及隨訪時拍攝普通肩關節正側位X線片評價復位及愈合情況。以肩關節Constant評分與加州大學洛杉磯分校肩關節UCLA評分評價肩關節功能，采用SPSS 13．0軟件計算均值。

結 果

術中發現，10例患者中有5例骨折塊為粉碎性骨折，骨塊之間為骨膜、肩袖軟組織附著，故骨塊彼此之間均無明顯分離。所有10例患者骨折范圍均不超過大結節，骨塊厚度均不超過0．8cm。所有患者傷口均獲得一期愈合。肩關節X線片均提示：術后骨折端獲解剖復位（圖3）。術后隨訪無復位丟失，均獲骨性愈合。隨訪終末Constant評分平均90．3分（85～100分），UCLA 評分平均32．2分（28～35分）。

圖3 術后X線片示骨折端已獲解剖復位

討 論

肱骨大結節骨折向外上方移位，使肩峰下間隙變窄，可能引起肩部撞擊癥和肩袖撕裂［2］。早在1959年McLaughlin即指出大結節上移0．5cm即應手術治療，Platzer等［3］認為移位＜0．5cm 的大結節骨折可不需手術治療。Park等［4］于1997年提出，對于運動員或需要手臂過頭的體力勞動者，大結節骨塊發生0．3cm的移位也應當手術復位。肱骨大結節骨折畸形愈合，可能影響肩袖及三角肌力量，從而影響肩關節旋轉功能及外展等［5］。大結節撕脫骨折可伴隨著肩袖損傷，可引起將來骨折愈合后的疼痛［6］。Kim等［7］一組X線片上平均移位為2．3mm的肱骨大結節骨折患者的關節鏡手術中，發現其后期慢性疼痛與肩袖部分損傷有關。手術治療大結節撕脫骨折，可以處理肩袖損傷，避免肩峰下撞擊［8］。目前一般認為單獨的肱骨大結節骨折移位＞0．5cm具有手術指征，對于活動要求高的年輕人或運動員手術指征可進一步放寬，當然這仍有爭議［9］。

對于大結節骨折，傳統的術式有空心釘或螺釘固定。我們既往在術中發現因大結節骨折片較薄弱，單純依靠螺釘釘尾壓迫致骨片碎裂，導致固定不可靠或術中固定失效。而對于粉碎性大結節骨折，不論是空心釘或螺釘均將無法獲得有效固定。也有應用鋼板及微型鋼板固定，同樣存在骨片碎裂問題，若采用“跨越”固定，可能出現肩峰撞擊的風險。為克服這些問題，曾有人應用編織縫合肩袖經骨隧道固定方法治療大結節骨折，但經骨道固定易出現縫線在骨隧道的磨損致固定失??；也有人應用空心釘固定結合錨釘方法，但對于大結節粉碎性骨折不適用，也同樣面臨著骨片劈裂致空心釘失效情況。

大結節骨折可被認為是肩袖的撕脫骨折［10］。不論是關節鏡下修補或是開放性修補，錨釘縫合已成為公認的修補肩袖損傷的有效固定，因而應用錨釘縫合完全可滿足維持大結節骨折復位的力學要求。有實驗表明，在大結節骨折，應用錨釘的力學穩定性優于單純應用螺釘或空心釘［11］，也優于經骨道固定［12］?，F有研究認為雙排錨釘橋式縫合修補肩袖損傷有助于增大肩袖附著面積，從而有利于肩袖損傷修復［13－14］。所以雙排錨釘縫合可應用于大結節骨折，我們在臨床上也獲得了滿意效果。

錨釘縫合公認的薄弱點在于縫線斷裂、釘尾線孔破壞及螺釘拔出。錨釘的置入應注意指向撕脫方向，以期減小縫線的拔出角，減少錨釘的拔釘應力。一般認為應使縫線方向與錨釘縱軸垂線的夾角（即拔出角）＜45°。錨釘縫線對于肩袖肌腱的切割可能是固定失敗的另一重要原因［15］。可以通過增加縫合的針數來分擔減小相應的切割力量。通過增加錨釘數是一種方法，但是有限的骨床不可能置入過多錨釘，錨釘之間的距離過近，將造成骨質的進一步丟失，而造成錨釘脫拔或是骨折。那么通過增加單枚錨釘的縫線數就成為一種選擇。Twinfix具有兩根互不干擾的尾線，可滿足上述要求。有力學研究表明，2枚雙線錨釘較3枚單線錨釘可能更強［16］。通過骨床近、遠端的雙排錨釘置入，在撕脫骨塊表面縫線交織成網狀均勻將骨折塊壓向骨床更有利于術后骨折塊復位的維持。雙排錨釘可分擔應力，具有更好的力學可靠性，較單排錨釘更具有優勢［17－19］。

我們的體會是，雙排錨釘固定可應用于肱骨大結節撕脫骨折，耗材較昂貴，加重患者的經濟負擔，但是對于粉碎性肱骨大結節骨折仍是不錯的選擇。另外，對于要求將來取出內固定的患者，錨釘將不適用。有文獻指出，在骨質疏松患者肩袖修補術或大結節骨折內固定術中應用錨釘固定存在錨釘拔出的可能［20］，故對于骨質疏松患者應用錨釘固定有一定的顧慮。

目前關節鏡下雙排錨釘修復肩袖損傷已日益成熟，那么作為肩袖撕脫骨折的大結節骨折也可在關節鏡下行復位雙排錨釘固定。肩關節鏡下手術手術切口較小，軟組織剝離更少，術后黏連發生更少，當然這需要有更精巧的肩關節鏡技術［21］。

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Double－row suture anchor fixation of displaced greater tuberosity fractures

ZhangShaozhan，Huang Changming，FuYangpan，DongHuixiang，GanZhiyong．DepartmentofOrthopaedicWard2，the 174thHospitalofPeople′sLiberationArmy，OrthopedicsCenterofNanjinMilitaryDistrict，Xiamen361003，China

：HuangChangming，Email：huangchm123＠163．com

BackgroundAmong the proximal humeral fractures，the incidence of isolated fractures has been reported to be approximately 14%to 21% ．In addition，during rotator cuff injury，as a result of a strong pulling power，fractures of the greater tuberosity occur frequently during avulsion fracture of the rotator cuff．Particularly，a strong external rotation power acts on the greater tuberosity，and thus avulsion fracture may occur during anterior shoulder dislocation．Some authors have reported that greater tuberosity fractures were associated with approximately 10%to 30%of shoulder joint dislocation cases．Several arthroscopic and open techniques utilizing screws，wire or sutures through bone have been described for reduction and internal fixation of the greater tuberosity to the proximal humerus．But these are often inadequate in the presence of comminution and may prevent accurate restoration of the tuberosity－head relation．Bhatia have performed open reduction–internal fixation by use of the double－row suture anchor fixation technique in 21cases of comminuted and displaced fractures of the greater tuberosity，and the long－term results suggest a satisfactory outcome in most patients．However，the retrospective study or follow－up data about the surgical treatment of displaced humeral greater tuberosity fractures is still very limited．The purpose of this retrospective study is to evaluate the therapeutic outcomes of the open reduction and internal fixation using double－row fixation with suture anchors for the treatment of humeral greater tuberosity fractures．MethodsThe study included 10patients with isolated greater tuberosity fractures．The cases were reviewed at a mean post－operative follow－up duration is 12．3months（range from 7to 18months）from 2010to 2013．The average age of the patients was 48．2years old（range：41to 63years old），including 4males and 6 females．Among them，3patients were associated with anterior dislocation of the shoulder joint．All radiographs were examined by a single observer．The displacement was more than 5mm in X－ray plain film．All patients were operated by a single surgeon and with the same surgical technique．All the patients were treated by double－row anchor suture fixation through a mini－open approach and the operations were carried out in 2to 21days after trauma．The skin incision was made in Langer’s linesjust medial to the anterolateral aspect of the acromion．The deltoid was split from the anterolateral corner of the acromion distally for 4－5cm，without detaching the origin of the deltoid．The greater tuberosity fragment with the attached cuff was located and tagged with traction sutures through the cuff tendon．After the fractured bone surface on the proximal humerus was cleared of soft tissue，and two anchors（TwinFix）were inserted at the proximal margin of the humeral fracture surface．The strands of each suture were passed through the tendinous part of the attached cuff．The sutures were tied as mattress sutures with the arm in a neutral position．A second row of suture－anchors was passed distal to the humeral fracture surface．Two sutures were passed through the tendon between the first row of mattress sutures and the bone fragments．The strands from these two sutures were used to buttress the greater tuberosity fragments to the proximal humerus by tying these to four strands from the second row of anchors．The arm was suspended by a strap for 2weeks postoperatively，during which the shoulder started to do the pendulum exercise passively．Then they were required to do the abduction and flexion exercise over 90°after 6weeks．The patients were evaluated by interview，physical examination，and radiographs at 7－18months，with a mean follow－up of 12．3months．Details of complications and additional procedures were obtained from the clinical and operative records of the patients．The reductions and healing condition of the fractures were assessed by X－ray examination postoperatively．Then we use the Constant Score and UCLA shoulder rating scale to evaluate the function of shoulders．ResultsAccording to the intro－operative findings in the ten patients，five of them were communicated fracture，and there were soft tissues，such as periosteal membrane and rotator cuff，connecting the fractured fragments．Therefore，there is not significant separation between the fragments if the soft tissue around was properly protected during the exposure of fracture site．Moreover，the affected fracture area of the ten patients did not go over the greater tuberosity and the thickness of all the fracture fragments was within 0．8cm．All the patients’wound got healed．The X－ray showed an anatomic reduction with no re－displacement during the follow－up．Radiographic union of the tuberosity below the level of the articular surface of the humeral head was seen in all of 10 fractures．There was no heterotopic bone formation in any patient．All patients with radiographic union were satisfied with the outcome and the overall mean Constant score was 90．3and the final mean UCLA score was 32．2．There were no neurological complications，infections or complications of wound healing．ConclusionsGreater tuberosity fracture are well described and frequently discussed．They can be considered as an avulsion fracture of the rotator cuff．Suture anchors have recognized as an effective fixation of rotator cuff injury．The double－row anchors are more mechanically reliable，compared with single－row anchors．This technique has several advantages：First，biomechanical and clinical evaluation of the double－row fixation technique in arthroscopic rotator cuff repair has demonstrated significantly better biomechanical properties and structural outcome compared to other techniques；Second，proximal mattress sutures accurately restore the tuberosity－head relationship by approximating the bone－tendon junction to the proximal edge of the humeral fracture surface；Third，proximal fixation repairs the partial－thickness articular－surface tears of the supraspinatus tendon which may be associated with greater tuberosity fractures；Fourth，distal sutures serve as a tension band to effectively buttress the tuberosity fragments against the humeral fracture surface．The application of double－row anchors is clinically effective to treat the displaced greater tuberosity fractures．With the development of arthroscopic techniques，the outcome of double－row anchor suture fixation under arthroscopy is really to be expected．

Humerus fractures，greater tuberosity；Anchors

2014－01－16）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．02．003

361003 廈門，南京軍區骨科中心 解放軍一七四醫院骨二科

黃長明，Email：huangchm123＠163．com

張少戰，黃長明，傅仰攀，等．雙排錨釘橋式縫合在肱骨大結節骨折中的應用［J／CD］．中華肩肘外科電子雜志，2014，2（2）：80－84．