反球型人工肩關節置換術治療肱骨近端陳舊骨折不愈合

李奉龍 姜春巖

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·論著·

反球型人工肩關節置換術治療肱骨近端陳舊骨折不愈合

李奉龍 姜春巖

目的 評價采用反球型人工肩關節置換術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,收治并進行反球型人工肩關節假體置換手術的9例肱骨近端陳舊骨折不愈合，均為肱骨近端骨折切開復位內固定術后患者，其中3例患者為大結節不愈合，6例患者為大結節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)。主力側受累6例。本次手術距上次手術平均時間為(15±7.3)個月(10～29個月)。結果 9例患者術后獲(37.9±10.2)個月(24～52個月)隨訪。末次隨訪時患者肩關節活動度：前屈上舉為131.2°±22.0°，外旋為22.6°±11.2°，內旋平均為第3腰椎椎體水平(±3個椎體)；VAS疼痛評分為(1.5±1.7)分(0～6分)，ASES評分為(74.3±15.6)分(48～94分)，Constant評分為(71.6±10.2)分(44～92分)，UCLA評分為(27.9±5.6)分(18～34分)。所有患者術后均無肩峰應力骨折、感染、假體松動、神經血管損傷等并發癥發生。結論 采用反球型人工肩關節置換術治療肱骨近端陳舊骨折不愈合可獲得良好的臨床療效。

肩關節；人工關節置換術；肱骨骨折，近端；骨折并發癥

肱骨近端骨折術后不愈合的治療是肩關節外科的難點之一，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或人工肱骨頭置換術，術后肩關節功能恢復結果難以預期[1-6]。近年來，國外有學者報道采用反球型人工肩關節假體置換術治療肱骨近端骨折，并取得了一定療效[7]，但反球型肩關節假體在治療肱骨近端陳舊骨折不愈合方面的作用，目前仍缺乏相關研究報道。本文通過分析近年來我院采用反球型人工肩關節假體置換術治療肱骨近端陳舊骨折不愈合的臨床結果，對此種手術方法的療效作一初步總結。

資 料 與 方 法

一、一般資料

病例入選標準：(1)因肱骨近端陳舊骨折不愈合于我院行反球型人工肩關節假體置換手術者，不合并血管神經損傷；(2)術后最短隨訪時間不低于2年。病例排除標準：(1)合并有血管神經損傷；(2)術后隨訪時間少于2年。

2010年10月至2013年2月，于我院收治并進行反球型人工肩關節假體置換手術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)。主力側受累6例。本次手術距上次手術平均時間為(15±7.3)個月(10～29個月)。所有患者均為肱骨近端骨折切開復位內固定術后患者，其中3例患者為大結節不愈合，6例患者為大結節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)反球型肩關節假體(Zimmer)進行人工全肩關節置換治療。

二、手術方法

手術采用沙灘椅位，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。術中應特別注意保護三角肌及其起止點。顯露并辨認肱二頭肌長頭腱以確定大、小結節，術中應仔細探查并明確陳舊骨折塊，確定肱骨近端各個骨折部分，必要時需行截骨以利于充分顯露肩盂及后續重建大小結節操作。術中用較粗的非可吸收線在肩袖止點部位固定陳舊骨折塊，以備牽引復位之用。

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，應采用假體試模仔細比對并試行復位，理想的復位狀態是獲得良好的假體盂肱關節順應性與理想的假體高度以維持適當的三角肌和聯合腱張力。復位大小結節骨折塊，利用取出的肱骨頭在大小結節與肱骨干結合部作松質骨植骨，以利骨折愈合。以鈦纜環抱固定骨折塊，并采用高強度縫合線進一步縫合，加固大小結節骨折塊。

三、康復方法

術后采用肩關節外展包支具制動6周。手、腕、肘的被動功能鍛煉在術后第1天根據患者疼痛允許情況下盡快進行，術后3周后進行肩關節被動功能鍛煉，術后6周后若存在大小結節愈合的證據，則可摘除支具開始主動活動度練習，根據患者具體康復情況逐步恢復日常生活活動。術后12周開始肌肉力量練習。

四、隨訪及評價方法

患者術后3周、6周、12周、6個月、12個月以及末次隨訪時拍攝肩外旋中立位肩關節正位、側位和腋位X線片，以判斷假體位置、大結節愈合情況等。末次隨訪時采用VAS(visual analogue score)疼痛評分、ASES(American shoulder and elbow surgeons)評分、Constant評分及UCLA(university of california los angeles)評分評價肩關節功能恢復情況。

結 果

9例患者術后獲平均(37.9±10.2)個月(24～52個月)隨訪。末次隨訪時患者肩關節活動度：前屈上舉平均為131.2°±22.0°，外旋平均為22.6°±11.2°，內旋平均為第3腰椎椎體水平(±3個椎體)；VAS疼痛評分平均為(1.5±1.7)分(0～6分)，ASES評分平均為(74.3±15.6)分(48～94分),Constant評分平均為(71.6±10.2)分(44～92分)，UCLA評分平均為(27.9±5.6)分(18～34分)。

所有患者通過肩關節正位、側位和腋位X線片定期復查，無大小結節不愈合發生；所有患者術后均無肩峰應力骨折、感染、假體松動、肩胛骨撞擊、神經血管損傷等并發癥發生。

討 論

第二代反球型肩關節假體最早由Grammont設計并提出，此種假體通過反轉盂肱關節對位關系，使盂肱關節旋轉中心內移，進而使三角肌在肩關節前屈上舉中發揮主要作用[8]。同時由于新設計使盂肱關節旋轉中心內移至肩盂關節面，大大降低了肩盂假體松動的幾率。反球型肩關節假體在設計初始階段，主要用于治療巨大或不可修復肩袖損傷所引起的關節病變，因為在此種患者中，肩袖的動態穩定機制已被破壞，三角肌的動力難以通過肩袖肌肉轉化為肩關節上舉的動力。而通過反球肩關節置換，可以使三角肌作為肩關節前屈上舉的動力直接發揮作用，進而替代了部分肩袖肌肉(岡上肌)的功能[9-12]。

雖然反球型關節置換手術可以降低患者肩關節功能預后對于大結節愈合的依賴性，但大小結節的愈合狀況仍對患者術后功能產生一定影響。Sirveaux等[13]通過研究發現，對于進行反球關節置換手術的患者，術中重建大小結節組的功能優于非重建組。因此，在進行反球關節置換手術時要仔細重建大小結節，以促進術后結節愈合，最大程度地改善患者術后肩關節功能。

文獻報道反球型肩關節置換術后的常見并發癥包括肩胛骨撞擊、關節不穩或脫位、肩峰應力骨折等[14-19]。其中肩胛骨撞擊是指肱骨側假體在肩關節內收時與肩胛頸下緣發生撞擊，進而導致假體松動以致失效。本組病例中術后無肩胛骨撞擊發生，考慮與隨訪時間較短有關。

本研究有一定的局限性。首先，隨訪時間較短，應延長隨訪時間以明確反球型肩關節置換術的遠期療效；其次，本研究為回顧性隨訪研究，將來仍需要設計更高等級的前瞻性隨機對照試驗或隊列研究，以論證反球型肩關節置換術在治療肱骨近端陳舊骨折不愈合方面的優勢。

小結：采用反球型人工肩關節置換術治療肱骨近端陳舊骨折不愈合，術后療效令人滿意，患者可獲得良好的肩關節功能。

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(本文編輯：李靜)

李奉龍，姜春巖.反球型人工肩關節置換術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

北京市新世紀百千萬人才工程培養經費(20111103)；“首都臨床特色應用研究”專項資助課題

100035北京積水潭醫院運動損傷科

姜春巖,Email:chunyanj@hotmail.com

2015-03-20)

(Z141107002514001)