Dimakopoulos Panayiotis, Panagopoulos Andreas, Kasimatis Georgios
Shoulder and Elbow Unit, Orthopaedic Department, University Hospital of Patras, Papanikolaou Street, Rio-Patras 26504, Greece.
J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:8-21. doi: 10.2106/JBJS.H.01290.
The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus.
Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis.
All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%.
The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.
肱骨近端移位骨折的最佳治疗方法仍存在争议。我们评估了经骨缝合固定术治疗一系列选定的肱骨近端移位骨折的长期功能和影像学结果。
在11年期间，连续188例具有特定定义的肱骨近端移位骨折患者接受了切开复位及经骨缝合内固定术。20例患者失访，3例在随访前死亡，剩余165例患者（94例女性和71例男性；平均年龄54岁）可供研究。45例（27%）损伤为伴有外翻嵌插的四部分骨折；64例（39%）为三部分骨折；56例（34%）为大结节的两部分骨折，其中36例（64%）伴有肩关节前脱位。所有骨折均用不可吸收的5号Ethibond缝线经骨固定。57例（35%）患者检测到的合并肩袖撕裂也进行了修复。平均随访5.4年，采用Constant评分评估功能结果。对随访X线片评估骨折愈合、畸形愈合、不愈合、异位骨化以及撞击征、肱骨头坏死和退行性骨关节炎的征象。
除2例大结节三部分骨折外，所有骨折均在4个月内愈合。术后第一张X线片上显示的骨折复位质量在155例患者（94%）中被视为优/良，7例（4%）为好，3例（2%）为差。末次随访时9例患者（5%）存在畸形愈合；9例中的6例初始复位为好或差，3例为优/良。165例患者中有11例（7%）出现肱骨头坏死；4例出现完全塌陷，7例出现部分塌陷。15例患者有异位骨化，但均无功能障碍。4例患者有撞击综合征征象，2例有关节炎。在最终评估时，平均Constant评分为91分，未根据年龄和性别调整的平均Constant评分占未受伤侧肩部评分的百分比为94%。
术后平均5.4年时，该经骨缝合技术的临床和影像学结果令人满意。该技术的优点包括手术软组织分离较少、肱骨头坏死率低、固定足以允许早期被动关节活动以及避免使用笨重且昂贵的植入物。
