Department of Orthopaedics and Traumatology, Clinical Epidemiology and Biometry research unit, Regional Hospital Center, Rennes-1 University, 2, rue Henri-Le-Guilloux, 35033 Rennes, France.
Orthop Traumatol Surg Res. 2012 Jun;98(4):383-9. doi: 10.1016/j.otsr.2012.01.008. Epub 2012 May 18.
To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion.
Prospective, consecutive, multicenter based.
Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study.
Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.
There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score.
Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.
Level IV: prospective study.
评估顺行髓内钉固定肱骨近端骨折的效果，包括骨折复位、骨愈合、骨坏死、骨坏死的功能后果和畸形愈合。
前瞻性、连续、多中心研究。
学术创伤中心；所涉及机构的伦理委员会已批准该项研究。
前瞻性纳入 51 例患者，其中 31 例为 3 部分移位骨折，20 例为 4 部分移位骨折（头部移位大于 45°，结节-头部间隙大于 10mm，骨干间隙大于 10mm）。使用 Telegraph™髓内钉（FH Orthopedics，Heimsbrunn，法国）作为固定装置，在透视引导下经超外侧经三角肌入路置入。评估包括简单肩部测试、绝对 Constant 评分、每 3 个月拍摄 X 线片和最终评估时进行 CT 扫描。12 例患者死亡，1 例失访。早期并发症包括 4 例患者出现继发性移位。
无感染、三角肌或腋神经损伤，所有骨折均愈合。平均随访 24.1 个月后，38 例存活患者中 29%存在畸形愈合，32%存在骨坏死。这两种并发症在 4 部分骨折患者中更为常见和广泛。骨坏死面积影响 Constant 评分，当面积小于 30%时为 55.8 分，30%至 50%时为 50.6 分，大于 50%时为 38 分。头部畸形愈合影响简单肩部测试和 Constant 评分。
因此，顺行髓内钉可推荐用于 3 部分骨折，因为在该亚组中骨坏死的发生率较低，范围较局限，且更易耐受。相反，对于 4 部分骨折患者，顺行髓内钉在预防骨坏死或头部畸形愈合方面并不优于其他内固定技术。
IV 级：前瞻性研究。
