Department of Orthopaedics and Sports Traumatology, Hôpital de l'Archet 2, Université de Nice-Sophia-Antipolis (UNSA), Nice, France.
J Shoulder Elbow Surg. 2013 Nov;22(11):1495-506. doi: 10.1016/j.jse.2013.04.018. Epub 2013 Jul 5.
The purposes of this study were (1) to identify the risk factors for tuberosity complications and poor functional outcomes and (2) to compare a standard humeral stem with a fracture-specific humeral stem in hemiarthroplasty for the treatment of 3- and 4-part proximal humeral fractures.
We retrospectively reviewed the cases of 60 consecutively operated patients (61 shoulders) using radiographs and computed tomography scans. There were 56 displaced four-part and 5 three-part fractures. The technique was standardized for prosthesis positioning in height and retroversion and for tuberosity fixation. A conventional standard stem was implanted in the first 31 shoulders (group A), and a specific fracture stem was implanted in the next 30 shoulders (group B). The sample size needed for comparison was predetermined with an a priori power analysis. The mean follow-up period was 64 months (range, 24 to 150 months).
At the last follow-up, the greater tuberosity was healed in an adequate (anatomic) position in 45% of the patients in group A (14 of 31) and 87% of those in group B (26 of 30) (P = .0001). Active forward elevation, active external rotation, and the Constant score were significantly better with fracture stems (136°, 34°, and 68 points, respectively) than with conventional stems (113°, 23°, and 58 points, respectively) (P < .0001). Regardless of the type of implant used, patients aged 75 years or older and women had significantly lower functional results and higher rates of tuberosity complications (P < .0001).
Good functional outcomes can be anticipated after hemiarthroplasty for proximal humeral fractures if the greater tuberosity is anatomically positioned (ie, lateral to the stem) and healed around the prosthesis. The use of a specific fracture stem allows to double the rate of tuberosity healing compared to a conventional stem (87% vs. 45%), decreases complications and improves shoulder function. Risk factors associated with poor functional results and anatomic failures are (1) patient age (≥75 years), (2) patient gender (women), and (3) use of a conventional (bulky) stem.
本研究旨在（1）确定结节并发症和功能不良结局的危险因素，（2）比较肱骨柄假体治疗三部分和四部分肱骨近端骨折的标准肱骨柄与骨折专用肱骨柄。
我们回顾性分析了 60 例连续手术患者（61 例肩）的病例，使用 X 线片和 CT 扫描。56 例为四部分移位骨折，5 例为三部分骨折。假体定位高度和后倾技术标准化，结节固定标准化。31 例（A 组）植入传统标准柄，30 例（B 组）植入特定骨折柄。比较样本量需要事先进行功效分析。平均随访时间为 64 个月（24 至 150 个月）。
末次随访时，A 组（31 例中的 14 例，45%）和 B 组（30 例中的 26 例，87%）患者的大结节在适当（解剖）位置愈合（P =.0001）。与常规柄（分别为 113°、23°和 58 点）相比，骨折柄的主动前向抬高、主动外旋和 Constant 评分明显更好（分别为 136°、34°和 68 点）（P <.0001）。无论使用何种植入物，年龄≥75 岁的患者和女性的功能结果明显较低，结节并发症的发生率较高（P <.0001）。
如果大结节位于假体的解剖位置（即位于假体外侧）并在假体周围愈合，那么肱骨近端骨折的半关节成形术可以获得良好的功能结果。与常规柄（87%比 45%）相比，使用特定骨折柄可使结节愈合率增加一倍，并发症减少，肩部功能改善。功能不良结果和解剖失败的危险因素是（1）患者年龄（≥75 岁），（2）患者性别（女性）和（3）使用常规（粗壮）柄。
