Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany.
Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany.
J Shoulder Elbow Surg. 2019 Sep;28(9):1674-1684. doi: 10.1016/j.jse.2019.02.017. Epub 2019 May 2.
To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques.
Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted.
Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group.
RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.
迄今为止，对于复杂肱骨近端骨折（PHF）模式的手术治疗建议，尤其是关节保留与关节置换技术之间，仍缺乏共识。
在 2012 年至 2017 年间，146 例（年龄 74.1±8.0 岁）复杂 PHF 患者接受了锁定钢板（切开复位内固定 [ORIF]）或反式全肩关节置换术（RTSA）治疗。在中期随访中记录了并发症和非计划翻修手术。提取了潜在的患者和手术并发症危险因素。进行了单变量和多变量分析。
125 例患者的随访数据可用，其中 66 例（52.8%）接受了锁定钢板治疗，59 例（41.2%）接受了 RTSA 治疗。两组的 Charlson 指数相当。ORIF 的总体并发症发生率为 37.8%，RTSA 为 22.0%，翻修率分别为 12.1%和 5.1%，主要由持续运动缺陷引起。多变量分析表明两种手术之间无显著差异（P=.500）。然而，年龄是总体并发症的独立保护因素（P=.018）。ORIF 中主要并发症的危险因素包括骨质疏松症、内翻撞击骨折、后内侧干骺端延伸<8mm、头干移位>4mm 和多节段大结节。对于 RTSA，Charlson 指数较高、患有糖尿病或肱骨头、结节有改变（较大）的患者并发症发生率更高。相比之下，Neer 分类系统在两组中均无预测价值。
RTSA 导致的并发症少于 ORIF，因此可以被认为是老年复杂 PHF 的一种有价值的选择。关注特定的预后因素可能有助于降低并发症发生率。
