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作者信息

Madeja R, JeČmÍnek V, Bialy L, StrÁnskÝ J, Voves J, Pleva L

机构信息

Klinika úrazové chirurgie Fakultní nemocnice Ostrava.

出版信息

Acta Chir Orthop Traumatol Cech. 2020;87(3):162-166.

Abstract

PURPOSE OF THE STUDY Fractures of the scapula are less frequent, with the incidence reported in literature of approximately 1% of all fractures and 3-5% fractures of shoulder. These fractures are predominantly treated non-operatively. Osteosynthesis is indicated in displaced intra-articular fractures and severely displaced extra-articular fractures of the scapular body, its lateral border in particular. Apart from open reposition and osteosynthesis, also minimally invasive osteosynthesis under fluoroscopic and arthroscopic control has recently been used to treat intra-articular fractures of the scapula. The arthroscopy facilitates debridement of the fracture line in the intra-articular region and control over the insertion of the osteosynthesis material in the subchondral bone of the glenoid and it also makes visible the accuracy of reduction of fractures of the glenoid articular surface. MATERIAL AND METHODS In 2013-2017, osteosyntheses of 9 intra-articular fractures of the scapula were performed with the use of both perioperative fluoroscopy and arthroscopy. The group included 7 men and 2 women, with the mean age of 37 years (range 24-52 years). 4.5 mm cannulated screws inserted in the subchondral bone either from the cranial or dorso-caudal part of the glenoid in dependence on the type of the fracture were used as osteosynthesis material. Postoperatively, the extremity was fixed by Desault type shoulder brace for 4 weeks. Rehabilitation using standard procedures for shoulder joint followed. The patients were followed up at regular intervals, namely on 10th day, at 4 weeks, 3, 6, 12 and 24 months postoperatively. The clinical outcomes and radiologic signs of healing were evaluated continuously and two years after the surgery the clinical outcomes were assessed using the Constant score. Arm elevation was assessed separately, as a dominant indicator of shoulder joint function. RESULTS No perioperative complications were reported, the operative times ranged from 45 to 120 minutes. Reduction was always performed in fractures with intra-articular displacement of less than 2 mm, which was measured both arthroscopically and on perioperative and postoperative radiographs. No complications of wound healing were observed. One patient experienced temporary paresthesia in the innervation zone of the sensitive branch of the radial nerve. The mean healing time of fractures was 121 days (range 107-146 days). The mean Constant score at two years after surgery was 83 points (range 78-87 points), the resulting restriction of elevation was 12° on average (range 0-23°). DISCUSSION There are not many papers covering a similar topic in world literature, most of them present the benefits of arthroscopy in some types of osteosyntheses of intra-articular fractures of the scapula. Most frequently mentioned are osteosyntheses of the anterior portion of the glenoid in case of a bony Bankart lesion. These papers highlight the benefits of minimal invasiveness of this procedure. CONCLUSIONS By visualising the fracture line, the arthroscopy facilitates a more accurate reduction of fragments and a minimally invasive osteosynthesis of some intra-articular fractures of the scapula when compared to closed reduction with fluoroscopic intraoperative control only. The use of arthroscopy in these interventions is conditional on perfect mastering of the surgical technique and also the use of special instruments both for arthroscopy and minimally invasive osteosynthesis. If these criteria are observed and the surgical technique mastered, the authors consider this method beneficial in treating the glenoid fractures. Key words: minimally invasive osteosynthesis, glenoid fractures.

摘要

研究目的 肩胛骨骨折相对少见,文献报道其发生率约占所有骨折的1%,占肩部骨折的3 - 5%。这些骨折主要采用非手术治疗。对于移位的关节内骨折以及肩胛体严重移位的关节外骨折,尤其是其外侧缘骨折,需进行骨内固定。除了开放复位和骨内固定外,近年来还采用在透视和关节镜控制下的微创骨内固定来治疗肩胛骨的关节内骨折。关节镜有助于清理关节内区域的骨折线,控制骨内固定材料在肩胛盂软骨下骨的植入,还能观察肩胛盂关节面骨折复位的准确性。

材料与方法 2013 - 2017年,对9例肩胛骨关节内骨折患者进行了骨内固定,术中采用了透视和关节镜技术。该组包括7名男性和2名女性,平均年龄37岁(范围24 - 52岁)。根据骨折类型,从肩胛盂的颅侧或背尾侧将4.5 mm空心螺钉插入软骨下骨作为骨内固定材料。术后,患肢用德索型肩托固定4周。随后按照肩关节的标准程序进行康复治疗。定期对患者进行随访,即在术后第10天、4周、3个月、6个月、12个月和24个月进行随访。持续评估临床结果和骨折愈合的影像学征象,术后两年采用Constant评分评估临床结果。单独评估手臂抬高情况,作为肩关节功能的主要指标。

结果 未报告围手术期并发症,手术时间为45至120分钟。对于关节内移位小于2 mm的骨折均进行了复位,通过关节镜以及术中、术后X线片测量。未观察到伤口愈合并发症。1例患者在桡神经感觉支的神经支配区域出现暂时性感觉异常。骨折的平均愈合时间为121天(范围107 - 146天)。术后两年的平均Constant评分为83分(范围78 - 87分),由此导致的手臂抬高受限平均为12°(范围0 - 23°)。

讨论 世界文献中涉及类似主题的论文不多,其中大多数介绍了关节镜在某些类型肩胛骨关节内骨折骨内固定中的益处。最常提到的是在骨性Bankart损伤情况下肩胛盂前部的骨内固定。这些论文强调了该手术微创的优点。

结论 与仅在术中透视控制下进行闭合复位相比,关节镜通过可视化骨折线有助于更准确地复位骨折碎片,并对一些肩胛骨关节内骨折进行微创骨内固定。在这些干预措施中使用关节镜取决于对手术技术的完美掌握,以及对关节镜和微创骨内固定专用器械的使用。如果遵循这些标准并掌握了手术技术,作者认为这种方法在治疗肩胛盂骨折方面是有益的。

关键词

微创骨内固定;肩胛盂骨折

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