Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA.
Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA.
J Shoulder Elbow Surg. 2023 Oct;32(10):2097-2104. doi: 10.1016/j.jse.2023.04.002. Epub 2023 May 22.
Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation.
All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate.
Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN.
Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.
肱骨近端骨折脱位，不包括 2 部分大结节骨折脱位，是罕见的损伤。这些损伤的切开复位内固定（ORIF）后的结果在文献中描述得并不充分。本研究的目的是报告接受肱骨近端骨折脱位切开复位内固定治疗的患者的影像学和功能结果。
确定了 2011 年至 2020 年间接受肱骨近端骨折脱位切开复位内固定的所有骨骼成熟患者。排除了单纯大结节骨折脱位的患者。主要结果是至少 2 年的美国肩肘外科医生标准化肩部评估表（ASES）评分。次要结果是发生缺血性坏死（AVN）和再次手术的发生率。
26 名患者符合纳入标准。平均年龄为 45 岁（标准差 16），77%为男性。中位数复位和手术时间为 1 天（四分位距 [IQR] 1-5）。有 2 例（8%）为 Neer 2 部分骨折，7 例（27%）为 3 部分骨折，17 例（65%）为 4 部分骨折。54%涉及解剖颈，31%包括头部分离成分。39%为前脱位。AVN 的发生率为 19%。再次手术率为 15%。再次手术包括去除内固定物（2 例）、肩胛下肌修复（1 例）和麻醉下手法复位（1 例）。没有患者进行关节置换。22 名患者（84%）的 ASES 评分可用，其中包括 5 例 AVN 患者中的 4 例。术后平均 6.0 年的 ASES 评分中位数为 98.3（IQR 86.7-100，范围 63.3-100），且有或无 AVN 的患者之间无差异（中位数 98.3 与 92.0，P=0.175）。仅术后影像学上存在内侧粉碎和非解剖头干对线与 AVN 风险增加相关。
在接受肱骨近端骨折脱位切开复位内固定治疗的患者中，AVN（19%）和再次手术（15%）的影像学发生率较高。尽管如此，没有患者需要进行关节置换，受伤后平均 6 年的患者报告的结果评分非常好，ASES 评分中位数为 98.5。对于肱骨近端骨折脱位，切开复位内固定不仅应作为年轻患者，也应作为中年患者的主要治疗方法。
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