Foruria Antonio M
Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery, Autónoma University, Fundación Jiménez Díaz University Hospital, Avenida Reyes Católicos 2, Madrid, Spain.
Curr Rev Musculoskelet Med. 2023 Oct;16(10):457-469. doi: 10.1007/s12178-023-09853-z. Epub 2023 Aug 12.
Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating.
Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.
使用锁定钢板进行切开复位内固定术（ORIF-LP）治疗肱骨近端骨折已有数十年历史。尽管文献中广泛报道了良好的治疗效果，但也有报道称并发症发生率高得令人难以接受（高达40%），其中许多并发症导致预后不良且需要再次手术（高达25%），尤其是在老年患者中。最常见的并发症与植入物失败有关，关节内螺钉穿透是最常见且最具破坏性的。
在患者选择和手术技术方面取得了进展，并实施了骨或骨水泥强化，有望降低并发症发生率。梅奥-FJD分类提供了预后信息，有助于肱骨近端骨折治疗的决策过程。移位的外翻嵌插骨折在ORIF-LP术后似乎与超过10%的缺血性坏死发生率相关。一种基于原则的逐步手术技术，结合解剖复位和短螺钉配置，在大多数患者（甚至老年患者）中都能取得良好的效果，将植入物失败率降低至10%以下。丙烯酸骨水泥强化有可能进一步将植入物失败率降低至1%。再次手术率较高，部分原因是需要取出硬件以解决肩峰下疼痛冲突。然而，迄今为止，尚无研究明确证明ORIF-LP与非手术治疗、髓内钉固定或反肩关节置换术相比具有优越性。即使在老年患者中，只要进行充分的患者选择，并采用基于原则的逐步手术技术，必要时辅以植骨或丙烯酸骨水泥，ORIF-LP就能为移位肱骨近端骨折的手术治疗提供良好效果。如果不遵循这些建议，预计会出现不良预后以及高并发症和再次手术率。
