Zhang Zhijun, Li Yijun, Zhao Yang, Lu Yi, Zhu Yiming, Jiang Chunyan
Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China.
Clin Orthop Relat Res. 2024 May 1;482(5):831-840. doi: 10.1097/CORR.0000000000002895. Epub 2023 Oct 24.
Proximal humeral fractures (PHFs) often occur in elderly individuals who experience low-energy falls. Open reduction and internal fixation (ORIF) of the proximal humerus is typically performed in young, active patients because of their good bone quality and high functional demands. Although good short-term results have been reported after ORIF in young patients, few studies have specifically evaluated long-term outcomes.
QUESTIONS/PURPOSES: (1) What are the long-term clinical outcomes scores and (2) radiologic outcomes of nonosteoporotic three-part and four-part PHFs treated with locking plates? (3) What complications occurred after treatment, and what factors are associated with poor postoperative functional outcomes scores and avascular necrosis (AVN) of the humeral head after ORIF?
Between June 2005 and December 2012, we surgically treated 774 patients for displaced two-, three-, and four-part PHFs. Approximately 75% (581 of 774) underwent ORIF, 10% (77 of 774) underwent hemiarthroplasty, 7% (54 of 774) underwent intramedullary nailing, 5% (39 of 774) underwent reverse shoulder arthroplasty, and the remaining 3% (23 of 774) underwent other surgical treatments. We considered those who had ORIF as potentially eligible. Based on that criterion, 75% (581) were eligible. However, only patients with nonosteoporotic three- and four-part PHFs (cortical thickness of the proximal humeral diaphysis greater than 6 mm on a preoperative AP radiograph of the affected shoulder) and a minimum of 10 years of follow-up were included. Sixty-four percent (498 of 774) of the patients were excluded because of simple or osteoporotic fractures, 1% (7 of 774) were excluded because of ipsilateral limb multiple fractures, 0.3% (2 of 774) were excluded because of pathologic PHFs, and another 2% (13 of 774) were lost before the minimum study follow-up of 10 years, leaving 8% (61 of 774) for analysis here. The mean age at surgery was 45 ± 12 years, with a mean follow-up of 13 years. Fifty-seven percent (35 of 61) of the patients were men. Patient-reported outcomes were evaluated using the University of California Loas Angeles (UCLA) score (range 0 to 35; higher scores represent better shoulder function) and Constant score (range 0 to 100; higher scores represent better shoulder function) at least 10 years postoperatively. Postoperative radiographs were reviewed to assess the cortical bone thickness of the proximal humerus, neck-shaft angle, head-to-tuberosity distance, and radiologically confirmable complications. Logistic regression analysis was performed to evaluate factors associated with poor postoperative functional scores (UCLA score ≤ 27 or Constant score ≤ 70) and AVN of the humeral head; the association between AVN and postoperative functional outcomes was also assessed.
At the most-recent follow-up, these patients had a mean UCLA score of 31 ± 3 and a Constant score of 88 ± 10. The mean neck-shaft angle was 133° ± 10°, and 23% (14 of 61) of patients experienced AVN of the humeral head during follow-up. Twenty-nine complications in 30% (18 of 61) of patients were reported. After controlling for potentially confounding variables such as age and gender, we found that the presence of greater tuberosity malposition (odds ratio 18 [95% confidence interval 2 to 167]; p = 0.01) and immediate postoperative neck-shaft angle less than 130° (OR 19 [95% CI 3 to 127]; p = 0.002) were associated with poor postoperative functional scores. Four-part PHFs (OR 13 [95% CI 2 to 82]; p = 0.008) and metaphyseal extension less than 8 mm (OR 7 [95% CI 1 to 35]; p = 0.03) were associated with AVN of the humeral head. For patients who met the criteria for anatomic reduction (achievement of all of the following three criteria: neck-shaft angle ≥ 130°, head-shaft displacement < 5 mm, and head-to-tuberosity distance greater than or equal to 3 mm and less than or equal to 20 mm), there were no differences in postoperative functional scores between patients with AVN and those without.
ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. When encountering complex PHFs in patients with good bone quality, every effort must be made to achieve an anatomic reduction of the fracture as far as possible, which may not reduce the risk of AVN (this occurred in nearly one-fourth of patients). However, good outcomes can usually be expected, even in patients with AVN. Because this was a retrospective study with a high risk of bias owing to sparse data, the factors associated with poor postoperative functional outcomes must be further investigated in large prospective studies.
Level III, therapeutic study.
肱骨近端骨折（PHFs）常发生于因低能量跌倒的老年人。由于年轻、活跃患者骨质良好且功能需求高，肱骨近端切开复位内固定术（ORIF）通常用于此类患者。尽管有报道称年轻患者行ORIF术后短期效果良好，但很少有研究专门评估其长期疗效。
问题/目的：（1）采用锁定钢板治疗非骨质疏松性三部分和四部分PHFs的长期临床疗效评分是多少？（2）影像学结果如何？（3）治疗后发生了哪些并发症，哪些因素与ORIF术后功能结局评分差及肱骨头缺血性坏死（AVN）相关？
2005年6月至2012年12月期间，我们对774例移位的二部分、三部分和四部分PHFs患者进行了手术治疗。约75%（774例中的581例）接受了ORIF，10%（774例中的77例）接受了半关节置换术，7%（774例中的54例）接受了髓内钉固定，5%（774例中的39例）接受了反肩关节置换术，其余3%（774例中的23例）接受了其他手术治疗。我们认为接受ORIF的患者可能符合条件。基于该标准，75%（581例）符合条件。然而，仅纳入非骨质疏松性三部分和四部分PHFs患者（患侧肩部术前前后位X线片显示肱骨近端骨干皮质厚度大于6mm）且随访至少10年的患者。774例患者中的64%（498例）因单纯或骨质疏松性骨折被排除，1%（774例中的7例）因同侧肢体多发骨折被排除，0.3%（774例中的2例）因病理性PHFs被排除，另外2%（774例中的13例）在最短10年的研究随访前失访，此处仅留8%（774例中的61例）进行分析。手术时的平均年龄为45±12岁，平均随访13年。57%（61例中的35例）为男性。术后至少10年采用加州大学洛杉矶分校（UCLA）评分（范围0至35分；分数越高表示肩部功能越好）和Constant评分（范围
