Akgün Doruk, Paksoy Alp, Imiolczyk Jan-Philipp, Bahlawane Soraya, Gebauer Henry, Dey Hazra Rony-Orijit, Stöckle Ulrich, Braun Karl Friedrich, Moroder Philipp
Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany.
University Hospital rechts der Isar, Technical University Munich, Germany.
JSES Int. 2024 Jul 8;8(5):990-994. doi: 10.1016/j.jseint.2024.06.012. eCollection 2024 Sep.
Understanding vascularity and assessing the risk of post-traumatic avascular necrosis are crucial for predicting outcomes and identifying optimal treatment options in proximal humerus fractures (PHFs). Until now, Hertel et al have been the only researchers to evaluate the intraoperative perfusion of the humeral head after fracture using Doppler flowmetry in a central single drill hole within the head. This pilot study aims to standardize the evaluation of intraoperative perfusion measurements in different areas of the humeral head in patients with PHF.
In this prospective pilot study, intraoperative semiquantitative Doppler perfusion measurements were conducted during plate osteosynthesis for PHF treatment in our institution between July 2021 and May 2022. The fracture morphology was classified radiologically according to Resch's criteria. Quality of reduction was determined postoperatively to be either anatomical, minor malreduced, or major malreduced according to Peters et al in conventional and computed tomography examinations. Medial hinge integrity and medial metaphyseal extension were assessed radiographically according to Hertel et al. Intraoperatively, after drilling screw holes through the plate, a Doppler probe was inserted through all nine drill holes on the humeral head and at least one on the humeral shaft to successively measure the presence of a pulse to indicate if perfusion is present.
A total of ten patients (mean age 59 years, range, 36-83) with a humeral head fracture (2 × 2GL, 3 × 3G, 2 × 4G, 2 × 4GL, 1 × 5aG according to Resch) were included. Nine of the ten patients showed a pulse signal on the humeral shaft. Overall, pulse-synchronous perfusion was detected using Doppler sonography in at least one hole in the humeral head of all patients. In patients with an intact medial hinge (N = 6), pulse-synchronous perfusion could be measured in almost twice as many humeral head holes on average (5.7 vs. 3.0 drill holes) compared to patients with a dislocated medial hinge (N = 4). In patients with metaphyseal extension (N = 3), pulse-synchronous perfusion was measured in an average of 6.7 humeral head holes compared to 3.7 holes in patients without metaphyseal extension (N = 7).
Semiquantitative, intraoperative Doppler flowmetry offers a noninvasive and rapid assessment of humeral perfusion which allows an understanding of humeral head perfusion, when used in a standardized fashion to measure flow in different areas of the humeral head.
了解血管情况并评估创伤后缺血性坏死的风险对于预测近端肱骨骨折（PHF）的预后以及确定最佳治疗方案至关重要。到目前为止，赫特尔等人是唯一使用多普勒血流仪在肱骨头中央单个钻孔内评估骨折后肱骨头术中灌注情况的研究人员。这项前瞻性研究旨在规范PHF患者肱骨头不同区域术中灌注测量的评估方法。
在这项前瞻性研究中，于2021年7月至2022年5月在我们机构对接受钢板接骨术治疗PHF的患者进行术中半定量多普勒灌注测量。根据雷施标准对骨折形态进行放射学分类。术后根据彼得斯等人的标准，在传统X线和计算机断层扫描检查中确定复位质量为解剖复位、轻度复位不良或重度复位不良。根据赫特尔等人的方法，通过X线评估内侧铰链完整性和内侧干骺端延伸情况。术中，在通过钢板钻出螺钉孔后，将多普勒探头插入肱骨头的所有九个钻孔以及肱骨干上至少一个钻孔中，依次测量是否有脉搏以指示是否存在灌注。
共纳入10例肱骨头骨折患者（平均年龄59岁，范围36 - 83岁）（根据雷施分类：2例2GL型、3例3G型、2例4G型、2例4GL型、1例5aG型）。10例患者中有9例在肱骨干上显示出脉搏信号。总体而言，所有患者的肱骨头至少有一个钻孔通过多普勒超声检测到脉搏同步灌注。在内侧铰链完整的患者（N = 6）中，与内侧铰链脱位的患者（N = 4）相比，肱骨头钻孔中平均可测量到脉搏同步灌注的数量几乎多一倍（5.7个钻孔对3.0个钻孔）。在有干骺端延伸的患者（N = 3）中，肱骨头钻孔中平均测量到脉搏同步灌注的数量为6.7个，而无干骺端延伸的患者（N = 7）为3.7个钻孔。
半定量术中多普勒血流仪提供了一种无创且快速的肱骨灌注评估方法，当以标准化方式用于测量肱骨头不同区域的血流时，有助于了解肱骨头灌注情况。
