Beredjiklian P K, Iannotti J P, Norris T R, Williams G R
Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia 19104, USA.
J Bone Joint Surg Am. 1998 Oct;80(10):1484-97. doi: 10.2106/00004623-199810000-00010.
We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.
我们回顾性分析了39例因肱骨近端骨折畸形愈合而接受手术治疗患者的病历、手术报告以及术前和术后的X线片。根据骨异常情况对畸形愈合进行分类，包括大结节或小结节位置异常（I型；28例患者）、关节面不平整（II型；26例患者）以及关节段对线不良（III型；16例患者）。还记录了软组织异常情况，如软组织挛缩、肩袖撕裂和撞击。术后平均44个月（范围12至53个月），对患者进行疼痛缓解情况、肩关节活动范围以及日常生活活动能力的评估。在最近的随访评估中，27例患者（69%）结果满意，其余12例（31%）结果不满意。在结果满意的27例患者中，26例（96%）所有骨和软组织异常均得到了完全手术矫正。在结果不满意的12例患者中，4例对这些异常进行了完全手术矫正（p < 0.0001）。26例患者（67%）就诊时存在盂肱关节不平整。其中23例患者通过人工关节置换术（22例）或盂肱关节融合术（1例）矫正了不平整；17例（74%）结果满意。相比之下，手术时未矫正不平整的3例患者结果均不满意（p = 0.01）。11例患者术前大结节或小结节位置异常但关节面平整。该组中有10例患者接受了结节截骨术或肩峰成形术，其中9例在最近的随访评估中结果满意。仅接受软组织挛缩矫正（即未处理位置异常）的1例患者结果不满意（p = 0.05）。骨和软组织异常均被确定为肱骨近端骨折畸形愈合患者疼痛和僵硬的原因。我们得出结论，只有在手术时矫正所有骨和软组织异常，这些患者的手术治疗才会成功。
