CAJ | 학술논문

目的：评价采用反球型人工肩关节置换术治疗肱骨近端陈旧骨折不愈合的临床疗效。方法回顾性研究2010年10月至2013年2月，收治并进行反球型人工肩关节假体置换手术的9例肱骨近端陈旧骨折不愈合，均为肱骨近端骨折切开复位内固定术后患者，其中3例患者为大结节不愈合，6例患者为大结节及肱骨外科颈不愈合，4例患者合并肱骨头缺血性坏死。男性3例，女性6例；平均年龄（75．2±8．6）岁（70～86岁）。主力侧受累6例。本次手术距上次手术平均时间为（15±7．3）个月（10～29个月）。结果9例患者术后获（37．9±10．2）个月（24～52个月）随访。末次随访时患者肩关节活动度：前屈上举为131．2°±22．0°，外旋为22．6°±11．2°，内旋平均为第3腰椎椎体水平（±3个椎体）；VAS疼痛评分为（1．5 ± 1．7）分（0～6分），ASES评分为（74．3±15．6）分（48～94分），Constant评分为（71．6±10．2）分（44～92分），UCLA评分为（27．9 ± 5．6）分（18～34分）。所有患者术后均无肩峰应力骨折、感染、假体松动、神经血管损伤等并发症发生。结论采用反球型人工肩关节置换术治疗肱骨近端陈旧骨折不愈合可获得良好的临床疗效。
목적：평개채용반구형인공견관절치환술치료굉골근단진구골절불유합적림상료효。방법회고성연구2010년10월지2013년2월，수치병진행반구형인공견관절가체치환수술적9례굉골근단진구골절불유합，균위굉골근단골절절개복위내고정술후환자，기중3례환자위대결절불유합，6례환자위대결절급굉골외과경불유합，4례환자합병굉골두결혈성배사。남성3례，녀성6례；평균년령（75．2±8．6）세（70～86세）。주력측수루6례。본차수술거상차수술평균시간위（15±7．3）개월（10～29개월）。결과9례환자술후획（37．9±10．2）개월（24～52개월）수방。말차수방시환자견관절활동도：전굴상거위131．2°±22．0°，외선위22．6°±11．2°，내선평균위제3요추추체수평（±3개추체）；VAS동통평분위（1．5 ± 1．7）분（0～6분），ASES평분위（74．3±15．6）분（48～94분），Constant평분위（71．6±10．2）분（44～92분），UCLA평분위（27．9 ± 5．6）분（18～34분）。소유환자술후균무견봉응력골절、감염、가체송동、신경혈관손상등병발증발생。결론채용반구형인공견관절치환술치료굉골근단진구골절불유합가획득량호적림상료효。
Background The nonunion treatment of proximal humerus fracture is one of the difficulties that the shoulder surgery faces .Usually these patients have old fracture are complicated with poor block blood supply ,dysfunction of rotator cuff as well as other unfavorable conditions .If the patients are operated with bone grafting and then fixation ,or artificial humeral head arthroplasty ,it will be difficult to predict the results of post‐operation functional shoulder recovery .During recent years ,there have been reports from abroad about adopting reverse total shoulder arthroplasty in treating proximal humerus fracture nonunion which achieved great curative effects .However ,reports about adopting reverse total shoulder arthroplasty in treating old proximal humerus fracture nonunion are still rare .This thesis will firstly analyze the clinical effects of adopting reverse total shoulder arthroplasty for treatment of old proximal humerus fracture nonunion in our hospital ,and then get preliminary conclusions on the curative effects of this arthroplasty .Methods General data:inclusion criteria of cases:(1) patients who had old proximal humerus fracture nonunion and were given reverse total shoulder arthroplasty in our hospital;(2) no complicated with neurovascular injury ;(3) the post‐operation visit should be not less than two years .Cases exclusion criteria:(1 ) complicated with neurovascular injury ;(2) the post‐operation visit less than two years .From October 2010 to February 2013 ,our hospital has received nine patients with old proximal humerus fracture nonunion who were performed reverse total shoulder arthroplasty .Three males and six females and their average ages were from 70 to 86 years old (75 .2 ± 8 .6) .Six patients among them got the dominant side affected .The latest operation was about 10 to 29 months (15 ± 7 .3) long from last time .All patients had gotten the proximal humerus fracture open reduction and internal fixation operation .Three patients had major tubercle nonunion ,six patients had major tubercle and humerus surgical neck fracture nonunion .Four patients were complicated with ischemic necrosis of the humeral head .Nine patients adopted the trabecular metal (TM ) reverse total shoulder prosthesis (Zimmer ) for the artificial shoulder arthroplasty .Operation methods :During the operation ,the beach chair position was adopted ,after general anesthesia ,the patients were operated from the deltopectoral groove and then the cephalic veins were separated clearly with further protection .The operators should protect the starting and the terminal points of deltoid .Revealed and recognized the long tendon of biceps for confirming the greater tuberosity and lesser tubercles .The operators should check clearly and confirm the old fracture bones , and then determine each fracture parts of the proximal humerus .Osteotomy was necessary when the spinoglenoid ligament need to be revealed and for the continuous operation of greater tuberosity and lesser tubercles .The comparative thick non‐absorbable thread was used to fix the old fracture bones at the terminal point of rotator cuff ,and for traction and restoration .The spinoglenoid ligament was revealed thoroughly ,the subchondral bone was abraded ,and the prosthesis was inserted into the base of spinoglenoid ligament and rotated down to the 10° .The spinoglenoid ligament ball was selected and then inserted into the base .The humerus lateral prosthesis was fixed with bone cement ,and the prosthesis was rotated to 5° to 10° .Before applying the bone cement ,the prosthesis was compared carefully using the prosthesis moulds and try to restore .A perfect restore state helps the compliance of prosthesis glenohumeral joint and an ideal prosthesis height helps to maintain the tension of deltoid and conjoint tendon .The greater tuberosity and lesser tubercles facture bones were restored ,the humerus head was taken out and cancellous bone graft was operated to the joint part of greater tuberosity and lesser tubercles and humerus shaft ,so as for better union of the fracture .The fracture bones were surrounded with the titanium cable ,and the high‐strength suture lines were applied for further suturing and consolidating the greater tuberosity and lesser tubercles fracture bones .Rehabilitation methods :After the operation ,the patients should use the shoulder joint outstretch pack for six weeks .On the first day the passive movements of hands ,wrists and elbows should be trained according to the patients′pain condition .The passive movements of shoulder joints should be trained three weeks after the operation .Six weeks after the operation ,if any evidences of the union of greater tuberosity and lesser tubercles fracture are found ,the pack could be taken away and the patients could start the active movements practice .Patients′normal daily life could be restored gradually depending on the patients′rehabilitation conditions .Patients started the muscles strength training twelve weeks after the operation .Follow‐up visit and evaluation methods :At the third week ,sixth weeks ,twelfth week ,sixth month ,twelfth month after operation as well as the last follow‐up visit ,patients should be taken X‐ray pictures of the shoulder extorsion neutral position ,shoulder joint front position ,shoulder joint side position ,and axilla position ,so as to confirm the prosthesis position and the union condition of greater tuberosity .On the last follow‐up visit ,the visitors should estimate the shoulder joints restoration condition by adopting VAS (Visual Analogue Score ) ,ASES (American Shoulder and Elbow Surgeons) ,Constant and UCLA(University of California Los Angeles) .Results After the operation , nine patients were followed up for 24 to 52 (37 .9 ± 10 .2) months .In the last follow‐up visit ,the patients′shoulder range motion conditions were as follows :the average forward bends and lifts was 131 .2°± 22 .0° ,the average extorsion was 22 .6° ± 11 .2° ,the average internal rotation was the third lumbar vertebrae level (± 3 centrums) ,the average VAS was (1 .5 ± 1 .7) points (0‐6 points) ,the average ASES was (74 .3 ± 15 .6) points (48‐94 points) ,the average Constant was (71 .6 ± 10 .2) points(44‐92 points) ,the average UCLA was (27 .9 ± 5 .6) points (18‐34 points) .All patients had periodic X‐ray review of the shoulder joint front ,shoulder joint sides and axilla ,no greater tuberosity nor lesser tubercles nonunion was found .After the operation ,no patients were found shoulder peak stress fracture ,infection ,prosthetic loosening ,shoulder blade ,neurovascular injury nor other complications .Conclusion The curative effects after adopting reverse total shoulder arthroplasty for treatment of old proximal humerus fracture nonunion is satisfactory ,which helps patients to have better shoulder joints functions .