李奉龙 姜春岩



·论著·

反球型人工肩关节置换术治疗肱骨近端陈旧骨折不愈合

李奉龙 姜春岩

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。

肩关节；人工关节置换术；肱骨骨折，近端；骨折并发症

肱骨近端骨折术后不愈合的治疗是肩关节外科的难点之一，此类患者常合并陈旧骨折块血供差、肩袖功能不良等，若行植骨再固定手术或人工肱骨头置换术，术后肩关节功能恢复结果难以预期[1-6]。近年来，国外有学者报道采用反球型人工肩关节假体置换术治疗肱骨近端骨折，并取得了一定疗效[7]，但反球型肩关节假体在治疗肱骨近端陈旧骨折不愈合方面的作用，目前仍缺乏相关研究报道。本文通过分析近年来我院采用反球型人工肩关节假体置换术治疗肱骨近端陈旧骨折不愈合的临床结果，对此种手术方法的疗效作一初步总结。

资 料 与 方 法

一、一般资料

病例入选标准：(1)因肱骨近端陈旧骨折不愈合于我院行反球型人工肩关节假体置换手术者，不合并血管神经损伤；(2)术后最短随访时间不低于2年。病例排除标准：(1)合并有血管神经损伤；(2)术后随访时间少于2年。

2010年10月至2013年2月，于我院收治并进行反球型人工肩关节假体置换手术的肱骨近端陈旧骨折不愈合患者共9例，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)。所有患者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。9例患者均使用骨小梁金属(TM)反球型肩关节假体(Zimmer)进行人工全肩关节置换治疗。

二、手术方法

手术采用沙滩椅位，全身麻醉后，选取三角肌胸肌间入路，分离显露头静脉并加以保护。术中应特别注意保护三角肌及其起止点。显露并辨认肱二头肌长头腱以确定大、小结节，术中应仔细探查并明确陈旧骨折块，确定肱骨近端各个骨折部分，必要时需行截骨以利于充分显露肩盂及后续重建大小结节操作。术中用较粗的非可吸收线在肩袖止点部位固定陈旧骨折块，以备牵引复位之用。

充分显露肩盂，打磨至软骨下骨，置入肩盂基座，使其向下方倾斜10°。选取肩盂球并将其置入基座。肱骨侧假体使用骨水泥固定，假体后倾角度确定为5°～10°。在使用骨水泥固定前，应采用假体试模仔细比对并试行复位，理想的复位状态是获得良好的假体盂肱关节顺应性与理想的假体高度以维持适当的三角肌和联合腱张力。复位大小结节骨折块，利用取出的肱骨头在大小结节与肱骨干结合部作松质骨植骨，以利骨折愈合。以钛缆环抱固定骨折块，并采用高强度缝合线进一步缝合，加固大小结节骨折块。

三、康复方法

术后采用肩关节外展包支具制动6周。手、腕、肘的被动功能锻炼在术后第1天根据患者疼痛允许情况下尽快进行，术后3周后进行肩关节被动功能锻炼，术后6周后若存在大小结节愈合的证据，则可摘除支具开始主动活动度练习，根据患者具体康复情况逐步恢复日常生活活动。术后12周开始肌肉力量练习。

四、随访及评价方法

患者术后3周、6周、12周、6个月、12个月以及末次随访时拍摄肩外旋中立位肩关节正位、侧位和腋位X线片，以判断假体位置、大结节愈合情况等。末次随访时采用VAS(visual analogue score)疼痛评分、ASES(American shoulder and elbow surgeons)评分、Constant评分及UCLA(university of california los angeles)评分评价肩关节功能恢复情况。

结 果

9例患者术后获平均(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：前屈上举平均为131.2°±22.0°，外旋平均为22.6°±11.2°，内旋平均为第3腰椎椎体水平(±3个椎体)；VAS疼痛评分平均为(1.5±1.7)分(0～6分)，ASES评分平均为(74.3±15.6)分(48～94分),Constant评分平均为(71.6±10.2)分(44～92分)，UCLA评分平均为(27.9±5.6)分(18～34分)。

所有患者通过肩关节正位、侧位和腋位X线片定期复查，无大小结节不愈合发生；所有患者术后均无肩峰应力骨折、感染、假体松动、肩胛骨撞击、神经血管损伤等并发症发生。

讨 论

第二代反球型肩关节假体最早由Grammont设计并提出，此种假体通过反转盂肱关节对位关系，使盂肱关节旋转中心内移，进而使三角肌在肩关节前屈上举中发挥主要作用[8]。同时由于新设计使盂肱关节旋转中心内移至肩盂关节面，大大降低了肩盂假体松动的几率。反球型肩关节假体在设计初始阶段，主要用于治疗巨大或不可修复肩袖损伤所引起的关节病变，因为在此种患者中，肩袖的动态稳定机制已被破坏，三角肌的动力难以通过肩袖肌肉转化为肩关节上举的动力。而通过反球肩关节置换，可以使三角肌作为肩关节前屈上举的动力直接发挥作用，进而替代了部分肩袖肌肉(冈上肌)的功能[9-12]。

虽然反球型关节置换手术可以降低患者肩关节功能预后对于大结节愈合的依赖性，但大小结节的愈合状况仍对患者术后功能产生一定影响。Sirveaux等[13]通过研究发现，对于进行反球关节置换手术的患者，术中重建大小结节组的功能优于非重建组。因此，在进行反球关节置换手术时要仔细重建大小结节，以促进术后结节愈合，最大程度地改善患者术后肩关节功能。

文献报道反球型肩关节置换术后的常见并发症包括肩胛骨撞击、关节不稳或脱位、肩峰应力骨折等[14-19]。其中肩胛骨撞击是指肱骨侧假体在肩关节内收时与肩胛颈下缘发生撞击，进而导致假体松动以致失效。本组病例中术后无肩胛骨撞击发生，考虑与随访时间较短有关。

本研究有一定的局限性。首先，随访时间较短，应延长随访时间以明确反球型肩关节置换术的远期疗效；其次，本研究为回顾性随访研究，将来仍需要设计更高等级的前瞻性随机对照试验或队列研究，以论证反球型肩关节置换术在治疗肱骨近端陈旧骨折不愈合方面的优势。

小结：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，术后疗效令人满意，患者可获得良好的肩关节功能。

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(本文编辑：李静)

李奉龙，姜春岩.反球型人工肩关节置换术治疗肱骨近端陈旧骨折不愈合[J/CD].中华肩肘外科电子杂志,2015,3(2):85-88.

Treatment of old proximal humerus fracture nonunion with reverse total shoulder arthroplasty

LiFenglong,JiangChunyan.

DepartmentofSportsInjuy,BeijingJishuitanHospital,Beijing100035,China

JiangChunyan,Email:chunyanj@hotmail.com

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

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.

Shoulder joint；Artificial joint replacement；Huneral fractures,proximal；Fracture complications

10.3877/cma.j.issn.2095-5790.2015.02.004

北京市新世纪百千万人才工程培养经费(20111103)；“首都临床特色应用研究”专项资助课题

100035北京积水潭医院运动损伤科

姜春岩,Email:chunyanj@hotmail.com

2015-03-20)

(Z141107002514001)