T形切口下微創鎖定鋼板治療肱骨近端骨折療效探討

韓立強 江漢 肖聯平 楊國躍 江毅 張殿英

T形切口下微創鎖定鋼板治療肱骨近端骨折療效探討

韓立強 江漢 肖聯平 楊國躍 江毅 張殿英

目的回顧性分析T形切口下微創鎖定鋼板治療肱骨近端骨折的療效。方法自2011年1月至2013年8月,我院收治肱骨近端骨折患者35例,分類方法采用AO分型,其中11-A2型7例,11-A3型12例,11-B1型8例,11-B2型6例,11-C1型2例,均采用T型切口下鎖定鋼板手術治療,術后2～3 d開始肩關節被動活動鍛煉,逐漸增加活動范圍,術后2周開始肩關節擺動鍛煉,術后3周開始肩關節鍛煉,并采用Neer肩關節功能評分。結果本組35例患者手術切口均一期愈合,所有患者均得到隨訪,隨訪時間5～16個月,平均13.1個月,骨折均骨性愈合,術后未發現腋神經損害表現,未發現退釘、鋼板松動。Neer肩關節功能評分:優19例,良10例,可6例。結論T形切口下微創鎖定鋼板治療肱骨近端骨折具有創傷小、功能恢復快、臨床療效佳的優點,尤其適于AO分型的A2、A3型和B型骨折的治療。

肱骨骨折,近端;微創;鎖定鋼板;切口

在65歲以上的人口中,肱骨近端骨折發病率排在髖部骨折和Colles骨折之后,處于第三位。隨著社會人口的老齡化,肱骨近端骨折日益普遍,移位性的肱骨近端骨折往往會造成長期的功能障礙。對不穩定并且移位的骨折而言,手術治療效果最佳。目前鎖定鋼板在肱骨近端骨折的治療中已得到廣泛應用,并取得了良好的臨床效果[1]。因傳統的胸大肌-三角肌入路創傷較大,近年來越來越多的醫生嘗試應用小切口下微創技術治療肱骨近端骨折[2]。我院自2011年1月至2013年8月采用T形切口微創鎖定鋼板治療肱骨近端骨折35例,在此作一總結分析。

資料與方法

一、一般資料

本組病例共35例,男性16例,女性19例,年齡31～72歲,平均年齡56.3歲,左側15例,右側20例,均為新鮮骨折。致傷原因:自行摔傷20例,高處墜落傷6例,車禍傷9例。所有患者術前均行X線及CT三維重建檢查(圖1,2)。

二、骨折分型

本組病例采用AO分型,其中11-A2型7例,11-A3型12例,11-B1型8例,11-B2型6例,11-C1型2例。

三、手術方法

患者麻醉后采取沙灘椅位,術前于體表標注手術切口、肩峰及腋神經大致位置,于肩關節外側肩峰下約一橫指處行長約6 cm橫行切口,切開皮下組織后縱行切開深筋膜,通過辨認肌腹之間的脂肪纖維紋,找到三角肌前部和中間部肌肉之間的間隙,縱行鈍性劈開,劈開距離不宜超過6 cm,以免損傷腋神經。將劈開的三角肌牽向兩側,暴露三角肌下滑囊,將其縱行切開暴露肱骨大結節及骨折端。在肩關節外展牽引下通過撬撥及手法推壓骨折塊的方法完成復位,以結節間溝、大結節作為復位指標,復位滿意后維持肘關節屈曲外展,保證30°～40°后傾角,以克氏針臨時固定,選用長度合適的鋼板(均選用AO辛迪斯公司的PHILOS鋼板),另于骨折遠端行長約3 cm縱行切口(圖3),將鋼板沿骨膜上植入,鋼板放置于距離肱骨大結節上緣5～8 mm、結節間溝外側2～4 mm,C臂X線機透視位置滿意后,近端植入5～9枚鎖定螺釘,遠端植入3枚雙皮質鎖定螺釘(圖4,5),常規植入引流管。術后以三角巾懸吊固定3～4周。

結 果

本組35例患者手術切口均一期愈合。術后2～3 d開始肩關節被動活動鍛煉,逐漸增加活動范圍,術后2周開始肩關節擺動鍛煉,術后3周開始肩關節上舉、外展、后伸及前屈鍛煉。所有患者均獲得隨訪,隨訪時間5～16個月,平均13.1個月,骨折均骨性愈合,未發現腋神經損傷表現,未發現退釘、鋼板松動。采用Neer肩關節功能評分[3]:優19例,良10例,可6例。

討 論

微創是指以最小的侵襲和最小的生理干擾達到最佳手術療效的一種手術或檢查方式,最主要特征是創傷小。意外創傷對人體有極大的危害性且難以避免,而外科手術作為有計劃的創傷,術者有必要力求將創傷降到最低限度,即達到微創的目的。微創手術理念目前在骨科各個領域均獲得了較大的發展,其致力于軟組織的保護、獲得更好的預后功能的理念已逐漸成為共識,并為臨床療效所證實。

圖1～5 患者,女,62歲,自行摔傷,骨折分型為11-C1型。圖1肱骨近端骨折術前正位X線片;圖2肱骨近端骨折術前CT三維重建片;圖3術中手術切口示意圖;圖4～5肱骨近端骨折術后正位及穿胸位X線片

一、微創治療適應證

鎖定鋼板的出現為肱骨近端骨折微創治療的實施提供了條件,并且在四肢骨折中的應用也取得了良好的臨床效果[4]。但并不是所有的肱骨近端骨折都適于微創治療,嚴格把握手術適應證才能取得最佳療效,不能一味追求微創而喪失手術固定的基本原則,良好的復位、固定仍是手術成功、獲得良好預后的重要決定因素。本組病例在手術適應證選擇上根據閉合復位的難易程度主要偏重于AO分型的A2、A3型與B型骨折,部分閉合復位不佳的病例亦可通過上端橫切口直接復位,但對于C型骨折來說,技術性要求較高,若閉合復位技巧掌握不好,則難以達到理想的復位,且T形切口暴露相對不充分,不利于直視復位,故仍建議采用傳統的胸大肌-三角肌入路。

二、手術切口

胸大肌-三角肌入路是治療肱骨近端骨折的傳統手術入路,其位于肩關節前方,可很好地暴露盂肱關節,但肱骨近端外側區域顯露欠佳,鎖定鋼板放置的理想位置位于肱骨側方,在此入路下鋼板的放置位置顯示困難,同時因鎖定螺釘由外向內的置入方向已固定,故在前方切口內完成鉆孔和置釘也較為困難。該入路術中為充分暴露肱骨頭側面,通常在肩袖上縫合絲線或在肱骨頭上置入臨時克氏針作為牽引,維持肱骨頭內旋,但在行肱骨頭復位和鋼板放置時通常需要內旋或外旋前臂,從而導致已復位的肱骨頭或者位置良好的鋼板出現位置丟失。另外,該手術入路對軟組織剝離廣泛,亦有損傷旋肱前動脈的潛在風險,可能不利于骨折的愈合,并且增加肱骨頭缺血性壞死的可能性。因此,目前鎖定鋼板廣泛應用于肱骨近端骨折治療的情況下,胸大肌-三角肌入路并不是最佳的入路選擇。

肩峰前外側入路,即劈開三角肌入路,最早僅適用于局限性手術,用于暴露止于肱骨大結節的肌腱和三角肌下的滑囊,但隨著鎖定鋼板技術的發展與廣泛應用,因其結合間接復位技術對骨折局部的軟組織破壞少,并使鋼板易于放置于最佳位置,可顯著改善功能預后,所以該入路又再次受到臨床重視。本組病例采用的手術切口在此基礎上進行了改善,近端皮膚切口未采用縱切口,而采用橫切口,整體呈“T”形切口(圖3),深部組織暴露與其相同,因肩部皮紋為橫行,橫行切口愈后瘢痕相對較小且更為美觀,患者也更易接受。

肩峰前外側入路相對于胸大肌-三角肌入路來說,鋼板的放置相對更容易,T型切口優越性顯著,但文獻報道不多,普及率不高,究其原因主要是解剖不熟悉,難以保證腋神經不受損。解剖學研究顯示腋神經自四邊孔穿出后繞行于肱骨外科頸后方,位于三角肌后緣中點,其解剖位置位于上肢中立位時肩峰下緣大約6.5 cm處,由三角肌后緣橫行直至其前緣,沿途分出眾多細支至肌纖維,由腋神經主干發出的分支走向兩個肌束毗鄰處,然后發出分支走向每一肌束,三角肌中部包含有極稠密的神經網。根據腋神經的分布情況可以看到,理論上三角肌任何部位的縱行劈開,一定會引起腋神經損傷。但根據我們的經驗,術前仔細規劃,將腋神經的水平位置在皮膚上進行標識,術中經三角肌前、中肌間隙縱行劈開三角肌,從此間進入可很好地避開了腋神經在三角肌各肌束的入肌點,不會損傷腋神經分支,同時只要劈開距離不超過6 cm,就不會損傷腋神經主干,而且術中可在接近6 cm處以手指去感受腋神經,但并不需要徹底游離暴露腋神經,以免不必要的損傷。許文勝等[5]認為腋神經前支經外科頸水平前行時,與肱骨骨膜關系并不密切,而是緊貼三角肌底面走形,表面有三角肌束膜包裹,可以經此間隙將其連同三角肌一起從骨面推開。本組病例采用的即是沿骨膜外剝離肌肉,且6 cm的縱行暴露區間對于鋼板置入及顯露骨折端已相當充足,若術野不充分,可在肩峰上切斷部分三角肌擴大顯露范圍,在這些措施下腋神經損傷的風險極低。

因此,針對肱骨近端骨折,T型切口肩峰前外側入路和傳統的胸大肌-三角肌入路相比更符合微創原則,術后患者疼痛程度明顯減輕,并且可取得相類似的功能預后,而同時具有傳統胸大肌-三角肌入路不具備的優勢,如鋼板植入更方便、軟組織損傷更小等優點,若術中全程注意腋神經的保護,損傷腋神經的風險非常低。但該切口相對于傳統縱切口來說,近端橫切口手術視野的暴露充分性欠佳,初學者會不適應,但隨著手術的熟練不適應感覺會逐漸消失,學習曲線相對較短。

三、肱骨距的復位與維持

術中肱骨近端內下方(肱骨距)的良好復位是手術成功的決定因素,肱骨距的機械支撐對于維持骨折復位很重要,肱骨距完整與否和患者的功能及主觀療效預后有關,其作為一項簡便的評估方法可用于術后患者臨床療效的預測。Bj?rkenheim等[6]發現使用PHILOS系統具有較高的骨折再移位率(26.4%),這主要是由于復位時沒有強調頭干角的恢復和內側皮質完整性的重建。Osterhoff等[7]總結病例后發現鎖定鋼板單從張力側并不能支撐肱骨頭、解剖復位或輕度壓縮性穩定復位,并于近端肱骨塊內下方植入斜向上的鎖定釘可以獲得更穩定的內側柱支撐,并可更好地維持復位。不穩定肱骨近端骨折由于粉碎及骨量差,常常難以獲得穩定固定,可通過向肱骨頭骨折塊的內下方鉆入鎖定螺釘可獲得適當的內側支撐,重建內側肱骨距,若未能建立內側支撐則可能會導致早期復位丟失,鎖定釘常常無法單獨支撐內側柱,手術失敗的幾率亦會大大增加。

本組病例中有9例病例復位后因內側肱骨距處骨折呈粉碎狀,難以維持穩定,因此均于近端肱骨塊內下方植入斜向上的鎖定釘以協助支撐,術后隨訪至骨折愈合,均未發生內固定失效所致的手術失敗。

四、螺釘數量

肱骨以承受高旋轉扭力為主,在骨折遠端應至少使用3～4枚雙皮質固定螺釘以減少松動及退釘已基本達到共識,但對于骨折近端以幾枚螺釘固定最佳尚無臨床相關報道。Erhardt等[8]在體外力學研究后建議對于肱骨近端骨折至少運用5枚螺釘對肱骨頭進行固定,此時螺釘失效幾率最低,同時如果內側無法依靠復位獲得支撐則有必要使用一枚內下支撐螺釘。但該研究僅限于體外實驗研究,尚沒有進一步的臨床療效證實。本組病例均選取PHILOS鋼板,保證肱骨頭內至少有5枚螺釘進行固定,對于骨質疏松患者,則盡量將近端9枚螺釘全部植入,本組所有病例均未出現螺釘松動、退釘等并發癥。

針對肱骨近端骨折,在嚴格把握手術適應證的條件下,T形切口下微創鎖定鋼板治療方式具有創傷小、恢復快、臨床療效佳的優點,尤其適于AO分型的A2、A3型與B型骨折的治療。但本組病例缺乏對于有關三角肌損傷程度的相關支持研究及與胸大肌-三角肌傳統入路的對比研究,若能在術后隨訪中檢測三角肌的神經肌電圖,明確損傷程度,并設立傳統的胸大肌-三角肌入路對照組,則會更有臨床說服力。

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Operative treatment of proximal humeral fractures with T incision and MIPPO locking compression plate

Han Liqiang,Jiang Han,Xiao Lianping,Yang Guoyue,Jiang Yi.Department of Orthopedics,Tianjin Third Central Hospital,Tianjing 300170,China

BackgroundWith the aging of population,the proximal humerus fractures are becoming more and more common.The displaced proximal humeral fractures often result in long-term disability.For the instability and displacement of the fracture,the operation treatment is of the best effect so far.At present,the locking plate has been widely used in the treatment of proximal humerus fractures,and has already achieved good clinical results.This paper retrospectively analysis the functional effect of minimally invasive locking plate in the treatment of proximal humeral fractures in our hospital with T shape incision.MethodsThirty-five cases in our hospital suffered from proximal humeral fractures were included in this study(16 males,19 females,aged 31-72 years old)during the past years.The average age was 56.3 years old.Fifteen cases were injured on the left side,20 cases were injured on the right side.All the fractures were fresh.The cause of injury:20 cases were living accident,6 cases were of high falling injury,9 cases were of traffic accident.All the Patients had undergone X-ray examinations and three-dimensional CT reconstruction before receiving surgery.According to the AO classification,there were 7 cases of type 11-A2,12 cases of type 11-A3,8 cases of type 11-B1,6 cases of type 11-B2 and type 11-C1 in 2 cases.All were treated with locking plates through the type T incision.Patients were in the beach chair position after anesthesia to get operation.Then mark the operating incision,the axillary nerve and the acromion on the surface before surgery.A 6 cm transverse incision was made one finger subacromially in the lateral side of shoulder.The subcutaneous tissue was incised before a longitudinal dissection of the deep fascia.Find the anteriorand middle part of the deltoid muscle by identifying the fat fiber lines between the gap and the muscle belly.Bluntly split it longitudinally,not exceeding 6 cm of the distance in order to avoid the injury of axillary nerve.Stretch the splitted deltoid to the sides,expose deltoid bursa,incise it longitudinally to expose the greater tuberosity of humerus and the fracture.Make the reduction by poking and manual pressing the fracture with the traction of the shoulder in the abduction position.Take the intertubercular sulcus and greater tuberosity as the reduction index,then flex and abduct the elbow after a satisfactory reduction to guarantee the 30-40 degree retroverted angle,fix it with the Kirschner wire temporarily and then select a steel plate with an appropriate length(select AO Synthes,PHILOS steel plate).Then make a 3 cm longitudinal incision on the distal part of the fracture,implant the steel plate along the periosteum,place the plate 5-8 mm upper the greater tuberosity,2-4 mm laterally of the intertubercular sulcus.After an satisfactory position of the C-arm fluoroscopy,implant 5-9 locking screws proximally and 3 bicortical locking screws distally,place a drainage tube conventionally.Sling the arm with a triangular scarf for immobilization for 3 to 4 weeks postoperatively.ResultsThe operation incision of the 35 patients of this group got healed in the first period.They were required to exercise the shoulder joint passively after 2-3 days postoperatively.Increase the range of motion gradually.Then start to do the shoulder swing exercise 2 weeks after operation,try the lift,abduction,posterior extension and flexion exercise 3 weeks after operation.All the patients were followed up from 5 to 16 months,averagely 13.1 months.All the fractures got healed,there was no sign of damage of the axillary nerve.No loosening of the nails and plate were found.For the Neer score:there are 19 cases of excellence,10 cases of good,6 cases of fair.ConclusionsMinimal invasion refers to an operation or a check with less invasion and less physiological disturbance to achieve the best operation effect,the main feature is the micro trauma.Accidental trauma does great harm to the human body,and it is really hard to avoid.But as a planned trauma of surgical operation,surgeons have to try all they can to minimize the trauma,that is to say,to achieve the goal of minimal invasion.This concept has achieved great development now in various fields of orthopedics,it commits to the protection of soft tissue and obtaining better prognosis function,which has gradually become a consensus and been confirmed by clinical effect.When we comes to the fracture of the proximal humerus,in strict confidence condition operation indications,the minimally invasive locking plate treatment under T shaped incision has the advantage of less trauma,quicker recovery and perfect clinical curative effect,which is especially suitable for AO type A2,type A3 and type B fractures.But this group of patients lack the related supportive study for the degree of deltoid muscle damage and the comparison of traditional pectoralis major-deltoid muscle approach,if we can take a detection of deltoid muscle electromyography in the postoperative follow-up to ensure the degree of injury,and then establish a control group of the pectoralis major-deltoid muscle approach,then it would be more clinically convincing.

Humeral fracture,proximal;Minimally invasion;Locking compression plate;Incision

Han Liqiang,Email:liqianghan9809@163.com

2014-05-06)

(本文編輯:李靜)

10.3877/cma.j.issn.2095-5790.2014.04.004

衛生公益性行業科研專項(201002014,201302007);教育部創新團隊(IRT1201)

300170 天津市第三中心醫院骨科(韓立強、江漢、肖聯平、楊國躍、江毅);300450 天津市第五中心醫院骨科(張殿英)

韓立強,Email:liqianghan9809@163.com

韓立強,江漢,肖聯平,等.T形切口下微創鎖定鋼板治療肱骨近端骨折療效探討[J/CD].中華肩肘外科電子雜志,2014,2(4):225-229.