張少戰(zhàn) 黃長明 傅仰攀 董輝詳 甘志勇

雙排錨釘橋式縫合在肱骨大結(jié)節(jié)骨折中的應(yīng)用

張少戰(zhàn) 黃長明 傅仰攀 董輝詳 甘志勇

目的探討雙排錨釘在肱骨大結(jié)節(jié)骨折有限切開復(fù)位內(nèi)固定中應(yīng)用的臨床價(jià)值。方法自2010年3月至2013年3月，對10例單獨(dú)大結(jié)節(jié)骨折患者通過有限切開復(fù)位，雙排錨釘橋式縫合內(nèi)固定治療肱骨大結(jié)節(jié)移位骨折。術(shù)后隨訪，復(fù)查X線片評價(jià)復(fù)位情況，以Constant評分和UCLA評分評價(jià)肩關(guān)節(jié)功能。結(jié)果所有患者術(shù)后均獲得解剖復(fù)位。在平均12．3個(gè)月的隨訪中，X線片顯示復(fù)位無丟失，骨折獲得愈合，Constant評分平均90．3分，UCLA評分平均32．2分。結(jié)論雙排錨釘內(nèi)固定治療單純移位的肱骨大結(jié)節(jié)骨折效果可靠。

肱骨骨折，大結(jié)節(jié)；錨釘

肱骨近端骨折占全身骨折的5%，其中單獨(dú)的肱骨大結(jié)節(jié)骨折占20%［1］，可伴或不伴盂肱關(guān)節(jié)脫位，在Neer分型上屬于2部分肱骨近端骨折，在AO分型上為11－A1．2或11－A1．3。自2010年3月至2013年3月對10例肱骨大結(jié)節(jié)撕脫骨折患者采用雙排錨釘縫合方法進(jìn)行內(nèi)固定，取得了較好效果。

材料和方法

一、一般資料

肱骨大結(jié)節(jié)骨折患者10例，其中男性4例，女性6例，年齡41～63歲，平均48．2歲。致傷原因：摔傷8例，車禍2例，其中伴盂肱關(guān)節(jié)前脫位3例。傷后肩關(guān)節(jié)X線片提示肱骨大結(jié)節(jié)骨折移位均＞0．5cm。

二、方法

盂肱關(guān)節(jié)脫位患者均急診予局麻下手法復(fù)位。所有患者于傷后2～21d，平均10d獲得有限切開復(fù)位，雙排錨釘內(nèi)固定手術(shù)。具體術(shù)式為：肩關(guān)節(jié)前外側(cè)縱向經(jīng)三角肌入路，切口避免超過肩峰遠(yuǎn)側(cè)5cm，以免造成腋神經(jīng)損傷。通過旋轉(zhuǎn)肩關(guān)節(jié)充分暴露大結(jié)節(jié)骨塊及骨折床，清理骨床，臨時(shí)復(fù)位骨折塊，選擇置釘點(diǎn)，于骨床近端偏前、后側(cè)接近肱骨頭關(guān)節(jié)面分別擰入Twinfix錨釘2枚作為內(nèi)側(cè)錨釘，通過縫針或過線器將縫線帶過骨折塊近端附著之肩袖組織，打結(jié)固定，于骨床遠(yuǎn)端內(nèi)外側(cè)擰入footprint錨釘作為外側(cè)錨釘，將內(nèi)側(cè)錨釘之尾線成編織狀覆蓋卡入footprint錨釘內(nèi)（圖1、2）。術(shù)后予頸腕吊帶懸吊固定2周，期間開始肩關(guān)節(jié)被動鐘擺練習(xí)。6周后開始外展、前屈過90°練習(xí)。

圖1 內(nèi)排錨釘置入后準(zhǔn)備裝入Footprint錨釘

圖2 外排Footprint置入

三、隨訪及評價(jià)方法

本組所有患者均獲得門診隨訪，術(shù)后隨訪時(shí)間7～18個(gè)月，平均12．3個(gè)月。術(shù)后及隨訪時(shí)拍攝普通肩關(guān)節(jié)正側(cè)位X線片評價(jià)復(fù)位及愈合情況。以肩關(guān)節(jié)Constant評分與加州大學(xué)洛杉磯分校肩關(guān)節(jié)UCLA評分評價(jià)肩關(guān)節(jié)功能，采用SPSS 13．0軟件計(jì)算均值。

結(jié) 果

術(shù)中發(fā)現(xiàn)，10例患者中有5例骨折塊為粉碎性骨折，骨塊之間為骨膜、肩袖軟組織附著，故骨塊彼此之間均無明顯分離。所有10例患者骨折范圍均不超過大結(jié)節(jié)，骨塊厚度均不超過0．8cm。所有患者傷口均獲得一期愈合。肩關(guān)節(jié)X線片均提示：術(shù)后骨折端獲解剖復(fù)位（圖3）。術(shù)后隨訪無復(fù)位丟失，均獲骨性愈合。隨訪終末Constant評分平均90．3分（85～100分），UCLA 評分平均32．2分（28～35分）。

圖3 術(shù)后X線片示骨折端已獲解剖復(fù)位

討 論

肱骨大結(jié)節(jié)骨折向外上方移位，使肩峰下間隙變窄，可能引起肩部撞擊癥和肩袖撕裂［2］。早在1959年McLaughlin即指出大結(jié)節(jié)上移0．5cm即應(yīng)手術(shù)治療，Platzer等［3］認(rèn)為移位＜0．5cm 的大結(jié)節(jié)骨折可不需手術(shù)治療。Park等［4］于1997年提出，對于運(yùn)動員或需要手臂過頭的體力勞動者，大結(jié)節(jié)骨塊發(fā)生0．3cm的移位也應(yīng)當(dāng)手術(shù)復(fù)位。肱骨大結(jié)節(jié)骨折畸形愈合，可能影響肩袖及三角肌力量，從而影響肩關(guān)節(jié)旋轉(zhuǎn)功能及外展等［5］。大結(jié)節(jié)撕脫骨折可伴隨著肩袖損傷，可引起將來骨折愈合后的疼痛［6］。Kim等［7］一組X線片上平均移位為2．3mm的肱骨大結(jié)節(jié)骨折患者的關(guān)節(jié)鏡手術(shù)中，發(fā)現(xiàn)其后期慢性疼痛與肩袖部分損傷有關(guān)。手術(shù)治療大結(jié)節(jié)撕脫骨折，可以處理肩袖損傷，避免肩峰下撞擊［8］。目前一般認(rèn)為單獨(dú)的肱骨大結(jié)節(jié)骨折移位＞0．5cm具有手術(shù)指征，對于活動要求高的年輕人或運(yùn)動員手術(shù)指征可進(jìn)一步放寬，當(dāng)然這仍有爭議［9］。

對于大結(jié)節(jié)骨折，傳統(tǒng)的術(shù)式有空心釘或螺釘固定。我們既往在術(shù)中發(fā)現(xiàn)因大結(jié)節(jié)骨折片較薄弱，單純依靠螺釘釘尾壓迫致骨片碎裂，導(dǎo)致固定不可靠或術(shù)中固定失效。而對于粉碎性大結(jié)節(jié)骨折，不論是空心釘或螺釘均將無法獲得有效固定。也有應(yīng)用鋼板及微型鋼板固定，同樣存在骨片碎裂問題，若采用“跨越”固定，可能出現(xiàn)肩峰撞擊的風(fēng)險(xiǎn)。為克服這些問題，曾有人應(yīng)用編織縫合肩袖經(jīng)骨隧道固定方法治療大結(jié)節(jié)骨折，但經(jīng)骨道固定易出現(xiàn)縫線在骨隧道的磨損致固定失??；也有人應(yīng)用空心釘固定結(jié)合錨釘方法，但對于大結(jié)節(jié)粉碎性骨折不適用，也同樣面臨著骨片劈裂致空心釘失效情況。

大結(jié)節(jié)骨折可被認(rèn)為是肩袖的撕脫骨折［10］。不論是關(guān)節(jié)鏡下修補(bǔ)或是開放性修補(bǔ)，錨釘縫合已成為公認(rèn)的修補(bǔ)肩袖損傷的有效固定，因而應(yīng)用錨釘縫合完全可滿足維持大結(jié)節(jié)骨折復(fù)位的力學(xué)要求。有實(shí)驗(yàn)表明，在大結(jié)節(jié)骨折，應(yīng)用錨釘?shù)牧W(xué)穩(wěn)定性優(yōu)于單純應(yīng)用螺釘或空心釘［11］，也優(yōu)于經(jīng)骨道固定［12］。現(xiàn)有研究認(rèn)為雙排錨釘橋式縫合修補(bǔ)肩袖損傷有助于增大肩袖附著面積，從而有利于肩袖損傷修復(fù)［13－14］。所以雙排錨釘縫合可應(yīng)用于大結(jié)節(jié)骨折，我們在臨床上也獲得了滿意效果。

錨釘縫合公認(rèn)的薄弱點(diǎn)在于縫線斷裂、釘尾線孔破壞及螺釘拔出。錨釘?shù)闹萌霊?yīng)注意指向撕脫方向，以期減小縫線的拔出角，減少錨釘?shù)陌吾攽?yīng)力。一般認(rèn)為應(yīng)使縫線方向與錨釘縱軸垂線的夾角（即拔出角）＜45°。錨釘縫線對于肩袖肌腱的切割可能是固定失敗的另一重要原因［15］?？梢酝ㄟ^增加縫合的針數(shù)來分擔(dān)減小相應(yīng)的切割力量。通過增加錨釘數(shù)是一種方法，但是有限的骨床不可能置入過多錨釘，錨釘之間的距離過近，將造成骨質(zhì)的進(jìn)一步丟失，而造成錨釘脫拔或是骨折。那么通過增加單枚錨釘?shù)目p線數(shù)就成為一種選擇。Twinfix具有兩根互不干擾的尾線，可滿足上述要求。有力學(xué)研究表明，2枚雙線錨釘較3枚單線錨釘可能更強(qiáng)［16］。通過骨床近、遠(yuǎn)端的雙排錨釘置入，在撕脫骨塊表面縫線交織成網(wǎng)狀均勻?qū)⒐钦蹓K壓向骨床更有利于術(shù)后骨折塊復(fù)位的維持。雙排錨釘可分擔(dān)應(yīng)力，具有更好的力學(xué)可靠性，較單排錨釘更具有優(yōu)勢［17－19］。

我們的體會是，雙排錨釘固定可應(yīng)用于肱骨大結(jié)節(jié)撕脫骨折，耗材較昂貴，加重患者的經(jīng)濟(jì)負(fù)擔(dān)，但是對于粉碎性肱骨大結(jié)節(jié)骨折仍是不錯(cuò)的選擇。另外，對于要求將來取出內(nèi)固定的患者，錨釘將不適用。有文獻(xiàn)指出，在骨質(zhì)疏松患者肩袖修補(bǔ)術(shù)或大結(jié)節(jié)骨折內(nèi)固定術(shù)中應(yīng)用錨釘固定存在錨釘拔出的可能［20］，故對于骨質(zhì)疏松患者應(yīng)用錨釘固定有一定的顧慮。

目前關(guān)節(jié)鏡下雙排錨釘修復(fù)肩袖損傷已日益成熟，那么作為肩袖撕脫骨折的大結(jié)節(jié)骨折也可在關(guān)節(jié)鏡下行復(fù)位雙排錨釘固定。肩關(guān)節(jié)鏡下手術(shù)手術(shù)切口較小，軟組織剝離更少，術(shù)后黏連發(fā)生更少，當(dāng)然這需要有更精巧的肩關(guān)節(jié)鏡技術(shù)［21］。

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Double－row suture anchor fixation of displaced greater tuberosity fractures

ZhangShaozhan，Huang Changming，F(xiàn)uYangpan，DongHuixiang，GanZhiyong．DepartmentofOrthopaedicWard2，the 174thHospitalofPeople′sLiberationArmy，OrthopedicsCenterofNanjinMilitaryDistrict，Xiamen361003，China

：HuangChangming，Email：huangchm123＠163．com

BackgroundAmong the proximal humeral fractures，the incidence of isolated fractures has been reported to be approximately 14%to 21% ．In addition，during rotator cuff injury，as a result of a strong pulling power，fractures of the greater tuberosity occur frequently during avulsion fracture of the rotator cuff．Particularly，a strong external rotation power acts on the greater tuberosity，and thus avulsion fracture may occur during anterior shoulder dislocation．Some authors have reported that greater tuberosity fractures were associated with approximately 10%to 30%of shoulder joint dislocation cases．Several arthroscopic and open techniques utilizing screws，wire or sutures through bone have been described for reduction and internal fixation of the greater tuberosity to the proximal humerus．But these are often inadequate in the presence of comminution and may prevent accurate restoration of the tuberosity－h(huán)ead relation．Bhatia have performed open reduction–internal fixation by use of the double－row suture anchor fixation technique in 21cases of comminuted and displaced fractures of the greater tuberosity，and the long－term results suggest a satisfactory outcome in most patients．However，the retrospective study or follow－up data about the surgical treatment of displaced humeral greater tuberosity fractures is still very limited．The purpose of this retrospective study is to evaluate the therapeutic outcomes of the open reduction and internal fixation using double－row fixation with suture anchors for the treatment of humeral greater tuberosity fractures．MethodsThe study included 10patients with isolated greater tuberosity fractures．The cases were reviewed at a mean post－operative follow－up duration is 12．3months（range from 7to 18months）from 2010to 2013．The average age of the patients was 48．2years old（range：41to 63years old），including 4males and 6 females．Among them，3patients were associated with anterior dislocation of the shoulder joint．All radiographs were examined by a single observer．The displacement was more than 5mm in X－ray plain film．All patients were operated by a single surgeon and with the same surgical technique．All the patients were treated by double－row anchor suture fixation through a mini－open approach and the operations were carried out in 2to 21days after trauma．The skin incision was made in Langer’s linesjust medial to the anterolateral aspect of the acromion．The deltoid was split from the anterolateral corner of the acromion distally for 4－5cm，without detaching the origin of the deltoid．The greater tuberosity fragment with the attached cuff was located and tagged with traction sutures through the cuff tendon．After the fractured bone surface on the proximal humerus was cleared of soft tissue，and two anchors（TwinFix）were inserted at the proximal margin of the humeral fracture surface．The strands of each suture were passed through the tendinous part of the attached cuff．The sutures were tied as mattress sutures with the arm in a neutral position．A second row of suture－anchors was passed distal to the humeral fracture surface．Two sutures were passed through the tendon between the first row of mattress sutures and the bone fragments．The strands from these two sutures were used to buttress the greater tuberosity fragments to the proximal humerus by tying these to four strands from the second row of anchors．The arm was suspended by a strap for 2weeks postoperatively，during which the shoulder started to do the pendulum exercise passively．Then they were required to do the abduction and flexion exercise over 90°after 6weeks．The patients were evaluated by interview，physical examination，and radiographs at 7－18months，with a mean follow－up of 12．3months．Details of complications and additional procedures were obtained from the clinical and operative records of the patients．The reductions and healing condition of the fractures were assessed by X－ray examination postoperatively．Then we use the Constant Score and UCLA shoulder rating scale to evaluate the function of shoulders．ResultsAccording to the intro－operative findings in the ten patients，five of them were communicated fracture，and there were soft tissues，such as periosteal membrane and rotator cuff，connecting the fractured fragments．Therefore，there is not significant separation between the fragments if the soft tissue around was properly protected during the exposure of fracture site．Moreover，the affected fracture area of the ten patients did not go over the greater tuberosity and the thickness of all the fracture fragments was within 0．8cm．All the patients’wound got healed．The X－ray showed an anatomic reduction with no re－displacement during the follow－up．Radiographic union of the tuberosity below the level of the articular surface of the humeral head was seen in all of 10 fractures．There was no heterotopic bone formation in any patient．All patients with radiographic union were satisfied with the outcome and the overall mean Constant score was 90．3and the final mean UCLA score was 32．2．There were no neurological complications，infections or complications of wound healing．ConclusionsGreater tuberosity fracture are well described and frequently discussed．They can be considered as an avulsion fracture of the rotator cuff．Suture anchors have recognized as an effective fixation of rotator cuff injury．The double－row anchors are more mechanically reliable，compared with single－row anchors．This technique has several advantages：First，biomechanical and clinical evaluation of the double－row fixation technique in arthroscopic rotator cuff repair has demonstrated significantly better biomechanical properties and structural outcome compared to other techniques；Second，proximal mattress sutures accurately restore the tuberosity－h(huán)ead relationship by approximating the bone－tendon junction to the proximal edge of the humeral fracture surface；Third，proximal fixation repairs the partial－thickness articular－surface tears of the supraspinatus tendon which may be associated with greater tuberosity fractures；Fourth，distal sutures serve as a tension band to effectively buttress the tuberosity fragments against the humeral fracture surface．The application of double－row anchors is clinically effective to treat the displaced greater tuberosity fractures．With the development of arthroscopic techniques，the outcome of double－row anchor suture fixation under arthroscopy is really to be expected．

Humerus fractures，greater tuberosity；Anchors

2014－01－16）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．02．003

361003 廈門，南京軍區(qū)骨科中心 解放軍一七四醫(yī)院骨二科

黃長明，Email：huangchm123＠163．com

張少戰(zhàn)，黃長明，傅仰攀，等．雙排錨釘橋式縫合在肱骨大結(jié)節(jié)骨折中的應(yīng)用［J／CD］．中華肩肘外科電子雜志，2014，2（2）：80－84．