应用MIPPO技术前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折
2017-01-11张培训付中国王依林马明太薛峰
张培训 付中国 王依林 马明太 薛峰
·论著·
应用MIPPO技术前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折
张培训 付中国 王依林 马明太 薛峰
目的探讨采用微创经皮钢板内固定(minimally invasive percutaneous plate osteosynthesis,MIPPO)技术经前侧手术入路预旋转塑形锁定板钉治疗肱骨干中段B型和C型骨折的临床疗效。方法2012年1月至2015年12月,北京大学人民医院应用MIPPO技术前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折患者16例,其中男6例,女10例;年龄43~70岁,平均(55.8±9.1)岁;根据AO分型:B型11例,C型5例;所有患者均为闭合性骨折,不伴随桡神经损伤。患者行骨折远、近端上臂前方小切口,透视下闭合复位骨折,并于肱骨前方肱骨表面放置预旋转处理的锁定加压钢板(locking compression plate,LCP)桥接固定,LCP近端放置在肱骨外侧,远端放置在肱骨前侧。记录手术时间、术后并发症、骨折愈合时间、肩关节及肘关节活动范围。肩关节功能采用美国加州大学洛杉矶分校(University of California,Los Angeles,UCLA)评分评价,肘关节功能采用Mayo评分评价。结果16例患者均获得了8~24个月随访,平均(16.13±4.54)个月,手术时间45~120min,平均(70.5±18.5)min。16例患者中有1例出现术中的医源性桡神经损伤,经营养神经药物和电刺激的治疗,术后1个月时腕关节和拇指的背伸功能完全恢复。16例患者骨折愈合时间10~21周,平均(13.5±3.0)周。肩关节外展105~120°,平均(112.5±4.6)°;前屈150~170°,平均(165.4±6.0)°。肘关节伸直0~8°,平均(4.8±2.0)°;屈曲120~140°,平均(132.5±5.8)°。肩关节功能依据UCLA评分标准:优15例,良1例。肘关节功能依据Mayo评分标准:优14例,良2例。结论应用MIPPO技术前侧手术入路预旋转塑形锁定加压板钉治疗肱骨干中段B型和C型骨折临床疗效较好,手术操作方便,骨折断端血运影响小,恢复快,值得进一步临床推广。
MIPPO;LCP;内固定;肱骨干;骨折
肱骨干骨折临床常见,约占全身骨折的2%[1]。近年来肱骨干骨折的治疗方式已从传统保守石膏固定发展到钛板螺钉及髓内钉固定,应用钛板螺钉进行切开复位内固定或者闭合复位髓内钉内固定已成为肱骨干骨折手术治疗的金标准[2]。采用切开复位钛板内固定术治疗肱骨干骨折,需要较大范围的剥离软组织肌肉,干扰了骨折断端的血运,且存在桡神经损伤的风险[3]。随着AO骨折生物固定理论的更新,重视保护骨折断端周围软组织血运的骨折间接复位技术得到了蓬勃发展。通过微创经皮钢板内固定(minimally invasive percutaneous plate osteosynthesis,MIPPO)技术肱骨前方或外侧经皮置入钢板固定肱骨干骨折成为可能,国内屡有报道,骨折愈合快,并发症少[4]。肱骨解剖形态存在特异性,肱骨的前侧有纵行的嵴,钛板放置在正前方存在较大困难;钛板放置在前外侧对桡神经的干扰较大;钛板放置在前内侧对内侧血管神经束也存在干扰,且肱骨骨折线较高时近端钛板放置位置过高也会对肩关节的功能造成影响。肱骨中段骨折切开复位钛板内固定的治疗中,理想的钛板放置位置可能是骨折近端放置在肱骨的外侧,骨折远端放置在肱骨的前侧,因此预旋转塑形锁定板钉治疗肱骨中段骨折成为可能。北京大学人民医院创伤骨科自2012年1月至2015年12月,采取MIPPO技术经前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折患者16例,取得了较好的治疗效果,现将临床疗效及观察结果进行总结。
资料与方法
一、一般资料
2012年1月至2015年12月,应用MIPPO技术经前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折患者16例,其中男6例,女10例;年龄43~70岁,平均(55.8±9.1)岁;根据 AO分型:B型11例,C型5例。所有患者均为闭合性骨折,不伴随桡神经损伤。2例患者因交通事故合并头面部及下肢软组织开放伤,均远离骨折部位。致伤原因:交通事故5例,摔伤9例,高处坠落伤2例。受伤至手术时间1~6d,平均(2.5±1.5)d。
二、手术方法
14例患者手术采用臂丛麻醉,2例合并其他部位外伤患者采用全身麻醉。术中应用4.5mm干骺端锁定加压钢板(locking compression plate,LCP)(辛迪思公司)或者肱骨外侧解剖板(美国邦美公司)。手术开始前进行钛板的预塑形处理,将钛板的远、近端进行6~8°的旋转塑形。患者仰卧,患肢置于可透视外展手术板上,前臂旋后。首先于肘横纹上行纵形切口,长约4cm,于肱桡肌和肱肌之间找到桡神经(不必游离神经)后,于桡神经内侧纵行劈开肱肌,显露肱骨远端前方。另取上臂近端纵形切口,长约4cm,于三角肌及胸大肌间隙进入,显露肱骨近端。分别从远、近端切口作肱骨前方骨膜外肌下隧道,屈肘牵引复位,由上臂近端切口经肌下隧道插入10~12孔预旋转塑形处理过的LCP,LCP近端放置在肱骨外侧,远端放置在肱骨前侧。C型臂透视下见钛板放置位置,骨折对位、对线及旋转满意后,骨折远、近端各拧入3~4枚锁定螺钉固定,清洗伤口后逐层缝合关闭伤口。
三、术后处理
术后前臂吊带悬垂保护3周,术后第2天起,患者在疼痛允许范围内行被动肩关节及肘关节功能锻炼。术后3周后行主动肩关节和肘关节功能锻炼。
四、临床疗效评价指标
术后4个月内每个月行X线检查1次,以确定骨折愈合时间;4个月后每3个月行X线检查1次;1年后每6个月行X线检查1次。记录手术时间、术后并发症、骨折愈合时间、肩关节及肘关节活动范围。最后一次随访进行肩关节和肘关节功能评分,肩关节功能采用美国加州大学洛杉矶分校(University of California,Los Angeles,UCLA)评分,肘关节功能采用Mayo评分。UCLA肩关节功能评分是评价肩关节功能的常用指标,内容包括疼痛(10分),活动度(10分),向前屈曲活动度(5分),向前屈曲力量(5分)及患者满意度(5分)。Mayo肘关节功能评分系统是评价肘关节功能的常用指标,内容包括疼痛(45分)、关节活动范围(20分)、稳定程度(10分)及日常功能(25分)方面的评价内容。
结 果
所有患者均获得了8~24个月随访,平均(16.13±4.54)个月;手术时间45~120min,平均(70.5±18.5)min。16例患者中有1例出现术中医源性桡神经损伤,经营养神经药物和电刺激的治疗,术后1个月时腕关节和拇指的背伸功能完全恢复。骨折愈合时间10~21周,平均(13.5±3.0)周。肩关节外展105~120°,平均(112.5±4.6)°;前屈150~170°,平均(165.4±6.0)°。肘关节伸直0~8°,平均(4.8±2.0)°;屈曲 120~140°,平均 (132.5±5.8)°。在本组患者的随访中,肩关节功能依据UCLA评分标准:优15例,良1例。肘关节功能依据Mayo评分标准:优14例,良2例。
讨 论
肱骨干骨折临床常见,手术治疗方法多采用髓内针固定术及切开复位板钉内固定术[2]。目前肱骨干骨折的髓内钉的治疗仍存在争议,顺行入钉的髓内钉的入钉点会不可必免的损伤肩袖,从而影响肩关节的功能;逆行入钉的髓内钉也面临肱骨远端背侧皮质较薄,手术操作难度较大以及容易发生骨化性肌炎等缺点。切开复位板钉内固定,目前认为是治疗肱骨干骨折最可靠的的手术方法[5]。切开复位板钉内固定存在手术创伤较大,软组织骨膜血运破坏较重等缺点。现在随着生物固定的发展和进步,微创和充分保护骨折断端血运的理念逐步被接受,采用MIPPO技术治疗四肢骨折越来越普遍[6]。采用小切口经皮插入钛板,切口远离骨折部位,骨折断端不干预,尽量保护骨膜,局部软组织损伤少,最大程度保护了骨折断端的血供,骨折愈合时间明显缩短,减少了延迟愈合和不愈合的发生[7]。
根据AO分型和固定理念,A型骨折和部分B型骨折属于简单骨折,适用于断端加压的坚强内固定[8];而部分B型及C型骨折断端相对粉碎,属于相对复杂骨折,骨折断端血供保护的要求较高,适用于生物学桥接固定。因此,MIPPO桥接技术尤其适用于B型及C型骨折[9]。有学者报道骨折线应与冠状窝的距离在6cm以上,才能保证肱骨骨折的远端部分能有足够空间容纳3枚锁定螺钉[10]。本文报道16例病例均选择为肱骨中段的骨折,且AO分型均为B型及C型骨折,术后随访均达到骨性愈合。
MIPPO技术治疗肱骨干骨折尽量选择锁定板钉,可选择锁定加压钛板以及有限接触锁定加压钛板等。作者建议在考虑到肱骨长度的个体差异的前提下,尽量选择较长的钛板,骨折线远近端尽量要满足至少3枚锁定螺钉的固定密度。在本组16例患者中,选择辛迪思公司干骺端4.5mm LCP或者美国邦美公司的解剖锁定板钉作为内固定物,术前将钛板预旋转塑形处理,使得钛板近端放置在肱骨的外侧,远端放置在肱骨的前侧,具备了更高的贴合效应,取得了很好的治疗效果。通过MIPPO桥接技术获得骨折断端的稳定,需要术中辅助通过间接闭合手法复位来达到,这种断端未实现完全解剖复位的间接复位方法在获得肱骨的解剖力线上是有一定难度的,术中进行闭合复位的过程中不仅要维持肱骨的有效长度、注意成角畸形的发生,还要注意出现旋转畸形的可能[11]。作者的经验是:术中将上肢充分外展以避免内翻畸形,肘关节屈曲并保持前臂持续牵引以避免矢状位成角畸形,术中多角度透视正位、侧位及斜位,确保钛板的位置和肱骨的大体解剖力线。术中将肱骨干远端在中立位通过屈肘90°确定肱骨干的前方,近端通过同一切口在结节间沟处打入1枚克氏针,通过调整克氏针,将克氏针调整到与肱骨远端内外侧髁连线相垂直的位置,同时结合X线透视正位X线片,来确定旋转对位[12]。本组16例患者中术后肘关节的内外翻与正常侧对照均在3~5°的范围内,旋转移位2~5°,肘关节的功能基本不受影响,同时随访中也未发现螺钉拔出、折断及钛板断裂、移位等情况。当然,微创技术相对于切开复位内固定技术需要术中更多次的进行透视确认,在初期会增加患者及术者的射线暴露,随着技术及操作的成熟,后期可将这一弊端尽可能降低,相对于切开复位对患者造成的创伤,认为这些不利影响是可以接受的。
本组16例患者中,早期出现过1例医源性桡神经损伤,术后短时间内出现患侧不能腕关节背伸,虎口区域麻木不适,术后1个月随访时腕关节背伸功能恢复。作者认为,此1例医源性桡神经损伤的出现是由于开展该技术早期,对桡神经的游离保护性措施的不当有关。早期在远端切口内找到桡神经分离橡皮条牵引保护,可能与分离、牵拉有关。后期在进行远端切口显露时,找到桡神经后,不做游离,在桡神经内侧纵行切开肱肌,将桡神经连同肱肌一并牵向外侧,术中始终保持肘关节屈曲,桡神经松弛,未再次出现医源性桡神经损伤现象。
本组16例患者观察结果显示:虽然骨折愈合时间不同,但均达到临床骨性愈合。应用MIPPO桥接技术治疗肱骨干骨折,骨折达到二期愈合,较一期愈合强度更高,骨折经过再塑形后所能达到的强度更高[13]。在获得随访的病例中,未发现拆除钛板后再骨折病例。将锁定钛板预旋转塑形后,钛板更加贴合肱骨前外侧的解剖学形状。预旋转塑形后的锁定钛板与MIPPO技术相结合,减少了对肌肉软组织的刺激,有效的保护了骨折断端的血运,较好的保护了桡神经,提高了手术的安全性。
本研究是回顾性病例治疗经验总结,存在一定局限性,疗效是否确切还需要较大规模的临床前瞻性随机对照研究。
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Treatment of humeral shaft fracture (Type B,C)with pre-rotating moulding locking plate by anterior approach MIPPO technique
Zhang Peixun,Fu Zhongguo,Wang Yilin,Ma Mingtai,Xue Feng.Department of Trauma and Orthopedics,Peking University People′s Hospital,Beijing 100044,China
Xue Feng,Email:drxuefeng@163.com
BackgroundHumeral shaft fractures are common,accounting for 2%of the total cases.In recent years,the treatment of humeral shaft fracture has been developed from traditional conservative plaster fixation to plate-screw and intramedullary nail fixation.The application of plate screw for open reduction and internal fixation or closed reduction intramedullary nail fixation has become the golden standard for surgical treatment of humeral shaft fractures.The treatment of humeral shaft fracture with open reduction and internal plate fixation requires the stripping of soft tissuesand muscles.This operation interferes with the blood supply of fracture ends and increases therisk of radial nerve injury.With the renewal of biological fixation theory of AO,indirect reduction technique which emphasizes the protection of soft tissue around fracture has been thrived.It has been reported repeatedly in nation that humeral shaft fracture can be treat with percutaneous plate fixation through minimally invasive percutaneous osteosynthesis,a strategy that results in high curing speed and less complication.Because of the specific anatomical structure of the humeral shaft,it is difficult to put a plate in front of the anterior longitudinal ridge.While the plate placed on the anterolateral side usually interferes with the radial nerve,the plate placed on the anteromedial side of the shaft also interferes with the neurovascular bundle.When the humeral fracture line is high,the corresponding proximal plate placement will affect the function of the shoulder joint.To treat the humeral shaft fracture with open reduction and plate fixation,the ideal position of the plate placement may be the lateral side of the humeral shaft when the plate is proximal to humeral fracture and the front side of the humeral shaft whenthe plate isdistal to humeral fracture.Therefore,the pre-rotating moulding locking plate become a possible solution for the treatment of humeral shaft fracture.From January 2012to December 2015,16cases of humeral shaft type B and type C fractures were treated with anterior approach pre-rotating moulding locking plate.The clinical curative effects and observations are summarized as follows.Methods(1)General data.16patients(6males and 10females)aging from 43 to 70years old (55.8±9.1)was documented.According to AO classification,11cases are type B fracture,and 5cases are type C fracture.Of the total 16cases,5cases were caused by traffic accidents,9cases by tumble,and 2cases by falling injury.All fractures were closed without radial nerve injury,while 2patients with traffic accident suffered from combined head and lower limb soft tissue injury away from the fracture site.(2)Treatment measures.14patients
brachial plexus anesthesia,and the other 2patients received general anesthesia.4.5mm locking compressed plate or lateral humeral anatomical plate(Biomed,USA)was used during the surgical operation,and 6°to 8°of plastic rotating moulding were made beforehand.The patient was supine,and the affected limb was placed on the X-ray abduction surgical plate.First of all,a longitudinal incision of approximately 4cm in length were performed on the cubital upstream.After the radial nerve between the brachioradialis and brachialis was found,the front of the humeral distal part was exposed by splittingthe obrachialis under the radical nerve.Then,the proximal humerus was exposed with another 4cm proximal longitudinal incision between the deltoid and pectoralis.A lateral muscle tunnel beyond the periosteum was drawn between distal and proximal incisions.With elbow flexion and traction reduction,a 10-12 holes pre-rotating moulding plate was inserted into the muscle channel with the proximal end placed on the lateral side of proximal humerus and the distal end placed on the front sideof distal humerus.After being placed properly under the intraoperative fluoroscopy,the plate was fixed with 3-4locking screws on both the proximal and the distal side.Finally,the wound was closed after cleaning.(3)Postoperative treatment.All patients received forearm sling suspension protection for 3weeks after the surgical operation.Starting from the second day of the surgery,passive shoulder joint and elbow joint functional exercise were performed within the range of pain tolerance of the patients.Active shoulder joint and elbow joint functional exercise were performed 3weeks after the surgery.For the purpose of assessing the fracture curing time,the patients received X-ray check per month within 4months of the operation,per 3months after 4months of the operation,and per 6months after one year of the operation.The time of surgery,postsurgical complications,fracture curing time,and the range of motions ofshoulder joint and elbow jointwere also recorded.During the last time of postoperative follow-up,the visitors adopted the University of California Los Angeles(UCLA)systems and Morrey elbow joint function evaluation systems to evaluate the functions of shoulder and elbow.Functions of shoulder joint were assessed by the UCLA grading standard,a criterion that includes the shoulder joint pain(10points),range of motion(10points),the initiative lift angle on anterior direction(5 points),muscle strength(5points),and patients′subjective satisfaction(5points).The functions were evaluated from 4aspects:the pain degree(45points),range of motion(20points),stability(10 points),and daily life ability(25points).The total score is 100points:90-100points is excellent;75-89points is good;60-74is ok;less than 60points is poor.Results All patients had been followed up for 8to 24months(16.13±4.54).The surgical operation time rangesfrom 45to 120minutes(70.5±18.5),and the curing of the fracture take 10to 21weeks(13.5±3.0).The abduction of shoulder joint ranges from 105°to 120°(112.5°±4.6°);the forward flexion ranges from 150°to 170°(165.4°±6.0°).The extension of elbow joint ranges from 0°to 8°(4.8°±2.0°);the flexion ranges from 120°to 140°(132.5°±5.8°).Out of the 16treated patients,there was only one case of clinical triggered damage of radical nerve.With the treatment of neurotrophic drugs and electrostimulation,the dorsiflexion of wrist and thumb fully recovered one month after the surgery.In the last postoperative assessment,the UCLA score were excellent for 15patients and good for 1patient.During the last postoperative followup,the visitors further adopted the Morrey evaluation system for the evaluation of the functions of elbow and joint.The score were excellent for 14patients and good for 2patients.Conclusions
Nowadays,open reduction and internal fixation is considered asthe most reliable surgical method for the treatment of humeral shaft fractures.Open reduction and plate fixation may result in large operative trauma and severe destruction of the blood supply toward soft tissues and periosteal.With the current development of the biological fixation,the concepts of minimally invasive treatment and the protection for blood supply toward fracture ends aregradually accepted.Moreover,the use of MIPPO technology for the treatment of limb fractures is becoming more and moreprevalent.Humeral shaft fractures treated with MIPPO technology can achieve better outcomes,and fractures after remodeling can achieve higher strength.The locking plate with pre-rotating moulding anatomically fits better to the anterolateral side of humerus.Locking plate with pre-rotating moulding combined with MIPPO technology reduce the irritation to muscle and soft tissue,effectively protect the blood supply toward the fracture site and the radial nerve,and improve the safety of the surgical operation.
Minimally invasive percutaneous plate osteosynthesis;Locking compressed plate;Internal fixation;Humeral shaft;Fracture
2016-05-31)
(本文编辑:胡桂英;英文编辑:陈建海、张晓萌、张立佳)
10.3877/cma.j.issn.2095-5790.2017.01.002
国家科技部973计划(2014CB542201);国家科技部863计划(SS2015AA020501);教育部创新团队(IRT1201);国家自然科学基金(31571235);国家自然科学基金(31271284);国家自然科学基金(31171150);教育部新世纪优秀人才计划(BMU20110270)
100044 北京大学人民医院创伤骨科
薛峰,Email:drxuefeng@163.com
张培训,付中国,王依林,等.应用MIPPO技术前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折 [J/CD].中华肩肘外科电子杂志,2017,5(1):3-8.