【作者】 董宏然；

【导师】 施鑫；

【作者基本信息】 南方医科大学 ， 外科学， 2010， 硕士

【摘要】 肱骨近端骨折是骨科的常见创伤,20世纪50年代后,对于此损伤的病理解剖、愈合的理解及分型和治疗原则有了很大的进展,其中大部分轻度移位的骨折可通过保守治疗或切开复位内固定治疗获得良好的效果,但对于复杂肱骨近端骨折的治疗目前仍存在很大争议。随着生物力学研究的进展,肩关节假体设计的不断改进和手术技术的成熟,人工肱骨头置换为肱骨近端粉碎性骨折患者提供了一种有效的治疗手段,对缓解患者疼痛、增加肩关节的活动度、改善关节功能有确切的疗效。人工肱骨头置换治疗肱骨近端复杂骨折,疗效满意,但应严格掌握手术指征,只有那些肱骨近端严重粉碎、移位、无法复位或复位后难以固定、无法早期开始功能锻炼者,尤其是肱骨头血供丧失或严重破坏、必然发生肱骨头无菌性坏死者,才考虑切除肱骨头,行人工肱骨头置换。对于人工肱骨头置换术的手术时机,大多数学者认为对于此类骨折患者越早进行手术,术后效果越好,早期手术有利于结节和肩袖的重建与愈合。目前可调式假体其肱骨头直径、厚度、仰角、后倾、内／后偏距等均独立可调,使肱骨近端真正意义上实现解剖重建成为可能,并可实现理想的软组织张力。假体设计是一个永恒的话题,除了理想的假体,手术操作技术是另一个影响人工肱骨头置换成功与否的关键。人工肱骨头置换是-项技术要求较高的手术,术中正确选择并植入肱骨假体和软组织重建与平衡技术至关重要。很多的研究表明肱骨近端关节面后倾变异程度很大,不仅个体间差异大,而且在同一个体的左右侧间差异也很大。肱骨近端复杂骨折时,结节间沟大多破坏,术中应结合影像学表现,通过安置定位器和以前臂纵轴线为解剖标志,确定可靠的后倾角,肱骨头一般后倾30°-40°,但应该注意,目的是获得一个稳定的关节而不是一个特殊的数字。大多数学者认为肱骨头假体的理想高度是假体稍微高出大结节肩袖止点,一般2-3毫米,肱骨头过于偏下可能导致大结节太接近肩峰或向内撞击关节盂边缘,肱骨头位置过高会导致撞击和肩袖功能不良,肱骨头过于偏前偏后同样可能使肱骨颈撞击关节盂边缘并导致肩胛下肌和后肩袖肌腱张力过高。肩袖对于维持肩关节的稳定及外展上举功能起着重要作用,肩袖能否有效重建是确保肩关节功能恢复的关键,有学者认为肩袖重建的质量欠佳是导致手术失败的首要原因。术中肩袖的重建必须尽可能解剖复位,牢固地重建大、小结节,使结节覆盖肱骨干,并获得很好的愈合。肱骨近端如有较多的骨缺损,则必须植骨以保证大、小结节的愈合,对于肱骨干上端骨缺损较多者,可考虑安装定制假体。本研究的目的旨在探讨人工肱骨头置换术中假体植入、肩袖的处理及骨缺损的处理等技术要点及临床疗效。目的1、探讨人工肱骨头置换的手术适应症。2、探讨人工肱骨头置换的临床疗效及术中假体的正确植入、软组织重建与平衡、骨缺损的处理等手术技术要点。3、提高严重肱骨近端骨折的临床治疗效果。方法对2004年6月～2006年8月收治的26例有完整随访资料的应用肱骨头置换治疗肱骨近端粉碎性骨折患者的疗效进行回顾性分析,其中男11例,女15例。年龄36～77岁,平均58.8岁。按照Neer分型：Ⅲ型骨折8例,Ⅳ型骨折18例。手术采用Thompson入路方法。为了评价本组病例的疗效,采用检索文献的方法,找出治疗对象相似、疗效评价标准相同的研究作为对照。结果26例全部随访,随访时间为11～36个月,平均24个月。按Neer评分标准本组优：11例,满意：13例,不满意：2例,失败：0例。优良率92.3%,与查出文献采用锁定钢板治疗组比较无显著差异(P>0.05),与常规内固定组比较差异有显著意义(P<0.05)。结论肱骨头置换是治疗NeerⅢ型、Ⅳ型肱骨近端粉碎性骨折的有效方法,能迅速地消除患者的疼痛、恢复肩关节的功能和稳定性。严格掌握适应症,把握良好的手术时机,选择合适的假体,术中精确的肱骨假体植入和软组织重建与平衡技术是至关重要的。更多还原

【Abstract】 Proximal humerus comminuted fractures is a kind of common trauma in orthopedics.Since 1950s, great progress has been made in the pathological anatomy, the understanding and classification of healing and the principle of treatment on this kind of trauma. The majority of the cases of slightly-displaced fractures can obtain good effects through conservative treatment or the open reduction internal fixation. But the controversy over the complicated proximal humerus comminuted fractures still exists currently. With the development of the biomechanical research, the constant improvement of the design of the artificial limb, and the maturity of the operation technique, the operation of humeral head replacement has provided an effective means to treat proximal humerus comminuted fractures. It has definite curative effect on alleviating patients’pain, improving the mobility of the shoulder joint and its function. Humeral head replacement for the treatment of complex proximal humeral fractures, Satisfaction with treatment, but to master surgical indications should be strictly, only those serious displaced proximal humerus fractures、can not be reset or hard reset after a fixed, not the early days of functional exercise, especially humeral head blood supply loss or serious damage to the inevitable occurrence of aseptic necrosis of humeral head, and only consider the removal of humeral head, humeral head replacement line.Humeral head replacement for the surgical operation time, the majority of scholars believe that the sooner such fracture surgery patients, after the better, Early surgery is beneficial nodules and musculotendinous reconstruction and healing.Currently, the diameter, thickness, elevation, retroversion and deflection distance of the adjustable artificial limb can be adjusted, which makes it possible to realize the anatomical reconstruction of the proximal humerus and the ideal tension of the soft tissue. Not only the ideal artificial limb but also the techniques of the operator is the key to achieve the success of the humeral head replacement operation during which the techniques of correctly implanting the artificial limb and reestablishing and balancing the soft tissue are of the utmost importance. Many studies have shown that after the proximal humeral articular surface of the extent of dumping a large variation, not only large differences between individuals, but also in the same individual differences between the left and right side is also very strong. Complex proximal humerus fractures, the nodules are mostly inter-groove damage, surgery should be combined with imaging findings, through the placement and positioning to the forearm longitudinal axis line of anatomical landmark to determine the angle of post and reliable, after the general dumping of humeral head 30°～40°, it should be noted that the purpose is to obtain a stable joint and not a special number. The majority of scholars believe that the prosthetic humeral head height is ideal prosthesis macronodular slightly higher than the rotator cuff, the general 2 to 3 mm, is too partial humeral head may result in nodular or inward too close acromial joint impact the edge of the glenoid, humeral head position would lead to high impact and rotator cuff dysfunction, too partial humeral head after the former partial humeral neck may make the same impact and lead to the edge of the glenoid articular subscapularis muscle and tendon after rotator cuff hypertonicity. Shoulder rotator cuff to maintain stability and outreach on the move function plays an important role in the effectiveness of the reconstruction of the rotator cuff is to ensure that the key to the restoration of shoulder function, some scholars believe that the quality of rotator cuff reconstruction surgery is the failure of poor The primary reason. Rotator cuff surgery in the reconstruction of anatomical reduction must be as much as possible, a solid reconstruction of large and small nodules, so that coverage humeral tubercle, and good healing. For more proximal humeral bone defect, bone graft must be to ensure that large and small healing, top of the humeral bone defect more may consider installing custom prosthesis.The thesis paper is designed to probe into the techniques of the artificial humeral head replacement operation, such as correct implantation and the treatment of rotator cuff and the defects of bone. It also aims at discussing the clinical effect of the operation.Objective To study the clinical effect of humeral head replacement in treating proximal humerus comminuted fractures and its surgical techniques, such as the correct implantation, the reestablishment and balancing of the soft tissue and the treatment of the bone defects.Methods The effects of 26 cases of humeral head replacement in treating proximal humerus comminuted fractures were analyzed retrospectively. The patients in the 26 cases were hospitalized and treated from June 2004 to August 2006.11 are male and 15 are female, aged 36 to 77 and their average age is 58.8. The following-up data of all the cases are complete. According to the classification of Neer:8 fractures are of III type and 18 fractures are of IV type. Thompson approach was adopted in all the cases.Results All the cases were followed-up, from 11 to 36 months. According to the standard of Neer:Excellent in 11 cases, satisfied in 13 cases, unsatisfied in 2 cases, and no failure.Conclusion The malpractice in the treatment of proximal humerus comminuted fractures may lead to complications, such as the stiffness of shoulder joints, nonunion, or malunion. The soft tissues and vessels may be destroyed during the open reduction internal fixation and thus the risk of humeral head necrosis and bone nonunion will be increased. On the premises that the operational indications are fully grasped, the operation of humeral head replacement can alleviate or eliminate patients’pain, help restore the function and stability of the shoulder joint. Consequently, humeral head replacement is an effective way in treating proximal humerus comminuted fractures.更多还原