摘要
目的:研究肱骨近端骨折合并肩袖损伤对半肩关节置换术后的影响。方法:回顾性分析2008年12月至2022年11月西安交通大学第二附属医院骨科采用半肩关节置换术治疗的肱骨近端骨折患者(年龄≥50岁)33例，排除既往肩部有疾病史或手术史、陈旧性骨折及病理性骨折患者。男10例，女23例；年龄57～90岁；左侧18例，右侧15例；均为外伤导致的骨折；根据Neer分型，两部分骨折6例，三部分骨折19例，四部分骨折8例；17例患者合并肩袖损伤。同时记录患者术后首次X线指标(肩峰肱骨头间距、肩关节间隙和盂肱指数)和并发症，随访末次视觉模拟评分(VAS)、Neer肩关节评分和复旦大学肩关节功能评分(FUSS)。符合正态分布的计量资料以(±s)描述，符合偏态分布的计量资料以M(P25，P75)描述。组间比较服从正态分布的采用两独立样本t检验及方差分析，非正态分布资料比较采用秩和检验。计数资料比较采用Fisher确切概率检验。因变量为二分类变量采用二元logistic回归分析。分别评估不同骨折分型、肩袖损伤情况在患者一般情况、术后首次X线指标及术后肩关节功能方面的差异。结果:纳入患者年龄(73±8)岁，随访时间(67±54)个月。末次VAS评分为1(0，2)分；FUSS评分为56(50，74)分；患侧Neer评分为(64±13)分，健侧Neer评分为(75±11)分，患侧与健侧比例为86.3%(44%～97%)，肩袖损伤与无肩袖损伤患者的患侧与健侧Neer评分比较差异无统计学意义(W＝250.500，P>0.05)。33例患者有17例(51.5%)伴有肩袖损伤，二、三和四部分骨折患者的肩袖损伤率分别为50.0%、68.4%和12.5%(P＝0.034)。合并肩袖损伤患者的年龄(75±8)岁大于无肩袖损伤患者的年龄(69±6)岁(t＝－2.320，P＝0.027)，年龄[比值比(OR)＝1.124, 95%置信区间(CI)(1.006，1.256)]是肩袖损伤的独立危险因素(P＝0.039)；肩袖损伤患者的患侧Neer评分(58±10)分低于无肩袖损伤患者的Neer评分(71±12)分(t＝3.212，P＝0.003)；肩袖损伤患者的日常生活功能、肌力评分[9(3，9)、6(6，9)]低于无肩袖损伤患者[15(9，24.75)、9(8，11.75)](W＝224.00、220.50，均为P<0.05)。肩袖是否损伤患者的术后首次X线指标比较差异无统计学意义(均为P>0.05)。术后有2例出现脱位、1例假体周围松动、1例伤口感染，均无内固定失效。结论:半肩关节置换术对肱骨近端骨折合并肩袖损伤患者总体重建效果较好，术后疼痛、肩关节活动范围、医患满意度与无肩袖损伤组无明显差异。但患者的日常生活功能、肌力常恢复不佳，这也和年龄引起的肩袖退变有关，应在临床工作中引起重视。
Abstract
Objective:To investigate the effects of proximal humeral fracture with rotator cuff injury after hemi-shoulder arthroplasty.Methods:Thirty-three patients (age ≥50 years) with proximal humerus fractures treated by hemi-shoulder arthroplasty in the Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University from December 2008 to November 2022 were retrospectively analyzed, and patients with a history of previous shoulder disease or surgery, old fractures, and pathologic fractures were excluded. 10 men and 23 women; age were 57 to 90 years; 18 cases on the left side and 15 cases on the right side; all were traumatic fractures. According to Neer's classification, six cases were two-part fractures, 19 cases were three-part fractures and eight cases were four-part fractures; 17 patients had combined rotator cuff injuries. The first postoperative X-ray indices (acromioclavicular humeral head spacing, shoulder joint gap and glenohumeral index) and complications were also recorded, and the final visual analogue scale (VAS), Neer shoulder score and Fudan University shoulder function score (FUSS) were followed up. Measures that conformed to normal distribution were described as (±s), and those that conformed to skewed distribution were described as M(P25, P75). Comparisons between groups obeying normal distribution were performed using two independent samples t test and ANOVA, and comparisons of non-normally distributed data were performed using rank sum test. Fisher exact probability test was used for comparison of count data. Dependent variables were analyzed by binary logistic regression. The differences in general condition, first postoperative radiographic index and postoperative shoulder function were evaluated by different fracture types and rotator cuff injuries, respectively.Results:The average age of enrolled patients was(73±8) years, and the follow-up time was (67 ± 54) months on average. The final VAS score was 1 (0, 2); FUSS score was 56 (50, 74). Neer score on the affected side was (64±13) and Neer score on the healthy side was (75±11), and the ratio of affected side to healthy side was 86.3% (44%-97%) for rotator cuff injury. The ratio of affected side to healthy side Neer score was not statistically significant in patients with and without rotator cuff injury (W=250.500, P>0.05). Seventeen of 33 patients (51.5%) had concomitant rotator cuff injury, and the rates of rotator cuff injury were 50.0%, 68.4%, and 12.5% in patients with two-, three-, and four-part fractures, respectively (P=0.034). The age of patients with combined rotator cuff injury (75±8) years was older than the patients without rotator cuff injury (69±6) years (t=-2.320, P=0.027), and age [odds ratio (OR)=1.124, 95% confidence interval (CI)(1.006, 1.256), P=0.039] was an independent risk factor for rotator cuff injury. Neer score on the affected side in patients with rotator cuff injury was (58±10), which was lower than (71±12) in the patients without rotator cuff injury (t=3.212, P=0.003); the daily function and muscle strength of patients with rotator cuff injury [9 (3, 9) and 6 (6, 9)] were lower than those without rotator cuff injury [15 (9, 25) and 9 (8, 15)], respectively (W=224.00, 220.50, both P<0.05). There was no statistically significant difference in the first postoperative X-ray indices between patients with or without rotator cuff injury (all P>0.05). Postoperatively, there were two cases of dislocation, one case of periprosthetic loosening, and one case of wound infection, and none of them had internal fixation failure.Conclusions:The overall reconstructive effect of hemi-shoulder arthroplasty on proximal humeral fracture combined rotator cuff injury is good, and it shows almost the same effects in postoperative pain, shoulder range of motion, and doctor-patient satisfaction as proximal humeral fracture without rotator cuff injury. However, patients often have poor recovery of daily function and muscle strength, which is also related to age-induced rotator cuff degeneration and should be taken into account in clinical work.
基金项目
陕西省自然科学基金面上项目(2022JM-554)
万方数据