双钢板技术固定复杂不稳定肱骨近端骨折

复杂不稳定肱骨近端骨折的治疗仍存在挑战，钢板固定存在的内翻风险仍然较高，而肩关节置换术后功能恢复差，对年轻患者来说可能并不适用。

考虑到双钢板技术在四肢骨折中的广泛应用，有学者研究采用外侧钢板与小结节钢板治疗复杂肱骨近端骨折，取得了良好效果。结果发表在2021.08 Injury期刊上。

Introduction（介绍）

高度不稳定的肱骨近端骨折的稳定固定仍具有挑战性，其并发症发生率，尤其是继发的内翻脱位，仍然很高。不同的双钢板固定技术已经被建议用来治疗复杂的肱骨近端骨折，因为它们已被广泛应用于其他骨折。本研究的目的是评估一种使用角稳定的外侧钢板联合位于小结节前方的三分之一管型钢板支撑的手术技术，用于治疗不稳定的肱骨近端骨折。

[Introduction: A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.]

病例1：术前X线提示不稳定肱骨近端骨折，粉碎型

病例1：外侧接骨板固定，术后复查提示内翻

Patients and Methods（病例与方法）

回顾性分析自2014年1月至2017年12月接受双钢板固定治疗的患者。在31名患者中，有25名(80.6%)平均年龄为53.1岁(12.5岁)的患者进行了随访。60%的患者是男性。临床评估由体检和标准化问卷组成，包括主观和客观肩部评分，如Constant-Murley评分、简单肩部评分和主观肩关节评分（SSV）。

[Patients and Methods: Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.]

病例2：术前三维CT重建

病例2：a 骨撬复位，bc 外侧钢板临时固定，骨水泥加强，d 管型钢板塑形，e 管型钢板置于小结节 

病例2：术后，位置良好

病例3：术前术后图。骨折及内固定位置良好

Results（结果）

在平均随访30.9个月(范围12-76个月)后，18名患者(72%)在Constant-Murley肩关节评分方面获得了优秀或良好的结果，平均值为77.17。平均简易肩关节评分为76%± 0.2，主观肩关节评分为72% ±0.2%。随访时的平均NSA为135±13°。平均7.2个月后，9名患者接受了植入物取除术，5名患者接受了关节松解术。三名患者接受了二次关节成形术。研究显示并发症发生率为16%。没有因继发内翻脱位进行翻修手术的报道。

[Results: After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.]

表1：功能恢复情况

Conclusion（结论）

对于年轻、活动度大的高度不稳定型肱骨近端骨折患者群体来说，关节成形术是不太有利的治疗方法，因为结果不太好，而且翻修的选择有限。除了calcar螺钉、骨移植物增强、骨水泥增强和额外的自由螺钉之外，还可以使用双钢板接骨术，以获得更好的多向稳定性，并且显示出良好的临床效果和更高的初始稳定性，尽管与单钢板接骨术相比，其缺血性坏死率更高。这似乎是一种对初次骨折行关节成形术，并可以防止继发性内翻移位的有效替代方法。

[Conclusion: Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complicationrates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.]

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