| Objective: Proximal humeral fracture is very common which takes5-9%of all kinds of fractures. This kind of fracture is mostly seen among the seniorpopulation with osteoporosis. Among the shoulder injury of people older than65proximal humeral fracture takes81%. Open reduction internal fixationusing locking plate for its superior stability as well as limited interference tothe blood supply and rotator cuff has become one of the major surgical methodfor senior communicated proximal humeral fractures. Recent years as morethorough research carried out the medial support is drawing more and moreconcerns. Whether medial support is reconstructed directly determines the postoperation outcome of recovery. There are many methods to reconstruct themedial support. For example, the calcar screw set medial and inferior of thehumeral head, autograft using a fibula, injection of calcium sulfate etc.Biomechanical experiments and clinical surveys has been conducted to provethe effectiveness of these methods mentioned above. Because Neerclassification3or4parts fractures have the defect medially, it is sometimesvery difficult to reconstruct the medial support. Furthermore for the bloodsupply is devastated, there is high incidence that the surface of the humeralhead collapses following necrosis of the humeral head. In some cases of Neerclassification3or4parts fractures, while treating them by open reduction andinternal fixation our hospital used ilium crest bone autograft packed mediallynot only to give medial support and better hold of the screws but also toprompt the recovery of blood supply of humeral head whose blood supply iscompromised during the fracture. This survey was aimed at comparing themethod of open reduction internal fixation with ilium autograft and the wayopen reduction internal fixation without autograft at the aspect of its influence to the functional recovery so as to evaluate whether open reduction internalfixation with ilium autograft is competent in its effect.Methods: For this is a retrospect survey, we had to select subjects first.10cases treated by open reduction internal fixation with ilium autograft wereset as the observation group while10cases treated by open reduction internalfixation without ilium autograft were included by the control group. Theprocess of open reduction internal fixation with ilium autograft is as follows.When general anesthesia was completed, the patient lay in supine position,sterilized and draped as usual Take the incision from medial inferior aspect ofcoracoid to the inferolateral direction. Explode the fracture after dissectingbetween deltoid and pectoralis major while taking notice of the cephalic vein.What can be seen was the splitted major tubercle and comminuted lessertubercle and metaphysic which had the varus displacement. The majortubercle and the lesser tubercle were sutured and retracted. Reposition thehumeral head to the metaphysic correcting the varus displacement whileadjusting line of force. Take bone from illium crest, trim it to ladder-shapedform and imbed it to the medullary canal. The medial defect should be packedwith cortical bone. Fix the repositioned bone temporarily with Kirschner wireand then adhere the locking plate to the right position lateral of the bone whichis1cm inferior of the top of the replaced major tubercle. Fix the plate to thebone with locking screw and ligate the suture of major and lesser tuberclesthrough the hole of the plate. In this case because the major tubercle splittedwas very big, we additionally adapted a lag screw to better fix the majortubercle. The satisfactory reduction and the proper position of internal fixationis affirmed under C-arm, close the incision layer by layer and so is the end ofthe operation. Then1year of follow-up was conducted and data was recorded.By statistical methods we drew the conclusion that there were no differencebetween the two groups in age(t=1.036, P=0.314), sex(P=0.650) and type（W=996.000，P=0.650two sided）. Thus except the difference of operationother factors are excluded which means the two groups are comparable.According to the investigation, we got to know that the two groups are operated by the same group of experienced surgeons according to the standardstrictly and after the operation the patients were instructed to formal functionalrehabilitation by the surgeons. The functional recovery1year after theoperation shows high sensitivity comparing the final outcome, as a result thefollow-up1year after the operation was gathered and evaluated representingthe final result. The constant shoulder score and UCLA shoulder rating scalewhich include pain, the scale of movement and muscle force etc. were used toevaluate the functional recovery. We used nonparametric rank sum test as thestatistical analysis technique for the scores are ranked data.Results: There was no fixation failed, no refracture, no nonunion and noinfection that needed further treatment. After one year of follow-up, we gotthe constant shoulder score of ilum bone autograft group（median=10，sum ofranks=74.5）smaller than the control group（median=16，sum of ranks=135.5）（Z=-2.329，P=0.010，one tailed） whereas the UCLAshoulder rating scaleof experimental group （median=30.5，sum of ranks=131.5） greater than thescale （median=26.5，sum of ranks=78.5）of the control group（Z=-2.019，P=0.022，one tailed）.Conclusions: According to the criteria of the two kinds of scores, it canbe deemed as good or excellent that the constant shoulder score is smaller20or the UCLA shoulder rating scale is bigger than27. The constant shoulderscores of the two groups were smaller than20, while as to the UCLA shoulderrating scale there were2cases smaller than27in the autograft group while5cases smaller than27in the control group. It can be concluded that openreduction internal fixation using locking plate can achieve excellent outcome.However, regardless whether the constant shoulder score or the UCLAshoulder rating scale was considered and since as to the constant functionscore the smaller the better while the UCLA shoulder rating scale theopposite，we could be informed that ilium bone autograft group functionsbetter than the latter after rank sum test was tanken. The olds for theirosteoporosis lacking bone substance, when fractured are especially suitable forautograft. What’s more Neer classification3or4part fractures for the medial unstableness open reduction locking internal fixation with ilium boneautograft along with appropriate functional rehabilitation can assure a betterprognosis. Provided indication is carefully measured, we can practice themethod in a larger scale and its effectiveness should be further verified. |
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