The Research Of Posterior Minimal Invasive Approach By Treating Scapular Fractures

Objective To describe a minimally invasive approach to the scapula in detail and to investigate the clinical outcome of patients with displaced scapula fractures who were surgically treated using this approach.Methods1.From February2010to December2013,16patients (12male and four female) with scapular fractures underwent surgical fixation with a minimally invasive approach. The average patient age was53years (range:35-69).2.Eleven patients exhibited Displaced fracture of the glenoid. Of the16glenoid fractures, which were classified according to Ideberg, there were6type Ⅱ,2type Ⅲ, one type Ⅳ and2type Ⅴ fractures. All displacements with intra-articular steps or gaps exceeding3mm. In addition, five unstable scapular neck or body fractures were associated with a scapular neck angulation>20°(three cases with floating shoulder injury). Six patients exhibited additional associated injuries, mostly of the thorax (one cases), ipsilateral clavicle fracture (three cases) and the upper extremities (two cases). The preoperative radiological diagnostics included radiographic films of the affected shoulder in anteroposterior and lateral views, tangential view of the scapula and computer tomography. The surgical stabilisation was conducted on an average of6days (4-14days) after trauma.3.Based on the fracture pattern, incisions are made along the anatomic bony perimeter to access the scapula borders for reduction and fixation. Since the incisions are centered over sites of "perimeter" fracture displacement of this relatively flat bone, minimal soft tissue retraction and less muscular stripping are necessary, while indirect reduction of the intervening scapula body is accomplished to restore anatomic alignment.4.Length of stay, operative time, blood loss and postoperative complications for all patients were recorded. The mean follow-up period was24months (range,12-36 months). For clinical evaluation, we reviewed the Constant shoulder score, the Disability of the Arm, Shoulder, and Hand (DASH) score and the shoulder motion range (superduct, abduction, internal rotation, external rotation) which were assessed at preoperative period,3,6months postoperatively, and the final follow-up. Shoulder pain conditions for all patients were evaluated by using a visual analog scale (VAS) pain score. Radiographs were reviewed by an independent examiner in order to verify the state of the bone union.Results l.The mean operative time was105.8±39.6min. The time and complications of surgery decreased significantly with the experience of the team. The average blood loss was105.8±79.7mL. The average length of stay was17.6±1.3days.2.One case with atrogenic injury of suprascapular nerve was found after the surgery. The patient was healled by rehabilitation management. Three patients (second, sixth and eighth case) developed inflammation around the surgical incision, which were controlled by the enhanced dressing. The patients with longer operative time and complications were mainly in the first8cases.3.All patients were followed up for12-36months, with an average of24months. All patients have received fractures healed, without delayed union or nonunion.The average healing time of fractures was15.8w (12-19w), without abnormal healing. Fracture fragments with hypertrophic callus affected local appearance were not found. All patients were satisfacted with the appearance of the skin around the incision. Plates or screws breakage, screw pull-out and other fixed failures for all patients were not found during follow-up.4.Constant shoulder score, DASH score and VAS pain scores at each follow-up time points after surgery had a significant improvement compared with those before surgery (P<0.05), but for those after each time point, the difference was not statistically significance (P>0.05). Shoulder joint activities of all patients were gradually restored during the follow-up. To the last follow-up, although the level of joint activitiesis not restored to the contralateral shoulders, ipsilateral shoulders did not impact on daily life activities.Conclusions1.our approach does not yield a large subcutaneous flap, which to the scapula body, neck, and posterior glenoid that allows visualization of fracture reduction without an extensive Judet incision or creation of muscular flaps and was associated with excellent functional effect.2.The learning curve of the technique is shorter, and it is mastered easily by surgeons. However,compared with other approachs, the advantages and long-term outcomes of this minimally invasive approach still need be study in further.