肩峰指數(shù)與運(yùn)用Multiloc髓內(nèi)釘治療肱骨近端骨折的臨床相關(guān)性研究

鄒義源 向明 李一平 楊國勇 陳杭 胡曉川

·論著·

肩峰指數(shù)與運(yùn)用Multiloc髓內(nèi)釘治療肱骨近端骨折的臨床相關(guān)性研究

鄒義源1向明2李一平2楊國勇2陳杭2胡曉川2

目的 評估肩峰指數(shù)(acromionindex,AI)與Multiloc髓內(nèi)釘治療肱骨近端骨折的相關(guān)性。方法 將2014年2月至2015年6月，四川省骨科醫(yī)院采用Multiloc髓內(nèi)釘治療17例肱骨近端骨折患者的病例資料納入研究。其中男6例，女11例；年齡48～67歲，平均61.4歲；AI為0.69～0.94，平均0.78，其中男0.66，女0.75。根據(jù)Neer分型，二部分骨折8例(47%)，三部分骨折7例(41%)，四部分骨折2例(12%)，其中合并有鷹嘴骨折、橈骨遠(yuǎn)端骨折、肩袖損傷及腋神經(jīng)損傷。所有患者均為閉合性骨折。記錄手術(shù)時(shí)間，出血量，術(shù)后1、2、4、6、8、12個(gè)月門診定期復(fù)查，X線檢查復(fù)位效果及愈合情況，并采用美國肩肘外科協(xié)會(huì)評分(ratingscaleoftheAmericanshoulderandelbowsurgeons，ASES)，Constant評分等指標(biāo)評價(jià)患者肩關(guān)節(jié)功能。結(jié)果 17例患者均順利完成手術(shù),1例術(shù)后出現(xiàn)肘關(guān)節(jié)僵硬，術(shù)后并發(fā)癥發(fā)生率為5.8%。ASES評分中：總分P=0.670，疼痛P=0.078，生活功能P=0.010；Constant評分中：總分P=0.019，疼痛P=0.083，功能活動(dòng)P=0.453，肩關(guān)節(jié)活動(dòng)度P=0.007，力量P=0.869；出血量P<0.001；骨折愈合時(shí)間P=0.001；手術(shù)時(shí)間P=0.866。日?；顒?dòng)中：前屈上舉P=0.012，外展P=0.010，外旋P=0.038。6例男性平均AI為0.66±0.54，11例女性平均AI為0.75±0.40，兩者AI相比P=0.218。提示AI與患者術(shù)中出血量、骨折愈合時(shí)間及術(shù)后功能活動(dòng)(特別是前屈上舉、外展、外旋)有相關(guān)性。結(jié)論 肱骨近端骨折運(yùn)用髓內(nèi)釘治療時(shí)，AI大小與性別、年齡、手術(shù)時(shí)間無明顯相關(guān)性。AI越小，術(shù)中出血量越少，骨折愈合時(shí)間越短；AI越大，術(shù)中出血量相對較多，骨折愈合時(shí)間稍長。AI較大的患者，術(shù)后ASES評分及Constant評分較高，術(shù)后功能活動(dòng)(前屈上舉、外展及外旋)較好；相反，AI較小的患者，術(shù)后ASES評分及Constant評分相對較低，術(shù)后功能活動(dòng)(前屈上舉、外展及外旋)相對較差。在運(yùn)用Multiloc髓內(nèi)釘治療肱骨近端骨折時(shí)，暫未發(fā)現(xiàn)與手術(shù)相關(guān)并發(fā)癥，且AI的大小與術(shù)后并發(fā)癥的發(fā)生無明顯相關(guān)性。

肩峰指數(shù)；肱骨近端骨折；髓內(nèi)釘

肱骨近端骨折屬于骨科臨床常見病種，其發(fā)生率占所有骨折的4%～5%[1]，超過70%的肱骨近端骨折發(fā)生于60歲以上老年人，其發(fā)生趨勢隨著我國老齡化的到來，將會(huì)逐年遞增。其中多數(shù)肱骨近端骨折可以通過保守治療，能夠獲得較好的臨床功能預(yù)后[2-3]，但仍存在一定的并發(fā)癥。肱骨近端骨折手術(shù)治療方式包括：閉合或切開復(fù)位內(nèi)固定和肩關(guān)節(jié)置換。內(nèi)固定的選擇多樣，如Multiloc髓內(nèi)釘[4-6]。

在Multiloc髓內(nèi)釘治療的手術(shù)過程中，Rispoli等[7]發(fā)現(xiàn)肩峰指數(shù)(acromionindex,AI)的大小對手術(shù)有影響，但目前國內(nèi)尚無相關(guān)的文獻(xiàn)報(bào)道。故本文假設(shè)AI的大小與肱骨近端骨折運(yùn)用Multiloc髓內(nèi)釘治療時(shí)，在手術(shù)時(shí)間、術(shù)中出血量、骨折愈合時(shí)間、術(shù)后功能評分及功能恢復(fù)上有差異。本研究回顧性分析2014年2月至2015年6月四川省骨科醫(yī)院應(yīng)用Multiloc髓內(nèi)釘治療肱骨近端骨折17例患者的病例資料，并記錄手術(shù)時(shí)間、出血量、骨折愈合時(shí)間、術(shù)后功能恢復(fù)及功能評分等。

資 料 與 方 法

一、一般資料

2014年2月至2015年6月本院應(yīng)用Multiloc髓內(nèi)釘治療且隨訪1年的肱骨近端骨折患者17例,男6例，女11例；年齡48～67歲，平均61.4歲；AI為0.69～0.94，平均0.78，其中男0.66，女0.75。根據(jù)Neer分型，二部分骨折8例(47%)，三部分骨折7例(41%)，四部分骨折2例(12%)，其中合并有鷹嘴骨折、橈骨遠(yuǎn)端骨折、肩袖損傷及腋神經(jīng)損傷。17例患者中優(yōu)勢手受傷8例(47%)，非優(yōu)勢手受傷9 例(53%)。患者受傷原因：走路滑倒摔傷9例(53%)，自行車摔傷5 例(29.4%)，交通事故3 例(17.6%)。所有骨折均為閉合性骨折。本研究獲得醫(yī)院倫理委員會(huì)批準(zhǔn)，所有受試者均簽署知情同意書。

二、隨訪及評價(jià)指標(biāo)

手術(shù)均由同一組醫(yī)師完成，由另外2名高年資骨科醫(yī)師進(jìn)行門診隨訪和評價(jià)?；颊叱鲈汉箝T診密切隨訪，術(shù)后1、2、4、6、8、12個(gè)月定期復(fù)查，拍攝DR片。記錄手術(shù)時(shí)間、出血量、骨折愈合情況及功能活動(dòng)情況等。采用肩關(guān)節(jié)活動(dòng)度、美國肩肘外科協(xié)會(huì)評分(ratingscaleoftheamericanshoulderandelbowsurgeons,ASES)[8]、Constant肩關(guān)節(jié)評分評估肩關(guān)節(jié)功能[9]。ASES評分為美國肩肘外科協(xié)會(huì)制定的肩關(guān)節(jié)功能評價(jià)標(biāo)準(zhǔn)，包括疼痛(50%)和生活功能(50%)，滿分為100分，分?jǐn)?shù)越高表示肩關(guān)節(jié)功能越好。Constant肩關(guān)節(jié)評分系統(tǒng)滿分為100分，由疼痛(15分)、肌力(25分)、功能活動(dòng)(20分)及肩關(guān)節(jié)活動(dòng)度(40分)4個(gè)子量表組成，分?jǐn)?shù)越高，表示肩關(guān)節(jié)功能越好。

三、AI的測量

所有患者均拍攝標(biāo)準(zhǔn)肩關(guān)節(jié)正位、側(cè)位及腋位片，采用盲法由1名有豐富經(jīng)驗(yàn)的高年資放射科醫(yī)師完成。由2名上肢科醫(yī)師分別測量肩峰外側(cè)緣至肩關(guān)節(jié)盂平面的距離和肱骨頭外端外側(cè)緣至肩關(guān)節(jié)盂平面距離，結(jié)果取兩人平均值，且使用圖像均由院內(nèi)圖片存檔及通信系統(tǒng)(picturearchivingandcommunicationsystems,PACS)提供，避免不同設(shè)備和技術(shù)人員導(dǎo)致的測量誤差。

四、統(tǒng)計(jì)學(xué)分析

采用SPSS22.0統(tǒng)計(jì)軟件，患者性別使用獨(dú)立樣本t檢驗(yàn)，Neer二部分、三部分、四部分骨折患者肩關(guān)節(jié)功能、出血量、手術(shù)時(shí)間、骨折愈合時(shí)間、ASES評分及Constant評分采用直線相關(guān)分析。檢驗(yàn)水準(zhǔn)α值取雙側(cè)0.05。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

一、一般結(jié)果

ASES評分：總分P=0.670，疼痛P=0.078，生活功能P=0.010；Constant評分：總分P=0.019，疼痛P=0.083，功能活動(dòng)P=0.453，肩關(guān)節(jié)活動(dòng)度P=0.007，肌力P=0.869；出血量P<0.001；骨折愈合時(shí)間P=0.001；手術(shù)時(shí)間P=0.866。日?；顒?dòng)：前屈上舉P=0.012，外展P=0.010，外旋P=0.038。6例男性平均AI為0.66，11例女性平均AI為0.75，兩者比較P=0.218,見表1。

表1 AI指數(shù)與Multiloc髓內(nèi)釘治療肱骨近端骨折的統(tǒng)計(jì)學(xué)結(jié)果

注：AI為肩峰指數(shù)；ASES為美國肩肘外科協(xié)會(huì)評分

AI較小(<0.68)的患者5例，其中Neer二部分骨折1例，三部分骨折3例，四部分骨折1例。平均年齡55.8歲(43～69歲)，平均AI0.55(0.47～0.66)；術(shù)中出血量平均110ml(100～150ml)；前屈上舉角度平均146°(120°～170°)，外旋角度平均36°(30°～40°)，外展角度平均88°(80°～110°)；術(shù)后ASES評分平均83.8分(80～90分)，Constant評分平均81分(76～91分)；骨折愈合時(shí)間平均1.6個(gè)月(1.5～2個(gè)月)。

AI較大(>0.68)的患者12例，其中Neer二部分骨折7例，三部分骨折4例，四部分骨折1例。平均年齡61.4歲(48～69歲)，平均AI0.78(0.69～0.94)；術(shù)中出血量平均為257.5ml(150～300ml)；前屈上舉角度平均161.6°(120°～180°)，外旋角度平均40°(20°～50°)，外展角度平均106.5°(85°～160°)；術(shù)后ASES評分平均89.7分(80～96分)，Constant評分平均87.3分(79～98分)；骨折愈合時(shí)間平均2.25個(gè)月(1.5～3個(gè)月)。

二、術(shù)后并發(fā)癥

至末次隨訪，17例患者中無醫(yī)源性神經(jīng)、血管損傷，無一例出現(xiàn)切口感染，無內(nèi)固定物松動(dòng)斷裂失效，無肱骨頭壞死發(fā)生。1 例患者出現(xiàn)同側(cè)肘關(guān)節(jié)僵硬活動(dòng)障礙(屈110°，伸50°)，但無肌力減弱、肌肉萎縮或其他神經(jīng)損害表現(xiàn)，考慮與3 個(gè)月未能按時(shí)門診隨訪及康復(fù)治療有關(guān)，Multiloc髓內(nèi)釘固定術(shù)后1年行肘關(guān)節(jié)松解術(shù)，術(shù)后肘關(guān)節(jié)功能得到明顯恢復(fù)(屈130°，伸10°)。AI的大小與患者術(shù)后是否出血并發(fā)癥并無明顯相關(guān)性。

討 論

肱骨近端骨折大部分是閉合性骨折，且絕大多數(shù)穩(wěn)定的輕度或無移位骨折可以采取非手術(shù)治療[10]，然而有15%～64%的肱骨近端骨折是移位型骨折，需要手術(shù)治療。如采取非手術(shù)治療，其并發(fā)癥如骨折畸形愈合、骨折不愈合、肩關(guān)節(jié)僵硬以及創(chuàng)傷后肩關(guān)節(jié)炎等[10-11]。

本組在治療肱骨近端骨折時(shí)選用Multiloc髓內(nèi)釘[4-5]。術(shù)中沙灘椅位，通過三角肌前束與中束之間，劈開三角肌，必要時(shí)分離保護(hù)腋神經(jīng)。通過強(qiáng)生5#線牽拉或帶螺紋克氏針做Joy-stick技術(shù)復(fù)位骨折塊。理想的髓內(nèi)釘進(jìn)針點(diǎn)為：肱骨頭頂端，肱二頭肌腱后外側(cè)，大結(jié)節(jié)和肱骨頭之間的溝內(nèi)側(cè)，岡上肌肌腱止點(diǎn)內(nèi)側(cè)1～1.5cm處。恰當(dāng)?shù)倪M(jìn)針點(diǎn)將決定了復(fù)位的結(jié)果，而不恰當(dāng)?shù)倪M(jìn)針點(diǎn)將直接導(dǎo)致復(fù)位不良[12]。此時(shí)需術(shù)中探查肩袖，若肩袖撕裂，可適當(dāng)沿長破口選擇進(jìn)針；若肩袖完整，可沿岡上肌肌纖維方向作約1cm小切口。導(dǎo)針位置確認(rèn)后，插入組裝Multiloc髓內(nèi)釘，C臂透視再次確認(rèn)髓內(nèi)釘位置。依據(jù)骨折類型，在近端選用3枚以上4.5mm螺釘及數(shù)枚3.5mm釘中釘增加肱骨頭及后內(nèi)側(cè)區(qū)把持力[13-14],根據(jù)需要選擇4mm上升螺釘對肱骨距進(jìn)行支撐[15-16]，遠(yuǎn)端用1或2枚4mm鎖定螺釘固定，以減少髓內(nèi)釘在髓腔內(nèi)擺動(dòng)。最后選用Orthocord線或強(qiáng)生5#線修復(fù)肩袖。此入路會(huì)不可避免損傷肩袖，Park等[17]指出雖然髓內(nèi)釘治療肱骨近端骨折患者術(shù)后可能出現(xiàn)肩關(guān)節(jié)疼痛和活動(dòng)受限，是否與切開肩袖有關(guān)存在爭議，但實(shí)際上是醫(yī)師術(shù)中對肩袖處理不當(dāng)所致。

AI這一概念首先由Nyffeler等[18]提出，它直接反映了肩峰橫向延展度。肩峰向外側(cè)延伸越長，AI越高。測量AI需要一張肩關(guān)節(jié)前后位X線片。具體方法是三條特殊的平行線之間的距離測定。第一條線連接肩胛盂的上皮質(zhì)緣和下皮質(zhì)緣的最邊緣，第二條線平行于第一條線，與肩峰的最邊緣相切；第三條線與此二線平行，與肱骨頭的最邊緣相切(圖1)。

圖1 AI指肩峰外側(cè)緣至肩關(guān)節(jié)盂平面的距離與肱骨頭外端外側(cè)緣至肩關(guān)節(jié)盂平面距離的比值。圖A肩峰覆蓋較大，AI較高；圖B肩峰覆蓋較小，AI較低

有研究表明男女肩峰形態(tài)存在明顯差異[11-20]，在其研究中雖然右肩和左肩差異無統(tǒng)計(jì)學(xué)意義，但發(fā)現(xiàn)女性比男性更容易發(fā)病，原因是女性有更高的肩峰覆蓋率，即AI高，并且AI的大小并不與年齡成正相關(guān)。

據(jù)Rispoli等[7]指出肩袖撕裂的程度與AI成正相關(guān)：肩袖全層撕裂患者的AI為0.73±0.06，而健康對照組AI為0.64±0.06。Hamid等[19]研究證實(shí)：肩袖損傷時(shí)AI為0.69±0.06。Torrens等[11]指出在肩袖損傷病例中AI的平均值為0.69(0.49～0.89)。Zumstein等[21]研究結(jié)果示：肩袖的損傷有些是兩條肌腱的復(fù)合傷(平均AI為0.68，范圍0.54～0.86)，有的是三條肌腱的復(fù)合傷(平均AI為0.75，范圍0.66～0.88)，并且術(shù)后隨訪發(fā)現(xiàn)部分患者出現(xiàn)了肩袖再撕裂。而對比完全康復(fù) (平均AI為0.65)和再撕裂 (平均AI為0.75)的患者，AI差異有統(tǒng)計(jì)學(xué)意義，即平均AI>0.68的患者其手術(shù)時(shí)間要比<0.68的患者較長，且出血量也較多。

Ames等[22]的研究結(jié)果顯示：對比有較大AI與較小AI的患者，前者比后者更易患有2條及以上肩袖撕裂，術(shù)中需要更多的錨釘來修復(fù)肩袖，并且術(shù)后患者滿意度較低。AI較大的患者對術(shù)者來說，是一種技術(shù)性挑戰(zhàn)?；颊咝g(shù)后恢復(fù)不太理想，雖可能與術(shù)者術(shù)中粗糙的縫合技術(shù)有關(guān)，但與AI的大小密切相關(guān)。對于AI較大的患者，術(shù)中為了達(dá)到理想錨釘置入點(diǎn)，需要助手協(xié)助從患者腋下橫向外側(cè)牽拉，人為降低AI，并使手術(shù)視野暴露更充分(圖2)。

注：AI為肩峰指數(shù)；ASES為美國肩肘外科協(xié)會(huì)評分圖3 AI大小與統(tǒng)計(jì)數(shù)據(jù)相關(guān)性。圖A AI與 ASES生活功能評分相關(guān)性；圖B AI與Constant肩關(guān)節(jié)活動(dòng)度相關(guān)性；圖C AI與術(shù)中出血量相關(guān)性;圖D AI與肩關(guān)節(jié)外展角度相關(guān)性；圖E AI與肩關(guān)節(jié)外旋角度相關(guān)性；圖F AI與肩關(guān)節(jié)前屈上舉角度相關(guān)性

圖2 AI較大的患者為取得理想進(jìn)針點(diǎn)，需人為牽拉肱骨近端。圖A較大AI的患者，對于Multiloc進(jìn)針點(diǎn)選擇上非常困難；圖B需要從腋窩處橫向牽拉肱骨近端，人為減少AI，取得理想進(jìn)針點(diǎn)

本研究中，在AI與肱骨近端骨折運(yùn)用Multiloc髓內(nèi)釘治療時(shí)，筆者發(fā)現(xiàn)所有參與本研究的患者中，性別與肩峰大小差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。AI較大的患者其術(shù)中出血量較AI較小的患者多，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。雖然本研究中手術(shù)時(shí)間與AI在治療肱骨近端骨折時(shí)，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，但對于較大的AI患者，需要橫向牽拉肱骨近端，以充分暴露髓內(nèi)釘進(jìn)針點(diǎn)。且術(shù)前懷疑患者合并肩袖損傷，也需充分顯露術(shù)區(qū)才能發(fā)現(xiàn)并及時(shí)修補(bǔ)肩袖，這點(diǎn)對于患者預(yù)后相當(dāng)重要(圖2)。根據(jù)患者術(shù)后VAS、ASES、Constant功能評分顯示，術(shù)后疼痛與AI大小差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，但在患者術(shù)后功能活動(dòng)，如前屈上舉、外展及外旋，AI越大，術(shù)后功能活動(dòng)相對較好；相反，AI較小，術(shù)后功能活動(dòng)，如前屈上舉、外展及外旋反而較差(P<0.05)，見圖3。

結(jié) 論

肱骨近端骨折運(yùn)用髓內(nèi)釘治療時(shí)，AI大小與性別、年齡、手術(shù)時(shí)間無明顯相關(guān)性。AI越小，術(shù)中出血量越少，骨折愈合時(shí)間越短；AI越大，術(shù)中出血量相對較多，骨折愈合時(shí)間稍長。AI較大的患者，術(shù)后ASES評分及Constant評分較高，術(shù)后功能活動(dòng)(前屈上舉、外展及外旋)較好；相反，AI較小的患者，術(shù)后ASES評分及Constant評分相對較低，術(shù)后功能活動(dòng)(前屈上舉、外展及外旋)相對較差。在運(yùn)用Multiloc髓內(nèi)釘治療肱骨近端骨折時(shí)，暫未發(fā)現(xiàn)與手術(shù)相關(guān)并發(fā)癥，且AI的大小與術(shù)后并發(fā)癥的發(fā)生無明顯相關(guān)性。

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(本文編輯：胡桂英)

鄒義源,向明,李一平，等.肩峰指數(shù)與運(yùn)用Multiloc髓內(nèi)釘治療肱骨近端骨折的臨床相關(guān)性研究[J/CD]. 中華肩肘外科電子雜志,2016,4(4):214-220.

CorrelationstudiesbetweenacromionindexandMultilocintramedullarynailinthetreatmentofproximalhumeralfracture

ZouYiyuan1,XiangMing2,LiYiping2,YangGuoyong2,ChenHang2,HuXiaochuan2.

1SouthwestMedicalUniversity,Luzhou646000,China;2DepartmentofUpperExtremityTraumatology,SichuanProvincialOrthopaedicHospital,Chengdu610041,China

XiangMing,Email:josceph_xm@sina.com

Background The proximal humeral fracture is a common clinical disease in the department of orthopedics, accounting for 4%-5% of all the fractures. More than 70% of the proximal humeral fractures occur in the elderly patients of over 60 years, and the number will increase year by year with the trend of population aging in China. The majority of proximal humeral fractures obtain good clinical prognosis through conservative treatment, but there are still some complications. The surgical treatment methods include close or open reduction and internal fixation and shoulder joint arthroplasty. The internal fixators are numerous, such as Multiloc intramedullary nail. During the intramedullary nailing treatment, Rispoli,etc. discovered the value of acromion index (AI) had an effect on the surgery, but no domestic literatures are reported at present. So this study assumes that the operation time, intraoperative blood loss, fracture healing time, postoperative functional scores and functional rehabilitation are different as the AI varies during the treatment of proximal humeral fractures with Multiloc intramedullary nail. In this study, seventeen patients of proximal humeral fractures were treated with Multiloc intramedullary nails from February 2014 to June 2015 in Sichuan provincial orthopedic hospital and the operation time, blood loss, fracture healing time, postoperative functional rehabilitation (anteflexion and uplift, internal and external rotation) and functional scores, etc. were recorded. All the clinical data were retrospectively analyzed to assess the correlation between AI and Multiloc intramedullary nailing in the treatment of proximal humeral fractures.Methods (1)General information.From February 2014 to June 2015, seventeen patients of proximal humeral fractures, including 6 males and 11 females were treated with Multiloc intramedullary nails and followed up for 1 year. The ages ranged from 48 to 67 years with 61.4 years on average. The AI ranged from 0.69 to 0.94 with 0.78 on average. The mean AI were 0.66 in male patients and 0.75 in females. According to Neer classification, there were 8 cases (47%) of 2-part fracture, 7 cases (41%) of 3-part fracture and 2 cases (12%) of 4-part fracture, including olecranon fracture, distal radius fracture, rotator cuff tear and axillary nerve injury. 8 cases (47%) were injured in the dominant sides and 9 cases (53%) were non-dominant sides. The causes were slips during walking in 9 cases (53%), falls from bicycles in 5 cases (29.4%) and traffic accidents in 3 cases (17.6%) and all the injuries were closed fractures. This research was approved by the hospital ethics committee and all the subjects signed the informed consents.(2)Follow-ups and evaluation index.All the operations were performed by physicians of the same group, and the follow-ups and assessments were conducted by another 2 senior orthopedic clinicians in the outpatient department. The postoperative routine visits were in the 1st, 2nd, 4th, 6th, 8th and 12th months and the X-ray radiographs were taken at the same time. The shoulder activity scale, rating scale of the American shoulder and elbow surgeons (AESE) and Constant scoring system were applied in the evaluation of shoulder function. ASES is made by the association of American shoulder and elbow surgeons, including pain (50%) and life function (50%). The total score is 100 points and the higher score indicates the better function. The Constant scoring system is composed of pain (15 points), muscle strength (25 points), functional activity (20 points) and range of motion of shoulder joint (40 points),and the total score is 100 points. The higher score reveals the better shoulder function as well. (3)AI measurement Standard.The X-ray radiographs of anteroposterior view, lateral view and axillary view were taken in all the patients by 1 senior and experienced radiologist with blind method. The respective distances from the lateral margin of acromion and the outer end of humeral head to the glenoid plane were measured by two physicians and the results were the mean values. All the radiographic images were provided by picture archiving and communication systems (PACS) in the hospital to avoid the measurement bias caused by different equipments and technical personnel. (4)Statistical analysis.The SPSS 22.0 statistical software was adopted and the independent samplesttestwasusedintheanalysisofpatientgenders.Thelinearcorrelationanalysiswasappliedinshoulderjointfunction,bloodloss,operationtime,fracturehealingtime,ASESscoresandConstantscores.Theαvalueofinspectionlevelwas0.05ondoublesidesandthedifferencewasconsideredstatisticallysignificantwithP<0.05.Results(1)Generalresults.ASESscore:totalscoreP=0.670,painP=0.078,lifefunctionP=0.010;Constantscore:totalscoreP=0.019,painP=0.083,functionalactivityP=0.453，shoulderactivityscaleP=0.007,musclestrengthP=0.869,bloodlossP<0.001,fracturehealingtimeP=0.001,operativetimeP=0.866.Dailylife:anteflexionandupliftP=0.012,abductionP=0.010,externalrotationP=0.038.ThemeanAIwas0.66in6malesand0.75in11femaleswiththecomparisonP=0.218.FivepatientshadsmallerAI(<0.68),including1caseof2-partfracture, 3casesof3-partfractureand1caseof4-partfracture.Themeanagewas55.8years(43-69years)andthemeanAIwas0.55 (0.47-0.66);Themeanintraoperativebloodlosswas110ml(100-150ml);Themeandegreeofanteflexionandupliftwas146° (120°-170°)with36°ofabductiononaverage(30°-40°)and88°ofexternalrotationonaverage(80°-110°);ThemeanASESscorewas83.8points(80-90points)andthemeanConstantscorewas81points(76-91points);Themeanfracturehealingtimewas1.6months(1.5-2months).TwelvepatientshadlargerAI(>0.68),including7casesof2-partfracture, 4casesof3-partfractureand1caseof4-partfracture.Themeanagewas61.4years(48-69years)andthemeanAIwas0.78 (0.69-0.94);Themeanintraoperativebloodlosswas257.5ml(150-300ml);Themeandegreeofanteflexionandupliftwas161.6° (120°-180°)with40°ofabductiononaverage(20°-50°)and106.5°ofexternalrotationonaverage(85°-160°);ThemeanASESscorewas89.7points(80-96points)andthemeanConstantscorewas87.3points(79-98points);themeanfracturehealingtimewas2.25months(1.5-3months).(2)Postoperativecomplications.Inthelastfollow-ups,noiatrogenicneurovascularinjury,woundinfection,internalfixationfailureorhumeralheadnecrosiswerefoundin17patients.Onepatienthadipsilateralelbowjointstiffness(110°offlexionand50°ofextension)butnomusclestrengthloss,muscleatrophyorothernervedamages,whichwasconsideredtoberelevantwiththe3monthsabsenceofoutpatientfollow-ups.Thereleasesurgeryofelbowjointwasperformed1yearafterMultilocintramedullarynailfixationandthefunctionalrehabilitationwasacquiredafteroperation(130°offlexionand10°ofextension).TherewasnoobviouscorrelationbetweenAIandpostoperativebleedingcomplications.ConclusionsNoobviouscorrelationwasfoundbetweentheAIandthegenders,agesandoperationtimeinthetreatmentofproximalhumeralfractureswithintramedullarynails.ThesmallerAIindicatedlessintraoperativebloodlossandfracturehealingtime.Onthecontrary,thelargerAIindicatedmoreintraoperativebloodlossandfracturehealingtime.ThepatientswithlargerAIobtainedhigherASESandConstantscoresandbetterpostoperativefunction(anteflexion,abductionandexternalrotation).OtherwisethepatientwithsmallerAIacquiredlessASESandConstantscoresandrelativelypoorpostoperativefunction.NooperativecomplicationsoccurredinthetreatmentofproximalfractureswithMultilocintramedullarynailandtheAIhadnosignificantcorrelationwiththepostoperativecomplications.

Acromionindex;Proximalhumeralfractures;Intramedullarynail

10.3877/cma.j.issn.2095-5790.2016.04.005

四川省中醫(yī)院管理局課題(2016C040)

646000瀘州，西南醫(yī)科大學(xué)1；610041成都，四川省骨科醫(yī)院上肢科2

向明，Email：josceph_xm@sina.com

2016-09-29)