Atilla Sancar PARMAKSIZOĞLU, SAMİ SÖKÜCÜ, Ufuk ÖZKAYA, Yavuz KABUKÇUOĞLU, MURAT GÜL

Proksimal humerus üç ve dört parçalı kırıklarının kilitli plakla tedavisi

Amaç: Üç ve dört parçalı proksimal humerus kırığı nedeniyle açık redüksiyonla kilitli plak tespiti uygulanan hastalarda fonksiyonel sonuçlar değerlendirildi. Çalışma planı: Proksimal humerus parçalı kırık nedeniyle açık redüksiyon ve PHILOS kilitli plakla tespit uygulanan 32 ardışık hasta (22 kadın, 10 erkek; ort. yaş 63; dağılım 29-82) geriye dönük olarak değerlendirildi. Neer sınıflamasına göre, 12 hastada (ort. yaş 56) üç parçalı kırık, 19 hastada (ort. yaş 67) dört parçalı kırık, bir hastada da dört parçalı kırıklı çıkık vardı. Hastaların 10’u 60 yaşın altında, 22’si 60 yaş veya üzerinde idi. Ameliyat öncesinde tüm hastalar düz grafilerle incelendi; eklem yüzeyi hakkında yeterli bilgi elde edilemeyen 14 hastada bilgisayarlı tomografiye başvuruldu. Ameliyatta standart deltopektoral insizyon kullanılarak, kırık parçaların damarlanmasının daha fazla bozulmasını önlemek için minimal yumuşak doku diseksiyonu yapıldı. On iki hastada ameliyat sırasında redüksiyona yardımcı olmak için serklaj teli kullanıldı. Medialden yeterli kortikal temasın sağlanamadığı olgularda oblik bir vida ile medial destek sağlandı. Ameliyatta kemik grefti kullanılmadı. Ameliyat sonrası ikinci günde yardımlı aktif ve pasif hareketlere başlandı. Ameliyat sonrası ikinci haftada 90 dereceye kadar aktif omuz abdüksiyonuna izin verildi. Takipler sırasında düz radyografilerde implant yetmezliği, redüksiyon kaybı, yanlış kaynama ve kırık kaynaması araştırıldı. Avasküler nekroz gelişimi, tüm hastalarda 12 aydan sonra çekilen kemik sintigrafisi ile kontrol edildi. Son kontrollerde hastalar Constant skoru ile değerlendirildi. Ortalama takip süresi 25 ay (dağılım 18-36 ay) idi. Sonuçlar: Otuz iki hastanın 29’unda (%90.6) tam anatomik veya anatomiğe yakın redüksiyon sağlandı. İki hastada ameliyat sırasında kırıklar varus pozisyonunda tespit edildi, bir hastada ameliyat sonrası erken dönemde büyük tüberkülün proksimale yer değiştirmiş olduğu görüldü. Tüm kırıklar ortalama üç ayda (dağılım 2-5 ay) kaynadı. Ortalama Constant skoru 79.5 (dağılım 50-100) bulundu. On üç hastada (%40.6) mükemmel, dokuz hastada (%28.1) iyi, sekiz hastada (%25) orta, iki hastada (%6.3) kötü sonuç elde edildi. Ortalama Constant skoru üç ve dört parçalı kırıklarda sırasıyla 88.3 (dağılım 69-100) ve 74.2 (dağılım 50-100), 60 yaş altı ve üstündeki hastalarda sırasıyla 88.3 (dağılım 71-100) ve 75.5 (dağılım 50-100) idi. Constant skoru kırık parça sayısına ve yaş grubuna göre anlamlı farklılık gösterdi (p=0.03). Avasküler nekroz iki hastada görüldü. Hiçbir hastada redüksiyon kaybı, implant yetmezliği, derin enfeksiyon, nörovasküler yaralanma gözlenmedi, implantın çıkarılması gerekmedi. Çıkarımlar: Proksimal humerus üç-dört parçalı kırıklarının cerrahi tedavisinde, minimal yu- muşak doku diseksiyonu ile humerus başının kanlanması korunarak kilitli plak uygulaması ve erken hareket verilmesi potansiyel komplikasyonların azaltılmasında etkili olmuştur. Fonksiyo- nel sonuçların başarısı kırık parça sayısı ve yaş faktöründen etkilenmektedir.

Anahtar Kelimeler:

Bariatrik cerrahi

Locking plate fixation of three- and four-part proximal humeral fractures

Objectives: We evaluated the functional results of open reduction and internal fxation with a locking plate in patients with three- or four-part fractures of the proximal humerus. Methods: We reviewed 32 consecutive patients (22 women, 10 men; mean age 63 years; range 29 to 82 years) who were treated with open reduction and internal fxation using the PHILOS locking plate for comminuted proximal humeral fractures. According to the Neer classifcation, 12 patients (mean age 56 years) had three-part fractures, 19 patients (mean age 67 years) had four-part fractures, and one patient had a four-part fracture dislocation. Ten patients were in the age group of <60 years, 22 patients were in the age group of 60≥years. All the patients were evaluated with plain radiographs preoperatively; in addition, computed tomography was used in 14 patients in whom articular surface and tuberculum displacement could not be assessed adequately. The operation was performed through a standard deltopectoral approach, and minimal soft tissue dissection was used aiming not to impair vascularization of the fracture fragments. A cerclage wire was used to help reduction in 12 patients. An oblique screw was inserted to stabilize the medial colon in cases in which medial cortical contact was insuffcient. Bone grafting was not used in any of the patients. Active-assisted and passive exercises of the shoulder were initiated on the second postoperative day. Active abduction to 90 degrees was allowed two weeks after surgery. During follow-up, implant failure, loss of reduction, malunion, and bone healing were assessed on plain radiographs. Bone scintigraphy was performed after 12 postop- erative months for the detection of avascular necrosis. The results were assessed using the Constant shoulder score. The mean follow-up period was 25 months (range 18 to 36 months). Results: An anatomic or near-anatomic reduction was obtained in 29 patients (90.6%). In two patients, the fractures were fxed in a varus position, and in one patient, the greater tubercle was displaced proximally. All fractures united in a mean of three months (range 2 to 5 months). The mean Constant score of the patients was 79.5 (range 50 to 100). The results were excellent in 13 patients (40.6%), good in nine patients (28.1%), fair in eight patients (25%), and poor in two pa- tients (6.3%). The mean Constant scores were 88.3 (range 69 to 100) and 74.2 (range 50 to 100) in three-part and four-part fractures, and 88.3 (range 71 to 100) and 75.5 (range 50 to 100) in the age groups of <60 years and ≥60 years, respectively. Constant scores showed signifcant differences with respect to the number of comminution and age groups (p=0.03). Avascular necrosis was observed in two patients. None of the patients had reduction loss, implant failure, deep infection, or neurovascular injury, and none required implant removal. Conclusion: Preservation of humeral head vascularity through minimal soft tissue dissection, fxation with a locking plate, and early postoperative motion were effective in decreasing potential complications following surgical treatment of three- and four-part proximal humeral fractures. The degree of fracture comminution and age of the patients affect functional results signifcantly.

Keywords:

Bariatric Surgery,

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