MIPPO技术治疗有楔形骨块的锁骨干骨折

杨明 司徒炫明 张殿英 王天兵 付中国 张培训 陈建海 姜保国

·论著·

MIPPO技术治疗有楔形骨块的锁骨干骨折

杨明 司徒炫明 张殿英 王天兵 付中国 张培训 陈建海 姜保国

目的 探讨MIPPO技术治疗有楔形骨块的锁骨干骨折的手术方法及疗效。方法 自2011年4月至2014年4月，应用闭合复位、髓内克氏针临时固定并行MIPPO技术，治疗有楔形骨块的锁骨干骨折26例患者为试验组(MIPPO组)。术后定期复查X线片，观察骨折愈合情况，并用Constant评分评估患者的肩关节功能。同时以2007年3月至2011年11月收治的传统切开复位板钉固定的29例患者为对照组(ORIF组),进行回顾性随访研究,比较两组的疗效和并发症。结果 经过平均15个月的随访，MIPPO组无1例骨折不愈合，ORIF组有1例骨折不愈合并接骨板失效，两组之间失效率差异无统计学意义。MIPPO组在手术时间、出血量方面优于ORIF组，差异有统计学意义。在骨折愈合时间以及Constant评分方面,两组间差异无统计学意义。MIPPO组有2例患者因接骨板隆起而坚决要求二次手术取出内固定物。结论MIPPO技术治疗有楔形骨块锁骨干骨折，创伤小，可减少手术时间和出血量，提高愈合几率。

克氏针；锁骨干；螺钉钢板固定术

对于有楔形骨块的锁骨中段骨折，保守治疗不愈合率高达15%[1]，近年来以手术治疗为主。接骨板固定仍是最主流的内固定方式[2]，也有少数学者提倡各种髓内固定[3]。在传统的板钉固定术中，尽可能对游离楔形骨折块采用拉力螺钉固定是原则之一。我们曾改良传统技术，采用髓内克氏针临时固定并桥接钢板固定，以及缝线捆绑骨折块，获得良好疗效[4]，但发现切开复位固定，即使只对骨折块进行缝线捆绑，也因长切口增加了手术创伤。我们在此基础上进一步改良，采用对游离骨块进行闭合复位三切口(minimalinvasivepercutaneousplateosteosynthesis，MIPPO)技术，治疗了26例自2011年4月至2014年4月收治的有楔形骨块锁骨干骨折患者，并以2007年3月至2011年11月收治且随访资料完整的传统切开复位内固定(openreductionandinternalfixation,ORIF)29例患者为对照，进行了回顾性随访研究。

资 料 与 方 法

一、一般资料

所有病例来自我科2007年3月至2014年4月收治的病例，其中采用MIPPO技术固定的患者26例为试验组(MIPPO组)，采用传统切开复位，骨折块拉力螺钉固定，并中和或加压钢板固定的患者29例为对照组(ORIF组)。两组患者的受伤机制均为摔伤居多，两组各有2例高处坠落伤，各有1例合并其余部位骨折。骨折分型按照Robinson′s分类[5]，ⅡB1型骨折定义为锁骨中段，有移位，断端有1个楔形骨块，ⅡB2型定义为断端有2个或2个以上的游离骨块。两组患者的性别、年龄、优势侧、手术距受伤时间及骨折类型等资料见表1。

二、手术方式

1.MIPPO组：采用能够获得满意肌松的全身麻醉，沙滩椅半坐卧位，消毒范围包括患肢腕部以上，保证术中可以屈肘位被动抬高或后伸上臂。首先触摸明显向上翘起的锁骨近端主骨折的尖端，然后行2cm切口，显露近端主骨折块的尖端，不剥离骨膜，然后沿其后上方皮质经过髓腔，向近端主骨折块髓腔内打入2mm或2.5mm的双尖头髓内克氏针，直至此克氏针的尾端恰好没入近端髓腔内，克氏针近侧尖端则由锁骨近端前面穿出皮肤。然后由助手将患肢屈肘位上抬并向外牵引上臂，类似保守治疗时采用的手法闭合复位的操作，使远端与近端的主骨折块复位。此时术者可用手触摸近端主骨折块表面，感觉到远侧主骨折块的后上方皮质接触近端后上方皮质后，将髓内克氏针由近端向远端打入髓腔，直至穿出锁骨后缘，并位于肩峰后角表面。行术中透视，证实术前游离骨块已经复位，且主骨折块有接触。然后将10孔解剖型锁定锁骨接骨板(美国通用公司)经中间切口沿锁骨表面向近端经皮插入一半，从皮肤表面触摸到接骨板近侧端，在此上行2cm切口，显露接骨板近端。然后将接骨板完全向近端插入，直至接骨板远端位于骨折上方切口处，然后再将接骨板远端沿锁骨表面向远端插入，使骨折处恰好位于接骨板中段。然后在锁骨远端触摸到接骨板远端，再于其表面行2cm切口，显露接骨板远端。以钻头或测深尺等经接骨板的最近端和最远端的2个螺钉孔感触锁骨上表面，证实接骨板放置前后位置合适，然后由外围向中间先打入最远端和最近端的各1枚锁定螺钉，然后依次向中间打入第2枚锁钉，如恰好碰到位于髓内的克氏针，可逐步退出克氏针，打入剩余锁钉(图1)。远、近端各打入3枚双皮质锁定螺钉固定即可。透视下证实位置满意，关闭切口，不放引流管。

表1 两组患者临床资料比较

注：ORIF为传统切开复位内固定术；MIPPO为闭合复位三切口技术

2.ORIF组：麻醉采用颈丛加臂丛或者全身麻醉。体位同MIPPO组，取锁骨上表面切口，对较大游离骨块尽可能和主骨折块间采用拉力螺钉固定，将带游离骨块锁骨干骨折变为简单骨折，然后在直视下钳夹复位，并以7～9孔直重建接骨板预弯后置入锁骨上表面固定，两端各打入3枚螺钉。常规留置引流管。

三、术后康复和随访

术后第2天开始肩关节的被动活动，以外旋和外展为主，外展不超过90°。上、下午及晚上共3组，每组10次，其余时间悬吊患肢保护。4周以后可以去掉悬吊保护，并进行简单日常生活，但仍限制患肢提重物或主动外展过高。12周后可恢复完全的工作，重体力劳动者则需要X线片证实骨折愈合情况。术后4、8、12、16周定期摄X线片。随访时采用Constant评分评估患者肩关节功能[6]，并记录并发症情况。

四、统计学分析

结 果

经过平均15(6～31)个月的随访，MIPPO组所有骨折均获得骨性愈合(典型病例见图1)，而ORIF组1例出现骨折不愈合，且致接骨板断裂失效，并接受再次手术治疗。两组之间失效率没有显著差异。MIPPO组患者的平均手术时间、术中出血量和骨折愈合时间见表2。在手术时间和出血量方面，MIPPO组明显优于ORIF组，MIPPO组平均骨折愈合时间差异无统计学意义，Constant评分两组间差异无统计学意义。两组均有部分患者因为年轻而遵医嘱采用二次手术取出了内固定，MIPPO组有2例体形偏瘦的患者出现明显的皮肤隆起，强烈要求二次手术取出内植物。

图1 27岁男性患者，带有楔形骨块的锁骨干骨折，Robinson′s分型IIB1型，行闭合复位、术中克氏针临时固定、MIPPO技术，术后恢复良好。图A左肩正位片提示左侧锁骨干骨折，断端有1枚翻转的大游离骨块，Robinson′s分型IIB1型;图B经锁骨近端主骨折块髓腔向近端插入克氏针，穿出近端皮下，闭合复位后经锁骨远端髓腔从锁骨远端后面穿出;图C术中透视证实主骨折块和游离骨块的闭合复位满意，髓内克氏针维持复位;图D放置解剖型接骨板，先于最远端和最近端各打入1枚锁定螺钉，髓内克氏针不影响最远端和最近端的各1枚螺钉置入;图E退出克氏针，打入剩余锁定螺钉，透视位置满意;图F术后复查锁骨正位片，证实主骨折块复位满意并有接触，游离骨块获得满意功能复位;图G术后16周锁骨正位片见骨折愈合良好;图H术后16周，患者切口瘢痕情况;图I术后16周，左肩有满意的上举功能;图J术后16周，左肩有满意的外旋功能

组别例数手术时间(x-±s，min)手术出血量(x-±s，ml)骨折愈合时间(x-±s，周)Constant评分(x-±s，分)内固定物取出例数(%)不愈合或失效例数(%)ORIF组2983．3±13．2043．8±13．4714．9±3．1788．8±4．439(31．03)1(3．45)MIPPO组2673．5±7．9831．9±9．3913．7±2．0490．8±5．7713(50．00)0(0)t值3．3603．8211．698-1．3552．0550．913P值0．0020．0000．1030．1430．1520．339

注：ORIF为传统切开复位内固定术；MIPPO为闭合复位三切口技术

讨 论

多中心的随机对照前瞻性临床研究[1]和Meta分析均证实[7]，对移位且有游离骨块的锁骨干骨折进行手术治疗会获得更好疗效。究竟是板钉固定还是髓内固定更好，一直存有争议[8-10]。一些回顾性研究[11]或Meta分析[7]证实两者疗效没有绝对区别，只是各具特点。目前板钉固定仍是主流术式，其固定牢固，可早期活动[2]；缺点是创伤大，内固定物刺激症状明显，手术瘢痕重，容易破坏骨折块的血运而影响骨折愈合。近几年接骨板趋向于解剖设计[1，12]，改善了内植物刺激症状。也有学者将接骨板置于锁骨前、下缘而不是上缘，虽然生物力学实验证实可以获得满意的固定[13]，但仅少数医师愿意尝试这种方法[14-15]。

传统ORIF术中，要求对游离骨折块采用拉力螺钉固定，这增加手术时间和难度，也影响游离骨块血运。由于锁骨中段的肌肉附着并非牢固的腱性附着，而是肌肉直接疏松地附着在骨膜上，极易因拉力螺钉的操作而破坏游离骨块血供，容易造成延迟愈合或不愈合。另外虽然接骨板的工作长度越长越好，但在切开手术中采用长板必然增加切口长度和手术创伤，很多医生会因此放弃长接骨板，而采用短接骨板并紧贴骨折端打入螺钉，这对于有游离骨块的锁骨干骨折容易造成应力集中，致接骨板失效。另外，传统的直重建板越长越不贴服，术中需要反复预弯，也增加了疲劳断裂可能。

我们前期报道了切开复位、术中克氏针临时固定并桥接钢板固定技术，取得良好疗效[4]。但其切口长、创伤大，尽管是采用缝线而不是拉力螺钉固定游离骨块，但毕竟是直视下操作，仍然会损伤骨膜等软组织。因此，我们进行了再改良，采用完全的闭合复位技术复位楔形骨块，并将一个长切口改为三个2cm的小切口。改良的目的是不对游离骨块进行任何直视下操作而进一步保护其血运，通过MIPPO技术进一步减小手术创伤。该技术有4个主要特点：(1)术中上抬并向外牵引患肢上臂，通过间接复位主骨折块和游离骨块。由于保留了完整的骨膜和软组织袖套，闭合复位都会使术前翻转的游离骨块获得功能复位，对游离骨块不强求解剖复位，只要对位对线满意就行。这可保护血运，增加骨折愈合几率。(2)应用髓内克氏针临时固定主骨折块，强调主骨折块之间有接触，避免明显的分离移位。中间切口只是利于穿针，而不要经此小切口进行任何直视下骨块的复位，但可以经此切口触摸主骨折块的后上方皮质，以证实主骨折块闭合复位满意并互相接触。保证主骨折块接触目的是利于骨折愈合。(3)采用长板固定，以增加其工作长度，减少因应力集中所致骨折不愈合和接骨板断裂的风险。我们常规选择解剖型接骨板中最长的10孔接骨板。固定时先在最远端和最近端各打入1枚锁定螺钉固定接骨板，然后在逐渐退出克氏针的过程中打入剩余锁钉。前期经验证实，髓内克氏针不影响接骨板最远端的1枚螺钉固定，偶尔会影响最近端的1枚螺钉固定。本组就有2例患者在进行近端第1枚螺钉的钻孔时，即遇到髓内克氏针的阻挡，此时技巧是先打入1枚短的单皮质锁钉，然后将克氏针逐渐向外退出，打入其他螺钉后，最后将该单皮质螺钉换成双皮质螺钉。(4)螺钉由外周向中间置入，在两侧各打入3枚锁钉后，剩余钉孔不再置钉，以免应力集中。当然MIPPO技术也有其缺点：(1)个别肥胖患者的三个切口加起来的长度并不小于单个长切口。(2)锁骨本身变异大，钢板长度增加后不完全贴服，致术后皮肤隆起。MIPPO组病例全部采用锁钉固定，并不要求接骨板和锁骨完全贴服，这使本组病例中有2例患者因内植物致皮肤隆起而坚决要求二次手术取出内固定物。(3)其他学者采用MIPPO技术治疗锁骨干骨折时，由于复位质量不佳[16]，致使骨折愈合时间较长。我们通过中间小切口的髓内克氏针临时固定，来维持满意的闭合复位和强调主骨折块接触，改善了MIPPO技术中复位欠佳、难以维持、需要多次透视的缺点。(4)对于罕见的两端主骨折块复位后无接触的多段锁骨干骨折病例，本技术的应用尚无经验。(5)闭合复位需要良好肌松，因此常需全身麻醉。

总之，本研究证实对于带游离骨块的锁骨干中段骨折，完全可以通过闭合复位获得满意的游离骨块功能复位。与传统对骨折块进行拉力螺钉的坚强内固定技术比较，MIPPO技术操作简单、创伤小、疗效满意。这说明在进行有楔形骨块骨折固定时，不必追求游离骨块的解剖复位和骨折块间的坚强拉力螺钉固定。当然，本研究也存在缺点，如病例数相对少，随访时间短，属于回顾性研究，不同术者参与了手术和对术后疗效的评估可能导致主观偏见等。后期将进一步积累病例，总结经验。

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杨明，司徒炫明，张殿英，等.MIPPO技术治疗有楔形骨块的锁骨干骨折[J/CD]. 中华肩肘外科电子杂志,2016,4(1):41-47.

ApplyingMIPPOtechniquetotreatclavicleshaftfractureswithwedgefracturefragment

YangMing,SituXuanming,ZhangDianying,WangTianbing,FuZhongguo,ZhangPeixun,ChenJianhai,JiangBaoguo.

DepartmentofTraumatologyandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

Correspondingauthor：JiangBaoguo，Email:jiangbaoguo@vip.sina.com

Background Because the nonunion rate of conservative treatment was up to 15%, midshaft clavicle fractures with wedge-shaped fragments had been mainly treated with operation in recent years. Plate fixation was still one of the mainstream internal fixation methods, although a few scholars advocated various intramedullary fixations.For conventional plate and screw fixation techniques, one of the principles was to fix the free wedge-shaped fragments with lag screws as far as possible. We had ever improved the conventional techniques by intramedullary K-wire assistance in reduction, binding fragments with suture, and bridging plate fixation, which obtained good effects. But we found that the open reduction and bridging plate fixation increased the operation trauma because of the long incisions. We had made further improvement on this basis. From April 2011 to April 2014, 26 patients of midshaft clavicular fracture with wedge-shaped fragments were treated by close reduction and MIPPO (minimal invasive percutaneous plate osteosynthesis) technique with three incisions. We performed this retrospective study to explore the operation methods and treatment effects of the midshaft clavicular fractures with wedge-shaped fragments using MIPPO technique. A group of 29 patients treated by conventional open reduction and internal fixation techniques, from March 2007 to November 2011, were also performed study as control group with complete follow-up data.Methods (1)General information: All the cases were selected from the patients who were treated in our department from March 2007 to April 2014. Among them, 26 patients were treated with three-incision MIPPO bridging technique, and 29 patients were treated with conventional open reduction, lag screw fixation for fragments and neutralization or compression plate fixation. The mechanisms of injury were mainly fall damage. The two groups respectively had 2 cases of falling injury from height and 1 case with multiple fractures. According to Robinson classification, the fracture types were classified as follows: II B1 type was defined as the midshaft clavicular fracture with displacement and 1 wedged-shape fragment in the fracture site; IIB2 type was defined as the fracture with 2 or more free fragments in the facture site. The gender, age, dominant side, time from injury to operation and fracture type can be seen in table 1.(2)Operation methods:MIPPO group: Patients were on beach chair position under general anesthesia which had good muscular relaxation. The posterolateral side of the affected shoulder, upper arm and forearm were disinfected to guarantee that the surgeon can adequately move the shoulder during operation. The upward tilt tip of the proximal clavicular main fragment was obviously be palpated. A 2 cm incision was applied to expose the tip of the proximal fragments without periosteal dissection. A double-tip intramedullary K-wire with a diameter of 2 mm or 2.5 mm was inserted retrogradely into the medullary cavity of the proximal main fragment till the end of the K-wire was at the same level to the tip of the proximal fragment. The proximal tip of the K-wire pierced out of the skin in front of the proximal clavicle. The affected upper arm of the patient was elevated upward and tracted laterally by an assistant doctor in a way similar to the manipulative reduction to reduce the main fragment. At this point the operator could feel that the posterosuperior cortexes of both the distal and proximal main fragments were connected with palpation. Once the posterosuperior clavicular cortexes were matched, the intramedullary K-wire was inserted into the distal medullary cavity from the proximal medullary cavity till it pierced out of the clavicular posterior edge and was located at the posterior corner of acromion. Intraoperative fluoroscopy was conducted to confirm the reduction of the free fragments and the connection of the main fragments. The 10-hole anatomical locking plate (GE medical, US) was inserted percutaneously along the surface of the clavicle towards the proximal end through the middle incision. The proximal end of the plate was touched from the surface of the skin. A 2 cm incision was made on top of that to expose the proximal end of the plate. The plate was completely inserted to the proximal end till its distal end was located at the incision above the fracture site. Then the plate was moved towards the distal side along the surface of the clavicle until the fracture site was located right in the middle of the plate. The plate was touched at the distal end and then exposed with a 2 cm incision. After the plate was confirmed to be placed at the appropriate position, one locking screw was respectively driven in at both ends. Then other locking screws were inserted from lateral to middle at each of the distal and proximal ends. If the screw was obstructed, then the K-wire was pulled out gradually and the remaining screws were driven in. Three bicortical screws were inserted at each of the distal and proximal ends for fixation. The position of internal fixation was confirmed satisfactory under fluoroscopy. The incision was closed without the drainage tube.Conventional ORIF group：Cervical plexus block combined with brachial plexus block or general anesthesia was applied. The patient position was the same as that of the MIPPO group. The incision of clavicle surface was adopted to first expose the fracture site. The lag screw fixation was used between the larger free fragments and the main fragments to convert the clavicular shaft fracture with free fragments into simple fracture and then reduce it using Kocher clamp. The straight plate with 7-9 holes was fixed on the surface of clavicle after reduction and 3 screws were inserted respectively on each side.(3)Post-operative rehabilitation and follow-ups: The passive activities of the shoulder joint, mainly including external rotation and abduction, were initiated at the second day after surgery. The abduction angle is not more than 90°. Three sets of exercises respectively distributed in the morning, afternoon and evening were carried out every day with 10 times in each set while the affected limb was put in a sling for protection during the rest of the time. After 4 weeks, the sling was removed and the shoulder was allowed for simple daily life use, but the affected limb was limited to lift heavy objects and hyperabduct. 12 weeks later, the affected limb was restored for complete work. The fracture healing of heavy manual workers should be confirmed by fluoroscopy. The X-ray examinations were performed in the 4th, 8th, 12th, and 16th week. During follow-ups Constant Score System was applied to assess their shoulder functions and the complications were recorded.(4) Statistical methods: SPSS 19.0 software was used. The measurement data were indicated as means ± standard deviations.χ2testandFisher′sexactprobabilitywereperformedinthecomparisonofthemeasurementdatabetweentwogroups.Ifthemeasurementdataofthetwogroupsmetthenormaldistribution,thentheIndependent-Samplettestwasusedforthecomparison;otherwise,theWilcoxonranksumtestwasadopted;apvaluelessthan0.05wasconsideredassignificantdifference.ResultsAfteranaverageof15months(6～31months)follow-ups,allthefracturesintheMIPPOgroupobtainedbonyunion.OnecaseofnonunionoccurredintheconventionalORIFgroupwithplatebreakageandlossofreduction.Thepatientunderwentreoperation.Thetwogroupshadnosignificantdifferenceinthefailurerate.TheoperationtimeoftheMIPPOgroupwas73.5minutesinaveragewiththemeanintraoperativebloodlossof31.9ml.TheMIPPOgroupwasobviouslybetterthantheconventionalORIFgroupintherespectsofoperationtimeandbloodloss.Thetimeoffracturehealingwas13.7weeksinaverageandhadnosignificantdifferencewhencomparedtotheconventionalORIFgroup.TheConstantscoreshadnosignificantdifferencebetweentwothegroupseither.Somepatientsinthetwogroupsacceptedsecondoperationtoremoveimplantsalthoughtherewasnocomplication.TwoleanpatientsoftheMIPPOgrouphadobviousskinupliftandstronglyurgedthesecondsurgeriesofimplantsremoval.ConclusionsThisstudysuggestedthatforthemidshaftclaviclefractureswithfreewedged-shapefragments,thesatisfactoryfunctionalreductionoffreefragmentscanbeobtainedcompletelythroughclosereduction.Comparedtotheconventionalrigidinternalfixationtechniquewithlagscrewsforwedge-shapedfragments,itisunnecessarytopursuitanatomicalreduction.MIPPOtechniquehastheadvantagesofsimpleoperation,smalltraumaandsatisfactorytreatmenteffects,reducestheoperationtimeandincreasesthehealingrate.

K-wire;Clavicleshaft;Screw-platefixation

10.3877/cma.j.issn.2095-5790.2016.01.008

卫生公益性行业科研专项(201002014、201302007)；教育部创新团队(IRT1201)；北京市科委重大专项

100044北京大学人民医院创伤骨科 北京大学交通医学中心

姜保国，Email:jiangbaoguo@vip.sina.com

2014-12-11)

(Z101107052210001)；北京大学人民医院研究与发展基金(RDB2014-01)