老年肱骨近端3-4部分骨折手术与保守治疗的疗效和费用分析

doi:10.3877/cma.j.issn.1673-9450.2021.05.007

中华损伤与修复杂志(电子版) ›› 2021, Vol. 16 ›› Issue (05) : 411 -416. doi: 10.3877/cma.j.issn.1673-9450.2021.05.007

论著

老年肱骨近端3-4部分骨折手术与保守治疗的疗效和费用分析

李宇能¹, 刘昊楠², 朱仕文¹, 苏永刚¹, 毛玉江¹, 周萌¹, 王颢³, 吴新宝¹^,^†(

)

^1. 100035　北京积水潭医院创伤骨科
^2. 100045　国家儿童医学中心　首都医科大学附属北京儿童医院骨科
^3. 510080　广州，广东省人民医院（广东省医学科学院）骨科中心

收稿日期:2021-07-24 出版日期:2021-10-01
通信作者: 吴新宝
基金资助:
北京市属医院科研培育计划(PX2019016)

Comparison of clinical result and total costs between surgical and non-operative treatment for 3 and 4 part proximal humeral fracture in the elderly

Yuneng Li¹, Haonan Liu², Shiwen Zhu¹, Yonggang Su¹, Yujiang Mao¹, Meng Zhou¹, Hao Wang³, Xinbao Wu¹^,^†()

^1. Department of Orthopedics&Traumatology, Beijing Jishuitan Hospital, Beijing 100035, China
^2. Department of Orthopedics, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health, Beijing 100045, China
^3. Department of Orthopedics Surgery, GuangDong Provincial People′s Hospital, Guangzhou 510080, China

Received:2021-07-24 Published:2021-10-01
Corresponding author: Xinbao Wu

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引用本文：

李宇能, 刘昊楠, 朱仕文, 苏永刚, 毛玉江, 周萌, 王颢, 吴新宝. 老年肱骨近端3-4部分骨折手术与保守治疗的疗效和费用分析[J/OL]. 中华损伤与修复杂志(电子版), 2021, 16(05): 411-416.

Yuneng Li, Haonan Liu, Shiwen Zhu, Yonggang Su, Yujiang Mao, Meng Zhou, Hao Wang, Xinbao Wu. Comparison of clinical result and total costs between surgical and non-operative treatment for 3 and 4 part proximal humeral fracture in the elderly[J/OL]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2021, 16(05): 411-416.

目的

比较老年肱骨近端骨折手术与保守治疗的临床疗效和总体费用，总结临床经验。

方法

收集2019年1月至2020年3月于北京积水潭医院就诊的72例老年肱骨近端3-4部分骨折患者的临床资料，根据治疗方式不同将患者分为手术组和保守组，其中手术组患者39例，住院后接受切开复位内固定术；保守组患者33例，给予患肢制动、肢具固定等非手术处理。治疗结束后通过电话和门诊复查的方式对患者进行定期随访。采用Constant-murley评分和DASH调查表评估患者肩关节和上肢整体功能，采用欧洲五维健康量表(EQ-5D)评估患者生活质量，根据北京积水潭医院医疗记录和标准费用法统计患者伤后总体费用。数据比较采用t检验、秩和检验以及卡方检验。

结果

所有患者均完成2年随访。随访期间手术组和保守组患者并发症发生率分别为28.2%和21.2%，差异无统计学意义(χ²＝0.466, P＝0.495)。术后1年手术组和保守组患者肩关节功能分别为(76.1±10.5)分和(68.6±11.7)分，差异有统计学意义(t＝8.772，P<0.05)，上肢整体功能分别为(26.7±20.5)分和(32.1±11.7)分，差异有统计学意义(t＝8.331，P<0.05)，生活质量分别为(0.78±0.21)分和(0.72±0.21)分，差异有统计学意义(t＝9.033，P<0.05)，手术组均明显优于保守组。术后2年手术组和保守组患者肩关节功能分别为(78.3± 10.3)分和(69.6± 8.5)分，差异有统计学意义(t＝9.031，P<0.05)，上肢整体功能分别为(24.2± 19.3)和(31.1± 11.5)分，差异有统计学意义(t＝9.309，P<0.05)，生活质量分别为(0.79±0.19)分和(0.76±0.16)分，差异无统计学意义(t＝1.201，P＝0.102)。末次随访时手术组和保守组患者总体费用分别为52 171.2元和11 108.5元，手术组明显高于保守组，差异有统计学意义(Z＝8.201，P<0.05)。

结论

老年肱骨近端3-4部分骨折手术和保守治疗均可取得良好的临床疗效。与保守治疗相比切开复位内固定术更有利于患者早期关节功能恢复和生活质量的提高，但患者的总体花费也较高。

关键词: 肱骨骨折, 骨折固定术, 保守治疗, 临床疗效

Objective

To compare the clinical effect and costs of open reduction with internal fixation (ORIF) and conservative treatment for 3 and 4 part proximal humeral fractures.

Methods

The data of 72 elderly patients with 3 and 4 part proximal humeral fractures were collected in this study from January 2019 to March 2020. According to the treatment plan the patients were divided into operative group (39 cases) and non-operative group (33 cases) respectively. The Constant-murley scores and DASH (disabilities of the arm, should and hand) questionnaire were applied to evaluate the function of shoulder joint and upper limbs. The EuroQol 5 dimensions scores (EQ-5D) were applied to evaluate the quality of life after injury. The total costs of each group were collected by medical record and standard methods.

Results

All the patients completed more than 2 years follow-up. Compared to non-operative group the incidence rate of complication was higher in operation group, the difference was not statistically significant (28.2% vs. 21.2%, χ²=0.466, P=0.495). In 1 year follow-up the Constant-murley scale in operative and non-operative group was (76.1±10.5) pointsand (68.6±11.7) points, the difference was statistically significant(t=8.772, P<0.05), Dash sacel was (26.7±20.5) points and (32.1±11.7) points, repectively, the difference was statistically significant(t=8.331, P<0.05), and EQ-5D scale was (0.78±0.21) points and (0.72±0.21) points, the difference was statistically significant(t=9.033, P<0.05). All the outcome favored ORIF. After 2 years Constant-murley scale in operative and non-operative group was (78.3±10.3) points and (69.6±8.5) points, the difference was statistically significant(t=8.772, P<0.05), Dash sacel was (24.2±19.3) points and (31.1±11.5) points, repectively, the difference was statistically significant (t=8.331, P<0.05), and EQ-5D scale was(0.79±0.19)points and (0.76±0.16) points, repectively, the difference was statistically significant (t=9.033, P<0.05). At the last follow-up the total costs for operative and non-operative group were 52 171.2 yuan and 11 108.5 yuan, the difference was statistically significant(Z=8.201, P<0.05).

Conclusion

Both operation and conservative treatment can provide satisfactory clinical effect for elderly patients with 3 and 4 part proximal humeral fracture. However compared to conservative treatment ORIF is a more desirable treatment for early function recovery and quality of life with higher total costs.

Key words: Humeral fracture, Fracture fixation, Non-operative treatment, Clinical effect

表1 手术组和保守组肱骨近端骨折老年患者伤前一般资料对比

组别	例数	平均年龄(岁，±s)	性别(例)		Neer分型(例)		患有内科疾病[例(%)]	优势侧骨折[例(%)]	Constant-murley评分(分，±s)	DASH评分(分，±s)	EQ-5D评分(分，±s)
组别	例数	平均年龄(岁，±s)	男	女	Ⅲ	Ⅳ	患有内科疾病[例(%)]	优势侧骨折[例(%)]	Constant-murley评分(分，±s)	DASH评分(分，±s)	EQ-5D评分(分，±s)
手术组	39	67.8±6.1	12	27	30	9	25(64.1)	23(59.0)	93.9±6.1	7.1±3.1	0.92±0.08
保守组	33	71.8±8.6	11	22	24	9	24(72.7)	18(54.5)	91.4±7.6	8.4±4.3	0.91±0.09
t/χ²值		1.871	0.054		0.168		0.612	0.143	0.533	0.826	0.501
P值		0.021	0.816		0.682		0.434	0.705	0.734	0.541	0.773

表1 手术组和保守组肱骨近端骨折老年患者伤前一般资料对比

组别	例数	平均年龄(岁，±s)	性别(例)		Neer分型(例)		患有内科疾病[例(%)]	优势侧骨折[例(%)]	Constant-murley评分(分，±s)	DASH评分(分，±s)	EQ-5D评分(分，±s)
组别	例数	平均年龄(岁，±s)	男	女	Ⅲ	Ⅳ	患有内科疾病[例(%)]	优势侧骨折[例(%)]	Constant-murley评分(分，±s)	DASH评分(分，±s)	EQ-5D评分(分，±s)
手术组	39	67.8±6.1	12	27	30	9	25(64.1)	23(59.0)	93.9±6.1	7.1±3.1	0.92±0.08
保守组	33	71.8±8.6	11	22	24	9	24(72.7)	18(54.5)	91.4±7.6	8.4±4.3	0.91±0.09
t/χ²值		1.871	0.054		0.168		0.612	0.143	0.533	0.826	0.501
P值		0.021	0.816		0.682		0.434	0.705	0.734	0.541	0.773

表2 手术组和保守组肱骨近端骨折老年患者各随访时间点疗效对比(分，±s)

组别	例数	Constant-murley评分		DASH评分		EQ-5D评分
组别	例数	术后1年	术后2年	术后1年	术后2年	术后1年	术后2年
手术组	39	76.1±10.5	78.3± 10.3	26.7±20.5	24.2± 19.3	0.78±0.21	0.79±0.19
保守组	33	68.6±11.7	69.6± 8.5	32.1±11.7.	31.1± 11.5	0.72±0.21	0.76±0.16
t值		8.772	9.031	8.331	9.309	9.033	1.201
P值		<0.001	<0.001	<0.001	<0.001	<0.001	0.102

表2 手术组和保守组肱骨近端骨折老年患者各随访时间点疗效对比(分，±s)

组别	例数	Constant-murley评分		DASH评分		EQ-5D评分
组别	例数	术后1年	术后2年	术后1年	术后2年	术后1年	术后2年
手术组	39	76.1±10.5	78.3± 10.3	26.7±20.5	24.2± 19.3	0.78±0.21	0.79±0.19
保守组	33	68.6±11.7	69.6± 8.5	32.1±11.7.	31.1± 11.5	0.72±0.21	0.76±0.16
t值		8.772	9.031	8.331	9.309	9.033	1.201
P值		<0.001	<0.001	<0.001	<0.001	<0.001	0.102

表3 手术组和保守组肱骨近端骨折老年患者2年内总体费用对比(元)

组别	例数	挂号	药品/辅助器械费用	化验检查费用	康复费用	住院费用	医疗费用	非医疗费用	总体费用
手术组	39	186.4	2 472.3	678.1	174.4	4 6317.6	49 828.8	2 342.4	5 2171.2
保守组	33	303.7	1 864.5	772.4	96.8	3 976.4	7 013.8	4 094.7	1 1108.5
检验值		1.063	2.464	0.368	1.812	9.164	10.164	3.022	8.201
P值		0.224	0.031	0.682	0.034	<0.001	<0.001	<0.012	<0.001

表3 手术组和保守组肱骨近端骨折老年患者2年内总体费用对比(元)

组别	例数	挂号	药品/辅助器械费用	化验检查费用	康复费用	住院费用	医疗费用	非医疗费用	总体费用
手术组	39	186.4	2 472.3	678.1	174.4	4 6317.6	49 828.8	2 342.4	5 2171.2
保守组	33	303.7	1 864.5	772.4	96.8	3 976.4	7 013.8	4 094.7	1 1108.5
检验值		1.063	2.464	0.368	1.812	9.164	10.164	3.022	8.201
P值		0.224	0.031	0.682	0.034	<0.001	<0.001	<0.012	<0.001

表4 手术组和保守组肱骨近端骨折老年患者并发症发生情况对比[例(%)]

并发症	手术组	保守组
肱骨头坏死	2(5.1)	1(3.0)
肩部撞击	2(5.1)	3(9.1)
骨折不愈合	2(5.1)	1(3.0)
骨性关节炎	0	2(6.1)
螺钉穿出	1(2.6)
切口感染	1(2.6)
骨折复位丢失	2(5.1)
术后急性呼吸衰竭	1(2.6)
总数	11(28.2)	7(21.2)

表4 手术组和保守组肱骨近端骨折老年患者并发症发生情况对比[例(%)]

并发症	手术组	保守组
肱骨头坏死	2(5.1)	1(3.0)
肩部撞击	2(5.1)	3(9.1)
骨折不愈合	2(5.1)	1(3.0)
骨性关节炎	0	2(6.1)
螺钉穿出	1(2.6)
切口感染	1(2.6)
骨折复位丢失	2(5.1)
术后急性呼吸衰竭	1(2.6)
总数	11(28.2)	7(21.2)

[1]	Olerud P, Ahrengart L, Ponzer S, et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial[J]. J Shoulder Elbow Surg, 2011, 20(5): 747-755.
[2]	Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures[J]. Acta Orthop Scand, 2001，72(4): 365-371.
[3]	Bachelier F, Pizanis A, Schwitalla J, et al. Treatment for displaced proximal humerus fractures: comparison of interlocking plate fixation versus minimal invasive techniques[J]. Eur J Orthop Surg Traumatol, 2014, 24(5): 707-714.
[4]	Sanders RJ, Thissen LG, Teepen JC, et al. Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment[J]. J Shoulder Elbow Surg, 2011, 20(7): 1118-1124.
[5]	Mao Z, Zhang L, Zhang L, et al. Operative versus nonoperative treatment in complex proximal humeral fractures[J]. Orthopedics, 2014, 37(5): e410-e419.
[6]	Handoll H, Brealey S, Rangan A, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial- a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults[J]. Health Technol Assess, 2015，19(24): 1-280.
[8]	Hanson B, Neidenbach P, de Boer P, et al. Functional outcomes after nonoperative management of fractures of the proximal humerus[J]. J Shoulder Elbow Surg, 2009, 18(4): 612-621.
[9]	田子睿，姚敏，王拥军，等. 中文版Constant-Murley肩关节评分量表的研制与应用[J]. 中医正骨，2019, 31(5): 20-21, 25.
[10]	Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG)[J]. Am J Ind Med, 1996, 29(6): 602-608.
[11]	李明晖，罗南. 欧洲五维健康量表(EQ-5D)中文版应用介绍[J]. 中国药物经济学，2009(1): 49-57.
[12]	Oostenbrink JB, Koopmanschap MA, Rutten FF. Standardisation of costs: the Dutch Manual for Costing in economic evaluations[J]. Pharmacoeconomics, 2002, 20(7): 443-454.
[13]	Song JQ, Deng XF, Wang YM, et al. Operative vs. nonoperative treatment for comminuted proximal humeral fractures in elderly patients: a current meta-analysis[J]. Acta Orthop Traumatol Turc, 2015, 49(4): 345-353.
[14]	Fu T, Xia C, Li Z, et al. Surgical versus conservative treatment for displaced proximal humeral fractures in elderly patients: a meta-analysis[J]. Int J Clin Exp Med, 2014, 7(12): 4607-4615.
[15]	Ilchmann T, Ochsner PE, Wingstrand H, et al. Non-operative treatment versus tension-band osteosynthesis in three- and four-part proximal humeral fractures. A retrospective study of 34 fractures from two different trauma centers[J]. Int Orthop, 1998, 22(5): 316-320.
[16]	Fjalestad T, Hole MO, Jorgensen JJ, et al. Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients[J]. Injury, 2010, 41(6): 599-605.
[17]	Corbacho B, Duarte A, Keding A, et al. Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial[J]. Bone Joint J, 2016, 98-B(2): 152-159.
[18]	Launonen AP, Lepola V, Flinkkila T, et al. Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study[J]. BMC Musculoskelet Disord, 2012, 13: 167.
[19]	黄强，王满宜，荣国威. 复杂肱骨近端骨折的手术治疗[J]. 中华骨科杂志，2005, 25(3): 159-164.

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Comparison of clinical result and total costs between surgical and non-operative treatment for 3 and 4 part proximal humeral fracture in the elderly

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Comparison of clinical result and total costs between surgical and non-operative treatment for 3 and 4 part proximal humeral fracture in the elderly