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中华老年骨科与康复电子杂志

中华老年骨科与康复电子杂志 ›› 2022, Vol. 08 ›› Issue (05) : 276 -284. doi: 10.3877/cma.j.issn.2096-0263.2022.05.005

骨质疏松

3D打印结合PMMA骨水泥髓内支撑技术在老年肱骨近端骨质疏松性骨折中的应用
金万通1, 薛海鹏2, 周大鹏2,†(), 刘兵2, 纪振钢2, 马翔宇2, 杨超2, 张昊2, 韩宁2, 宗宇宁2, 张咏晧2, 马泽方2   
  1. 1. 110015　沈阳，锦州医科大学北部战区总医院研究生培养基地；110015　沈阳，中国人民解放军北部战区总医院骨科
    2. 110015　沈阳，锦州医科大学北部战区总医院研究生培养基地
  • 收稿日期:2021-09-06 出版日期:2022-10-05
  • 通信作者: 周大鹏
  • 基金资助:
    辽宁省民生科技计划项目(2021JH2/10300057)

Application of 3D printing technology combined with PMMA bone cement intramedullary support in the treatment of senile proximal humeral osteoporotic fractures

Wantong Jin1, Haipeng Xue2, Dapeng Zhou2,†(), Bing Liu2, Zhengang Ji2, Xiangyu Ma2, Chao Yang2, Hao Zhang2, Ning Han2, Yuning Zong2, Yonghao Zhang2, Zefang Ma2   

  1. 1. Postgraduate training base of northern theater General Hospital of Jinzhou Medical UniversityJinzhou Medical University, JinZhou121001, China; Department of orthopedics, General Hospital of the northern theater of the Chinese people's Liberation Army, ShenYang 110015, China
    2. Postgraduate training base of northern theater General Hospital of Jinzhou Medical UniversityJinzhou Medical University, JinZhou121001, China
  • Received:2021-09-06 Published:2022-10-05
  • Corresponding author: Dapeng Zhou
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引用本文：

金万通, 薛海鹏, 周大鹏, 刘兵, 纪振钢, 马翔宇, 杨超, 张昊, 韩宁, 宗宇宁, 张咏晧, 马泽方. 3D打印结合PMMA骨水泥髓内支撑技术在老年肱骨近端骨质疏松性骨折中的应用[J/OL]. 中华老年骨科与康复电子杂志, 2022, 08(05): 276-284.

Wantong Jin, Haipeng Xue, Dapeng Zhou, Bing Liu, Zhengang Ji, Xiangyu Ma, Chao Yang, Hao Zhang, Ning Han, Yuning Zong, Yonghao Zhang, Zefang Ma. Application of 3D printing technology combined with PMMA bone cement intramedullary support in the treatment of senile proximal humeral osteoporotic fractures[J/OL]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2022, 08(05): 276-284.

目的

探讨3D打印技术结合聚甲基丙烯酸甲酯（PMMA）骨水泥髓内支撑辅助锁定钢板治疗肱骨近端Neer二、三、四部分骨质疏松性骨折的应用效果。

方法

回顾性分析2017年9月至2020年5月北部战区总医院收治的33例肱骨近端Neer二、三、四部分骨质疏松性骨折。男5例，女28例，平均年龄（68.4±2.5）岁。按Neer分型，二部分骨折3例，三部分骨折21例，四部分骨折9例。术前收集患者双侧肱骨三维重建CT扫描数据通过Mimics Research 20.0软件进行模拟复位及镜像比对，获得骨折复位后骨缺损范围并以此设计髓内支撑假体模具。通过3D打印技术打印髓内支撑假体模具，术中应用模具制作PMMA骨水泥髓内支撑假体。将该假体植入肱骨近端髓腔内，支撑肱骨头部骨折块，辅助锁定钢板进行骨折的复位和固定，术后即刻行肱骨近端正侧位X线评估骨折复位质量，术后定期复查，观察骨折愈合及并发症情况，测量并记录肱骨近端颈干角、肱骨头高度变化情况；术后1年通过Constant-Murley肩关节功能评分、VAS疼痛评分。

结果

33例患者均获得随访，随访时间（13.2±1.5）月。Neer二部分骨折中，健侧、术前及术后1年颈干角比较，差异有统计学意义（F=39.038，P<0.05），两两比较中发现健侧颈干角（145.33±1.52）°与术前颈干角（102.00±11.13）°比较，差异有统计学意义（P<0.05），与术后1年颈干角（145.67±2.52）°比较，差异无统计学意义。Neer三部分骨折中，健侧、术前及术后1年颈干角比较，差异有统计学意义（F=13.957，P<0.05），两两比较中发现健侧颈干角（145.86±3.18）°与术前颈干角（173.90±35.33）°比较，差异有统计学意义（P<0.05），与术后1年颈干角（143.81±4.19）°对比，差异无统计学意义。Neer四部分骨折中，健侧、术前及术后1年颈干角比较，差异有统计学意义（F=89.297，P<0.05），两两比较中健侧颈干角（146.44±3.74）°与术前颈干角（96.22±14.09）°比较，差异有统计学意义（P<0.05），与术后1年颈干角（141.11±3.96）°比较，差异无统计学意义。Neer二、三、四部分骨折中，术中肱骨头高度与术后1年肱骨头高度比较，差异无统计学意义。Neer二部分骨折中，肱骨头高度差异平均为（0.70±0.18）mm，Neer三部分骨折中，肱骨头高度差异平均为（1.12±0.24）mm，Neer四部分骨折中肱骨头高度差异平均为1.92±0.21mm。术中与术后1年肱骨头高度比较，差异无统计学意义。术后1年三维重建CT显示所有患者均已获得骨折愈合。Constant-Murley肩关节功能评分中，二部分骨折患者为（78.42±4.31）分，三部分骨折患者为（74.34±3.82）分，四部分骨折患者为（69.31±3.43）分，VAS疼痛评分中二部分骨折患者为（1.53±0.81）分，三部分骨折患者为（2.12±0.63）分，四部分骨折患者为（3.14±1.22）分。

结论

应用3D打印结合PMMA骨水泥髓内支撑技术辅助锁定钢板治疗老年肱骨近端Neer二、三、四部分骨质疏松性骨折，可以增强骨折固定的稳定性，有效保持术后颈干角、肱骨头高度，获得较好的临床结果。

关键词: 骨质疏松症, 肱骨近端骨折, 聚甲基丙烯酸甲酯, 内侧支撑, 3D打印
Objective

To investigate the application effect of 3D printing technology combined with PMMA (polymethylmethacrylate) bone cement intramedullary support assisted locking plate in the treatment of proximal humeral Neer Ⅱ, Ⅲ and Ⅳ osteoporotic fractures.

Methods

From September 2017 to may 2020, 33 cases of proximal humeral neer Ⅱ, Ⅲand Ⅳ osteoporotic fractures were retrospectively analyzed. There were 5 males and 28 females, with an average age of (68.4±2.5) years. According to neer classification, there were 3 cases of two-part fracture, 21 cases of three part fracture and 9 cases of four part fracture. The CT scanning data of three-dimensional reconstruction of bilateral humerus were collected before operation, and the simulated reduction and mirror image comparison were carried out through mimics research 20.0 software to obtain the bone defect range after fracture reduction, and then the intramedullary support prosthesis mold was designed. The mold of intramedullary support prosthesis was printed by 3D printing technology, and the mold was used to make PMMA bone cement intramedullary support prosthesis during operation. The prosthesis was implanted into the medullary cavity of the proximal humerus to support the fracture block of the humeral head, and the locking plate was used to reduce and fix the fracture. Immediately after the operation, the proximal humerus positive and lateral X-ray was performed to evaluate the quality of fracture reduction. After the operation, regular reexamination was performed to observe the fracture healing and complications, and the changes of the proximal humeral neck shaft angle and the height of the humeral head were measured and recorded; One year after operation, it passed the constant Murley shoulder function score and VAS pain score. In neer's four part fracture, there was significant difference between the healthy side of the neck shaft angle (146.44±3.74) ° and the preoperative neck shaft angle (96.22±14.09) ° (P<0.05), but there was no significant difference between the healthy side of the neck shaft angle and the postoperative neck shaft angle (141.11±3.96) ° one year later.

Results

All 33 patients were followed up for (13.2±1.5) months. In neer's two-part fracture, there was a statistically significant difference in the cervical trunk angle of the healthy side, before operation and one year after operation (F=39.038, P<0.05). In the two-part comparison, it was found that there was a statistically significant difference between the cervical trunk angle of the healthy side (145.33±1.52) ° and the preoperative cervical trunk angle (102.00±11.13) ° (P<0.05), and there was no statistically significant difference between the cervical trunk angle of the healthy side (145.67±2.52) ° and the postoperative cervical trunk angle of one year. In neer's three part fractures, there was a statistically significant difference in the angle of the neck trunk on the healthy side, before operation and one year after operation (F=13.957, P<0.05). It was found that there was a statistically significant difference in the angle of the neck trunk on the healthy side (145.86±3.18) °, compared with the angle of the neck trunk before operation (173.90±35.33) ° (P<0.05), and there was no statistically significant difference in the angle of the neck trunk one year after operation (143.81±4.19) °. In neer's four part fractures, there was a statistically significant difference in the cervical trunk angle between the healthy side, before operation and one year after operation (F=89.297, P<0.05). There was a statistically significant difference in the cervical trunk angle between the healthy side (146.44±3.74) ° and the preoperative cervical trunk angle (96.22±14.09) ° (P<0.05), and there was no statistically significant difference between the healthy side and the postoperative cervical trunk angle one year after operation (141.11±3.96) °. In neer's second, third and fourth part fractures, there was no significant difference between the height of humeral head during operation and that one year after operation. In neer two-part fracture, the average height difference of humeral head is (0.70±0.18) mm, in neer three part fracture, the average height difference of humeral head is (1.12±0.24) mm, and in neer four part fracture, the average height difference of humeral head is (1.92±0.21)mm. There was no significant difference in the height of humeral head between intraoperative and 1 year after operation. One year after operation, three-dimensional reconstruction CT showed that all patients had achieved fracture healing. In the constant Murley shoulder function score, patients with two-part fractures scored (78.42±4.31), patients with three-part fractures scored (74.34±3.82), patients with four part fractures scored (69.31±3.43), patients with two-part fractures scored (1.53±0.81), patients with three part fractures scored (2.12±0.63), and patients with four part fractures scored (3.14±1.22).

Conclusion

Using 3D printing combined with PMMA bone cement intramedullary support technology to assist locking plate in the treatment of elderly proximal humeral neer Ⅱ, Ⅲ and Ⅳ osteoporotic fractures can enhance the stability of fracture fixation, effectively maintain the postoperative neck shaft angle and humeral head height, and obtain better clinical results.

Key words: Osteoporosis, Proximal humerus, Polymethylmethacrylate, Medial support, 3D printing
图11 沿肱骨头盂肱关节面上缘与下缘边界绘制线AB，通过肱骨头中心垂直于关节面绘制线C。D线平行于肱骨干，CD线交汇的颈骨干角度为α角。沿肱骨头和钢板的上缘绘制两条线（由黄色水平虚线表示），这两条线之间的距离（E）是肱骨头的高度
图18 将PMMA骨水泥占位器插入肱骨髓腔内，进行骨折复位
表1 33例患者术前患侧颈干角与健侧颈干角、术后1年患侧颈干角比较（°，±s）
Neer分型 健侧颈干角 术前颈干角 术后1年颈干角 F值 P值
Ⅱ部分 145.3±1.2 102.7±11. 3* 145.7±2.5 39.038 <0.05
Ⅲ部分 145.9±3.1 173.9±35.3* 143.8±4.1 13.957 <0.05
Ⅳ部分 146.4±3.5 96.2±14.1* 141.1±3.9 89.297 <0.05
表2 33例患者患侧术中肱骨头高度与术后1年肱骨头高度比较（mm，±s）
项目 Ⅱ部分 Ⅲ部分 Ⅳ部分
肱骨头高度-术中（） 16.70±0.37 17.3±0.51 17.83±0.21
肱骨头高度-术后1年（） 16.00±0.21 16.22±0.32 15.91±0.41
肱骨头高度差异（|－|） 0.70±0.18 1.12±0.24 1.92±0.21
t值 3.780 1.273 1.881
P值 >0.05 >0.05 >0.05
表3 33例患者术后1年患侧Constant-Murley肩关节功能评分与VAS评分（±s）
Neer分型 Constant－Murley肩关节功能评分 VAS评分
Ⅱ部分 78.42±4.31 1.53±0.81
Ⅲ部分 74.34±3.82 2.12±0.63
Ⅳ部分 69.31±3.43 3.14±1.22
图19~44 女性，65岁，摔伤致左肱骨近端粉碎性骨折，按Neer分型为肱骨近端三部分骨折。图19~21术前患侧肱骨X线并测量其颈干角为161.5°；健侧肱骨X线，并测量其颈干角为145.7°；图22~25患侧术前三维重建CT；图26~28术中C臂机透视情况，并测量骨折复位且置入骨水泥占位器后颈干角为143.2°；图29~30术后1个月X线。测量其颈干角为143.8°；图31~32术后1年患侧肱骨X线并测得颈干角为146.9°；图33~37术后1年患侧肱骨CT，提示骨折获得骨性愈合；图38~44术后1年随访患者上肢功能满意
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