Different treatments for two-part and three-part proximal humeral fractures by Neer classification: follow-up results analyzed using clinical economics

doi:10.3969/j.issn.2095-4344.1082

Abstract

Abstract:

BACKGROUND: The impact of the total medical insurance prepayment system on hospital medical expenses control is further strengthened. Providing appropriate technologies for patients, improving the efficiency of medical resources, reducing the burden on patients, controlling medical costs, and ensuring medical quality have become important decision-making factors for hospital management, which profoundly affect the clinical medical decision-making and service behavior.

OBJECTIVE: To explore the clinical efficacy and total cost of different treatments for two-part and three-part proximal humeral fractures, and to evaluate the different treatment options using clinical economics.

METHODS: One hundred and thirty patients with two-part and three-part proximal humeral fractures admitted at the First Affiliated Hospital of the Medical College, Shihezi University, from January 2011 to December 2016 were enrolled, and then divided into conservative group (n=40) and minimally invasive group (n=22), the locking compression plate group (n=32) and intramedullary nail group (n=36). Patients in the conservative group were treated with skin traction or manual reduction with cast immobilization. Patients in each surgical group received open reduction and internal fixation, separately. The total cost of treatment for 1 year after fracture was calculated using the standard cost method. The Constant-Murley score, Visual Analogue Scale, and Neer score were used to evaluate functional outcome after treatment. The minimum cost and cost-effectiveness of patients in different groups were analyzed by the clinical economic method.

RESULTS AND CONCLUSION: (1) There was no significant difference in the clinical efficacy for two-part proximal humeral fractures among groups, but the cost for treatment in the conservative group was slowest. The clinical efficacy for two-part proximal humeral fractures in each surgical group was superior to the conservative group, but the cost was higher than that in the conservative group. (2) The cost-effect analysis showed that it cost 854.25, 3 573.84, 4 730.35 yuan more for each 1 point increase of the Constant-Murley score in the minimally invasive group, the locking compression plate group and the intramedullary nail internal fixation group. (3) The minimum cost and cost-effectiveness results showed that there was no significant difference in the clinical efficacy for two-part proximal humeral fractures among groups. The cost for treatment in each surgical group was higher than that in the conservative group. The conservative group exhibited the same treatment effectiveness with the surgical groups and better economic effect. (4) These results indicate that conservative and surgical treatment for the two-part and three-part proximal humeral fractures are effective, and conservative treatment of the two-part proximal humeral fractures is a more economical and effective treatment. The surgical treatment of the three-part proximal humeral fractures is better than the conservative treatment group, but the cost of the surgical groups is higher than the conservative treatment group.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Humeral Fractures, Internal Fixators, Tissue Engineering

CLC Number:

R459.9

Qiu Zhongpeng, Li Ke, Li Gang, Liu Keyu, Du Xinhui, Meng Defeng, Shi Chenhui, Wang Weishan. Different treatments for two-part and three-part proximal humeral fractures by Neer classification: follow-up results analyzed using clinical economics [J]. Chinese Journal of Tissue Engineering Research, 2019, 23(8): 1188-1195.

Figures/Tables 6

2.5 并发症及生物相容性情况 1年内4组手术干预组并发症明显高于保守治疗组，见表6。骨折不愈合：微创手术组有2例患者为老年合并骨质疏松患者，骨折不愈合考虑与患者本身骨质疏松，肩关节制动时间不够，不恰当功能锻炼造成。锁定钢板组4例患者骨折未愈合，其中2例发生脱钉，考虑骨折断端未能形成坚强固定制动，严重骨质疏松内固定置入材料选择不当导致；另2例患者考虑手术过程中反复复位，骨折断端周围骨膜剥离过多，肱骨近端血运破坏严重引起。髓内钉组2例患者，其中1例术中计划使用锁定钢板固定，术中更改为髓内钉固定，骨折处血运破坏较重引起；另外1例骨折不愈合，考虑与患者合并糖尿病、骨质疏松多种基础疾病有关。肱骨头坏死：保守治疗组2例考虑与患者骨折损伤旋肱前动脉的终末枝弓形动脉，以及本身基础疾病有关。微创手术组2例、锁定钢板组2例考虑术中反复复位，破坏肱骨近端血运导致。髓内钉固定组1例与术中操作破坏了肱骨近端血运有关。肩部撞击并发症：保守治疗组2例考虑手法复位不满意，及局部血肿机化导致。微创手术组1例患者肩缝撞击考虑术中复位不确切及肩峰下血肿机化导致。锁定钢板组1例患者与锁定钢板放置位置不恰当及肩峰处创伤后骨性关节炎有关。髓内钉组患者肩缝撞击综合征考虑与患者术中对肩袖损伤、髓内钉尾帽凸起等原因有关。切口感染并发症：锁定钢板组4例考虑手术过程创面暴露时间长，术中使用电刀导致脂肪液化坏死，患者合并糖尿病等基础病及自身免疫力等原因导致。髓内钉组1例感染考虑手术持续时间长，术野暴露时间长导致。神经损伤：微创手术组2例考虑术后置入克氏针临时固定时损伤。锁定钢板组2例考虑术中钢板置入不服帖、过度牵拉、骨折后参照系统不准导致。髓内钉组1例考虑术中肩关节复位过度牵拉及克氏针临时固定时损伤，为预防腋神经损伤，应注意轻柔操作、争取良好复位、注意内固定服帖置入，同时重视术前查体，必要时电生理检查术前术后排除腋神经损伤。术后确诊神经损伤后给予患者营养神经药物对症治疗，在术后1年的随访时间里患者三角肌表面皮肤感觉障碍感觉恢复满意度较低，肩外展功能未见明显受损。 Chowdary等[11]报道50例患者中有8例出现术后并发症，并发症发生率为16%；Matejci?等[12]报道患者随访14-36个月，总并发症发生率为27.1%；Sproul等[13]报道锁定钢板治疗肱骨近端骨折术后并发症发生率为49%，常见的并发症有内翻畸形愈合(16%)、肱骨头缺血性坏死(10%)、螺钉穿出肱骨头(8%)。此次研究中，患者总并发症发生率为22%，与文献报道相比并发症发生率较高，考虑与手术医生操作熟练程度、患者本身基础疾病、内固定材料选择、治疗方案选择及患者术后康复等因素相关。此次研究中的3种植入物生物相容性良好，各组患者均未出现植入物周围感染、过敏反应、免疫反应及排斥反应。 2.6 费用统计见表7。此次研究中5例患者再次入院，其中微创手术组内固定克氏针脱落1例，锁定钢板组创面感染4例入院给予清创手术治疗。1年内微创手术组、锁定钢板组、髓内钉组总体费用均高于保守治疗组(P=0.000)，各手术干预组的非医疗费用和康复费用较保守治疗组明显偏低，其中非医疗费用主要包含家庭护理费用，保守治疗组患者院外康复及关节制动时间较长，是家庭护理费用高的原因；手术干预组的制动时间短，康复时间也短，是非医疗费用及康复费用花费较少的原因。 2.7 成本-效果分析、增量成本效果比对于Neer二部分肱骨近端骨折，各手术干预组与保守治疗组疗效差异无显著性意义，但保守治疗组患者治疗支付成本更低，提示Neer二部分肱骨近端骨折采取保守治疗是更经济、有效的治疗方案，见表8。 Neer三部分肱骨近端骨折，各手术干预组治疗效果优于保守治疗组，但手术干预组患者治疗支付成本比保守治疗组更高，见表9。根据增量成本-效果比结果，对于Neer 分型三部分肱骨近端骨折，微创手术组、锁定钢板组、髓内钉组患者肩关节功能Constant-Murley评分每提高1分需分别花费854.25，3 573.84，4730.35元，见表10。 "

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