MIPPO技術(shù)治療有楔形骨塊的鎖骨干骨折

楊明 司徒炫明 張殿英 王天兵 付中國(guó) 張培訓(xùn) 陳建海 姜保國(guó)

·論著·

MIPPO技術(shù)治療有楔形骨塊的鎖骨干骨折

楊明 司徒炫明 張殿英 王天兵 付中國(guó) 張培訓(xùn) 陳建海 姜保國(guó)

目的 探討MIPPO技術(shù)治療有楔形骨塊的鎖骨干骨折的手術(shù)方法及療效。方法 自2011年4月至2014年4月，應(yīng)用閉合復(fù)位、髓內(nèi)克氏針臨時(shí)固定并行MIPPO技術(shù)，治療有楔形骨塊的鎖骨干骨折26例患者為試驗(yàn)組(MIPPO組)。術(shù)后定期復(fù)查X線片，觀察骨折愈合情況，并用Constant評(píng)分評(píng)估患者的肩關(guān)節(jié)功能。同時(shí)以2007年3月至2011年11月收治的傳統(tǒng)切開復(fù)位板釘固定的29例患者為對(duì)照組(ORIF組),進(jìn)行回顧性隨訪研究,比較兩組的療效和并發(fā)癥。結(jié)果 經(jīng)過平均15個(gè)月的隨訪，MIPPO組無(wú)1例骨折不愈合，ORIF組有1例骨折不愈合并接骨板失效，兩組之間失效率差異無(wú)統(tǒng)計(jì)學(xué)意義。MIPPO組在手術(shù)時(shí)間、出血量方面優(yōu)于ORIF組，差異有統(tǒng)計(jì)學(xué)意義。在骨折愈合時(shí)間以及Constant評(píng)分方面,兩組間差異無(wú)統(tǒng)計(jì)學(xué)意義。MIPPO組有2例患者因接骨板隆起而堅(jiān)決要求二次手術(shù)取出內(nèi)固定物。結(jié)論MIPPO技術(shù)治療有楔形骨塊鎖骨干骨折，創(chuàng)傷小，可減少手術(shù)時(shí)間和出血量，提高愈合幾率。

克氏針；鎖骨干；螺釘鋼板固定術(shù)

對(duì)于有楔形骨塊的鎖骨中段骨折，保守治療不愈合率高達(dá)15%[1]，近年來(lái)以手術(shù)治療為主。接骨板固定仍是最主流的內(nèi)固定方式[2]，也有少數(shù)學(xué)者提倡各種髓內(nèi)固定[3]。在傳統(tǒng)的板釘固定術(shù)中，盡可能對(duì)游離楔形骨折塊采用拉力螺釘固定是原則之一。我們?cè)牧紓鹘y(tǒng)技術(shù)，采用髓內(nèi)克氏針臨時(shí)固定并橋接鋼板固定，以及縫線捆綁骨折塊，獲得良好療效[4]，但發(fā)現(xiàn)切開復(fù)位固定，即使只對(duì)骨折塊進(jìn)行縫線捆綁，也因長(zhǎng)切口增加了手術(shù)創(chuàng)傷。我們?cè)诖嘶A(chǔ)上進(jìn)一步改良，采用對(duì)游離骨塊進(jìn)行閉合復(fù)位三切口(minimalinvasivepercutaneousplateosteosynthesis，MIPPO)技術(shù)，治療了26例自2011年4月至2014年4月收治的有楔形骨塊鎖骨干骨折患者，并以2007年3月至2011年11月收治且隨訪資料完整的傳統(tǒng)切開復(fù)位內(nèi)固定(openreductionandinternalfixation,ORIF)29例患者為對(duì)照，進(jìn)行了回顧性隨訪研究。

資 料 與 方 法

一、一般資料

所有病例來(lái)自我科2007年3月至2014年4月收治的病例，其中采用MIPPO技術(shù)固定的患者26例為試驗(yàn)組(MIPPO組)，采用傳統(tǒng)切開復(fù)位，骨折塊拉力螺釘固定，并中和或加壓鋼板固定的患者29例為對(duì)照組(ORIF組)。兩組患者的受傷機(jī)制均為摔傷居多，兩組各有2例高處墜落傷，各有1例合并其余部位骨折。骨折分型按照Robinson′s分類[5]，ⅡB1型骨折定義為鎖骨中段，有移位，斷端有1個(gè)楔形骨塊，ⅡB2型定義為斷端有2個(gè)或2個(gè)以上的游離骨塊。兩組患者的性別、年齡、優(yōu)勢(shì)側(cè)、手術(shù)距受傷時(shí)間及骨折類型等資料見表1。

二、手術(shù)方式

1.MIPPO組：采用能夠獲得滿意肌松的全身麻醉，沙灘椅半坐臥位，消毒范圍包括患肢腕部以上，保證術(shù)中可以屈肘位被動(dòng)抬高或后伸上臂。首先觸摸明顯向上翹起的鎖骨近端主骨折的尖端，然后行2cm切口，顯露近端主骨折塊的尖端，不剝離骨膜，然后沿其后上方皮質(zhì)經(jīng)過髓腔，向近端主骨折塊髓腔內(nèi)打入2mm或2.5mm的雙尖頭髓內(nèi)克氏針，直至此克氏針的尾端恰好沒入近端髓腔內(nèi)，克氏針近側(cè)尖端則由鎖骨近端前面穿出皮膚。然后由助手將患肢屈肘位上抬并向外牽引上臂，類似保守治療時(shí)采用的手法閉合復(fù)位的操作，使遠(yuǎn)端與近端的主骨折塊復(fù)位。此時(shí)術(shù)者可用手觸摸近端主骨折塊表面，感覺到遠(yuǎn)側(cè)主骨折塊的后上方皮質(zhì)接觸近端后上方皮質(zhì)后，將髓內(nèi)克氏針由近端向遠(yuǎn)端打入髓腔，直至穿出鎖骨后緣，并位于肩峰后角表面。行術(shù)中透視，證實(shí)術(shù)前游離骨塊已經(jīng)復(fù)位，且主骨折塊有接觸。然后將10孔解剖型鎖定鎖骨接骨板(美國(guó)通用公司)經(jīng)中間切口沿鎖骨表面向近端經(jīng)皮插入一半，從皮膚表面觸摸到接骨板近側(cè)端，在此上行2cm切口，顯露接骨板近端。然后將接骨板完全向近端插入，直至接骨板遠(yuǎn)端位于骨折上方切口處，然后再將接骨板遠(yuǎn)端沿鎖骨表面向遠(yuǎn)端插入，使骨折處恰好位于接骨板中段。然后在鎖骨遠(yuǎn)端觸摸到接骨板遠(yuǎn)端，再于其表面行2cm切口，顯露接骨板遠(yuǎn)端。以鉆頭或測(cè)深尺等經(jīng)接骨板的最近端和最遠(yuǎn)端的2個(gè)螺釘孔感觸鎖骨上表面，證實(shí)接骨板放置前后位置合適，然后由外圍向中間先打入最遠(yuǎn)端和最近端的各1枚鎖定螺釘，然后依次向中間打入第2枚鎖釘，如恰好碰到位于髓內(nèi)的克氏針，可逐步退出克氏針，打入剩余鎖釘(圖1)。遠(yuǎn)、近端各打入3枚雙皮質(zhì)鎖定螺釘固定即可。透視下證實(shí)位置滿意，關(guān)閉切口，不放引流管。

表1 兩組患者臨床資料比較

注：ORIF為傳統(tǒng)切開復(fù)位內(nèi)固定術(shù)；MIPPO為閉合復(fù)位三切口技術(shù)

2.ORIF組：麻醉采用頸叢加臂叢或者全身麻醉。體位同MIPPO組，取鎖骨上表面切口，對(duì)較大游離骨塊盡可能和主骨折塊間采用拉力螺釘固定，將帶游離骨塊鎖骨干骨折變?yōu)楹?jiǎn)單骨折，然后在直視下鉗夾復(fù)位，并以7～9孔直重建接骨板預(yù)彎后置入鎖骨上表面固定，兩端各打入3枚螺釘。常規(guī)留置引流管。

三、術(shù)后康復(fù)和隨訪

術(shù)后第2天開始肩關(guān)節(jié)的被動(dòng)活動(dòng)，以外旋和外展為主，外展不超過90°。上、下午及晚上共3組，每組10次，其余時(shí)間懸吊患肢保護(hù)。4周以后可以去掉懸吊保護(hù)，并進(jìn)行簡(jiǎn)單日常生活，但仍限制患肢提重物或主動(dòng)外展過高。12周后可恢復(fù)完全的工作，重體力勞動(dòng)者則需要X線片證實(shí)骨折愈合情況。術(shù)后4、8、12、16周定期攝X線片。隨訪時(shí)采用Constant評(píng)分評(píng)估患者肩關(guān)節(jié)功能[6]，并記錄并發(fā)癥情況。

四、統(tǒng)計(jì)學(xué)分析

結(jié) 果

經(jīng)過平均15(6～31)個(gè)月的隨訪，MIPPO組所有骨折均獲得骨性愈合(典型病例見圖1)，而ORIF組1例出現(xiàn)骨折不愈合，且致接骨板斷裂失效，并接受再次手術(shù)治療。兩組之間失效率沒有顯著差異。MIPPO組患者的平均手術(shù)時(shí)間、術(shù)中出血量和骨折愈合時(shí)間見表2。在手術(shù)時(shí)間和出血量方面，MIPPO組明顯優(yōu)于ORIF組，MIPPO組平均骨折愈合時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義，Constant評(píng)分兩組間差異無(wú)統(tǒng)計(jì)學(xué)意義。兩組均有部分患者因?yàn)槟贻p而遵醫(yī)囑采用二次手術(shù)取出了內(nèi)固定，MIPPO組有2例體形偏瘦的患者出現(xiàn)明顯的皮膚隆起，強(qiáng)烈要求二次手術(shù)取出內(nèi)植物。

圖1 27歲男性患者，帶有楔形骨塊的鎖骨干骨折，Robinson′s分型IIB1型，行閉合復(fù)位、術(shù)中克氏針臨時(shí)固定、MIPPO技術(shù)，術(shù)后恢復(fù)良好。圖A左肩正位片提示左側(cè)鎖骨干骨折，斷端有1枚翻轉(zhuǎn)的大游離骨塊，Robinson′s分型IIB1型;圖B經(jīng)鎖骨近端主骨折塊髓腔向近端插入克氏針，穿出近端皮下，閉合復(fù)位后經(jīng)鎖骨遠(yuǎn)端髓腔從鎖骨遠(yuǎn)端后面穿出;圖C術(shù)中透視證實(shí)主骨折塊和游離骨塊的閉合復(fù)位滿意，髓內(nèi)克氏針維持復(fù)位;圖D放置解剖型接骨板，先于最遠(yuǎn)端和最近端各打入1枚鎖定螺釘，髓內(nèi)克氏針不影響最遠(yuǎn)端和最近端的各1枚螺釘置入;圖E退出克氏針，打入剩余鎖定螺釘，透視位置滿意;圖F術(shù)后復(fù)查鎖骨正位片，證實(shí)主骨折塊復(fù)位滿意并有接觸，游離骨塊獲得滿意功能復(fù)位;圖G術(shù)后16周鎖骨正位片見骨折愈合良好;圖H術(shù)后16周，患者切口瘢痕情況;圖I術(shù)后16周，左肩有滿意的上舉功能;圖J術(shù)后16周，左肩有滿意的外旋功能

組別例數(shù)手術(shù)時(shí)間(x-±s，min)手術(shù)出血量(x-±s，ml)骨折愈合時(shí)間(x-±s，周)Constant評(píng)分(x-±s，分)內(nèi)固定物取出例數(shù)(%)不愈合或失效例數(shù)(%)ORIF組2983．3±13．2043．8±13．4714．9±3．1788．8±4．439(31．03)1(3．45)MIPPO組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為傳統(tǒng)切開復(fù)位內(nèi)固定術(shù)；MIPPO為閉合復(fù)位三切口技術(shù)

討 論

多中心的隨機(jī)對(duì)照前瞻性臨床研究[1]和Meta分析均證實(shí)[7]，對(duì)移位且有游離骨塊的鎖骨干骨折進(jìn)行手術(shù)治療會(huì)獲得更好療效。究竟是板釘固定還是髓內(nèi)固定更好，一直存有爭(zhēng)議[8-10]。一些回顧性研究[11]或Meta分析[7]證實(shí)兩者療效沒有絕對(duì)區(qū)別，只是各具特點(diǎn)。目前板釘固定仍是主流術(shù)式，其固定牢固，可早期活動(dòng)[2]；缺點(diǎn)是創(chuàng)傷大，內(nèi)固定物刺激癥狀明顯，手術(shù)瘢痕重，容易破壞骨折塊的血運(yùn)而影響骨折愈合。近幾年接骨板趨向于解剖設(shè)計(jì)[1，12]，改善了內(nèi)植物刺激癥狀。也有學(xué)者將接骨板置于鎖骨前、下緣而不是上緣，雖然生物力學(xué)實(shí)驗(yàn)證實(shí)可以獲得滿意的固定[13]，但僅少數(shù)醫(yī)師愿意嘗試這種方法[14-15]。

傳統(tǒng)ORIF術(shù)中，要求對(duì)游離骨折塊采用拉力螺釘固定，這增加手術(shù)時(shí)間和難度，也影響游離骨塊血運(yùn)。由于鎖骨中段的肌肉附著并非牢固的腱性附著，而是肌肉直接疏松地附著在骨膜上，極易因拉力螺釘?shù)牟僮鞫茐挠坞x骨塊血供，容易造成延遲愈合或不愈合。另外雖然接骨板的工作長(zhǎng)度越長(zhǎng)越好，但在切開手術(shù)中采用長(zhǎng)板必然增加切口長(zhǎng)度和手術(shù)創(chuàng)傷，很多醫(yī)生會(huì)因此放棄長(zhǎng)接骨板，而采用短接骨板并緊貼骨折端打入螺釘，這對(duì)于有游離骨塊的鎖骨干骨折容易造成應(yīng)力集中，致接骨板失效。另外，傳統(tǒng)的直重建板越長(zhǎng)越不貼服，術(shù)中需要反復(fù)預(yù)彎，也增加了疲勞斷裂可能。

我們前期報(bào)道了切開復(fù)位、術(shù)中克氏針臨時(shí)固定并橋接鋼板固定技術(shù)，取得良好療效[4]。但其切口長(zhǎng)、創(chuàng)傷大，盡管是采用縫線而不是拉力螺釘固定游離骨塊，但畢竟是直視下操作，仍然會(huì)損傷骨膜等軟組織。因此，我們進(jìn)行了再改良，采用完全的閉合復(fù)位技術(shù)復(fù)位楔形骨塊，并將一個(gè)長(zhǎng)切口改為三個(gè)2cm的小切口。改良的目的是不對(duì)游離骨塊進(jìn)行任何直視下操作而進(jìn)一步保護(hù)其血運(yùn)，通過MIPPO技術(shù)進(jìn)一步減小手術(shù)創(chuàng)傷。該技術(shù)有4個(gè)主要特點(diǎn)：(1)術(shù)中上抬并向外牽引患肢上臂，通過間接復(fù)位主骨折塊和游離骨塊。由于保留了完整的骨膜和軟組織袖套，閉合復(fù)位都會(huì)使術(shù)前翻轉(zhuǎn)的游離骨塊獲得功能復(fù)位，對(duì)游離骨塊不強(qiáng)求解剖復(fù)位，只要對(duì)位對(duì)線滿意就行。這可保護(hù)血運(yùn)，增加骨折愈合幾率。(2)應(yīng)用髓內(nèi)克氏針臨時(shí)固定主骨折塊，強(qiáng)調(diào)主骨折塊之間有接觸，避免明顯的分離移位。中間切口只是利于穿針，而不要經(jīng)此小切口進(jìn)行任何直視下骨塊的復(fù)位，但可以經(jīng)此切口觸摸主骨折塊的后上方皮質(zhì)，以證實(shí)主骨折塊閉合復(fù)位滿意并互相接觸。保證主骨折塊接觸目的是利于骨折愈合。(3)采用長(zhǎng)板固定，以增加其工作長(zhǎng)度，減少因應(yīng)力集中所致骨折不愈合和接骨板斷裂的風(fēng)險(xiǎn)。我們常規(guī)選擇解剖型接骨板中最長(zhǎng)的10孔接骨板。固定時(shí)先在最遠(yuǎn)端和最近端各打入1枚鎖定螺釘固定接骨板，然后在逐漸退出克氏針的過程中打入剩余鎖釘。前期經(jīng)驗(yàn)證實(shí)，髓內(nèi)克氏針不影響接骨板最遠(yuǎn)端的1枚螺釘固定，偶爾會(huì)影響最近端的1枚螺釘固定。本組就有2例患者在進(jìn)行近端第1枚螺釘?shù)你@孔時(shí)，即遇到髓內(nèi)克氏針的阻擋，此時(shí)技巧是先打入1枚短的單皮質(zhì)鎖釘，然后將克氏針逐漸向外退出，打入其他螺釘后，最后將該單皮質(zhì)螺釘換成雙皮質(zhì)螺釘。(4)螺釘由外周向中間置入，在兩側(cè)各打入3枚鎖釘后，剩余釘孔不再置釘，以免應(yīng)力集中。當(dāng)然MIPPO技術(shù)也有其缺點(diǎn)：(1)個(gè)別肥胖患者的三個(gè)切口加起來(lái)的長(zhǎng)度并不小于單個(gè)長(zhǎng)切口。(2)鎖骨本身變異大，鋼板長(zhǎng)度增加后不完全貼服，致術(shù)后皮膚隆起。MIPPO組病例全部采用鎖釘固定，并不要求接骨板和鎖骨完全貼服，這使本組病例中有2例患者因內(nèi)植物致皮膚隆起而堅(jiān)決要求二次手術(shù)取出內(nèi)固定物。(3)其他學(xué)者采用MIPPO技術(shù)治療鎖骨干骨折時(shí)，由于復(fù)位質(zhì)量不佳[16]，致使骨折愈合時(shí)間較長(zhǎng)。我們通過中間小切口的髓內(nèi)克氏針臨時(shí)固定，來(lái)維持滿意的閉合復(fù)位和強(qiáng)調(diào)主骨折塊接觸，改善了MIPPO技術(shù)中復(fù)位欠佳、難以維持、需要多次透視的缺點(diǎn)。(4)對(duì)于罕見的兩端主骨折塊復(fù)位后無(wú)接觸的多段鎖骨干骨折病例，本技術(shù)的應(yīng)用尚無(wú)經(jīng)驗(yàn)。(5)閉合復(fù)位需要良好肌松，因此常需全身麻醉。

總之，本研究證實(shí)對(duì)于帶游離骨塊的鎖骨干中段骨折，完全可以通過閉合復(fù)位獲得滿意的游離骨塊功能復(fù)位。與傳統(tǒng)對(duì)骨折塊進(jìn)行拉力螺釘?shù)膱?jiān)強(qiáng)內(nèi)固定技術(shù)比較，MIPPO技術(shù)操作簡(jiǎn)單、創(chuàng)傷小、療效滿意。這說(shuō)明在進(jìn)行有楔形骨塊骨折固定時(shí)，不必追求游離骨塊的解剖復(fù)位和骨折塊間的堅(jiān)強(qiáng)拉力螺釘固定。當(dāng)然，本研究也存在缺點(diǎn)，如病例數(shù)相對(duì)少，隨訪時(shí)間短，屬于回顧性研究，不同術(shù)者參與了手術(shù)和對(duì)術(shù)后療效的評(píng)估可能導(dǎo)致主觀偏見等。后期將進(jìn)一步積累病例，總結(jié)經(jīng)驗(yàn)。

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(本文編輯：李靜)

楊明，司徒炫明，張殿英，等.MIPPO技術(shù)治療有楔形骨塊的鎖骨干骨折[J/CD]. 中華肩肘外科電子雜志,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

衛(wèi)生公益性行業(yè)科研專項(xiàng)(201002014、201302007)；教育部創(chuàng)新團(tuán)隊(duì)(IRT1201)；北京市科委重大專項(xiàng)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

姜保國(guó)，Email:jiangbaoguo@vip.sina.com

2014-12-11)

(Z101107052210001)；北京大學(xué)人民醫(yī)院研究與發(fā)展基金(RDB2014-01)