Observation on the clinical effect of axillary approach in the treatment of scapular fractures involving the glenoid

doi:10.21203/rs.3.rs-1612907/v1

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Research Article

Observation on the clinical effect of axillary approach in the treatment of scapular fractures involving the glenoid

https://doi.org/10.21203/rs.3.rs-1612907/v1

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Objective

To compare the clinical efficacy of the axillary approach and the pectoralis deltoid approach in the treatment of scapular fractures involving the glenoid.

Methods

A retrospective analysis of 37 cases of scapular fractures diagnosed and treated from 2017-09 to 2019-09, 15 cases were treated by axillary approach (axillary approach group), and 22 cases were treated by pectoralis major deltoid approach (pectoralis major). The deltoid approach group), and the operation time, intraoperative blood loss, hospital stay, incision length, and clinical efficacy at the last follow-up were compared between the two groups.

Results

Conclusion

The axillary approach in the treatment of scapular fractures involving the glenoid has the advantages of small incision, less intraoperative blood loss, short operation time, concealment, and stable curative effect, and is worthy of further promotion and application.

scapula fracture

glenoid

axillary approach

pectoralis major deltoid approach

clinical outcomes

Scapular fractures are relatively rare in clinical practice, accounting for 3–5% of shoulder joint fractures and about 0.5% of systemic fractures [1–2]. Fractures of the scapula are usually the result of high-energy violence, often with head or lung injury, and less often glenoid fractures are involved [3–5]. Because the front of the scapular glenoid is surrounded by the cephalic vein and brachial plexus, and the trilateral foramen and quadrilateral foramen are accompanied by the axillary nerve and circumflex scapular artery, etc., the scapular fractures involving the scapular glenoid are often accompanied by important neurovascular injuries., Surgery is usually required after injury, otherwise it may lead to shoulder joint dysfunction and even life-threatening. At present, the common surgical approaches for scapula fractures mainly include the pectoralis major and deltoid space approach, Judet approach, and the infraspinatus and teres minor space approach at the lateral border of the scapula [6]. The efficacy of pectoralis major deltoid approach in the treatment of scapular fractures involving the glenoid was compared and reported as follows.

2.1 normal information Inclusion criteria: Ideberg type I and II scapular fractures involving the scapular glenoid; time from injury to operation < 3 weeks; no severe cardiopulmonary disease and long-term history of taking steroids. Exclusion criteria: those with incomplete follow-up data; those with more underlying diseases who cannot tolerate surgery. A retrospective analysis of 37 cases of scapula fractures diagnosed and treated from 2017-09 to 2019-09, 15 cases were treated with axillary approach (axillary approach group), and 22 cases were treated with pectoralis major deltoid approach (pectoralis major deltoid approach). Muscle approach group), axillary approach group 10 males and 5 females, age (34.2 ± 6.9) years old, disease duration (6.4 ± 1.1) d, preoperative pain VAS score (6.8 ± 0.6) points; triangle of pectoralis major The muscle approach group included 15 males and 7 females, aged (35.8 ± 7.2) years, disease duration (6.1 ± 1.1) days, and VAS score of preoperative pain (6.7 ± 0.7). Comparison of gender (χ2 = 0.009, P = 0.923), age (t = 0.405, P = 0.692), disease duration (t = 0.211, P = 0.835), preoperative pain VAS score (t = 0.107, P = 0.915) between the two groups The difference was not statistically significant (P > 0.05).

This research protocol was conducted following the Declaration of Helsinki and was approved by the Ethics Committee of The People's Hospital of Shangrao City. We reviewed and collected the relevant medical records and follow-up data after obtaining informed consent from the patients.

2.2 Surgical methods Under general anesthesia, the axillary approach group was placed in a lateral decubitus position, with the affected shoulder on top, the shoulder joint was abducted at 90°, the forearm could swing freely, and the forearm and shoulder joint were routinely disinfected and draped. The incision for the axillary approach is made at the posterior border of the axilla, that is, the anterior border of the latissimus dorsi. The incision is 6–8 cm long. The skin, the superficial and deep fascia are incised in sequence, and the axillary lymph nodes and fat are pushed forward along the anterior edge of the latissimus dorsi muscle, and enter between the anterior edge of the latissimus dorsi muscle and the fat in the axilla to expose the upper quadrilateral area, and the upper quadrilateral area is the surgery. Operating window, the upper border is the axillary nerve and the posterior circumflex artery, the lower border is the circumflex scapular artery, the anterior border is the subscapularis vein, the posterior border is the latissimus dorsi tendon and the teres major muscle, and the fracture line of the lateral border of the scapula is exposed; the middle trilateral area is exposed., and mark the superior circumflex scapular artery, anterior thoracic dorsal nerve vessels, posterior latissimus dorsi muscle, and teres major muscle; reveal the lateral border of the scapula and the fracture end; reveal the lateral border of the scapula and the fracture line in the middle trilateral area, and reduce the fracture under direct vision After the block, Kirschner wire was temporarily fixed, and then the anatomical reconstruction plate was used to strengthen the fixation to ensure the smoothness of the articular surface. During the operation, C-arm X-ray machine was used to confirm the anatomical reduction of the fracture, the internal fixation position was good, the drainage tube was routinely placed, and the incision was sutured layer by layer.

The patients in the pectoralis major deltoid approach group were placed in the supine position, a 10–15 cm long incision was made along the deltoid pectoralis major space, the skin, subcutaneous tissue, and superficial fascia were incised in sequence, the cephalic vein was separated and protected, and the cephalic vein was retracted medially. The pectoralis major muscle is retracted laterally, the fascia on the surface of the joint tendon is incised, the subscapularis muscle is exposed, the subscapularis muscle is split along the direction of the muscle fibers, the shoulder joint capsule is exposed, and the joint capsule is cut longitudinally to expose the shoulder Inside the joint, reduction and internal fixation of the fracture are performed under direct vision. After C-arm X-ray fluoroscopy was used to confirm that the fracture end was well reduced and the internal fixation position was correct, the joint capsule was sutured, drainage tubes were routinely placed, and the incision was sutured layer by layer.

2.3 Post-operative treatment Cefuroxime, celecoxib and other drugs were routinely used within 24 hours after operation, passive functional exercise of shoulder joint was started 3 days after operation, and shoulder anteroposterior X-ray and CT film were reviewed to observe the curative effect. The drainage tube was removed 2 or 3 days after the operation according to the drainage situation. The incision was changed regularly and the healing condition was paid attention to, and the sutures were removed 10 to 14 days after the operation. Active functional exercise of the shoulder joint was gradually carried out within 2 weeks after operation. After the X-ray film was reviewed 6 weeks after the operation to confirm the appearance of callus, the active and passive functional exercise of the shoulder joint in all directions was further strengthened, and regular reexamination was performed.

2.4 Observations and Statistical Methods Observation indicators and statistical methods The operation time, intraoperative blood loss, hospital stay, incision length and clinical efficacy at the last follow-up were compared between the two groups [7]. SPSS 22.0 software was used for statistical analysis of data. Measurement data that conformed to normal distribution were expressed as mean ± standard deviation (x ± s) and two independent samples t test was used. The count data were compared by χ2 test, with P < 0.05 as the difference. statistically significant.

Both groups successfully completed the operation and obtained complete follow-up. The follow-up time was 12–18 months, with an average of 15.2 months. All fractures healed at the last follow-up, and the fracture healing time was 2 to 6 months, with an average of 3.2 months. Compared with the pectoralis major deltoid approach group, the operation time, intraoperative blood loss, and hospital stay in the axillary approach group were shorter than those in the pectoralis major deltoid approach group, and the incision length was smaller than that in the pectoralis major deltoid approach group, and the differences were statistically significant (P < 0.05). See Table 1. There was 1 case of axillary nerve injury in the pectoralis major deltoid approach group after operation, and symptomatic treatment was given. The nerve injury had improved significantly at the last follow-up. At the last follow-up, according to the Neer shoulder joint function score, the results were excellent in 10 cases and good in 5 cases in the axillary approach group; excellent in 9 cases and good in 7 cases in the pectoralis deltoid approach group, and the excellent and good rate in the axillary approach group was higher than that in the chest The muscle deltoid approach group was higher, and the difference was statistically significant (χ2 = 4.883, P = 0.030).

Chart 1 Comparison of operative time, intraoperative blood loss, hospital stay, and incision length between the axillary approach group and the pectoralis major deltoid approach group (x ± s)

Scapular fractures are relatively rare in clinical practice. In early treatment, due to patients' unclear description of their symptoms and insufficient understanding of scapular fractures by physicians, the misdiagnosis rate and missed diagnosis rate are high [8–10]. Therefore, how the scapula fracture is diagnosed at an early stage is the key to affecting the function of the shoulder joint. Imaging data are the key to early diagnosis of scapula fractures, including scapula frontal and lateral X-rays, shoulder CT three-dimensional reconstruction, etc. Through these data, the whole picture of the scapula and its corresponding relationship with the shoulder joint can be observed [11–12]. However, the scapula is a wide and flat irregular bone, located on the upper side of the thoracic cavity. X-ray films can see that the scapula overlaps with the ribs and the clavicle. Therefore, it is difficult to find the fracture of the scapula body with a simple frontal and lateral X-ray of the shoulder joint. CT three-dimensional reconstruction of shoulder joint can not only fully show the degree and direction of fracture displacement, but also has important significance for the judgment of fracture shape, type and surgical approach [13].

In the past, due to the lack of anatomical knowledge of the scapula and the lack of clinical experience, when a scapula fracture occurs, most scholars usually advocate non-surgical treatment, including pain relief, local immobilization, and suspension fixation. However, long-term immobilization can lead to shoulder joint adhesion or malunion of the scapula, which can lead to traumatic arthritis of the shoulder joint, resulting in limited movement of the shoulder joint, which seriously affects the quality of work and life of patients. For scapula fractures, the conventional surgical approaches mainly include anterior approach, posterior approach, and posterior-superior approach [14]. Yu Baoqing[15] believed that the selection of surgical approach for scapula fractures should follow the principle of the same injury site and approach. For complex fractures combined with anterior and posterior injuries, the combined approach of the anterior and posterior scapula should be selected according to the stability of the fracture and the function of the shoulder joint.. The patients included in this study were all Ideberg type I and II scapular fractures involving the glenoid, and the injury site was mainly anterior. Although the traditional anterior approach to the pectoralis major deltoid muscle can reveal the anterior injury, due to the limited visual field and the scapula The anatomical characteristics of the glenoid often have many problems: the anterior approach is not enough to expose the fracture ends of the subglenoid and posterior glenoid, and only a small part of anterior glenoid fractures can be solved; when the anterior approach is used for fracture fragment fixation, the direction of the screw It is often impossible to form a vertical relationship with the fracture line, resulting in difficult fixation and unsatisfactory fixation effect. In addition, the anterior approach causes great damage to the tissues around the shoulder joint, and is often associated with subscapularis muscle atrophy. Poor functional recovery and unsightly incision.

Axillary approach surgery is an innovative approach proposed by Chinese scholars for the first time. Its incision has the advantages of beautiful appearance and concealment. In the process of exposing the operative field, the operation is highly maneuverable and has little damage. The vascular space is entered without cutting the subscapularis tendon. The joint capsule and joint cavity can be exposed by the upward extension, and the lateral border of the scapula can be exposed by the downward extension. There is no need to expose the brachial plexus and axillary blood vessels, and the axillary lymph nodes will not be damaged. After the fracture site is exposed, the thick cortical bone on the lateral border of the scapula can form a good support for the glenoid, and the fracture end can be reduced by local anatomic reduction and functional fixation under direct vision, which not only shortens the operation time, but also reduces the operation time. Medium bleeding. According to the type of fracture, appropriate bone plates and screws can be selected for fixation, so that the purpose of fully exposing the fracture end and obtaining strong internal fixation can be achieved through a small surgical incision. The results of this study showed that the operative time, intraoperative blood loss and hospital stay in the transaxillary approach group were shorter than those in the pectoralis major deltoid approach group, and the incision length was shorter than that in the pectoralis major deltoid approach group, and the differences were statistically significant (P < 0.05), demonstrating the advantages of the axillary approach. The following points should be paid attention to when using the axillary approach for the treatment of scapula fractures: ①The incision should be made at the anterior and upper edge of the axillary fold, and the axilla should be on the posterior side, which can reduce the stimulation of the scar tissue to the axilla during sweating; ② the axilla The key to the surgical approach is to fully expose the axillary nerve and the posterior circumflex artery to protect them and avoid iatrogenic neurovascular damage; ③Through the 3D model printing technology, the 3D printing model of the scapula fracture is accurately reconstructed, and the printing model is used to accurately reconstruct the 3D printing model of the scapula fracture. Measure the intraoperative fixation screw hole point, deduce the direction of the intraoperative screw and reconstruction plate, reduce the difficulty of the operation, and reduce the number of intraoperative fluoroscopy[16–17]; ④After the fracture end is fully exposed, Kirschner wire can be used to temporarily fix the fracture. For stable fracture fragments, reduce and fix the fracture end under direct vision. The operator should control the position and direction of the screw, and the C-arm X-ray machine should assist in fluoroscopy to prevent the screw from entering the glenoid.

Due to the diverse locations and types of scapular fractures, it is still necessary to select an appropriate surgical approach according to the type of fracture and specific circumstances in clinical work [18–19]. Since the axillary approach surgery is relatively new, the author only applies it to Ideberg type I and II glenoid fractures. At the last follow-up, the axillary approach group achieved good recovery results of the shoulder joint after surgery. The author believes that the clinical effect of this operation is very accurate. On the premise of meeting the requirements for surgical indications and fracture types, it is recommended to give priority to the use of the axillary approach for the treatment of scapular fractures or bony Bankert injuries involving the glenoid. Research.

Ethical approval and consent to participate

The study was approved by the Medical Ethical Committee of the Shangrao People's Hospital. Informed consent was obtained from all patients before enrolled in the study.

Consent for publication

All the authors listed have approved the manuscript that is enclosed.

Competing interests

The authors declare that they have no competing interests.

Authors’contributions

All authors made signifcant contributions to the writing and editing process.

All authors read and approved the fnal manuscript.

Funding

Not applicable.

Availability of data and materials

The data used for analysis in our study are available from the corresponding author on reasonable request.

Tatro JM, Schroder LK, Molitor BA, et al. Injury mechanism, epidemiology, and hospital trends of scapula fractures: a 10-year retrospective study of the national trauma data bank[J]. Injury,2019,50(2):376–381.
Court BCM, Clement ND, Duckworth AD, et al. The changing epidemiology of fall-related fractures in adults[J]. Injury,2017,48(4):819–824.
Bai Xiaodong, Chen Wentao, Liu Zhenyu, et al. Observation of the curative effect of Brodsky approach in the treatment of scapular fracture with plate and screw fixation [J]. Chinese Journal of Bone and Joint Injury, 2021,36(7):736–738.
Xu Lijun, Duan Jun, Li Daming, et al. Clinical observation of scapula straight incision and internal fixation in the treatment of scapular fractures [J]. China Journal of Bone and Joint Injury, 2019,34(11):1186–1187.
Nunes SR, Filho MRF, Fernandes MR. Acromion fracture and lateral angle of the scapula spine: case report and literature review[J]. Int J Surg Case Rep,2019,60:353–357.
LIU Fengxiang, TANG Jian, GONG Weihua, et al. Treatment of scapular fractures by modified posterior shoulder approach [J]. Chinese Journal of Bone and Joint Surgery, 2018,11(10):768–777.
Jia Jian, et al. Classification and surgical treatment of scapula fractures[J]. Chinese Journal of Orthopedics, 2003,23(2):39–43.
Lantry JM, Roberts CS, Giannoudis PV. Operative treatment of scapular fractures: a systematic review[J]. Injury,2008,39(3):271–283.
Kannan S, Singh HP, Pandey R. A systematic review of management of scapular fractures[J]. Acta Orthop Belg,2018,84(4):497–508.
Vidovic D, Bencic I, Cuti T, et al. Surgical treatment of scapular fractures: results and complications injury[J]. Injury,2020,52(20):38–43.
Esenkaya I, Unay K. Anatomical frame plate osteosynthesis in Ada-Miller Type 2 or 4 scapula fractures[J]. Acta Orthop Traumatol Turc,2011,45(3):156–161.
Mallon WJ, Brown HR, Vogler 3rd JB, et al. Radiographic and geometric anatomy of the scapula[J]. Clin Orthop Relat Res,1992,277:142–154.
Dugarte AJ, Tkany L, Schroder LK, et al. Comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures[J]. J Orthop Res,2018,36(1):265–271.
Guo Qinghe, Chen Aimin, Ye Tianwen, et al. Analysis of the curative effect of surgical treatment of 23 cases of scapular fractures[J]. Journal of Clinical Orthopedics, 2011,14(6):666–668.
Yu Baoqing. Surgical approach for scapula fractures[J] Chinese Journal of Shoulder and Elbow Surgery, 2016,4(3):192.
Tatro JM, Gilbertson JA, Schroder LK, et al. Five to ten-year outcomes of operatively treated scapular fractures[J]. J Bone Joint Surg Am,2018,100(10):871–878.
Shi Huiming, Wang Fei, Hu Yuanjun, et al. Scapula measurement based on 3D model and scapula plate design [J]. Chinese Journal of Clinical Anatomy, 2018,36(4):387–391.
LIU Fengxiang, TANG Jian, GONG Weihua, et al. Treatment of scapular fractures by modified posterior shoulder approach [J]. Chinese Journal of Bone and Joint Surgery, 2018,11(10):768–771.
Zhou Dongsheng, Li Lianxin, Wang Lubo, et al. Modified Judet surgical approach for the treatment of complex scapular fractures[J]. Chinese Journal of Surgery, 2006,44(24):1686–1688.

No competing interests reported.

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Observation on the clinical effect of axillary approach in the treatment of scapular fractures involving the glenoid

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Abstract

Objective

Methods

Results

Conclusion

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1. Introduction

2. Materials And Methods

3. Result

4. Discuss And Conclusion

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