沈施耘王棟梁張炯豪何繼業(yè)彭建平張家紅

·論著·

肱骨頭骨折塊體積與治療方法的相關性研究

沈施耘1王棟梁2張炯豪3何繼業(yè)2彭建平2張家紅2

目的探討肱骨頭骨折塊性質與手術方法、預后之間的相關性，并獲得支持手術方法選擇的相關參數(shù)。方法自2013年1月至2015年12月上海交通大學醫(yī)學院附屬新華醫(yī)院骨科連續(xù)收治的49例肱骨近端四部分骨折患者，最終44例獲得隨訪，其中男21例，女23例，年齡范圍：58～89歲，平均（78.09±2.52）歲，其中32例行切開復位內固定術（open reduction and internal fixation，ORIF），12例行半肩關節(jié)置換術（hemi-arthroplasty，HA）。術前均行肩關節(jié)三維CT重建，分別測量出肱骨頭骨折塊體積與肱骨頭的體積，所得的加權比值擬代表肱骨頭骨折塊的性質?；颊咝g后功能的評價采用美國肩與肘協(xié)會評分系統(tǒng)（American shoulder and elbow surgeons'form，ASES）評分，隨訪時間12～58個月，平均（29.26±2.58）個月。結果行ORIF的32例患者，術后ASES評分40.0～85.0分，平均（66.78±4.51）分，優(yōu)良率為68.7%（22例）；行HA的12例患者，術后ASES評分18.0～88.0分，平均（61.83±12.34）分，優(yōu)良率為41.6%（5例）。對肱骨頭骨折塊性質與肩關節(jié)功能的相關性分析顯示，ORIF后，兩者間存在線性關系（P＜0.01），而HA后兩者間無明顯相關性。結論肱骨頭骨折塊體積比＞54.46%的四部分骨折，ORIF較HA功能恢復更佳。肱骨頭骨折塊體積比 ＜54.46%的四部分骨折，尤其是當患者年齡較大伴骨質疏松時，HA預后較好。

肱骨近端粉碎性骨折； 手術方法； 預后； 半肩關節(jié)置換術； 鎖定鋼板

肱骨近端骨折在全身骨折中約占5%[1］，其中80%的患者通過非手術治療可獲得較為滿意的結果[2］。但對于不穩(wěn)定的骨折，保守治療可能導致嚴重的畸形和肩關節(jié)功能障礙[3］，具體的手術方式較多，但都具有一定的并發(fā)癥發(fā)生率，其中切開復位內固定術（open reduction internal fixation，ORIF）和半肩關節(jié)置換術（hemiarthroplasty，HA）是有效而常用的方法。

目前臨床被廣泛使用的鎖定鋼板能較好地固定松質骨骨折塊[4］，多數(shù)患者獲得了良好的功能恢復。但對于復雜的肱骨近端骨折，總體治療效果仍不甚理想[5］。HA一般用于骨質差或粉碎程度嚴重的老年患者。雖然有報道認為HA術后患者功能的恢復并不十分理想[6］，且ORIF相對HA術后短期并發(fā)癥更少，術后功能更好[7-8］。但也有報道顯示HA相較ORIF能獲得更好的肩關節(jié)活動度[9］，而肩袖的完整程度往往起到了重要的作用[10］。

本研究擬探討通過影像資料來測量肱骨頭骨折塊體積，評估其與手術方法選擇及其預后之間的相關性，并獲得支持手術方法選擇的相關參數(shù)。

資料與方法

一、 一般資料

自2013年1月至2015年12月本院連續(xù)收治符合篩選標準的49例肱骨近端四部分骨折患者，5例失聯(lián)，其中2例拒絕接受隨訪，3例因與本次手術無關的原因死亡。其余44例中，男21例，女23例，年齡：58～89歲，平均（78.09±2.52）歲。其中32例患者接受ORIF，12例患者接受HA。手術均由2名有豐富肩關節(jié)手術經驗的副主任以上醫(yī)師完成?；颊哂谛g前常規(guī)行患側肱骨近端正側位X線片以及肩關節(jié)三維重建CT，術后僅復查肩關節(jié)X線正側位片。患者隨訪時間12～58個月，平均（29.26±2.58）個月。

二、納入及排除標準

納入標準：①急性、閉合性肱骨近端粉碎性骨折（根據(jù)Neer分類系統(tǒng)四部分骨折）；②患者年齡超過18歲；③患者無神經功能損傷。

排除標準：①病理性骨折和開放性骨折；②合并有其他四肢骨折的患者；③肱骨頭骨折塊關節(jié)面不完整。

三、測量與計算方法

1.測量與計算：數(shù)據(jù)的測量均采用Unisight（3.0）軟件進行，為避免個體差異對試驗結果的影響，實際測得的肱骨頭骨折塊體積均加權以消除此差異，所得的加權比值R代表肱骨頭骨折塊的體積。

圖1 肱骨頭骨折塊在一個層面上面積的測量

圖2 肱骨頭標準體積在一個層面上面積的測量

2.體積Vm的測量及加權值R的計算：在三維CT重建圖像上（圖1～2）選取骨折塊截面，軟件自動測量選取范圍面積Sm，分別測量出肱骨頭骨折塊各斷面面積后，使用微積分法計算出骨折塊體積Vm。同時，在各個掃描斷面上連接肱骨頭關節(jié)面兩側邊界點以及關節(jié)面，用同樣的方法計算出完整肱骨頭的體積V。

Vm：肱骨頭骨折塊體積；Sm：骨折塊截面面積；V：肱骨頭體積；S：肱骨頭截面積；H：CT層厚；n：掃描層數(shù)。

四、手術方法及術后康復練習

1.ORIF（PHILOS?）：均采用全身麻醉，沙灘椅位，標準胸大肌三角肌入路，并使用縫線技術加強固定。術后用前臂吊帶懸吊，術后第1天即開始手腕關節(jié)和肘關節(jié)的主動活動；術后第2天拔除引流管后開始聳肩和鐘擺樣運動；術后3周增加患肢的被動活動，包括前屈、后伸運動，內收、內旋運動，外展、外旋運動；術后6周X線復查發(fā)現(xiàn)明顯骨痂形成后可開始肩關節(jié)周圍肌肉的力量和順應性鍛煉。

2.HA（ZIMMER?）：手術體位及入路同ORIF，按照ZIMMER?放置標準操作，術后將肩關節(jié)放置于外展45°，旋轉中立位，術后即開始患肢肌肉的等長收縮；術后第2天拔除引流管后開始聳肩活動和漸進鐘擺樣運動；術后3周開始行被動前屈、后伸、內旋、外旋及外展活動（同ORIF組）；術后6周行X線檢查，發(fā)現(xiàn)有結節(jié)間骨痂形成后，開始肩關節(jié)漸進性主動鍛煉，并逐步增加肩關節(jié)的活動度；術后12周開始行肩關節(jié)牽拉和抗阻力訓練，并逐漸增加肩關節(jié)周圍肌肉群的協(xié)調性和順應性。

五、評價指標

功能評估根據(jù)美國肩與肘協(xié)會評分系統(tǒng)（American shoulder and elbow surgeons'form，ASES）評分，它由兩部分組成：患者的疼痛感覺（50%）和日常功能活動（50%）。滿分為100分，0～54分為差，55～69分為中，70～84分為良，85～100分為優(yōu)。

結 果

一、AESE評分結果

32例行ORIF的患者，ASES評分40.0～85.0分，平均（66.78±4.51）分；12例行HA的患者，術后ASES評分18.0～88.0分，平均（61.83±12.34）分，其中1例（8.3%）為優(yōu)、4例（33.3%）良好、4例（33.3%）中等、3例（25.0%）較差。

二、統(tǒng)計學分析結果

1. ORIF后患者相關數(shù)據(jù)的統(tǒng)計學分析：將肱骨頭骨折塊體積加權值R與肩關節(jié)術后ASES評分進行正態(tài)檢驗，P＞0.01，表明符合二元正態(tài)分布，故可作線性相關與線性回歸。使用SAS軟件（V9.4）分析發(fā)現(xiàn)，加權后肱骨頭骨折塊的體積與術后ASES評分存在線性關系，P ＜0.01，可見肱骨頭骨折塊體積與ORIF肩關節(jié)的功能評分間存在線性關系，隨后求得線性回歸方程 ：y=34.60+0.50x，R2=0.82，P ＜0.01（方程 1）。

2. HA后患者相關數(shù)據(jù)的統(tǒng)計學分析:將肱骨頭骨折塊體積加權值與肩關節(jié)功能進行正態(tài)性檢驗，P＞0.01，表明符合二元正態(tài)分布，故可作線性相關與線性回歸。使用SAS軟件（V9.4）作線性相關分析，肱骨頭骨折塊體積與術后ASES評分相關性P=0.032，即肱骨頭骨折塊性質與HA后肩關節(jié)的功能之間不存在線性關系，故不可作線性回歸分析；但因體積與術后ASES評分符合二元正態(tài)分布，故可采用均數(shù)61.83±12.35代表其平均值。

三、并發(fā)癥

ORIF組未發(fā)現(xiàn)有內固定失敗、神經損傷或深部感染的患者，患者由于鎖定鋼板位置偏高出現(xiàn)了肩峰下撞擊1例，肱骨頭缺血性壞死1例，螺釘松動1例，骨折延遲愈合2例（其中1例接受手術，1例最終愈合）；HA組未出現(xiàn)假體周圍骨折、異位骨化、神經損傷或深部組織感染，出現(xiàn)人工假體關節(jié)松動1例，未行翻修手術。

討 論

手術治療肱骨近端粉碎性骨折是復雜而具有挑戰(zhàn)性的，ORIF和HA是較為成熟而常用的術式。雖經多年的臨床實踐，手術方法的選擇依然存在爭議[11］，ORIF和HA各具優(yōu)點的同時，也都存在相當比率的并發(fā)癥發(fā)生率[12］。

鎖定鋼板的使用克服了許多傳統(tǒng)鋼板的不足，發(fā)散的螺釘對疏松的骨質有更大的把持力，盡可能降低復位丟失的幾率。穩(wěn)定的固定后，患者能早期進行功能鍛煉，降低術后關節(jié)粘連的發(fā)生率，改善了肩關節(jié)活動度，從而獲得理想的肩關節(jié)功能。多位學者的臨床試驗也都證明，肱骨近端骨折行鎖定鋼板內固定后可獲得比較理想的功能預后[13-16］。

HA較適合骨折粉碎程度嚴重或存在明顯骨質疏松的患者[6］，這樣的患者往往復位較為困難或內固定后穩(wěn)定性較差。Popescu等[17］的研究認為大多數(shù)患者行HA后，其肩關節(jié)功能和活動范圍不佳。Bastian等[6］的研究顯示，肱骨近端粉碎性骨折術后的功能恢復，HA略差于ORIF，這種差異可能是由于不同的年齡和性別所致。雖然對術后功能的恢復存在爭議[18-20］，但HA對患者疼痛的緩解卻是得到廣泛認可的。

盡管已有許多學者對肱骨近端骨折手術方法選擇做了相關研究，但肱骨頭骨折塊的體積與手術方法選擇是否有相關性尚未見報道。

隨著肱骨頭骨折塊體積的增加，患者ORIF后ASES功能評分均隨之上升，并且經SAS軟件計算統(tǒng)計，它們之間存在線性關系，而在HA后的患者中，沒有得到存在相關性的依據(jù)。

12例行HA的患者，術后ASES評分平均值為（61.83±12.35）分，代入方程1，當y=61.83時，x=54.46，即統(tǒng)計學上，當肱骨頭骨塊體積大于54.46%時，ORIF會有大于61.83的評分，此時ORIF后肩關節(jié)功能較HA后好。故可以認為，這些患者建議選擇ORIF，反之則建議選擇HA。

行ORIF的患者，若骨折粉碎較嚴重，特別對于高齡骨質明顯疏松患者，易致骨折復位丟失。Spross等[21］報道 PHILOS?鋼板難以固定 Neer 4型骨折，他認為鋼板不能提供長期的穩(wěn)定性，容易導致骨折內翻移位。而本研究顯示，在四部分骨折患者中，當肱骨頭骨折塊體積比大于54.46%時，鎖定鋼板多能提供足夠的穩(wěn)定性，即便出現(xiàn)骨折內翻移位，其肩關節(jié)功能仍較HA后為好。

行HA的患者，除假體放置位置外，肩袖的質量對于HA后的功能康復也至關重要[10］。高齡患者接受HA后，盡管能顯著緩解疼痛，但功能結果往往并不令人滿意。Wild等[22］報道ORIF相對HA，有更為理想的手術效果，并認為如果HA的術后功能不佳，往往與旋轉肩袖的完整性、高齡、大小結節(jié)的難以解剖復位、軟組織過度剝離、假體位置不佳等因素有關。研究結果顯示四部分骨折患者肱骨頭骨塊折體積比小于54.46%時，HA后肩關節(jié)功能可優(yōu)于ORIF。目前，反肩關節(jié)置換術在國外大量開展，其手術效果也得到了廣泛的肯定，但由于價格昂貴，國內的應用受到了限制，如HA后關節(jié)功能差，特別是伴有肩袖功能障礙時，反肩關節(jié)置換術可能是唯一的挽救方法[23］。

從術后的并發(fā)癥上可以看到有1例患者出現(xiàn)肩峰下撞擊，這可能是由于鋼板放置的位置偏高引起的。1例肱骨頭缺血性壞死的患者其肱骨頭骨折塊的體積較小，而肱骨頭血供破壞較為嚴重，該患者術前肱骨頭骨折塊完全脫位，應高度懷疑肱骨頭血供嚴重破壞，需進一步考慮HA。1例鋼板松動與過早的開始肩關節(jié)負荷有關，對這類患者應加強術后隨訪，增加其順應性。鋼板松動還可能與術中反復調整螺釘位置有關，螺釘位置調整后，原螺釘孔處的骨質強度明顯降低。1例假體松動考慮與患者未按要求行康復訓練有關。

本研究尚存不足，一是部分患者失訪（失訪5例）；二是行HA的患者總例數(shù)僅12例，病例數(shù)較少。本研究顯示肱骨頭骨折塊的性質與術后肩關節(jié)功能無線性關系，但隨著例數(shù)的增加不排除存在相關性的可能，此時可取兩直線的交點，作為手術方法選擇的臨界點。研究本身的不足在于它是一個回顧性的研究，所以缺乏隨機對照性，一些粉碎嚴重的肱骨近端骨折或者老年骨質明顯疏松的患者多采用了HA而沒有行ORIF，相對而言，行ORIF的患者骨折粉碎程度較輕，可能導致ORIF后的功能較實際更好，而HA后的功能較實際更差。

綜上所述：①肱骨頭骨折塊體積比＞54.46%的四部分骨折，ORIF較HA功能恢復更佳；②肱骨頭骨折塊體積比 ＜54.46%的四部分骨折，尤其是當患者年齡較大伴骨質疏松時，HA預后較好；③本研究擬為肱骨近端粉碎性骨折手術方法的選擇提供理論依據(jù)。

[1]Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures[J］. Clin Orthop Relat Res,2006, 442: 87-92.

[2]Tamimi I, Montesa G, Collado F, et al. Displaced proximal humeral fractures: when is surgery necessary?[J］. Injury,2015, 46（10）: 1921-1929.

[3]Hessmann M, Baumgaertel F, Gehling H, et al. Plate fixation of proximal humeral fractures with indirect reduction: surgical technique and results utilizing three shoulder scores[J］.Injury, 1999, 30（7）: 453-462.

[4]Bj?rkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year[J］. Acta Orthop Scand, 2004, 75（6）: 741-745.

[5]Parmaksizo?lu AS, S?kücü S, Ozkaya U, et al. Locking plate fixation of three- and four-part proximal humeral fractures [J］.Acta Orthop Traumatol Turc, 2010, 44（2）: 97-104.

[6]Bastian JD, Hertel R. Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: Outcomes in a consecutive case series[J］. J Shoulder Elbow Surg, 2009, 18（2）: 216-219.

[7]Cvetanovich GL, Chalmers PN, Verma NN, et al. Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures[J］.J Shoulder Elbow Surg, 2016, 25（4）: 624-631.

[8]Dai J, Chai Y, Wang C, et al. Meta-analysis comparing locking plate fixation with hemiarthroplasty for complex proximal humeral fractures[J］. Eur J Orthop Surg Traumatol, 2014, 24（3）: 305-313.

[9]Cai M, Tao K, Yang C, et al. Internal fixation versus shoulder hemiarthroplasty for displaced 4-part proximal humeral fractures in elderly patients[J］. Orthopedics, 2012, 35（9）:e1340-e1346.

[10]Hashiguchi H, Iwashita S, Ohkubo A, et al. The outcome of hemiarthroplasty for proximal humeral fractures is dependent on the status of the rotator cuff [J］. Int Orthop, 2015, 39（6）:1115-1119.

[11]Price MC, Horn PL, Latshaw JC. Proximal humerus fractures[J］. Orthop Nurs, 2013, 32（5）: 251-258.

[12]K?nigshausen M, Kübler L, Godry H, et al. Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?[J］. Injury, 2012, 43（2）: 223-231.

[13]Erasmo R, Guerra G, Guerra L. Fractures and fracturedislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos（?） locking plate[J］.Injury, 2014, 45（6）: S43-S48.

[14]Sun JC, Li YL, Ning GZ, et al. Treatment of three-and four-part proximal humeral fractures with locking proximal humerus plate[J］. Eur J Orthop Surg Traumatol, 2013, 23（6）: 699-704.

[15]Panchal K, Jeong JJ, Park SE, et al. Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft[J］. Int Orthop, 2016,40（3）: 569-577.

[16]Matejci? A, Vidovi? D, Ivica M, et al. Internal fixation with locking plate of 3- and 4-part proximal humeral fractures in elderly patients: complications and functional outcome[J］.Acta Clin Croat, 2013, 52（1）: 17-22.

[17]Popescu D, Fernandez-Valencia JA, Rios MA, et al. Internal fixation of proximal humerus fractures using the T2-proximal humeral nail[J］. Arch Orthop Trauma Surg, 2009, 129（9）:1239-1244.

[18]Agarwal S, Rana A, Sharma RK. Functional outcome after primary hemiarthroplasty in three or four part proximal humerus fracture: A short term followup[J］. Indian J Orthop, 2016, 50（6）: 590-594.

[19]Leblanc JE, Macdermid JC, Faber KJ, et al. Outcomes after hemiarthroplasty for proximal humerus fracture are significantly affected by hand dominance [J］. J Orthop Trauma, 2015, 29（8）: 379-383.

[20]Cuff DJ, Pupello DR, Santoni BG. Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up[J］. J Shoulder Elbow Surg,2016, 25（11）: 1803-1809.

[21]Spross C, Platz A, Erschbamer MA, et al. Surgical treatment of neer group VI proximal humeral fractures retrospective comparison of PHILOS （R） and hemiarthroplasty[J］. Clin Orthop Relat Res, 2012, 470（7）: 2035-2042.

[22]Wild JR, Demers A, French R, et al. Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures [J］.Orthopedics, 2011, 34（10）: e629-e633.

[23]Szerlip BW, Morris BJ, Edwards TB. Reverse shoulder arthroplasty for trauma: when, where, and how[J］. Instr Course Lect, 2016, 65: 171-179.

Study on the correlation between fragment volume and treatment methods of humeral head fractures

Shen Shiyun1, Wang Dongliang2, Zhang Jionghao3, He Jiye2, Peng Jianping2, Zhang Jiahong2.1Shanghai Jiao Tong University School of Medicine, Shanghai 200025,China;2Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine,Shanghai 200092, China;3Department of Orthopaedic Surgery, Jing'an District Centre Hospital of Shanghai, Shanghai 200040, China

Wang Dongliang, Email: wang02-73@126.com

BackgroundProximal humerus fractures account for approximately 5% of all fractures, and 80% of them can achieve satisfactory results with nonoperative methods. However, the conservative treatment for unstable fractures may lead to severe deformity and shoulder dysfunction. There are multiple specific surgical methods, but complications usually happen. The open reduction and internal fixation （ORIF）and hemiarthroplasty（HA）are two effective strategies that are commonly used.Currently, the widely used locking plate can well stabilize the cancellous bone fragment in clinic, and most of the patients achieve good functional recovery. However, the overall treatment outcome is still not satisfactory for complex proximal humeral fractures. HA is generally used in elderly patients with poor bone quality or severe comminution. Although previous reports showed unsatisfactory functional recovery of patients after HA and fewer short-term complication and better function of ORIF compared to HA, somereport showed that HA achieves better shoulder mobility than ORIF does. More importantly, the integrity of rotator cuff often plays an important role. In this study, the fragment volume of humeral head was measured based on imaging data in order to obtain the parameters that support the selection of surgical methods and to access the correlation in between.Methods（1） General information. From January 2013 to December 2015, 49 patients with comminuted proximal humeral fractures were treated in our hospital. Among them, 5 cases lost contact; 2 cases refused to be followed up; 3 cases died because of reasons unrelated to this operation. 21 males and 23 females comprised the other 44 treated cases, and the ages ranged from 58 to 89 （78.09±2.52） years. Within the treated group, 32 cases

ORIF, and 12 cases received HA. All operations were performed by two associate chief physicians who had sufficient experiences in the shoulder joint surgery. Before the operation, all patients took the routine X-ray film of proximal humerus in anteroposterior lateral views and 3D reconstruction CT. Only the X-ray film of anteroposterior lateral views were taken postoperatively. Patients were followed up for 12-58 （29.26±2.58） months. （2）Inclusive and exclusive criteria. Inclusion criteria:① acute and closed comminuted proximal humeral fractures（according to Neer classification of 4 parts fractures）;② over 18 years old;③ no neurological impairment.Exclusive criteria: ① pathological or open fractures;② combined fractures of other limbs;③ incomplete articular surface of humeral head fragments.（3） Methods.① Measurement and calculation: The data were measured with the Unisight 3.0 software. In order to avoid the impact of individual differences on the test result, the actual measurement of humeral head fracture volume was weighted. The weighted ratio R represented the volume of humeral head. ② Calculations of volume Vm and weighted R: The fragment section was selected on 3D reconstruction images, and the corresponding selected area Sm was automatically calculated. The cross - sectional area of humeral head fragment was measured respectively to calculate the fragment volume using calculus. Meanwhile, the articular surface of the humeral head and its boundary points were connected on each scanning section, and the volume V of entire humeral head was calculated using the same strategy. R=Vm/V*100%. Vm= Sm1H+Sm2H+Sm3H+Sm4H+…+SmnH=H∑sm1smn. V=S1H+S2H+S3H+S4H+…+SnH=H∑s1sn. Vm: volume of humeral head fragment;Sm: sectional area of fracture fragment; V: volume of humeral head; S: sectional area of humeral head; H:thickness of CT layer; n: number of scanning layer. （4） Operative methods and postoperative rehabilitation exercises.① ORIF（PHILOS?）：All patients were applied with general anesthesia and put in beach chair position. The standard deltopectoral approach was taken, and the suture technique was used to strengthen fixation. The affected arm was suspended postoperatively using forearm sling. The wrist and elbow joint were allowed with active movements starting from the first day after operation; the shrug and pendular exercises were allowed starting from the second day after operation （after the removal of drainage tube） ; the passive movements were introduced 3 weeks after operation, including anteflexion, extension,adduction, abduction, internal rotation and external rotation; the strength and compliance exercises around shoulder muscles started once the obvious callus formation was found under fluoroscopy 6 weeks after operation.② HA （ZIMMER?）：The operation position and approach were same as those of ORIF, which were operated based on the ZIMMER?. After the operation, the shoulder joint was placed in rotating neutral position with 45°of abduction. The isometric muscle contraction of affected limb began right after surgery;the shrug and pendular exercises were allowed starting from the second day after operation （after the removal of drainage tube） ; passive anteflexion, extension, adduction, abduction, internal rotation and external rotation were introduced 3 weeks after operation （the same as ORIF group）; the gradual active exercises with increasing shoulder joint mobility began once the callus formation between nodules were found under fluoroscopy 6 weeks after operation; the shoulder traction and resistance training were started 12 weeks after surgery, and the coordination and compliance of muscle groups around the shoulder were enhanced gradually.（5） Functional evaluation. The functional evaluation was based on the ASES score,which consisted of two components: the patient's pain perception （50%） and the daily functional activity（50%）. The total score was 100 points with 0-55 points for bad, 55-69 points for middle, 70-84 points for good and 85-100 points for excellent.Results（1）AESE scoring results. ① For 32 patients with the treatment of ORIF, the ASES score ranged from 40.0 to 85.0（66.78±4.51）points , and the excellent andgood rate was 68.7%（22 cases）; For 12 patients with the treatment of HA, the postoperative ASES score ranged from 18.0 to 88.0（61.83±12.34）, and the excellent and good rate was 41.6%（5 cases）.（2）Statistical analysis.① Statistical analysis of relevant data of patients after ORIF: The weighted value R of humeral head fragment volume and post-operative ASES scores were analyzed using normal test.P＞0.01 suggested the fitness for bivariate normal distribution, which indicated the viability of conducting linear correlation analysis. The analysis with SAS software （V9.4） showed that the weighted volume of humeral head fragment and postoperative ASES scores were in a linear relationship withP＜0.01. Furthermore,there was a linear relationship between the humeral head fragment volume and ORIF shoulder joint function scores. The regression equation: y = 34.60 + 0.50 x, R2= 0.82,P＜0.01. ② Statistical analysis of relevant data of patients after HA: The weighted value R of humeral head fragment volume and post-operative ASES scores were analyzed using normal test.P＞0.01 suggested the fitness for bivariate normal distribution,which indicated the viability of conducting linear correlation analysis. The analysis with SAS software（V9.4） showed the correlation of the weighted volume of humeral head fragment and postoperative ASES scores to beP=0.032 （P＞0.01）, which meant that there was no liner correlation between humeral head bone quality and shoulder joint function after HA. Thus, it was impossible to conduct linear regression analysis; As the volume and postoperative ASES scores fitted bivariate normal distribution, the average value could be expressed as 61.83±12.35. （3） Complications. No fixation failure, nerve injury or deep infection was found in the ORIF group. Subacromial impingement occurred in one patient due to high position of locking plate. There were 1 case of ischemic necrosis of humeral head, 1 case of screw loosening and 2 cases of delayed union （one received surgery and the other obtained bone union）; no periprosthetic fracture, heterotopic ossification, nerve injury or deep tissue infection was found in patients of HA group.One patient had artificial prosthesis loosening and did not receive revision surgery. Conclusion The purpose of this study is to provide a theoretical basis for the selection of surgical methods of proximal humerus comminuted fractures. If the volume ratio of fragment＞54.46% for the four-part proximal humeral fracture, good clinical results could be achieved by ORIF. Otherwise, HA would be an ideal treatment for the older patient with osteoporosis.

Comminuted proximal humeral fracture; Surgical methods; Prognosis;Hemiarthroplasty; Locking plate

2017-03-20）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.003

上海市科學技術委員會（13DZ1940704）

工作單位: 200025 上海交通大學醫(yī)學院1；200092 上海交通大學醫(yī)學院附屬新華醫(yī)院骨科2；200040 上海市靜安區(qū)中心醫(yī)院骨科3

王棟梁，Email:wang02_73@126.com

沈施耘,王棟梁,張炯豪,等. 肱骨頭骨折塊體積與治療方法的相關性研究[J/CD］.中華肩肘外科電子雜志,2017,5（2）：90-95.