Ethical statement
All procedures were approved by the Ethical Committee of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University (SWMCTCM2017-0710) and performed by the 1964 Helsinki declaration and amendments or comparable ethical standards. The specific illustration and agreement were obtained from all individual participants included in our study.
Inclusion Criteria
Patients were employed to meet such inclusion criteria: i) Aged 18-80, patient’s history, physical examination, X-Ray and CT (2D and 3D) should conform to the humeral fractures of GT. ii) Confirmed isolated Mutch II (split) GT fracture of the proximal humerus, (2 people assessed respectively, and if there were any divergences to the results of the classification, it would be given to the third person to take a comprehensive evaluation and got the final results included in this experiment. iii) The patient and family members were willing to cooperate with the postoperative treatment. Then the doctor illustrated the advantages and disadvantages of surgical and the study plan before an operation. Finally, the patient and the family signed on the agreement.
Exclusion Criteria
Other Patients should be excluded with such criteria: i) Type Mutch I or III of humeral GT fracture. ii) Patient whoever was followed up less than one year and did not cooperate with the medical staff for postoperative follow-up evaluation. iii) Patients with complications such as severe neurological and vascular injury. iv) The patient who had a history of mental illness or epilepsy or who are medicine or narcotic abuser.
Pre-op assessment
On admission, asking disease history in detail to be familiar with the time and mechanism of injury. Judged their ROM through the shoulder examination and X-ray, CT (3D), and MRI should be taken, especially for CT scan. According to the author's experience, the fracture fragment showed better on CT (3D), which was very important for specific plans and assessments before surgery. Therefore, we recommended that all patients should have CT (3D), and MRI could better understand whether the patient had combined rotator cuff lesion, to make a comprehensive strategy.
Surgical technique
Group A: Modified PHILOS plate; with satisfactory anesthesia, patients were placed in the beach chair position, and taken the split deltoid incision; sharply and bluntly separated subcutaneous tissue, deep fascia, muscle, and other tissues layer-by-layer, until the fracture was exposed. (Noted to protect the axillary nerve, marked and protected Posterior humeral circumflex artery). On the other hand, we prepared the modified PHILOS plate and cut off the three holes screw on the shaft. Moreover, the fragment was accurately fixed by K-wires, and the modified plate was at 5 mm under the top of the GT and the medial intertubercular sulcus. The correct position was checked with fluoroscopy. Finally, fragment reduction and screw length were ensured by fluoroscopy.
Group B: The hollow screw; the same preparation as group A. Then, 2.0 K-wires wires were used to have reduction and fixation under fluoroscopy in a 90°. (Note: The direction of the inserting needle should not be parallel to the biomechanical direction of the supraspinatus muscle pull as far as possible; the best position was to form an angle and increase the fixation biomechanics). Two K-wires were used to fix fracture fragments, and then, the C-arm was used to fluoroscopy reset effect. If the reset effect was not effective as expected, adjust its position until having a reduction. Screws have been fixed by the guidance K-wire.
Postoperative review and functional exercise
Functional exercises were started two days after the operation. The arm was supported by a sling for three weeks, which was protected at the abduction of 45 degrees. We tried to avoid making the fixed GT fragment displacement via the supraspinatus or shoulder activities. Passive motion exercises began in the third weeks of operation. Active motion exercises and strengthening exercises were started at six weeks after surgery. Further continual follow-ups were carried out at every 1, 3, 6 and 12 months at least after surgery. The functional scores Constant‑Murley Score (CMS), American Shoulder and Elbow Surgeons (ASES), the University of California at Los Angeles shoulder rating scale (UCLA) and Visual Analogue Score (VAS) were assessed in both pre-op and post-op final follow.
Statistics
SPSS 17.0 statistical software was used for data analysis. The gender and injury sites (left and right) of the two groups included in the A and B groups were analyzed by chi-square test, indicated by c2. The data of Shoulder function scores of CMS, ASES, UCLA, and VAS in the two groups were expressed as the mean ± standard deviation (± S) analyzed by independent samples t test. The test level was α=0.05.