1、 Inclusion criteria and exclusion criteria
Inclusive criteria: ① Severe comminution of the humeral head with several bone defects; ② Neer classification III, IV cases; ③ Fresh fracture; ④ A shoulder prosthesis replacement was not suitable.
Exclusion criteria: ① There were clear surgical contraindications, infection in the operation area or severe medical diseases; ② Shoulder joint disease; ③ The follow-up data were incomplete or the follow-up time was less than 1 year.
2、 General information
Clinical data: there was a total of 10 cases: 7 cases had complete followed up data, 6 cases had right proximal humerus fractures, 1 case had a left proximal humerus fracture, 6 cases were female, 1 case was male, 4 cases had hypertension, 1 case had diabetes, 2 cases had cerebral infarction, 1 case had osteoporosis. The mean of the patients was age 65.57 ± 11.13 years old. The cases were also classified according to the fracture: Neer fracture type Ⅲ 3 cases and type Ⅳ 4 cases. The mean height was 157.00 ± 6.83 m, and the mean body weight was 58.14 ± 12.77 kg. One case smoked, 5 cases had a walking injury, 1 case had a collision between an electric bicycle and a tricycle, and 1 case had trauma due to cycling. The mean HSS score of the knee joint before the operation was 90.14 ± 4.95 points. The mean intraoperative blood transfusion was 285.71 ± 219.31 ml, the mean intraoperative blood loss of the shoulder wound was 400.00 ± 294.39 ml, and the mean intraoperative leg wound bleeding was 32. 86 ± 13.80 ml. The mean length of the fibula was 7.00 ± 1.83 cm, the mean operation time was 2.86 ± 0.38 hours, and the mean follow-up time was 18.00 ± 3.65 months.
This study was approved by the ethics committee of the author's unit, and all patients signed the informed consent before the operation.
3、 Operation method
The operation technique of the comminuted fracture of proximal humerus: after successful general anesthesia, iodine and alcohol was used to disinfect the skin of the operation field, and the sterile operation sheet was placed. A deltoid and pectoralis major intramuscular approach was made along the injured shoulder, and the subcutaneous and fascia were dissected layer by layer. The cephalic vein was exposed and protected, the muscle space was entered, the proximal humerus was exposed, the intertubercular groove was found, which was used as the reduction mark, and the large and small nodules were found. The insertion points of supraspinatus and teres major of the large and small tubercles were sutured with "8" shape suture (Johnson, Vicki 1–0 suture), and the suture was reserved for traction reduction. The fracture end was cleaned, and the fibular segment was inserted into the humeral medullary cavity. Then, the humeral head, large tuberosity and small tuberosity were reset and fixed temporarily with Kirschner wire. Under C-arm fluoroscopy, if the fracture reduction was good, then the proximal humerus was fixed with a locking titanium plate (Shandong Weigao proximal humerus locking plate). The large and small nodules were sutured to strengthen the fixation. The wound was thoroughly washed to stop the bleeding. The fracture reduction and internal fixation position were examined by radiography. After checking the gauze instruments, the wound was closed layer by layer.
The procedure of fibula removal: After successful general anesthesia, the air bag tourniquet of the ipsilateral lower limb was inflated at 50 kPa, the skin of the operation field was disinfected with iodine and alcohol, a sterile operation sheet was laid, a longitudinal incision was made at the middle and upper lateral sides of the ipsilateral leg, the skin and subcutaneous fascia were incised, and the fibula was exposed along the extensor flexor muscle space. At the same time, the superficial peroneal nerve was exposed and protected, a fibular segment was excised with a swing saw, the fibular segment was located in the middle and upper fibula, and the length of the fibular segment was approximately 7–8 cm. The tourniquet was slowly loosened, the wound was washed, the bleeding was thoroughly stopped, and the wound was sutured layer by layer (Fig. 1).
4、 Postoperative management
Antibiotics were prophylactically administered 24–72 hours after the operation, the patient would sit up on the first day after the operation, and the patient would get out of bed within 3–7 days based on the functional rehabilitation needs of the combined operation site. The upper limb did not lift any weight for 8 weeks, passive pendulum movements were started within 6 weeks, active movement was started after 6 weeks, the patient received routine dressing changes, and the sutures were removed after 2 weeks.
5、 Efficacy evaluation criteria
The patients were reexamined 1, 2, 3, 4, 5, 6 and 12 months after the operation, and the X-ray films were reexamined regularly. The operation time, intraoperative bleeding, postoperative pain score and fracture healing time of proximal humeral fractures were recorded. Shoulder function at 3 months, 6 months and 12 months after the operation was recorded by a constant Murley score. The shoulder range of motion at 3 months, 6 months and 12 months after the operation was recorded by a constant Murley score. The neck shaft angle of the proximal humerus and 12 months after the operation were measured and recorded. The HSS scores of the knee joint before the operation and 3 months, 6 months and 12 months after the operation were recorded.
6、 Statistical analysis
SPSS 20.0 software was used to analyze the data, and the range of motion of the shoulder joint, constant Murley score of shoulder joint, humeral neck shaft angle during and after the operation, and HSS score of knee joint before and after operation were tested by a paired sample t test α= 0.05。