Comparison Of Clinical Effects Of Plate Combined With Large Iliac Bone Graft And Artificial Humeral Head Replacement In The Treatment Of Comminuted Proximal Humeral Fractures In The Elderly

Objective:At present,artificial humeral head replacement and open reduction and plate internal fixation are the main surgical methods for the elderly proximal humeral fractures.However,the choice of Neer ⅲ and ⅳ surgical methods for the proximal humeral fractures is controversial.However,the elderly often have osteoporosis and bone loss [2],so the surgical method for comminuted fractures of the proximal humerus in the elderly should be more cautious.This paper is a retrospective study of proximal humeral locking plate internal fixation combined with autogenous iliac bone graft and artificial humeral head replacement for the treatment of comminuted proximal humeral fractures in the elderly,comparing the clinical efficacy of the two surgical methods.Materials and Methods:Among the patients admitted to our hospital from July 2016 to December 2020,81 patients meeting the criteria were selected,including36 males and 45 females.The age requirement was > 65 years old,and most of the patients were complicated with osteoporosis.According to Neer typing: 49 cases of Neer type III fractures and 32 cases of Neer type IV fractures.The choice of incisional repositioning locked plate internal fixation combined with autologous iliac bone grafting was made in 42cases（recorded as the internal fixation group）,and the choice of artificial humeral head replacement was made in 39 cases（recorded as the replacement group）.The mean age was（74.9±6.4）years.After perfect preoperative preparation and surgical treatment,follow-up data（pain,shoulder mobility,muscle strength,etc.）were recorded in both groups,and data were evaluated by Constant-Murley shoulder score criteria to compare the shoulder function of both groups.The data were analyzed and compared using the SP24.0 statistical software from IBM,USA.Results:Complete follow-up was obtained in both groups,with a follow-up period of 12 to 18 months.None of the patients developed serious complications such as neurovascular injury,prosthesis loosening and position change,and the incision healed in one stage.In the internal fixation group,all proximal humerus fractures healed,with one patient experiencing delayed healing and no humeral head necrosis or deformity affecting shoulder joint function.Replacement group: No loosening of the prosthesis,good position and angle of the prosthesis,no joint dislocation,etc.The Constant-Murley shoulder joint score was used to score the postoperative shoulder joint function of the two groups,and the results were compared with statistical software for significance.At 3 months postoperatively,the scores of the replacement group were higher than those of the internal fixation group,and the difference was statistically significant（P < 0.05）;at 6 months postoperatively,there was no significant difference between the scores of the two groups,and the difference was not statistically significant（P > 0.05）;at 12 months postoperatively,the scores of the internal fixation group were better than those of the replacement group,and the difference was statistically significant（P < 0.05）.The operating time was（73.0±6.1）minutes and intraoperative blood loss was（221±14.43）ml in the internal fixation group and（67.1±5.4）minutes and（212±16.09）ml in the replacement group.there was a difference in the operating time and blood loss between the two groups,P<0.05,and the replacement group was better than the internal fixation group in terms of operating time and intraoperative blood loss（see Table 3）Conclusion:Comparison according to Constant-Murley shoulder joint score criteria: at 3 months,the replacement group was superior to the internal fixation group;at 6 months,there was no significant difference between the two groups;at 12 months,the shoulder function of the internal fixation group was superior to that of the replacement group.This indicates that the plate combined with autologous iliac bone graft is more advantageous in the long term,while the artificial humeral head replacement is more advantageous in the early stage.Therefore,in elderly patients with comminuted fractures of the proximal humerus,the use of locking plates combined with autologous iliac bone graft is an effective and superior method to humeral head replacement that can achieve clinically satisfactory results.However,there are complications such as postoperative pain and sometimes a second operation may be required to remove the internal fixation.Therefore,artificial humeral head replacement can be used for patients who do not have high shoulder joint requirements,do not accept bone grafting or a second operation,or require some shoulder joint function to be restored as soon as possible.Regardless of the surgical method,standardized anti-osteoporosis treatment and functional exercise of the shoulder joint should be given after surgery,which is crucial to ensure the surgical results and shoulder joint recovery.