研究加速康复理念在严重肱骨近端骨折治疗中应用的意义。

成都大学附属医院2017年1月至2020年1月应用加速康复方法治疗37例Neer分型属于3部分或4部分骨折的肱骨近端骨折患者，其中采用骨折切开复位内固定术29例（内固定组）、人工肱骨头置换手术8例（关节置换组）。从手术时间、术中出血量、手术操作难度、术后患者骨愈合情况以及术后肩关节功能情况进行对比分析，评估手术治疗疗效并总结手术治疗体会及加速康复经验。

内固定组和关节置换组患者在平均手术时间、平均出血量、平均住院时间和引流管放置时间上差异无统计学意义。加速康复理念始终贯穿于术前病情评估、术中细节处理、术后功能锻炼等整个治疗过程中。术后随访，内固定组有27例术后3个月时达到骨愈合，1例因术后2个月时外伤再发骨折行翻修手术，1例发生骨折延迟愈合，予患肢悬吊，术后5个月时达到骨愈合。关节置换组8例患者均在术后3 ~ 4个月达到术后骨性愈合，术后无肩峰骨折及肩胛骨骨折病例。两组患者术后视觉模拟评分无显著差异，内固定组患肢肩关节功能评分在术后3个月、6个月及1年时明显优于关节置换组（P<0.05）。

严重的肱骨近端骨折应根据不同的骨折类型选择手术方案。加速康复治疗理念自始至终贯穿于肱骨近端骨折的诊治过程中，对术后疗效影响显著。

Severe proximal humeral fracture often occurs in the high energy trauma, many of which are accompanied with osteoporosis. The humeral head often has serious displacement and less bone mass, which is difficult to fix. It is also often accompanied with rotator cuff injury, resulting in different degrees of postoperative shoulder joint dysfunction. The concept of fast track surgery (FTS) is of great significance to the postoperative curative effect and functional reconstruction of proximal humeral fracture.

To retrospectively analyze and study the significance of fast track surgery in the treatment of severe proximal humeral fractures.

From January 2017 to January 2020, 37 cases of proximal humeral fractures classified by Neer part-3 or 4 fractures were treated with FTS. Among them, 29 cases were treated with open reduction and internal fixation (internal fixation group) , and 8 cases were treated with artificial humeral head replacement (arthroplasty group) . The operation time, intraoperative hemorrhage, operation difficulty, bone healing and shoulder joint function were compared and analyzed. The therapeutic effect of operation was evaluated and the experience of operation and FTS was summarized.

There was no significant difference in the mean operation time, mean bleeding volume, mean hospitalization time and mean tube placement time between the internal fixation group and the joint replacement group. The concept of FTS runs through the whole treatment process, such as preoperative condition evaluation, intraoperative detail treatment, and postoperative functional exercise. In the internal fixation group, 27 cases achieved bone union at 3 months after operation, 1 case underwent revision operation due to the second fracture at 2 months after operation, 1 case had delayed fracture union, and achieved bone union at 5 months after the limb suspension. In the arthroplasty group, 8 patients achieved postoperative bone union within 3 to 4 months without acromial fracture or scapular fracture. There was no significant difference in VAS score of postoperative pain between the two groups. The shoulder function score in the internal fixation group was significantly better than that in the arthroplasty group at 3 months, 6 months and 1 year after operation (P<0.05) .

For severe proximal humeral fracture, the operation plan should be selected according to different fracture types. The concept of FTS should be valued throughout the process of diagnosis and treatment of proximal humeral fractures, and it has a significant impact on the postoperative effect. Neer part-3 fractures are recommended to be treated with open reduction and internal fixation, while Neer part- 4 fractures, especially severely comminuted humeral head fracture, humeral head dislocation and cartilage damage of humeral head, can be treated with shoulder arthroplasty. Spitted or comminuted humeral head fractures are the major indications of shoulder replacement. The classification of split-type humeral head fracture is not perfect, and the operation plan and prognosis were not effectively evaluated. Animal experiments or clinical experimental studies are further required.