肱骨近端骨折切开复位内固定术（钢板与髓内钉固定）资料 知情同意

为何建议进行此手术

本页面反映了罗克汉普顿 Mater 私人医院上肢外科医生 Kieran Hirpara 博士在门诊中的诊疗思路。我们通过全科医生或物理治疗师的转诊接诊患者。门诊评估用于明确诊断。对于急性结构性问题，我们可能会立即建议手术。对于长期存在的问题，我们通常先尝试非手术治疗。当非手术治疗未能带来足够改善时，才会进行手术。

您的外科医生可能会建议采用切开复位内固定术，以将骨折块固定在原位。该方法通过一个常规切口使用接骨板和螺钉进行固定。我们提供此项手术，旨在帮助您恢复稳定性和功能。证据表明，对于非骨质疏松性骨折，锁定接骨板在术后 10 年能提供有利的预后结果。然而，在 60 岁以上的患者中，并发症发生率为 44%，失败率为 34%。我们会与您讨论这些数据，以支持您参与医疗决策。

手术前

您需要进行血液检查和麻醉评估，以确认您是否适合手术。可能会安排X线或MRI检查以明确骨折情况。您必须在到达前禁食六小时。仅在您的外科医生给出具体指示后，方可停用抗凝药物。请安排他人接送回家，因为您术后无法立即驾驶。请携带所有当前用药清单，并穿着宽松舒适的衣物。您的外科医生将通过手术部位上方的一个常规切口进行手术，使用钢板或髓内钉固定骨折。这种开放入路可直接到达骨折部位，实现稳定固定。

手术当天

您将抵达医院办理入院手续。我们的团队将指导您完成登记流程。该手术在全身麻醉联合区域神经阻滞下进行。手术期间您将完全入睡，而神经阻滞（在苏醒前注射以麻醉支配手臂的神经）可在术后前12至24小时内提供镇痛效果。麻醉医师将在术前与您会面，并向您详细说明这两个部分。

准备就绪后，您将进入手术室。您的外科医生采用开放入路进行该手术，在手术部位做一个常规的单一切口。这有助于直接显露骨折端以恢复对位。术后，您将在复苏室苏醒。护士将密切监测您的舒适度及生命体征。您将在复苏室留观，直至病情稳定并准备转入病房床位。

手术内容

您的外科医生将在您肩部前方做一个长约 8 至 10 厘米的切口。这种开放入路可清晰暴露骨折部位。通过该切口，您的外科医生会仔细将肌肉和组织移开，以便直接观察骨折处。

一旦骨折块显露，您的外科医生会将其复位至正确位置。此步骤称为复位。为在愈合过程中保持骨骼稳定，您的外科医生会使用金属板和螺钉。钢板贴合于您的肱骨（上臂骨）表面。螺钉穿过钢板并进入骨折块，以牢固固定所有结构。这种方法称为切开复位内固定，可为愈合中的骨骼提供稳定的支撑。

固定牢固后，您的外科医生会检查对位是否正确。随后，将肌肉和组织移回其正常位置。切口使用缝线或钉合器闭合。敷料覆盖于该区域以提供保护。此手术使您的外科医生能够直接恢复肩关节的结构。

术后

您将在复苏室苏醒，等待麻醉效果消退。我们将通过药物控制您的疼痛，以确保您的舒适。您的肩部将使用吊带或支具固定，切口处覆盖无菌敷料。大多数患者在此手术后需住院一晚，但部分患者可在当天回家。请安排他人在术后前24小时陪护您。任何肩部手术后至少六周内严禁驾驶，无论手术涉及哪一侧手臂。经您的外科医生评估许可后（通常在六周复查时），您可恢复驾驶。详见上肢手术后驾驶。

恢复

在术后的前几天，您的肩部和上臂可能会出现酸痛和肿胀。这是身体从开放手术中愈合的正常现象。我们采用一个常规切口置于手术部位以放置固定装置。使用冰袋和处方止痛药有助于缓解这种不适。休息时请将手臂抬高以减轻肿胀。

愈合期间，您将佩戴悬带以支撑手臂。佩戴悬带期间请勿驾驶。我们的政策要求您至少等待六周才能驾驶，无论哪一侧手臂接受了手术。通常在六周复查时，您的外科医生会评估并允许您驾驶。有关更多详细信息，请参阅我们的指南上肢手术后的驾驶。

您的物理治疗师将指导您进行康复锻炼。这些轻柔的动作有助于恢复活动范围和力量。通常鼓励早期主动运动以防止僵硬。随着疼痛减轻和活动能力恢复，您将逐渐恢复日常活动。您的恢复时间表可能有所不同；您的外科医生和物理治疗师将指导您完成恢复的每一步。

可能发生的问题

大多数患者恢复良好，但偶尔也会出现并发症。您的外科医生和医疗团队会密切监测您，以便尽早发现任何问题。

感染是手术后的一种严重风险。您可能会注意到伤口周围出现扩散的红斑、局部发热或脓液流出。如果剧烈疼痛无法通过常规止痛药缓解，这也是一个警示信号。一旦出现这些迹象，请立即联系诊所或前往急诊科。早期治疗对于保护您的骨骼和关节至关重要。

您的骨骼可能无法正确愈合，这种情况称为骨不连。您可能会感到持续性疼痛，或在术后数周仍感觉手臂不稳定。有时，骨骼会在不良位置愈合，称为畸形愈合，这可能会限制您肩部的活动范围。如果在随访期间您的疼痛未按预期改善，请告知您的外科医生。

供应您肱骨头（上臂骨顶端）的血液供应可能受损，导致缺血性坏死。这意味着由于缺乏血液供应，骨组织发生死亡。您可能会经历肩部深处、呈酸痛性质的疼痛，且随时间推移而加重。您的外科医生将在定期复查中通过影像学检查来排查这种情况。

用于固定骨骼的金属内植物可能会引起问题。您可能会感到钢板放置处的皮下有刺激感。在某些情况下，螺钉或钢板可能会松动或断裂。这可能导致活动时突然出现疼痛或咔哒声。请将任何新的机械性不适或锐痛报告给您的医疗团队。

存在一般性的健康风险，尤其是对于老年患者。手术可能会增加您在住院期间发生不良事件的风险。请注意胸痛、呼吸困难或腿部突然肿胀等迹象。这些情况需要立即就医。您的医疗团队将在手术前后采取措施以最大限度地降低这些风险。

本页的并发症表格列出了典型的发生率，如果您需要了解具体数据，请参阅该表格。

何时联系我们

如果您出现发热、伤口红肿加重或分泌物，请立即联系我们。如突发剧烈疼痛、小腿肿胀或呼吸困难，请前往急诊。如出现感觉丧失或肢体无法活动，请立即寻求紧急医疗救助。这些症状需要立即评估，以确保您的康复进程不受影响。

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Modern proximal humeral nail designs and techniques demonstrate promising outcomes and provide stable fixation [1].
Intramedullary nailing and locked plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults [2].
Intramedullary nailing is superior to locking plates in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rates [3].
Both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures [6].
There is unclear superiority of intramedullary nails versus locking plates for the treatment of displaced proximal humeral fractures [6].
Limited evidence suggests that both locking plates and intramedullary nails are valuable options for the treatment of proximal humeral fractures [13].
Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages [7].
Reported outcomes for intramedullary fixation are comparable with other techniques [7].
Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation [9].
Augmentation of plate fixation for proximal humeral fractures mechanically increases construct stability and reduces complication rates while improving patient outcomes [18].
Augmentation of plate fixation for proximal humeral fractures is a reliable and safe procedure [18].
No single fixation method is a panacea for proximal humeral fractures [21].
The choice of implant and method for proximal humeral fractures should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [21].
Treatment for proximal humerus fractures remains controversial [5].
Nonsurgical management of proximal humerus fractures demonstrates successful outcomes and union rates greater than 90% [5].

Anatomy & Pathophysiology

Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy [29].

Classification

Intramedullary nailing of the proximal humerus can provide stable fixation [1].
Intramedullary nailing is superior to locking plate in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
There is unclear superiority of intramedullary nails versus locking plates for displaced proximal humeral fractures [6].
Reported outcomes with intramedullary fixation are comparable with other techniques [7].
Plate fixation was associated with a higher risk of avascular necrosis (AVN) development than conservative treatment in patients with proximal humeral fractures [11].
Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures [13].
No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures [14].
Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics [16].
Treatment options for displaced proximal humerus fractures range from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty [16].
The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status [25].

Clinical Presentation

Intramedullary nailing is superior to locking plate in reducing total complication rate, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [4].
Both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method [6].
Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques [7].
Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [8].
Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].
Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [15].
Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty [16].
Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging [17].
Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion [38].
Optimal management of osteoporotic proximal humeral fractures has evolved to include the use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft [43].

Investigations

Intramedullary nailing and plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults [2].
Intramedullary nailing is superior to locking plate in reducing total complication rates, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation [1].
Patients undergoing ORIF for proximal humerus fracture dislocations have relatively high avascular necrosis and reoperation rates [4].
Preoperative CT is extremely valuable for careful analysis of fracture type, fragment displacement, and bone quality in the surgical treatment of three and four-part proximal humeral fractures [54].
Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries [52].

Treatment

Non-Operative Management

Most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [15].
Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes [27].
Non-operative treatment is advocated for the majority of non-displaced and minimally displaced proximal humerus fractures, which generally yield good outcomes [41].

Operative Management: General Considerations

No single fixation method is a panacea for proximal humerus fractures; the choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [21].
Surgical management of proximal humeral fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results [19].
Technical strategies to maximize the success of surgical treatment for proximal humerus fractures emphasize innovations in technique and implant design to mitigate high complication rates [39].
Modern management controversies surrounding adult proximal humerus fractures include surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty [53].

Intramedullary Nailing vs. Locking Plate Fixation

The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of proximal humerus fractures [3].

Augmentation Techniques

Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes [18].
Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone [26].

Specific Fracture Patterns and Populations

Anesthesia

Regional anesthesia is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anesthesia alone [44].

Complications and Definitions

Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures, calling for standardized definitions to improve evidence synthesis [20].

Complications

Intramedullary fixation represents an alternative treatment option with reported outcomes comparable with other techniques [7].
Fixation of proximal humeral fractures in elderly patients using locked plates with cement augmentation may have lesser implant failure and total complication rates than using a locked plate alone [26].
Standard components and fracture-specific components in reverse shoulder arthroplasty (RSA) for proximal humerus fractures show no significant differences in complication rates [47].
Venous thromboembolism (VTE) was the most frequently reported complication after shoulder arthroplasty (SA) compared to ORIF, with RSA having the highest VTE rate [50].
Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty [57].
Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures [58].
Open fractures and 4-part proximal humerus fractures had the highest complication rates following intramedullary nailing [59].
Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures [60].
Proximal humerus fractures treated with a locking compression plate (LCP) augmented with a fibular allograft have decreased odds of a major complication when compared with patients treated with an LCP alone [61].

Recovery

Modern proximal humeral nail designs and techniques can provide stable fixation [1].
In most studies of proximal humerus fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied [24].
Patients 65 years of age with 3- or 4-part proximal humerus fractures achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing reverse total shoulder arthroplasty (rTSA) with a noncemented stem and early postoperative ROM compared to rTSA with cemented stem and delayed rehabilitation [48].
Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [49].

Key Evidence

[L5] Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation. [1] (10.1016/j.jse.2015.11.016)
[L1] Intramedullary nailing and plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults. [2] (10.1016/j.jse.2026.02.016)
[L1] The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. [3] (10.1186/s13018-019-1345-0)
[L4] Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. [4] (10.1016/j.jse.2022.04.018)
[L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [5] (10.5435/jaaos-d-24-01073)
[L5] The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. [6] (10.1016/j.xrrt.2024.01.001)
[L4] Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques. [7] (10.5435/jaaos-d-18-00360)
[L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [8] (10.2106/jbjs.l.01293)
[L4] Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. [9] (10.1016/j.injury.2010.11.058)
[L1] Plate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures. [11] (10.1186/1749-799x-9-31)
[L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [12] (10.5435/jaaos-d-14-00033)
[L1] Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures. [13] (10.1186/s13018-015-0242-4)
[L1] No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures. [14] (10.1007/s00264-017-3683-z)
[L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [15] (10.1016/j.jseint.2021.08.006)
[L5] Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty. [16] (10.5435/00124635-200701000-00003)
[L4] Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. [17] (10.1016/j.jse.2020.04.006)
[L1] Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes. [18] (10.1007/s00402-019-03162-2)
[L5] The paper concludes that surgical management of proximal humeral fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results. [19] (10.1016/j.jse.2010.12.006)
[L1] This systematic review highlights significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures, calling for standardized definitions to improve evidence synthesis. [20] (10.1186/s12891-019-2459-6)
[L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. [21] (10.1016/j.injury.2010.10.016)
[L2] In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied. [24] (10.1016/j.jse.2022.01.141)
[L4] The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status. [25] (10.5435/jaaos-d-15-00240)
[L1] Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. [26] (10.1186/s12891-024-07502-1)
[L5] Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. [27] (10.2106/jbjs.20.00665)
[L5] Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy, with biomechanical studies showing that locked plating provides stable fixation. [29] (10.5435/jaaos-d-20-00558)
[L5] Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion. [38] (10.1016/j.xrrt.2025.100616)
[L5] This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates. [39] (10.5435/jaaos-d-22-01211)
[L4] Non-operative treatment is advocated for the majority of non-displaced and minimally displaced fractures with generally good outcomes, while displaced fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors. [41] (10.1016/j.injury.2007.09.022)
[L4] Optimal management of osteoporotic proximal humeral fractures has evolved to include the use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft. [43] (10.1016/j.jse.2012.04.003)
[L1] This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. [44] (10.1007/s00402-019-03253-0)
[L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. [47] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
[L1] Patients 65 years of age with 3- or 4-part proximal humerus fractures achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM compared to rTSA with cemented stem and delayed rehabilitation. [48] (10.1016/j.jse.2024.03.040)
[L4] Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management. [49] (10.1177/17585732231182374)
[L4] Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate. [50] (10.1016/j.xrrt.2023.06.003)
[L5] Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries. [52] (10.1530/eor-2026-0043)
[L5] This review discusses modern management controversies surrounding adult proximal humerus fractures, including surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty to assist surgeons in making evidence-based decisions. [53] (10.1016/j.jhsa.2025.07.009)
[L4] All available ORIF techniques require careful analysis of fracture type, fragment displacement, and bone quality, making preoperative CT extremely valuable. [54] (10.1016/j.otsr.2012.12.006)
[L5] Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty. [57] (10.5435/jaaos-d-17-00051)
[L4] Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures. [58] (10.1016/j.xrrt.2025.100625)
[L4] Open fractures and 4-part proximal humerus fractures had the highest complication rates. [59] (10.1016/j.jse.2024.07.049)
[L1] Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. [60] (10.1016/j.jse.2020.09.044)
[L1] The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with an LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared with patients treated with an LCP alone. [61] (10.1016/j.jse.2021.11.004)

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