肘關節內翻—后內側旋轉不穩定的手術療效分析

殷照陽 殷建 孫曉 霍永峰 盛路新

肘關節內翻—后內側旋轉不穩定的手術療效分析

殷照陽1殷建2孫曉1霍永峰1盛路新1

目的探討創傷性肘關節內翻-后內側旋轉不穩定的術后療效。方法2011年6月至2015年12月連云港市第一人民醫院收治創傷性肘關節內翻-后內側旋轉不穩定患者10例（10個肘），其中男6例、女4例，平均年齡34.8歲（20～67歲）。術后早期功能鍛煉，采用Mayo肘關節功能評分系統（Mayo elbow performance score，MEPS）評價肘關節功能。定期復查X線片，采用Broberg和Morrey肘關節退行性關節炎X射線分級進行評價。結果所有患者肘關節骨折3個月后獲得愈合，肘關節活動穩定，8例無疼痛癥狀，1例靜止時偶有疼痛，1例活動時疼痛。肘關節活動伸直平均角度（29.6±11.4）°，屈曲平均角度（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°。1例術后2個月開始出現骨化性肌炎，半年后予以手術松解，滿足日常生活需要。根據MEPS評分結果優7例、良1例、中2例、差0例，優良率80%。結論肘關節內翻-后內側旋轉不穩定一期手術治療至關重要，根據不同損傷類型制定個性化治療方案有利于關節功能恢復。

肘關節； 外科手術； 骨折固定術

肘關節內翻-后內側旋轉不穩定是由于肘關節受到內翻、后內側旋轉及軸向的應力導致外側副韌帶復合體從肱骨外髁止點撕脫，肱骨遠端滑車撞擊尺骨冠狀突內側面，引起以冠狀突內側面骨折為基礎合并冠狀突、橈骨頭或尺骨近端骨折為特點的損傷類型。此種類型肘關節損傷臨床上少見，一期手術治療不當而導致的肘關節功能障礙較為多見，而二期再次矯形手術的效果難以令人滿意，所以一期手術治療至關重要。自2011年6月至2015年12月連云港市第一人民醫院收治創傷性肘關節內翻-后內側旋轉不穩定患者10例，療效滿意，報道如下。

資料與方法

一、 一般資料

本組患者共10例（10個肘），其中男6例、女4例，平均年齡34.8歲（20～67歲）。均為優勢肘，且無既往肘關節手術史。損傷原因：騎車摔傷4例、車禍4例、高處墜落傷1例、運動損傷1例。按O'Driscoll分型分為：ⅡA型3例、ⅡB型4例、ⅡC型3例。合并傷包括：合并橈骨小頭骨折1例（Mason Ⅲ型）、合并橈骨遠端骨折3例。

二、納入及排除標準

納入標準：①放射線檢查證實存在冠狀突內側面骨折基礎損傷，合并或不合并尺骨鷹嘴骨折、肘關節脫位，具有明確手術指征；②受傷至手術時間＜3周；③肘關節閉合性損傷；④無心、肺功能障礙等明顯手術禁忌證；⑤術前無認知障礙，不影響術后隨訪。

排除標準：①陳舊性肘關節骨折脫位；②合并神經、血管損傷的病例；③既往肘關節手術病史；④隨訪資料不完整或不配合治療的患者。

三、術前評估

術前應著重注意軟組織腫脹情況，有無脫位和前臂骨筋膜室綜合癥，有無血管、神經損傷。術前常規檢查肘關節前后位、側位及肘關節三維CT重建，重點觀察肱骨內外側髁有無撕脫骨折片影，冠狀突骨折的部位及大小。肘關節MRI檢查提高了內外側韌帶損傷程度診斷的正確率。術前如有脫位應首先予以手法復位，然后屈肘90°位制動，臥床患肢抬高以減輕軟組織的腫脹程度。

四、手術方法

手術修復的順序為先內后外，即先固定冠狀突骨折塊。冠狀突內側面骨折或涉及高聳結節的骨塊予以克氏針、螺釘或鋼板固定，冠狀突尖部骨折予以“套鎖”固定，然后探查內側韌帶復合體，前束肱骨或尺骨止點撕脫或撕脫骨折予以錨釘縫線編織固定。前臂施加內翻應力，術中透視證實有無明顯的外側肱橈關節增寬，明顯增寬提示外側韌帶復合體斷裂，予以切開骨縫合或帶線錨釘修復，再次透視下檢查外側肱橈關節間隙，然后施加前臂旋前、軸向應力檢查有無肘關節半脫位。如果仍然存在外側肱橈間隙增寬或肘關節半脫位，予以肘關節同心圓支架固定，透視下確定肘關節旋轉中心，肱骨和尺骨擰入Schaze螺釘并組裝肘關節同心圓鉸鏈式外固定支架（同心圓鉸鏈外固定支架的作用主要是保護修復的骨與軟組織結構）。橈骨頭及橈骨遠端骨折予以鋼板及螺釘固定。

五、術后處理

術后患肢肘關節支具固定3周，每天屈伸鍛煉2～3次。外固定支架固定術后第1天即可進行肘關節屈伸活動，但是術后3周內肘關節伸直不宜超過30°，以后逐漸增加肘關節屈伸活動度。術后6周拆除外固定支架，固定尺骨冠狀突尖部的克氏針待術后3個月骨折愈合后予以拔出。術后口服吲哚美辛共計6周以預防肘關節骨化性肌炎。

六、評價指標

術后評估應用Mayo肘關節功能評分系統（Mayo elbow performance score，MEPS）［1］對肘關節功能進行評價，其主要內容包括四個方面：肘關節疼痛程度、屈伸活動度、穩定性及日常功能。術后定期復查X線片，采用Broberg和Morrey肘關節退行性關節炎X射線分級［2］進行評價。

結 果

10例患者均獲得隨訪，平均隨訪（13.8±3.6）個月（6～22個月）?；颊咝g前、術后及術后6個月影像學資料見圖1-6，10例肘關節骨折術后3個月后獲得骨性愈合，且肘關節活動穩定，1例偶有疼痛，1例活動后疼痛。最后一次隨訪9例肘關節活動伸直平均（29.6±11.4）°，屈曲平均（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°，滿足日常生活需要。1例術后2個月開始出現骨化性肌炎，半年后肘關節活動受限明顯，予以手術松解，效果滿意，滿足日常生活需要。本組10例患者無骨與軟組織感染，無神經、血管損傷癥狀。采用MEPS評價肘關節功能，平均82分（62～92分），優7例、良1例、中2例、差0例，優良率80%。Broberg和Morrey肘關節創傷性關節炎評估結果，8例無退行性改變，2例出現1級改變，未出現2級或3級創傷性關節炎改變。

圖1 肘關節骨折術前三維CT成像后面觀

圖2 肘關節骨折術前三維CT成像前面觀

圖3 肘關節骨折術后正位X線片

圖4 肘關節骨折術后側位X線片

圖5 肘關節骨折術后6個月正位X線片

圖6 肘關節骨折術后6個月側位X線片

討 論

肘關節不穩定根據部位分為外翻不穩定、內翻不穩定、前側不穩定和后外側旋轉不穩定，而在創傷引起的肘關節不穩中，后外側旋轉不穩定最為常見，內翻-后內側旋轉不穩定相對較為少見［3-6］，容易漏診或誤診，此類骨折脫位治療不當容易出現肘關節僵硬、創傷性骨性關節炎和肘內翻。肘關節內翻-后內側旋轉不穩定的損傷機制是肘關節受到軸向、內翻、后內側旋轉應力而發生肘關節內翻、前臂旋前并向后內側旋轉，導致外側韌帶復合體從肱骨外側髁撕脫或撕脫骨折，滑車撞擊冠狀突內側面引起冠狀突內側面骨折、合并或不合并內側副韌帶前束損傷后的肘關節骨折脫位。此種類型損傷后肘關節極度不穩，如果采用保守治療或者冠狀突骨折不固定的手術方式，最終肘關節功能均不滿意［7-10］。也有學者認為需在麻醉下進行肘關節屈伸活動，若發現肱尺關節半脫位，施加內翻應力時肱橈關節間隙增大，須進行手術治療［11-12］。

肘關節周圍軟組織韌帶結構包括內側韌帶、外側韌帶復合體及前方的關節囊結構。肘關節前方關節囊結構對于肘關節穩定性的影響相對較小。內側韌帶包括前、后、橫束，其中后、橫束與關節囊融合在一起，起到加強關節囊的作用，而前束起于肱骨內上髁，止于尺骨冠狀突基底部的高聳結節，是維持肘關節內側穩定、防止肘關節外翻最為重要的結構。外側韌帶復合體包括外側韌帶結構和伸肌、旋后肌等結構，復合體對維持關節外側的穩定約起50%的作用［13］，伸肌起協同作用。外側韌帶包括橈側副韌帶和環狀韌帶，橈側副韌帶起于肱骨外上髁的外下方，發出纖維組織一部分止于橈骨環狀韌帶，另一部分止于尺骨冠突的外下方為橈側尺副韌帶，后者對于維持肘關節后外側穩定有重要作用［14-15］。肘關節后外側伸肌結構在前臂旋后位時保持前臂穩定并防止前臂外旋脫位，力學實驗證實即使切斷肘關節后外側所有軟組織結構，肘關節旋后位仍可以降低關節脫位趨勢，這為術后前臂旋后位固定提供了依據。

目前在處理肘關節內翻-后內側旋轉不穩定時，對于手術入路、骨折的固定方式、是否修復內側和外側副韌帶、是否加用鉸鏈式外固定支架等方面仍未達成共識。肘關節內側手術入路最常用的是“過頂”入路，固定冠狀突骨折更加方便，冠狀突大的塊骨折可以選擇螺釘、3.0 mm空心螺釘或“T”型鋼板固定，小的骨折塊可予以“套索”、錨釘、克氏針連同附著的軟組織固定于原骨折處。如骨折塊太碎，則取出游離碎片，縫合前關節囊及肱肌腱。關于與前關節囊相連的尺骨冠狀突小骨折塊應用螺釘或“套索”固定，哪種技術固定效果更佳尚無定論。肘關節結構性穩定系統分為四個柱，內側柱由肱尺關節內側和內側副韌帶復合體組成，前側柱由冠狀突、橈骨頭前部及前方關節囊組成，肱肌提供輔助作用。冠狀突位于肱骨遠端滑車的前方，其主要作用是對抗上臂肌肉牽拉尺骨向后的力量，同時也是對抗外傷導致肘關節內翻的骨性結構，而當冠狀突骨折或缺失超過50%即可引起肘關節不穩，出現肘關節復發性脫位或半脫位［16］。冠狀突基底部是內側副韌帶前束的止點。王友華等［17］發現當冠狀突骨折累及高度達到1/2時必然導致前束損傷，此時重建冠狀突對比修復和不修復前束韌帶的肘關節的穩定性，發現肘關節在屈曲 0°、30°、60°、90°和120°時，外翻角度的顯著增加提示了肘關節的不穩，證實內側副韌帶前束在肘關節活動過程中對抗外翻旋轉應力起到非常重要的作用。O'Driscoll Ⅲ型冠狀突骨折多合并復雜肘關節損傷，冠狀突粉碎性骨折難以復位時，需取自體髂骨重建冠狀突，且重建冠狀突的高度至少達到原來高度1/2，從而獲得肘關節前方的骨性阻擋以維持肘關節的穩定性，但如果同時合并橈骨頭骨折，無論尺骨冠狀突骨折塊多小均可能增加肘關節的不穩［14］。因此，冠狀突同時參與組成肘關節前柱和內側柱，其基底部是內側副韌帶前束的止點，后者在肘關節活動過程中對抗外翻旋轉應力起到非常重要的作用，重建冠狀突的高度和修復內側副韌帶，對于術后肘關節的穩定性有決定性的作用。

關于內側副韌帶是否需要一期修復存在爭議，有學者認為復位固定冠狀突骨塊時應一期探查內側副韌帶前束，如果發現斷裂應予以修復或重建，修復斷裂的內側副韌帶明顯增加了肘關節的穩定性。但有學者認為內側副韌帶并非必須修復［18］，外側韌帶復合體作用更為重要，只要固定冠狀突骨折塊和肘關節外側結構（橈骨頭骨折塊和外側韌帶復合體），肘關節多數可獲得穩定，無需一期修復內側副韌帶。本組病例冠狀突內側面骨折塊較大，多連帶內側副韌帶前束一同移位，術中復位固定冠狀突骨折塊即可。肘關節內翻-后內側旋轉不穩定時常伴有外側副韌帶復合體損傷，肘關節外側副韌帶復合體損傷表現為肱骨止點處撕脫骨折或韌帶撕脫，也可能是韌帶體部的斷裂，以前者最為常見，韌帶止點處撕脫予以錨釘修復固定；若是韌帶體部斷裂，宜選擇韌帶重建，尺骨遠、近端重建的骨道應位于尺骨旋后肌嵴的橈骨頭近緣水平及遠端15 mm的橈骨頭頸交界處水平，而肱骨外側髁骨道的位置可以通過尺骨骨道穿過一根縫線，在屈伸肘關節的過程中，確定其在外上髁周圍的等距點［19-21］，即肱骨外上髁前下方4點左右，也就是肱骨小頭外側面的圓心點。值得注意的是橈側尺副韌帶重建時尺骨骨道離肘關節越遠，內翻穩定性越好，離肘關節越近，肘關節后外側穩定性越好，術中應根據具體情況酌情考慮。本組術中探查10例外側副韌帶均有損傷，均為橈側副韌帶肱骨止點撕脫或撕脫骨折，予以帶線錨釘編織韌帶后固定，透視下行肘關節內翻應力檢查，6例仍然出現肱橈間隙明顯增寬，加用同心圓外架固定。根據肘關節內翻后內側旋轉不穩定的受傷機制，首先傷及肘關節后外側結構導致后外側復合體的撕脫骨折或韌帶撕脫，術中是否需要常規探查修復尚無定論，有學者認為內翻-后內側旋轉不穩術中修復外側副韌帶難以牢固固定，需予以肘關節外固定支架固定以保護修復的軟組織，否則應制動患肢 1個月［22］。Ring［23］在術中不做切開修復，固定冠狀突骨折后予以肘關節同心圓外固定支架固定，取得了良好效果。作者發現術中切開修復后外側韌帶復合體且未使用同心圓外架的患者，術后每日主動屈伸功能鍛煉2～3次防止肘關節僵硬，骨折愈合后肘關節功能滿意且無肘關節不穩。雖然術中未使用同心圓支架固定可能會導致術后早期活動時出現肘關節不穩，但是通過術后肘關節的功能鍛煉可以明顯降低肘關節半脫位的發生率，有學者也作了相似報道［24］。因而，術中是否需要進行內側副韌帶修復，仍需要生物力學及臨床進一步研究和大宗病例的對照和隨訪，而外側副韌帶損傷多主張予以探查修復。

對于是否使用肘關節同心圓外固定支架，作者的經驗是在肘關節內側柱修復后，對外側韌帶復合體進行加強縫合，如果仍然不穩則加用鉸鏈式外固定支架。外固定支架的作用在于保持肘關節的同心圓活動，同時保護修復的骨與軟組織結構［25］，也便于早期功能鍛煉［26］，但是旋轉中心的定位非常重要，輕度的偏移則會明顯增加肘關節活動時的應力。相對于外固定支架，更傾向于手術探查修復后外側韌帶復合體，大多數肘關節可獲得穩定，而使用同心圓外固定支架可能出現更多的并發癥，如旋轉中心偏離過大致肘關節功能鍛煉時關節面磨損，橈神經損傷、釘道感染、松動等。

肘關節內翻-后內側旋轉不穩定較少發生橈骨頭骨折，偶爾伴有鷹嘴骨折。橈骨頭骨折的治療方法根據基于Mason分型，Ⅰ型骨折移位小予以保守治療；Ⅱ型骨折予以手術復位內固定，固定骨折塊盡可能選擇螺釘固定，若涉及整個橈骨頭骨折可選擇鋼板固定，鋼板需放置于橈骨頭“安全區”內，而當橈骨頭骨折快較?。ㄐ∮跇锕穷^25%）且不累及乙狀切跡時可考慮橈骨頭骨塊切除；Ⅲ型骨折粉碎選擇橈骨頭置換。對于無法修復的橈骨頭骨折，決定進行橈骨頭切除時應充分評估肘關節的穩定性，目前多數學者認為橈骨頭粉碎骨折同時合并內側副韌帶損傷，不宜進行橈骨頭切除，否則易導致肘關節嚴重不穩，如果行橈骨頭切除前提是內側副韌帶完整。

肘關節功能的恢復情況與術后康復期的功能鍛煉密切相關。術后應早期進行功能鍛煉，否則會導致關節僵硬，但是如果在穩定性和早期活動這兩者之間作選擇，應優先考慮關節的穩定性，矯正僵硬比慢性不穩定的肘關節相對要簡單?？傊?，術前應對肘關節骨與軟組織的損傷程度做充分的評估，根據不同患者骨與軟組織損傷的不同情況制定個性化手術方案。骨性結構的堅強固定、軟組織結構的修復以及術后正確的功能鍛煉是治療創傷性肘關節骨折脫位并取得滿意效果的必備條件。

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Yin Jian, Email:yinjian0511@163.com

Operative effect analysis of varus posteromedial rotatory instability of elbow joint

Yin Zhaoyang1, Yin Jian2,Sun Xiao1, Huo Yongfeng1, Sheng Luxin1.1Department of Orthopaedics, Lianyungang First People's Hospital,Lianyungang 222000, China;2Department of Orthopaedics, the Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 211100, China

BackgroundThe varus-posteromedial instability of elbow joint refers to the injury characterized by fractures of the medial surface of coronoid process combined with fractures of coronal process, radial head or proximal ulna. The fractures are caused by the avulsion of lateral collateral ligament from the insertion of external humeral condyle and the impingement of the medial surface of ulnar coronoid process by distal humeral trochlea due to varus, posteromedial and axial stresses on elbow joint. This type of elbow injury is rare in clinic. The elbow joint dysfunction is commonly seen if treated improperly at the first stage.Unfortunately, the effect of orthomorphia at the second stage is rarely satisfactory. Hence, the first stage operation is critical. From June 2011 to December 2015, 10 patients with traumatic varus-posteromedial rotatory instability were treated in the First People's Hospital of Lianyungang and obtained satisfactory results.Methods（1）General data. There were 10 patients （6 males and 4 females） in the group, and the average age was 34.8 years （20-67 years）. The dominate elbow joint was affected for all cases, and no patient had previous history of elbow surgery. The causes of injury included 4 cases of bicycle fall, 4 cases of traffic accident, 1 case of high fall and 1 case of athletic injury. According to the O' Driscoll classification, there were 3 cases of type IIA fractures, 4 cases of type IIB fractures and 3 cases of type IIC fractures. Thecombined injuries included 1 case of radial head fracture （Mason type III） and 3 cases of distal radial fracture.（2）Inclusive and exclusive criteria. Inclusive criteria: ① The presence of medial surface of coronoid process fracture with or without olecranon fracture or elbow joint dislocation confirmed by radiological examination suggested definite indication of operation; ②The time from injury to surgery ＜3 weeks ;③ Closed injuries of elbow joint；④ No obvious surgical contraindication such as cardio or pulmonary dysfunction;⑤ No preoperative cognitive impairment that affected postoperative follow ups. Exclusive criteria: ① Oboslete fracturedislocations of elbow joint; ② Combined neurovascular injuries; ③ Previous history of elbow joint surgery; ④ Incomplete follow-up data or patients who did not cooperate with treatment.（3）Preoperative evaluation. Special attentions should be paid preoperatively to the swelling of soft tissue and the presence of dislocation, compartment syndrome of forearm, or neurovascular injury. Preoperative routine examinations including anteroposterior and lateral views of elbow joint and three-dimensional CT reconstruction of elbow joint were conducted to mainly observe the presence of avulsion fractures at medial and lateral condyles of humerus and the location and size of coronoid fragment. Elbow MRI examination improved the diagnostic accuracy of the extent of medial and lateral ligament injury. If there was elbow joint dislocation before operation,manual reduction should be performed firstly. The elbow was then fixed in 90° of flexion, and the affected limb was raised in bed to reduce the swelling of soft tissue. （4）Operative method. The order of surgical repair was from inside to outside as described below. The fracture fragments of coronoid process were fixed firstly. The fractures of the medial surface of coronoid process or fracture fragments involving Sublime tubercle were fixed with Kirschner wires, screws or plates. Fractures of the apex of coronoid process were treated with “Lasso” fixation. Afterwards,the medial ligament complex was explored, and the anterior humeral or ulnar avulsion or the avulsion fracture was fixed with suture anchor. Varus stress was applied on the forearm to check whether the space of lateral radioulnar joint increased significantly under intraoperative fluoroscopy. The remarkable increment suggested the disruption of lateral ligament complex,which required open suture and/or suture anchor fixation. The gap of lateral radioulnar joint was checked again under fluoroscopy, and pronation and axial pressure was applied on the forearm to check whether there was elbow joint subluxation. If the increased lateral radioulnar joint space or elbow joint subluxation still exist, the elbow joint should be fixed by concentric circle bracket. As the rotating center of elbow joint was confirmed under fluoroscopy, the placement of Schaze screws on humerus and ulna and the assembly of hinged elbow external fixator （for protections of repaired bone and tissue structure） were executed subsequently. The fractures of radial head and distal radius were fixed with plates and screws. （5）Postoperative management.After operation, the affected limb was fixed with elbow brace for 3 weeks. Flexion and extension exercises were performed 2-3 times per day. The elbow flexion and extension activities were allowed on the 1st day after external fixation, but the range of elbow extension should not exceed 30° within 3 weeks after surgery. Later, the range of flexion and extension motions of elbow joint was gradually increased. The external fixator was removed 6 weeks after operation, and the Kirschner wire used for the fixation of ulnar coronoid process tip was removed when the fracture healed 3 months after operation. Oral indomethacin was given postoperatively for 6 weeks to prevent the myositis ossificans of elbow joint. （6）Evaluation index. Mayo elbow performance score （MEPS） was used for the postoperative evaluation of elbow function, which mainly included four aspects: level of pain, range of elbow flexion and extension, stability and daily function. The X-ray films were taken regularly for postoperative examinations, and the degenerative arthritis of elbow joint was evaluated by Morrey and Broberg classification. Results All patients were followed up for an average of （13.8±3.6） months （6-22 months）. Ten cases of fractures

bony union and achieved stable elbow joint movement 3 months after operation. There were one case of occasional pain and one case of pain after exercise. During the last follow up,9 cases of fracture had an average elbow extension angle of （29.6±11.4）°, an average elbow flexion angle of （113.6±10.2）°, an average pronation angle of （55.2±13.6）° and an average supination angle of （40.2±9.2）°. These results met the needs of daily life. Myositis ossificans occurred in 1 patient 2 months after operation. 6 months later, the elbow joint movement was remarkably limited. With arthrolysis, the operative effect was satisfactory, which met the needs of daily life. In this group of patients, no bone and soft tissue infection or neurovascular injury symptom was found. The elbow function was evaluated by MEPS, and the mean score was 82 points （62-92 points）. There were 7 excellent cases, 1 good case , 2 moderate cases and 0 poor case . The good and excellent rate was 80%. According to the elbow traumatic arthritis evaluation by Broberg and Morrey classification, there were 8 cases of no degenerative change, 2 cases of Grade 1 degenerative change and 0 case of Grade 2 or 3 degenerative change.ConclusionThe stage-one operative treatment is critical for the varus-posteromedial instability of elbow joint, and the individualized treatment based on injury types is beneficial to the recovery of joint function.The assessment of damage levels of elbow bone and soft tissue should be sufficiently made before operation. The individual operative plan is made based on the bone and soft tissue injury of patient. The rigid fixation of bone structure, the proper repair of soft tissue structure and the correct postoperative functional exercise are essential conditions for the successful treatment of traumatic elbow fracture-dislocation.

Elbow joint； Rotational instability； Facture fixation

10.3877/cma.j.issn.2095-5790.2017.03.004

連云港市衛計委面上項目（201703）；南京醫科大學科技發展基金（2016NJMU156）

工作單位: 222000 連云港市第一人民醫院骨科1；211100 南京醫科大學附屬江寧醫院骨科2

殷建，Email:yinjian0511@163.com

2017-02-04）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

殷照陽,殷建,孫曉,等. 肘關節內翻—后內側旋轉不穩定的手術療效分析［J/CD］.中華肩肘外科電子雜志,2017,5（3）：173-179.