股骨颈骨折内固定术后因素与股骨头坏死关系的分析

Analysis on relationship between postoperative factors and necrosis of femoral head following internal fixation of femoral neck fracture

目的采用Meta分析方法探讨股骨颈骨折内固定术后因素对股骨头坏死(ONFH)的影响,为临床术后康复和后续治疗提供依据。方法检索2000年1月至2021年3月中国知网、万方、维普数据库、PubMed、Cochrane图书馆及荷兰医学文摘(Embase)等数据库中有关股骨颈骨折行空心钉内固定手术后发生ONFH因素的相关研究,提取不同因素分组下发生ONFH患者数量;排除单一骨折类型、有严重内科合并症及动物实验等研究。采用纽卡斯尔渥太华评分(NOS)量表评价纳入研究的文献质量,并运用STATA 15.0软件对纳入研究的结局指标进行Meta分析。结果共纳入35项研究,均为病例对照研究。共计8465例股骨颈骨折患者,发生股骨头坏死1285例,总坏死率16%[95%置信区间(CI)(14%,17%)]。Meta分析结果显示,股骨颈骨折术后内固定取出组比内固定保留组ONFH发生率更高[比值比(OR)=1.96,95%CI(1.33,2.89)];内固定时间小于2年的患者较内固定时间大于2年的患者有更高坏死率[OR=1.83,95%CI(1.08,3.11)];术后3个月内下地负重是术后发生ONFH的危险因素[OR=1.64,95%CI(1.18,2.29)]。术后3~6个月下地负重和术后6个月后下地负重的ONFH发生率差异无统计学意义[OR=0.95,95%CI(0.74,1.22)]。结论临床上在对股骨颈骨折空心钉内固定术后患者的处理上,保留内固定及术后3个月内避免下地负重可能有效避免术后ONFH的发生,但将来尚需要更多的多中心大样本前瞻性研究及更深层次的生物力学和病理生理学研究加以证实。

Objective To investigate the influence of postoperative factors on osteonecrosis of femoral head(ONFH)after internal fixation for femoral neck fracture by meta-analysis,so as to provide evidence for clinical rehabilitation and follow-up treatment.Methods China National Knowledge Infrastructure(CNKI),Wanfang,China Science and Technology Journal Database(VIP),PubMed,Cochrane Library and Excerpta Medica Database(Embase)were searched for the relevant studies on the factors of ONFH after internal fixation of femoral neck fracture with caved nails;the literature retrieval time was from January 2000 to March 2021 and the numbers of the patients with ONFH under different factors were extracted.The studies containing simple fracture type,severe medical complications and animal studies were excluded.Newcastle-Ottawa scale(NOS)was used to evaluate the literature quality of the included studies,and STATA15.0 software was used for meta-analysis of the outcome indicators of the included studies.Results A total of 35 studies were included,all of which were case control studies.A total of 1285 cases in 8465 patients with femoral neck fracture suffered ONFH,and the total necrosis rate was 16%[95%confidence interval(CI)(14%,17%)].Meta-analysis results showed that the ONFH rate was higher in the implant removal group than in the implant retention group[odds ratio(OR)=1.96,95%CI(1.33,2.89)].The rate of necrosis was higher in the group with less than two years of internal fixation than in the group with more than two years of internal fixation[OR=1.83,95%CI(1.08,3.11)].Postoperative weight-bearing in three months was the risk factor associated with ONFH[OR=1.64,95%CI(1.18,2.29)].There was no statistically significant difference in the rate of ONFH between the patients who adopted weight-bearing in postoperative three to six months and the patients who adopted weight-bearing six months after the surgery[OR=0.95,95%CI(0.74,1.22)].Conclusions Clinically,retaining internal fixation devices and avoiding weight bearing during the first three postoperative months may effectively avoid the occurrence of ONFH in the treatment of patients with femoral neck fracture after internal fixation.However,more prospective multicenter studies with large samples and deeper biomechanical and pathophysiological studies are needed to verify these conclusions in the future.