外固定与切开复位内固定治疗桡骨远端不稳定性骨折疗效的Meta分析

A meta-analysis on the curative effects of external fixation and open reduction and internal fixation for unstable distal radial fractures

目的探讨外固定架(external fixation,EF)与切开复位内固定(open reduction internal fixation,ORIF)治疗不稳定性桡骨远端骨折的疗效。方法对术后的关节活动度(range of motion,ROM)及握力、影像学结果、上肢功能评分(disabilities of the arm,shoulder and hand scores,DASH评分)、再手术率及并发症进行Meta分析。计算机检索Medline、Embase、Cochrane Library、PubMed、维普资讯、中文科技期刊全文数据库和中国万方数据库等中英文数据库,手工检索国内相关杂志9种,均从创刊检索至2013年3月,搜集不稳定性桡骨远端骨折的内固定或外固定治疗的临床研究。纳入符合标准的文献,提取相关数据输入Review Manager 5.0软件进行Meta分析。结果共12篇文献符合。纳入标准,经改良Jadad评分均判定为高质量研究。纳入病例920例。在术后3个月时,EF组仅有前臂旋前角度优于ORIF组(open reduction internal fixation,ORIF)(MD 5.13,95%CI[2.04,8.22],P=0.001),ORIF组的掌屈(MD=-6.15,95%CI[-9.65,-2.65],P=0.0006)、背伸(MD=-11.12,95%CI[-16.59,-5.66],P<0.0001)、尺偏角(MD=-2.70,95%CI[-4.94,-0.46],P=0.02)、旋后(MD=-11.56,95%CI[-16.28,-6.84],P<0.00001)以及握力恢复(MD=-12.82,95%CI[-20.24,-5.41],P=0.0007)均优于EF组。但两组术后6个月及1年ROM和握力恢复的效果相同。ORIF组在术后3个月和1年时均有较好的DASH评分(3个月时DASH评分MD=15.54,95%CI[8.77,22.32],P<0.00001;12个月时DASH评分MD=3.14,95%CI[0.20,6.07],P=0.04)。此外,ORIF组更好地恢复掌倾角(MD=-1.95,95%CI[-3.18,-0.72],P=0.002)及尺骨方差(MD=0.60,95%CI[0.12,1.07],P=0.01),并同时降低了并发症的发生率(MD=1.63,95%CI[1.16,2.28],P=0.005)。两组间在桡倾角、桡骨高度、再手术率,感染以外的并发症发生率差异无统计学意义。结论 ORIF治疗不稳定桡骨远端骨折,术后患者可早期恢复握力并具有较好腕关节活动度,在术后较长时间内有较好的DASH评分,能更好地恢复尺骨方差和掌倾角同时明显降低感染率。术式的选择对术后长时间握力和关节活动度的恢复并无关联。EF与ORIF两种方法,在桡倾角、桡骨高度、再手术率,感染以外的并发症发生率方面,差异无统计学意义。

Objective To investigate the clinical effects between external fixation （ EF ） and open reduction internal fixation （ ORIF ） in the treatment of unstable distal radial fractures. Methods A meta-analysis on the joint range of motion （ ROM ）, grip strength, radiographic results, disabilities of the arm, shoulder and hand （ DASH ） scores, reoperation rates and complications was carried out postoperatively. A computer-based online search was done in the database in both English and Chinese such as Medline, Embase, Cochrane Library, Pubmed, VIP information, Chinese sci-tech periodical full-text database, Wanfang database and so on. 9 relevant Chinese orthopedic journals were manually searched from the initial issue to the issue published in March 2013, and the clinical studies on ORIF and EF for unstable distal radial fractures were gathered. The papers that met the inclusion criteria were collected, and then the extracted data were evaluated by Review Manager 5.0 for a meta-analysis. Results A total of 12 papers （ 920 patients ） met our inclusion criteria, and all of them were judged to be high-quality studies on the modified Jadad scale. Only forearm pronation in the EF group was （ MD=5.13, 95% CI [ 2.04, 8.22 ], P=-0.001 ） better than that of the ORIF group 3 months after the operation. The palmar flexion （ MD=-6.15, 95% CI [ -9.65, -2.65 ], P=0.0006 ）, dorsal flexion （ MD=-ll.12, 95% CI [ -16.59, -5.66 ], P〈0.0001 ）, ulnar deviation （ MD=-2.70, 95% CI [ -4.94, -0.46 ], P=0.02 ）, supination （ MD=-ll.56, 95% CI [ -16.28, -6.84 ], P〈0.00001 ） and grip strength recovery （ MD=-12.82, 95% CI [ -20.24, -5.41 ], P=0.0007 ） in the ORIF group were superior to that of the EF group. But 6 months and 1 year after the operation, there were no differences in the ROM and grip strength recovery effects between the 2 groups. The DASH scores in the ORIF group were superior to that of the EF group 3 months and 1 year after the operation （ MD=15.54, 95% CI [ 8.77, 22.32 ], P〈0.00001 at the 3rd month and MD=3.14, 95% CI [ 0.20, 6.07 ], P=0.04 at the 12th month after the operation ）. In addition, the volar tilt （ MD=-l.95, 95% CI [ -3.18, -0.72 ], P=0.002 ） and ulnar variance （ MD=0.60, 95% CI [ 0.12, 1.07 ], P=0.01 ） got better in the ORIF group, and meanwhile the incidence of complications was reduced （ MD=1.63, 95% CI [ 1.16, 2.28 ], P=0.005 ）. There were no significant differences in the radial inclination, radial height, reoperation rate and incidence of complications except for infection between the 2 groups. Conclusions The patients with unstable distal radial fractures who have received ORIF can obtain better grip strength and wrist ROM in the early period of postoperative recovery. Better DASH scores can be achieved in the long-term recovery, with better recovery of the ulnar variance and volar tilt and a significant reduction in the infection rate. But no relationship is found between the choice of surgical methods and the postoperative long-term recovery of grip strength and joint ROM. No statistically significant differences are noticed in the radial inclination, radial height, reoperation rate, incidence of complications except for infection between the EF and ORIF groups.