髓内钉与钢板内固定治疗肱骨干骨折疗效的系统评价

A systematic review of intramedullary nailing versus plate fixation for humeral shaft fractures

目的系统评价髓内钉与钢板内固定治疗肱骨干骨折的疗效.方法计算机检索Cochrane图书馆、Cochane协作网创伤数据库（2011.3）、MEDLINE（1966～2011.3）、EMbase（1966～2011）、中国生物医学文献数据库（1979.1～2011.3）、谷歌学术搜索、万方数据库和中国学术期刊数据库,同时对入选文献的参考文献以及中文骨科期刊进行手工检索.收集髓内钉与钢板内固定治疗肱骨干骨折的随机对照试验（RCTs）和半随机对照试验（CCTs）,评价纳入研究的方法学质量,提取有效数据按Cochrane协作网推荐的方法进行系统评价.结果共纳入10个RCT,其中1 篇提供仅摘要数据,共460 例患者,其中髓内钉组236 例,钢板组224例.Meta 分析结果显示,⑴在术后肩关节活动受限、延迟愈合和肩部撞击方面,钢板固定显著优于髓内钉;⑵在术后感染方面,髓内钉固定术后感染风险明显低于钢板固定;⑶在术后不愈合、功能评定、肘关节活动受限、畸形愈合、医源性骨折粉碎、内植物失败、粘连性关节囊炎、二次手术和术后桡神经麻痹的对比上,髓内钉与钢板固定之间并无统计学差异.结论现有的随机对照临床研究证据显示,对于成人肱骨干骨折行手术内固定,在术后肩关节活动受限、延迟愈合和肩部撞击方面,钢板显著优于髓内钉;而髓内钉固定术后感染的风险更低.因限于研究质量及样本量的局限性,该结论尚需开展更多高质量的大样本随机对照试验加以验证.

Objective To systematically reviewthe existing evidence about the effect of intramedullary nailing versus platingfixation on the fractures of the humeral shaft in adults.Methods Eligible studies were identified in Cochrane library,the Cochrane Bone,Joint and Muscle Trauma Group（2011.3）,MEDLINE（1966 to 2011.3）,EMbase（1966 to 2011）,CBM（1979.1 to 2011.3）,Google scholar,Wanfang Data（2000 to 2011.3）and CNKI and manually searched the referencesof included studies and several Chinese orthopedic journals.Then Randomized controlled trials（RCTs）and quasi-randomizedcontrolled trials（CCTs）about comparing two techniques（intramedullary and plate-screw system）for humeral shaftfractures in adults were collected.After evaluation of methodology with the enrolled studies,extracted available data wasextracted and systematic review was conducted via the method recommended by Cochrane Collaboration.Results 10RCTs involving 460 patients were included totally,one of which provides abstract data only.There are 236 patients in intramedullarygroup and 224 patients in plate group.In this meta-analysis,firstly,when regarding the delayed union, restrictionof shoulder movement and shoulder impingement, plate fixation shows better results than intramedullary nailing; Secondly,intramedullary fixation significantly lowers the risk of postoperative infection comparing the plate fixation; Thirdly,there is no significant difference between the two techniques in function grade and complications including nonunion, malunion,radial nerve palse, restriction of elbowmovement, iatrogenic fracture comminution, implant failure, adhesive capsulitis,reoperation.Conclusion With the surgical fixation of humeral shaft fractures in adults,plate fixation shortens theunion time and lowers incidence of restriction of shoulder movement and shoulder impingement but has a higher risk ofpostoperative infection while comparing to the intramedullary nail. Because of the limited methodology quality of enrolledstudies, yet further well-designed and large-scale randomized controlled trials are required to strengthen the conclusion onoptimal fixation.