人工关节置换与内固定术治疗老年股骨粗隆间骨折的Meta分析

Comparison between Artificial Hip Replacement and Internal Fixation for Treatment of Intertrochanteric Fractures in the Elderly:a Meta-Analysis

目的探讨老年人股骨粗隆间骨折采用人工关节置换与内固定术式的疗效及安全性,系统评价两种不同治疗选择的差异。方法计算机检索PubMed、EMBASE、Cochrane图书馆、中国知网(CNKI)等数据库,收集国内外关于老年(≥65岁)股骨粗隆间骨折行人工关节置换术与内固定术的临床随机对照试验(RCT),提取纳入研究的基本资料、手术操作时间、术中出血量、住院时间、术后负重下地时间、术后并发症、末次随访时的髋关节Harris评分、关节功能恢复优良率和术后死亡率等数据资料,对其进行质量评价分析,并采用RevMan 5.0软件对纳入研究结果进行Meta分析。结果纳入8个临床随机对照试验(RCT),共921例患者,其中人工关节置换组439例,内固定组482例。人工关节置换组与内固定组比较,手术操作时间、术中出血量及住院时间差异均无统计学意义,术后内科并发症及内植物相关并发症发生率低[RR=0.51,95%CI(0.31,0.84),P=0.008;RR=0.26,95%CI(0.11,0.61),P=0.002],术后负重下床时间较早[RR=-50.17,95%CI(-79.65,-20.68),P=0.001],末次随访时髋关节Harris评分[RR=3.19,95%CI(0.48,5.91),P=0.020]和关节功能恢复优良率[RR=2.99,95%CI(1.45,6.17),P=0.003]均较高。结论与Gamma钉、DHS、PFN等内固定相比,人工关节置换不增加手术操作时间、术中出血量及住院时间,但显著缩短术后负重下床时间,降低术后相关并发症,并提高了髋关节Harris评分及关节功能恢复优良率,对于老年人股骨粗隆间骨折的治疗,人工关节置换术具有明显的优势,但并不能显著降低术后死亡率。

Objective To compare the clinical effects and security between artificial hip replacement and internal fixation in treating intertrochanteric fractures in the elderly patients.Methods The databases of PubMed,EMBASE,Cochrane Library and CNKI were searched online.All the randomized controlled trials（RCT）comparing artificial hip replacement with internal fixation for the treatment of intertrochanteric fractures in the elderly （≥ 65 years） were included.Basic information,operation time,bleeding loss,hospitalization time,weight-bearing time,complication rate,Harris score on the last visit,the excellent rate of recovery of the joint function and the postoperative mortality were collected and meta-analyzed with RevMan 5.0.Results Eight randomized controlled trials with 921 patients were included,including 439 cases of artificial hip replacement and 482 cases of internal fixation.The meta-analysis showed that there were no significant differences in the operation time,bleeding loss and hospitalization time between the two groups.However,the incidence of internal and implant-related complications were lower [RR=0.51,95%CI（0.31,0.84）,P=0.008;RR=0.26,95%CI（0.11,0.61）,P=0.002],the weight-bearing time was shortened[RR=-50.17,95%CI（-79.65,-20.68）,P=0.001],the Harris score of the hip was higher[RR=3.19,95%CI（0.48,5.91）,P=0.020],and the excellent rate at final follow-up was higher[RR=2.99,95 %CI（1.45,6.17）,P=0.003]in the artificial hip replacement group.Conclusion The artificial hip replacement did not increase the operation time,bleeding amounts and hospitalization time,but shortened the weight-bearing time,reduced the incidence of internal and implant related complications and improved the hip function when compared with internal fixations with Gamma nail,DHS,and PFN.It has advantages in treating intertrochanteric fractures in the elderly.But it can not significantly reduce the postoperative mortality.