髓内固定与髓外固定治疗股骨转子下骨折的系统评价

Intramedullary fixation versus extramedullary fixation for treatment of subtrochanteric fractures: A systematic review

目的:比较髓内固定与髓外固定治疗股骨转子下骨折的临床疗效和安全性。方法:应用计算机检索Pub Med、The Cochrane Library、Embase、CBM、CNKI、Wan Fang Data1980年9月至2017年9月国内外公开发表的比较髓内固定(髓内固定组)和髓外固定(髓外固定组)治疗股骨转子下骨折的随机对照研究文献、半随机对照研究文献或回顾性研究文献。由2位研究者独立筛选文献、提取资料,依据Cochrane手册进行文献方法学质量评价后,采用Rev Man5.3软件进行Meta分析。结果:最初共检索出3410篇文献,经逐层筛选后最终纳入8篇文献,均为英文文献,5篇为随机对照研究、2篇为半随机对照研究、1篇为回顾性研究。纳入的研究对象共391例,髓内固定组225例、髓外固定组166例。Meta分析结果显示,髓内固定组和髓外固定组的手术时间、术中失血量、住院时间、术后感染率、再骨折率、骨折前及末次随访时的Parker活动评分比较,组间差异均无统计学意义[WMD=3.87,95%CI(-1.95,9.70);WMD=-20.66,95%CI(-221.96,180.64);WMD=-2.95,95%CI(-7.16,1.25);RR=1.51,95%CI(0.57,3.98);RR=2.71,95%CI(0.72,10.15);WMD=-0.13,95%CI(-0.45,0.19);WMD=0.10,95%CI(-0.47,0.67)];与髓外固定组相比,髓内固定组的术中透视时间长[WMD=19.25,95%CI(8.75,29.75)]、再手术率低[RR=0.22,95%CI(0.09,0.55)]、内固定失败率低[RR=0.24,95%CI(0.10,0.56)]、骨折不愈合率低[RR=0.23,95%CI(0.07,0.81)];亚组分析显示,老年(平均年龄≥50岁)股骨转子下骨折患者采用髓内固定的内固定失败率和骨折不愈合率更低[RR=0.18,95%CI(0.07,0.47);RR=0.22,95%CI(0.06,0.86)]。结论:与髓外固定相比,采用髓内固定治疗股骨转子下骨折,内固定失败率、骨折不愈合率及再手术率较低,但术中透视时间较长。老年股骨转子下骨折患者更宜采用髓内固定治疗。

Objective:To compare the curative effect and safety of intramedullary fixation versus extramedullary fixation for treatment of subtrochanteric fractures.Methods:All the randomized controlled trial(RCT)articles,controlled clinical trial(CCT)articles and retrospective trial articles about intramedullary fixation(intramedullary fixation group)versus extramedullary fixation(extramedullary fixation group)for treatment of subtrochanteric fractures that published at home and abroad included from September 1980 to September 2017 were retrieved from PubMed,The Cochrane Library,Embase,CBM,China national knowledge internet and WanFang Data through computer.The articles were screened and the information was extracted independently by two searchers.The methodological quality of research in the articles was evaluated according to Cochrane handbook and a Meta-analysis was conducted by using Revman 5.3 software.Results:Three thousand four hundred and ten articles were searched out.After screening,8 English articles(391 patients)were included in the final analysis,including 5 RCT articles,2 CCT articles and 1 retrospective trial article,225 patients in intramedullary fixation group and 166 patients in extramedullary fixation group.The results of Meta-analysis demonstrated that there was no statistical difference in operative time,intraoperative blood loss,hospital stay,postoperative infection rate,refracture rate and Parker activity scores before fracture and at last follow-up between intramedullary fixation group and extramedullary fixation group(WMD=3.87,95%CI(-1.95,9.70);WMD=-20.66,95%CI(-221.96,180.64);WMD=-2.95,95%CI(-7.16,1.25);RR=1.51,95%CI(0.57,3.98);RR=2.71,95%CI(0.72,10.15);WMD=-0.13,95%CI(-0.45,0.19);WMD=0.10,95%CI(-0.47,0.67)).The intraoperative fluoroscopy time was longer[WMD=19.25,95%CI(8.75,29.75)],and the incidence rate of reoperation,failed internal fixation and fracture nonunion was lower(RR=0.22,95%CI(0.09,0.55);RR=0.24,95%CI(0.10,0.56);RR=0.23,95%CI(0.07,0.81))in intramedullary fixation group compared to extramedullary fixation group.The results of subgroup analysis demonstrated that the incidence rate of failed internal fixation and fracture nonunion was much lower(RR=0.18,95%CI(0.07,0.47);RR=0.22,95%CI(0.06,0.86))in intramedullary fixation group compared to extramedullary fixation group in the treatment of subtrochanteric fractures in elderly patients(mean age≥50 years).Conclusion:Intramedullary fixation has the advantages of lower incidence rate of failed internal fixation,fracture nonunion and reoperation and the disadvantage of longer intraoperative fluoroscopy time compared to extramedullary fixation in the treatment of subtrochanteric fractures,and it is more appropriate for the aged.