石膏与钢板固定治疗成人桡骨远端骨折效果比较的Meta分析

Treatment outcomes of casting versus plate for distal radius fracture in adults: a meta-analysis

背景:对于成人远端骨折的患者,石膏外固定还是切开复位钢板固定治疗存在争议。目的:以Meta分析的方法比较手法复位石膏托外固定与切开复位钢板内固定治疗成人桡骨远端骨折的临床疗效。方法:计算机检索Pub Med、EMbase、TheCochraneLibrary(2017年第11期)、OVID、WebofScience数据库、知网及万方数据库。搜集所有关于手法复位石膏托外固定与切开复位钢板内固定比较治疗成人桡骨远端骨折的随机对照试验,检索时限均为建库至2018年3月。2名研究者对检索文献按照制定的纳入排除标准进行独立筛选,提取资料及数据并评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析。结果与结论:(1)最终纳入15个随机对照试验,共1545例患者;(2)Meta分析结果显示,2组患者上肢残疾评分[MD=1.83,95%CI(-0.06,3.72),P=0.06]、腕关节患者自行评估量表评分[MD=4.01,95%CI(-4.96,12.99),P=0.38]、腕关节活动度(背伸、尺偏)[MD=-7.47,95%CI(-15.40,0.47),P=0.07;MD=-5.45,95%CI(-13.82,2.93),P=0.20]方面差异均无显著性意义,而钢板组末次随访时具有更高的Gartlandand Werley优良率[OR=0.52,95%CI(0.30,0.90),P=0.02]和握力[MD=-10.01,95%CI(-17.04,-2.99),P=0.005];(3)并发症方面钢板组肌腱炎发生率[RR=0.10,95%CI(0.02,0.51),P=0.006]明显增加,石膏组腕管综合征[RR=3.20,95%CI(1.14,8.96), P=0.03]、手指僵硬发生率[RR=9.29,95%CI(1.80,47.79),P=0.008]增加,其余并发症差异无显著性意义;(4)现有证据表明,对于成人桡骨远端骨折,在远期功能方面,手法复位石膏托外固定与切开复位钢板内固定治疗效果相似,虽然影像学结果欠佳,不一定能完全解剖复位,但并未降低患者腕关节活动范围,亦未增加再次手术率,临床上对于老年患者可优先采用。

BACKGROUND:For fracture of distal radius in adults,choosing casting external or open reduction and internal fixation(ORIF)with plates remains controversial.OBJECTIVE:To analyze the results of closed reduction and casting versus ORIF with plates in treatment of fracture of distal radius in adults.METHODS:Databases of PubMed,EMbase,The Cochrane Library(Issue 11,2017),OVID,Web of Science,CNKI and WanFang were searched.The randomized controlled trials about casting and plate for the fracture of distal radius published before March 2018 were collected.The literature screening was conducted by two researchers independently based on the incision and exclusion criteria,followed by data extraction and bias evaluation.Meta-analysis was performed on RevManager 5.3 software.RESULTS AND CONCLUSION:(1)Fifteen randomized controlled trials were included involving 1 545 patients.(2)Meta-analysis results showed that there were no significant differences in the Disabilities of the Arm,Shoulder and Hand scores(MD=1.83,95%CI(-0.06,3.72),P=0.06),Patient-Rated Wrist Evaluation Questionnaire scores(MD=4.01,95%CI(-4.96,12.99),P=0.38),range of motion of the wrist joint in dorsiflexion and ulnar deviation(MD=-7.47,95%CI(-15.40,0.47),P=0.07;MD=-5.45,95%CI(-13.82,2.93),P=0.20)between two groups.The plate groups had a higher Gartland and Werley category(OR=0.52,95%CI(0.30,0.90),P=0.02)and grip strength(MD=-10.01,95%CI(-17.04,-2.99),P=0.005).(3)In the plate group,the incidence of tendinitis(RR=0.10,95%CI(0.02,0.51),P=0.006),carpal tunnel syndrome(RR=3.20,95%CI(1.14,8.96),P=0.03)and finger stiffness(RR=9.29,95%CI(1.80,47.79),P=0.008)were significantly increased.(4)To conclude,for adult patients with fracture of distal,the long-term function between casting and plate is similar.Although the radiological parameters of closed reduction and casting are poor,it does not reduce the range of motion of the wrist joint,nor increase the rate of reoperation,which is firstly chosen for older adults.