全髋关节置换和人工股骨头置换修复移位型股骨颈骨折效果:基于14项随机对照试验的Meta分析

Total hip arthroplasty versus artificial femoral head replacement for the effect of displaced femoral neck fracture:a meta-analysis of 14 randomized controlled trials

目的:移位型股骨颈骨折是老年人中常见的骨折,但其手术方式仍存争议,既往Meta分析存在纳入研究质量较低、病例数仍较少等缺点。文章采用Meta分析法比较人工全髋关节置换与人工股骨头置换治疗移位型股骨颈骨折的疗效。方法:使用计算机检索PubMed、EMbase、Cochrane Library、Google Scholar、中国知网、万方和维普数据库,检索时间为1970年1月至2020年6月,检索词:“Femoral Neck Fracture、hemiarthroplasty、Total Hip arthroplasty、半髋关节置换、全髋关节置换”,检索国内外所有关于对比研究人工全髋关节置换与人工股骨头置换治疗移位型股骨颈骨折的文献。由2名研究员根据纳入和排除标准分别独立筛选文献,提取数据,根据Cochrane手册评估文献偏倚。使用Stata 14.0统计软件,并且结合了更新的Meta-Analysis软件包进行结局指标Meta分析。结果:①共纳入14项随机对照试验,包括10项原始研究,其中4项为延长随访数据研究,移位型股骨颈骨折患者共2523例,试验组采取全髋关节置换,对照组采取人工股骨头置换,纳入文献整体质量较高;②Meta分析结果显示,人工全髋关节置换组术后脱位率(RR=0.450,95%CI:0.306-0.661,P<0.001)、Harris评分(WMD=-5.527,95%CI:-7.952至-3.103,P<0.001)、EQ-5D评分(WMD=-0.055,95%CI:-0.075至-0.034,P<0.001)高于人工股骨头置换组,而二次手术率(RR=1.741,95%CI:1.253-2.419,P=0.001)低于人工股骨头置换组,两组患者2年死亡率(RR=1.025,95%CI:0.845-1.243,P=0.804)、术后感染率(RR=0.896,95%CI:0.789-1.017,P=0.505)及全身并发症发生率(RR=0.896,95%CI:0.789-1.017,P=0.090)无显著性差异。结论:现有的临床证据表明,全髋关节置换具有更好的髋关节活动功能以及较低的二次手术率,对于全身身体状况较好、骨折前可独自活动以及认知功能良好的移位股骨颈骨折患者,全髋关节置换比人工股骨头置换更有优势。

OBJECTIVE:Displaced femoral neck fracture is a common fracture in the elderly,but the method of operation is still controversial.Previous meta-analysis has some shortcomings such as low quality of research and few cases.This study compared the efficacy of total hip arthroplasty and artificial femoral head replacement in the treatment of displaced femoral neck fracture by meta-analysis.METHODS:PubMed,EMbase,Cochrane Library,Google Scholar,CNKI,Wanfang and VIP databases were searched by computer from January 1970 to June 2020.The key words were“femoral neck fracture,hemiarthroplasty,total hip arthroplasty”in English and Chinese.All articles about the comparative study of total hip arthroplasty and artificial femoral head replacement in the treatment of displaced femoral neck fracture were searched.Two researchers independently screened the literature according to the inclusion and exclusion criteria,extracted data,and evaluated the risk of literature bias according to Cochrane Handbook.Stata 14.0 statistical software and the updated Meta-Analysis software package were used to analyze the outcome measures.RESULTS:(1)A total of 14 randomized controlled trials,containing 10 original studies and 4 extended follow-up data,were included in this article.A total of 2523 patients with displaced femoral neck fracture were included.The experimental group was treated with total hip arthroplasty and the control group was treated with artificial femoral head replacement.The overall quality of the literature was high.(2)The results of meta-analysis showed that the dislocation rate(RR=0.450,95%CI:0.306-0.661,P<0.001),Harris score(WMD=-5.527,95%CI:-7.952 to-3.103,P<0.001),and EQ-5D score(WMD=-0.055,95%CI:-0.075 to-0.034,P<0.001)in the total hip arthroplasty group were higher than those in the artificial femoral head replacement group.However,the second operation rate of total hip arthroplasty group was lower than that of artificial femoral head replacement group(RR=1.741,95%CI:1.253-2.419,P=0.001).There was no statistical difference in 2-year mortality(RR=1.025,95%CI:0.845-1.243,P=0.804),postoperative infection rate(RR=0.896,95%CI:0.789-1.017,P=0.505),and incidence of systemic complications(RR=0.896,95%CI:0.789-1.017,P=0.090)between the two groups.CONCLUSION:The available clinical evidence shows that total hip arthroplasty has better hip movement function and lower secondary operation rate.For patients with displaced femoral neck fracture who are in good physical condition,can move alone before fracture,and have good cognitive function,total hip arthroplasty has more advantages than artificial femoral head replacement.