股骨颈骨折空心螺钉内固定术后股骨颈短缩危险因素的Meta分析

Risk factors for femoral neck shortening after hollow screw internal fixation for femoral neck fracture:a meta analysis

目的:系统评价股骨颈骨折(femoral neck fracture,FNF)空心螺钉内固定术后股骨颈短缩(femoral neck shortening,FNS)的危险因素。方法:检索中国知网、中国生物医学文献服务系统、万方数据库、维普网、PubMed、Cochrane Library、Embase、Web of Science,搜集有关FNF空心螺钉内固定术后FNS危险因素的队列研究或病例对照研究,检索时限均为建库至2024年3月1日。由2名研究人员独立筛选文献、提取数据并评价纳入研究的偏倚风险后,采用Stata16.0软件进行Meta分析。结果:共纳入16项研究,均为病例对照研究,共涉及1583例FNF患者。Meta分析结果显示,年龄[MD=3.10,95%CI(0.36,5.84),P=0.026]、骨质疏松[OR=3.44,95%CI(2.50,4.75),P=0.000]、Singh指数Ⅳ~Ⅵ级[OR=1.57,95%CI(1.11,2.23),P=0.011]、GardenⅢ~Ⅳ型[OR=3.65,95%CI(1.95,6.85),P=0.000]、PauwelsⅢ型[OR=5.01,95%CI(2.98,8.43),P=0.000]、切开复位[OR=3.29,95%CI(1.69,6.42),P=0.000]、Garden指数Ⅲ~Ⅳ级[OR=5.15,95%CI(3.94,6.74),P=0.000]均为FNF空心螺钉内固定术后FNS的危险因素;性别、高血压病史、糖尿病病史、置钉方式、住院时间与FNS的关联性均无统计学意义。体质量指数按照数据类型进行亚组分析,二分类变量组(≤24 kg·m^(-2)/>24 kg·m^(-2))的分析结果显示,体质量指数>24 kg·m^(-2)是FNS的危险因素[OR=3.32,95%CI(2.19,5.03),P=0.000];连续性变量组的分析结果显示,体质量指数与FNS的关联性无统计学意义。受伤至手术时间按照时间划分的界值进行亚组分析,24 h界值组(≤24 h/>24 h)的分析结果显示,受伤至手术时间与FNS的关联性无统计学意义;4 d界值组(≤4 d/>4 d)的分析结果显示,受伤至手术时间>4 d是FNS的危险因素[OR=2.04,95%CI(1.46,2.86),P=0.000]。完全负重时间按照时间划分的界值进行亚组分析,2个月界值组(≤2个月/>2个月)的分析结果显示,术后2个月内完全负重是FNS的危险因素[OR=2.57,95%CI(1.03,6.38),P=0.000];3个月界值组(≤3个月/>3个月)的分析结果显示,完全负重时间与FNS的关联性无统计学意义。分别采用固定效应模型和随机效应模型对上述指标进行Meta分析,所得结果接近,表明研究结果稳健可靠。基于Garden分型进行发表偏倚分析,Egger’s检验结果提示不存在发表偏倚(P=0.190)。结论:现有证据表明,年龄、骨质疏松、Singh指数Ⅳ~Ⅵ级、GardenⅢ~Ⅳ型、PauwelsⅢ型、切开复位、Garden指数Ⅲ~Ⅳ级是FNF空心螺钉内固定术后FNS的危险因素,体质量指数、受伤至手术时间、完全负重时间与FNS的关系尚不明确。

Objective:To systematically review the risk factors for femoral neck shortening(FNS)after internal fixation with hollow screw for treating femoral neck fracture(FNF).Methods:All the cohort study articles and case-control study articles about the risk factors for FNS after internal fixation with hollow screw for FNF included from database's inception to March 1,2024 were retrieved from the China National Knowledge Infrastructure,Chinese Biomedical Literature Service System,Wanfang Database,Vip Database,PubMed,Cochrane Library,Embase and Web of Science.The pertinent articles were screened,the information was extracted and the risk of bias of the included researches was assessed independently by two researchers,and then a Meta-analysis was conducted by using Stata16.0 software.Results:Sixteen case-control study articles were included in the final analysis,involving 1583 FNF patients.The results of Meta-analysis revealed that the age(MD=3.10,95%CI(0.36,5.84),P=0.026),osteoporosis(OR=3.44,95%CI(2.50,4.75),P=0.000),Singh's index graded fromⅣtoⅥ(OR=1.57,95%CI(1.11,2.23),P=0.011),Garden typeⅢ-Ⅳ(OR=3.65,95%CI(1.95,6.85),P=0.000),Pauwels typeⅢ(OR=5.01,95%CI(2.98,8.43),P=0.000),open reduction(OR=3.29,95%CI(1.69,6.42),P=0.000),Garden's index graded fromⅢtoⅣ(OR=5.15,95%CI(3.94,6.74),P=0.000)were the risk factors for FNS in patients who underwent hollow screw internal fixation for FNF;while,the associations of gender,hypertension history,diabetes mellitus history,screw placement method,and hospital stays with FNS were not statistical significant.A subgroup analysis on body mass index(BMI)was conducted according to the data type,and the results of binary variable group(BMI≤24 kg/m^(2)or>24 kg/m^(2))showed that a BMI greater than 24 kg/m^(2)was the risk factor for FNS(OR=3.32,95%CI(2.19,5.03),P=0.000);while the results of continuous variable group indicated that the association between BMI and FNS was not statistical significant.Additionally,a subgroup analysis on time from injury to surgery was performed according to the cut-off value defined by time,and the results of 24-hour cut-off value group(time from injury to surgery≤24 hours or>24 hours)indicated that the association between time from injury to surgery and FNS was not statistical significant;while the results of 4-day cut-off value group(time from injury to surgery≤4 days or>4 days)suggested that the time from injury to surgery over 4 days was a risk factor for FNS(OR=2.04,95%CI(1.46,2.86),P=0.000).Moreover,a subgroup analysis on full weight-bearing walking start time was performed according to the cut-off value defined by time,and the results of 2-month cut-off value group(full weight-bearing walking start time≤2 months or>2 months)revealed that full weight-bearing within 2 months after surgery was a risk factor for FNS(OR=2.57,95%CI(1.03,6.38),P=0.000);while the results of 3-month cut-off value group(full weight-bearing walking start time≤3 months or>3 months)suggested that the association between full weight-bearing walking start time and FNS was not statistical significant.The Metaanalysis was performed on the aforementioned indicators by employing a fixed-effect model and a random-effect model,respectively,and the results showcased that no evident change was found in the result of each indicator,suggesting the findings of the Meta-analysis in this study were relatively stable and reliable.Moreover,the publication bias was analyzed based on the Garden typing,and the result of Egger's test showed that there was no publication bias in the included articles(P=0.190).Conclusion:Available evidences suggest that the age,osteoporosis,Singh's index graded fromⅣtoⅥ,Garden typeⅢ-Ⅳ,Pauwels typeⅢ,open reduction,Garden's index graded fromⅢtoⅣare the risk factors for FNS after internal fixation with hollow screw for FNF;while,the relation of BMI,time from injury to surgery and full weight-bearing walking start time to FNS are not yet clear.