髓内钉与锁定钢板治疗肱骨近端骨折疗效:Meta分析

Comparison of clinical outcome of locking intramedullary nails versus locking plates for proximal humerus fractures:Meta-analysis

目的采用Meta分析的方法对髓内钉与锁定钢板治疗肱骨近端骨折的疗效进行对比,为其临床应用提供循证证据。方法检索PubMed、SpringerLink、EMBASE、The Cochrane Library、Medline、Science Direct、中国知识资源总库、万方数据库、维普数据库,检索时间至2015年1月。收集髓内钉与锁定钢板治疗肱骨近端骨折疗效对比的相关文献,按纳入与排除标准筛选文献并对纳入文献进行质量评价,采用RevMan5.2软件进行统计学分析。结果共纳入11篇文献,病例数合计为700例,其中髓内钉组303例、锁定钢板组397例。结果显示在观察指标中,术后并发症、Constant评分、术后疗效优良率、二次手术率方面差异无统计学意义(P>0.05);而在术中出血量、手术时间方面髓内钉组明显优于锁定钢板组(P<0.05);术后肩关节活动范围方面,前举、外展、内旋髓内钉组低于锁定钢板组(P<0.05),而外旋髓内钉组高于锁定钢板组(P<0.05)。结论髓内钉治疗肱骨近端骨折,在手术时间、术中出血量、外旋方面明显优于锁定钢板,而无证据显示其在术后并发症、Constant评分、术后疗效优良率、二次手术率、术后肩关节活动范围方面,前举、外展、内旋方面优于锁定钢板。

Background proximal humerus fracture is often seen in the elderly population with osteoporosis.Open surgery and open reduction and internal fixation is necessary when fracture displacement is significant.However,the osteoporotic fragments are not likely to be securely fixed,so the traditional plate and screw fixation has a very high failure rate.On the other hand,the emerging locking plate and locking intramedullary nail techniques provide adequate locking strength for proximal humerus fractures.Objective The objective of this study is to use evidence-based method to evaluate the clinical outcomes of locking intramedullary nails and locking plates for the treatment of proximal humerus fractures,and to compare the advantages and limitations of these two procedures.MethodsElectronic databases including PubMed,SpringerLink,EMBASE,the Cochrane Library,Medline,Science Direct,CNKI,Wan Fang Data and VIP database were searched up to Jan 2015 using the following search terms:locking intramedullary nails,locking plates,PHILOS,PHN,LPHP,proximal humeral surgical neck fractures,and humeral head fractures.Inclusion criteria:(1)type of studies:published randomized controlled trials,randomized controlled clinical trials and cohort study,English literatures only,blinded or not;(2)subjects:preoperative diagnosis of proximal humeral fracture who underwent relocation fixation procedure for the first time;(3)interventions:patients in the experimental group received locking intramedullary nail and patients in the control group received locking plate fixation surgery.Exclusion criteria;(1)review,symposium,abstract,protocol and comment type of literatures;(2)abstracts of irretrievable full text article,duplicate abstracts,nonclinical trial,retrospective study and literatures with no control group;(3)less than 6 months of follow-up;(4)subjects with serious complications affecting healing of fracture.Included literatures were analyzed and the following information was extracted:researchers,type of research,published time,number of patients,age,gender ratio,duration of disease,follow-up time,number of patients lost during follow-up,amount of bleeding,length of operation,rate of secondary surgery,fracture healing time,Constant score,range of motion(ROM)of the shoulder joint,lateral rotation,internal rotation,anterior flexion,post-operative complications and rate of satisfactory clinical outcomes etc.Statistical software RevMan 5.2was used and heterogeneity was analyzed usingχ2 test.Results Total of 11 studies met our inclusion criteria.No significant heterogeneities were detected in analyzed studies.There were no significant differences in Constant Score,complications,and revision between the nail group and the plate group.The nail group showed superiority compared with the plate group in intraoperative blood loss,surgery time and external rotation,but the plate group was better in forward flexion,abduction and inversion.Conclusion locking intramedullary nails is superior to locking plates in intraoperative blood loss,surgery time and external rotation for the treatment of proximal humerus fractures,but there were no evidences show its superiority in Constant Score,complications,revision,forward flexion,abduction,internal rotation.