髓内与髓外固定修复股骨转子间骨折的Meta分析

背景：股骨转子间骨折在治疗上选择髓内固定还是髓外固定仍存在争议。 目的：系统评价固定治疗股骨转子间骨折各种髓内固定与髓外固定的疗效。 方法：计算机检索MEDLINE数据库、EMBASE数据库、Cochrane图书馆、中国生物医学文献数据库、中国知网等常用中英文数据库,并辅以手工检索,全面查找国内外比较髓内固定和髓外固定治疗股骨转子间骨折的随机对照试验。纳入国内外比较髓内固定与髓外固定治疗股骨转子间骨折疗效的随机对照试验。根据修改后Jadad质量评分量表对纳入研究进行质量评价,并应用统计学软件Stata 12.0和RevMan 5.1软件进行数据分析,统计方法采用Mantel-Haenszel法。 结果与结论：共纳入31项随机对照试验,共计5 217例患者。根据修改后Jadad质量评分量表进行评价,纳入的所有研究中19 篇方法学质量为高质量,12篇为低质量。Gamma钉组术中股骨骨折(RR= 4.00,95%CI：1.80-8.86,P < 0.01)、术后股骨骨折(RR =3.57,95%CI：1.68-7.60,P < 0.01)、内固定切出(RR =1.61,95%CI：1.02-2.52,P =0.04)、再骨折风险(RR =1.58,95%CI：1.09-2.30,P =0.02)和随访期内髋部或大腿部残留疼痛(RR =1.31,95%CI：1.09-1.57,P < 0.01)明显高于滑动髋螺钉组;股骨近端抗旋髓内钉组术中失血明显较滑动髋螺钉组少,髋关节功能Harris评分亦更高,但术中暴露于射线中的时间更长(MD=2.11,95%CI：1.78-2.43,P < 0.01);髓内髋螺钉组术中失血量明显少于滑动髋螺钉组,但术中暴露于射线中的时间更长(MD=1.20,95%CI：0.88-1.52,P < 0.01)。结果证实,对于稳定型股骨转子间骨折,钉板系统和髓内固定均可取得良好疗效,首选以动力髋螺钉为代表的髓外固定。对于不稳定转子间骨折,髓内系统优于髓外固定系统。

Intramedullary nails versus extramedullary fixation in the repair of intertrochanteric fractures: A Meta-analysis

BACKGROUND:The choice of intramedullary nails versus extramedullary fixation in surgical treatment of intertrochanteric fractures remains controversial. OBJECTIVE:To evaluate the efficacy of intramedullary versus extramedullary fixation for the treatment of intertrochanteric fractures. METHODS:A computer-based search was performed on the MEDLINE database, EMBASE database, Cochrane Library, CBM database, CNKI database and other commonly used electronic database, supplemented by manual searches to find the randomized controlled trials on the comparison of intramedullary versus extramedullary fixation for the treatment of intertrochanteric fractures at home and abroad. All randomized controlled trials comparing the efficacy of intramedullary versus extramedullary internal fixation for the treatment of intertrochanteric fractures were included. The included studies were evaluated with the modified Jadad quality scale, and the software Stata 12.0 and RevMan 5.1 were used for data analysis. The statistical method was the Mantel-Haenszel method. RESULTS AND CONCLUSION:A total of 31 randomized controlled trials were included, including 5 217 patients. According to the modified Jadad quality scale, 19 literatures of methodological quality showed high quality, and low quality of 12 literatures. The intraoperative femoral fractures relative risk (RR)=4.00, 95% confidence interval (CI) (1.80-8.86), P < 0.01], postoperative femoral fracture RR=3.57, 95%CI (1.68-7.60), P < 0.01], cut out RR=1.61, 95%CI (1.02-2.52); P=0.04], reoperation risk RR=1.58, 95%CI (1.09-2.30); P=0.02], and residual hip or thigh pain in the follow-up period RR=1.31, 95%CI (1.09-1.57), P < 0.01] in the Gamma nail group was significantly higher than those in the sliding hip screw group. The intraoperative blood loss in the proximal femoral nail anti-rotation group was significantly less than that in the sliding hip screw group, and the hip joint Harris score was higher, but the intraoperative radiation time was longer mean difference (MD)=2.11, 95%CI (1.78-2.43), P < 0.01]. The intraoperative blood loss in the intramedullary hip screw group was significantly less than that in the sliding hip screw group, but the radiation time was longer MD=1.20, 95%CI (0.88-1.52), P < 0.01]. For stable intertrochanteric fracture, both screw-plate system and intramedullary fixation have good outcome, but the dynamic hip screw as the representative of extramedullary fixation system is preferred. The intramedullary system is better than extramedullary fixation system in the treatment of unstable intertrochanteric fractures.