北京大学学报(医学版) ›› 2019, Vol. 51 ›› Issue (3): 493-500. doi: 10.19723/j.issn.1671-167X.2019.03.017

• 论著 • 上一篇    下一篇

股骨近端防旋髓内钉与动力髋螺钉治疗不稳定型粗隆间骨折的meta分析

张祎然,饶烽,皮伟,张培训(),姜保国()   

  1. 北京大学人民医院创伤骨科, 北京 100044
  • 收稿日期:2019-03-07 出版日期:2019-01-01 发布日期:2019-06-26
  • 作者简介:姜保国,现任北京大学人民医院院长、北京大学骨科学系主任、北京大学创伤医学中心主任、中国和国际创伤救治联盟主席、教育部创伤救治与神经再生重点实验室主任。兼任中华医学会常务理事、中华医学会创伤学分会第七届主任委员、中华医学会骨科学分会副主任委员、中国医师协会创伤外科医师分会侯任主任委员、北京医学会骨科学分会主任委员、中国医师协会肩肘外科工作委员会主任委员、中华医学会骨科学分会足踝外科学组组长、国际矫形与创伤外科学会中国分会副主席、中国医院协会大学附属医院分会主任委员。
    主要研究领域包括周围神经损伤修复与中枢重塑、严重创伤规范化救治、关节周围骨折等。
    主持国家自然科学基金、北京自然科学基金、国家高技术研究发展计划(863计划)、 “十一五” 国家科技支撑计划、卫生公益行业科研专项、北京市科学技术委员会重大研究专项、国家重点基础研究发展计划(973计划)等多项课题;2006年度获国家杰出青年基金资助,2012年作为团队学术带头人获得教育部创新团队,2013年作为首席科学家获国家973计划项目。发表学术论文370余篇,在国际SCI杂志Lancet、Spine等杂志发表论文69篇;获国家发明专利9项、实用新型专利15项;主编或主译《关节周围骨折》等著作21部;作为第一完成人获国家科学技术进步奖二等奖、教育部高等学校科学研究优秀成果奖(科学技术)技术发明一等奖和科技进步一等奖、中华医学科技进步奖一等奖;获得何梁何利基金科学与技术进步奖、吴阶平-保罗·杨森医学医药奖、国际顾氏和平奖、王正国基金会终身成就奖。
  • 基金资助:
    国家科技部重点研发项目(2018YFB1105504)、国家自然科学基金(31771322、31571235、81671215)、北京市科学技术委员会科技新星交叉项目(2018019)、教育部创新团队(IRT-16R01)和教育部重点实验室

Proximal femoral nails antirotation and dynamic hip screws for fixation of unstable intertrochanteric fractures of femur: A meta-analysis

Yi-ran ZHANG,Feng RAO,Wei PI,Pei-xun ZHANG(),Bao-guo JIANG()   

  1. Department of Trauma and Orthopedics, Peking University People’s Hospital, Beijing 100044, China
  • Received:2019-03-07 Online:2019-01-01 Published:2019-06-26
  • Supported by:
    Supported by Major R&D Program of National Ministry of Science and Technology (2018YFB1105504),National Natural Science Foundation of China (31771322, 31571235, 81671215), Beijing Municipal Science and Technology Commission Science and Technology Nova Cross Project (2018019),the Ministry of Education Innovation Program of China (IRT-16R01)

摘要: 目的 不稳定型粗隆间骨折手术治疗采用髓内固定还是髓外固定仍存在争议,本研究运用meta分析方法评价股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)和动力髋螺钉(dynamic hip screw,DHS)用于不稳定型粗隆间骨折的疗效及安全性。方法 计算机检索PubMed、Embase、The Cochrane Central Register of Controlled Trials(CENTRAL)、Google Scholar、中国科技论文与引文数据库(CSTPCD)、中国期刊全文数据库(CNKI)等数据库,截止日期为2019年1月1日,由2位研究者独立按照纳入与排除标准筛选PFNA与DHS治疗不稳定型粗隆间骨折的随机对照研究,进行质量评价,以切口长度、手术时间、术中出血量、开始负重时间、骨折愈合时间、Harris功能评分等临床疗效指标和并发症等安全性指标为观察指标,提取相关数据,应用RevMan 5.3统计软件进行数据分析。结果 纳入随机对照试验9篇,共779例患者,其中PFNA固定383例、DHS固定396例。分析结果提示,与DHS固定相比,PFNA固定的手术切口长度小[均数差(mean difference,MD)=-7.43, 95%CI(-9.31,5.55),P<0.05]、手术时间短[MD=-20.76, 95%CI(-29.57,-11.95),P<0.05]、术中出血量少[MD=-216.34, 95%CI(-275.18,-157.49),P<0.05]、术后可更早开始负重[MD=-12.34, 95%CI (-17.71,-6.97),P<0.05]、骨折愈合时间短[MD=-5.00, 95%CI(-7.73,-2.26),P<0.05]、术后Harris功能评分高[MD=12.22, 95%CI(3.88,20.55),P<0.05]、Harris评分优良率高[OR=3.56, 95%CI(1.44,8.81),P<0.05]、并发症发生率低[OR=0.48, 95%CI(0.33,0.70),P<0.05]。按年龄亚组分析,组间差异均无统计学意义。二者在住院时间及发生内固定松动、术中和术后股骨干骨折以及内固定断裂、切出、移位、退钉等固定失效并发症方面的差异均无统计学意义(P>0.05)。结论 现有证据表明针对不稳定型粗隆间骨折,PFNA内固定临床疗效优于DHS内固定,但二者的安全性分析仍需更多高质量随机对照研究提供更可靠的证据。

关键词: 髋骨折, 骨钉, 骨螺钉, 骨折固定术, 髓内, Meta分析

Abstract: Objective: To evaluate the efficacy and safety of proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) for unstable intertrochanteric fractures using meta-analysis. Methods: The PubMed, Embase, Cocharane Central Register of Controlled Trials, Google Scholar, China Science and Technology Papers and Citation Database (CSTPCD) and China Journal Full-text Database (CNKI) were searched for published randomized controlled trials before January 1, 2019. Two researchers independently screened the literature in the light of the inclusion and exclusion criteria, evaluated the quality of the studies and extracted the data which were consisted of clinical efficacy indexes, such as incision length, operation time,intraoperative blood loss, weight-bearing time,fracture-healing time, Harris hip score and safety indicators like complications. Meta-analysis was performed with the Revman 5.3 software provided by Cochrane Community in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. Results: Nine randomized controlled trials met the requirement with a total of 779 patients, of whom 383 were fixed with PFNA and 396 with DHS. Meta-analysis demonstrated that PFNA was associated with smaller surgical incision length [MD=-7.43, 95%CI (-9.31, -5.55), P<0.05], shorter operation time [MD=-22.76, 95%CI (-29.57, -11.95), P<0.05], less intraoperative blood loss [MD=-216.34, 95%CI (-275.18, -157.49), P<0.05], earlier weight bearing after surgery [MD=-12.34, 95%CI (-17.71, -6.97), P<0.05], shorter fracture healing time [MD=-5.00, 95%CI (-7.73, -2.26), P<0.05], higher postoperative Harris hip score [MD=12.22, 95%CI (3.88, 20.55), P<0.05], higher rate of excellent Harris hip score [OR=3.56, 95%CI (1.44, 8.81), P<0.05] and lower incidence rate of postoperative complications [OR=0.48, 95%CI (0.33, 0.70), P<0.05], such as hip varus, wound infection, urinary tract infection, pulmonary infection, pressure sore, deep vein thrombosis, pulmonary embolism, heart failure and cerebral infraction when compared with DHS. No statistical difference was shown between the groups when it came to subgroup analysis by age. However, there was no significant difference (P>0.05) in the duration of hospitalization and the complications resulting in the occurrences of internal fixation loosening, such as femoral shaft fracture (during or post operation), internal fixation fracture, cut-out, displacement or retraction. Conclusion: Current published evidence supports the superiority of PFNA to DHS for unstable intertrochanteric fractures in terms of clinical efficacy. The conclusion was limited because of the relatively low quality of evidence with low strength of confidence. Large scale and high-quality randomized controlled trials are required to validate the safety of PFNA and DHS for unstable intertrochanteric fractures.

Key words: Hip fractures, Bone nails, Bone screws, Fracture fixation, intramedullary, Meta-analysis

中图分类号: 

  • R683.3

图1

文献筛选流程图"

表1

纳入文献的特征"

Study Sample size (PFNA/DHS) Mean age/years Fracture type Follow-up/months
Dong, 2015[14] 30/30 67.6/68.3 A1-A3 12-18
Chen, 2012[15] 30/30 72* Evans Ⅲ/Ⅳ/Ⅴ 3
Yu, 2014[16] 33/33 37.8* A1-A3 3
Bai, 2015[17] 36/36 35.9/36.3 A1-A3 3
Han, 2011[18] 50/50 65/67 A2-A3 6
Zhan, 2013[19] 27/30 71.2* Evans Ⅲ/Ⅳ 12.3
Xu, 2010[20] 51/55 78.5/77.9 A2 12
Zehir, 2015[21] 96/102 77.22/76.86 A2 6
Huang, 2017[22] 30/30 75.07/74.01 Evans Ⅲ/Ⅳ/Ⅴ 19.4/19.8

图2

纳入研究的偏倚风险"

图3

PFNA与DHS内固定手术切口长度的比较"

图4

PFNA与DHS内固定术中出血的比较"

图5

PFNA与DHS内固定骨折愈合时间的比较"

图6

PFNA与DHS内固定Harris功能评分的比较"

图7

PFNA与DHS内固定并发症发生率的比较"

[1] Gullberg B, Johnell O, Kanis JA . World-wide projections for hip fracture[J]. Osteoporos Int, 1997,7(5):407-413.
doi: 10.1007/PL00004148
[2] Kanis JA, Johnell O, De Laet C , et al. International variations in hip fracture probabilities: implications for risk assessment[J]. J Bone Miner Res, 2002,17(7):1237-1244.
doi: 10.1359/jbmr.2002.17.7.1237
[3] Mattisson L, Bojan A, Enocson A . Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register[J]. BMC Musculoskelet Disord, 2018,19(1):369.
doi: 10.1186/s12891-018-2276-3
[4] Lizaur-Utrilla A, Gonzalez-Navarro B, Vizcaya-Moreno MF , et al. Reasons for delaying surgery following hip fractures and its impact on one year mortality[J]. Int Orthop, 2019,43(2):441-448.
doi: 10.1007/s00264-018-3936-5
[5] Brunner LC, Eshilian-Oates L, Kuo TY . Hip fractures in adults[J]. Am Fam Physician, 2003,67(3):537-542.
[6] Hagino H, Endo N, Harada A , et al. Survey of hip fractures in Japan: recent trends in prevalence and treatment[J]. J Orthop Sci, 2017,22(5):909-914.
doi: 10.1016/j.jos.2017.06.003
[7] Saudan M, Lübbeke A, Sadowski C , et al. Pertrochanteric fractures: is there an advantage to an intramedullary nail? A rando-mized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail[J]. J Orthop Trauma, 2002,16(6):386-393.
doi: 10.1097/00005131-200207000-00004
[8] Knobe M, Gradl G, Ladenburger A , et al. Unstable intertrochanteric femur fractures: Is there a consensus on definition and treatment in Germany?[J]. Clin Orthop Relar Res, 2013,471(9):2831-2840.
doi: 10.1007/s11999-013-2834-9
[9] Lenich A, Vester H, Nerlich M , et al. Clinical comparison of the second and third generation of intramedullary devices for trochanteric fractures of the hip: Blade vs. screw[J]. Injury, 2010,41(12):1292-1296.
doi: 10.1016/j.injury.2010.07.499
[10] Giraud B, Dehoux E, Jovenin N , et al. Pertrochanteric fractures: a randomized prospective study comparing dynamic screw plate and intramedullary fixation[J]. Rev Chir Orthop Reparatrice Appar Mot, 2005,91(8):732-736.
doi: 10.1016/S0035-1040(05)84484-8
[11] Yamauchi K, Fushimi K, Shirai G , et al. Comparison of func-tional recovery in the very early period after surgery between plate and nail fixation for correction of stable femoral intertrochanteric fractures: a controlled clinical trial of 18 patients[J]. Geriatr Orthop Surg Rehabil, 2014,5(2):63-68.
doi: 10.1177/2151458514527607
[12] Guerra MT, Pasqualin S, Souza MP , et al. Functional recovery of elderly patients with surgically-treated intertrochanteric fractures: preliminary results of a randomised trial comparing the dynamic hip screw and proximal femoral nail techniques[J]. Injury, 2014,45(Suppl. 5):S26-S31.
doi: 10.1016/S0020-1383(14)70017-8
[13] Liberati A, Altman DG, Tetzlaff J , et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration[J]. J Clin Epidemiol, 2009,62(10):e1-e34.
doi: 10.1016/j.jclinepi.2009.06.006
[14] 董宝铁, 高伟, 周振东 . 动力髋螺钉与防旋型股骨近端髓内钉治疗高龄不稳定型股骨粗隆间骨折比较[J]. 现代仪器与医疗, 2015,21(2):86-87, 92.
[15] 陈振宇, 黄福才, 钟巍巍 . PFNA治疗高龄股骨粗隆间不稳定型骨折应用研究[J]. 中国社区医师(医学专业), 2012,14(21):198-199.
[16] 于长明 . 股骨粗隆间不稳定骨折应用PFNA和DHS内固定的比较[J]. 中国实用医药, 2014,9(22):61-62.
[17] 白愉乐 . PFNA和DHS内固定治疗股骨粗隆间不稳定骨折的比较研究[J]. 中国现代药物应用, 2015,9(20):63-64.
[18] 韩成龙 . 老年股骨粗隆间不稳定骨折不同内固定方法的疗效比较[J]. 河北医药, 2011,33(22):3390-3392.
[19] 展振江, 李明, 张元凯 , 等. PFNA与DHS治疗老年股骨粗隆间不稳定性骨折疗效对比[J]. 山东大学学报(医学版), 2013,51(12):92-94, 99.
[20] Xu YZ, Geng DC, Mao HQ , et al. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture[J]. J Int Med Res, 2010,38(4):1266-1275.
doi: 10.1177/147323001003800408
[21] Zehir S, Zehir R, Zehir S , et al. Proximal femoral nail antirotation against dynamic hip screw for unstable trochanteric fractures; a prospective randomized comparison[J]. Eur J Trauma Emerg Surg, 2015,41(4):393-400.
doi: 10.1007/s00068-014-0463-y
[22] Huang SG, Chen B, Zhang Y , et al. Comparison of the clinical effectiveness of PFNA, PFLCP, and DHS in treatment of unstable intertrochanteric femoral fracture[J]. Am J Ther, 2017,24(6):e659-e666.
doi: 10.1097/MJT.0000000000000346
[23] Yin S, Dai X, Zhang DF , et al. Is proximal femoral nail antirotation superior to gamma nail and dynamic hip screw in treatment of intertrochanteric fractures? A pairwise and network meta-analysis[J]. Int J Clin Exp Med, 2016,9(12):22993-23007.
[24] Ma KL, Wang X, Luan FJ , et al. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis[J]. Orthop Traumatol Surg Res, 2014,100(8):859-866.
doi: 10.1016/j.otsr.2014.07.023
[25] Swart E, Makhni EC, Macaulay W , et al. Cost-effectiveness ana-lysis of fixation options for intertrochanteric hip fractures[J]. J Bone Joint Surg Am, 2014,96(19):1612-1620.
doi: 10.2106/JBJS.M.00603
[26] 程建, 雷会宁, 冯仕明 , 等. PFNA与DHS治疗不稳定型股骨粗隆间骨折的Meta分析[J]. 重庆医学, 2016,45(21):2956-2961.
[27] Audigé L, Hanson B, Swiontkowski MF . Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices[J]. Int Orthop, 2003,27(4):197-203.
doi: 10.1007/s00264-003-0457-6
[28] Parker MJ, Handoll HH. Gamma and other cephalocondylic intra-medullary nails versus extramedullary implants for extracapsular hip fractures in adults [J]. Cochrane Database Syst Rev, 2010( 9): CD000093.
[29] Weiser L, Ruppel AA, Nüchtern JV , et al. Extra- vs. intra-medullary treatment of pertrochanteric fractures: a biomechanical in vitro study comparing dynamic hip screw and intramedullary nail[J]. Arch Orthop Trauma Surg, 2015,135(8):1101-1106.
doi: 10.1007/s00402-015-2252-4
[1] 冯菁楠,高乐,孙一鑫,杨继春,邓思危,孙凤,詹思延. Xpert®MTB/RIF对我国人群活动性肺结核和利福平耐药肺结核诊断准确性的meta分析[J]. 北京大学学报(医学版), 2021, 53(2): 320-326.
[2] 侯国进,周方,田耘,姬洪全,张志山,郭琰,吕扬,杨钟玮,张雅文. 后路短节段跨伤椎椎弓根螺钉固定治疗胸腰段爆裂骨折术后再发后凸的危险因素[J]. 北京大学学报(医学版), 2021, 53(1): 167-174.
[3] 刘中砥,许庭珉,党育,张殿英,付中国. 有限切开复位髓内外联合固定技术治疗股骨转子下骨折的临床随访[J]. 北京大学学报(医学版), 2020, 52(6): 1102-1106.
[4] 曾保起,于树青,陈瑶,翟伟,刘斌,詹思延,孙凤. 主动脉瓣生物瓣膜安全性的系统评价与meta分析[J]. 北京大学学报(医学版), 2020, 52(3): 547-556.
[5] 孙建军,杨军,谢京城,常青,马长城,郑梅,LIAO Hung-I,王涛,陈晓东,韩芸峰,林国中,于涛,张嘉,司雨. 少节段和多节段髓内肿瘤的临床对照[J]. 北京大学学报(医学版), 2019, 51(5): 840-850.
[6] 张玮,张培训. 老年髋部骨折患者围手术期血栓预防时限分析[J]. 北京大学学报(医学版), 2019, 51(3): 501-504.
[7] 陈健,左才红,张财义,杨明,张培训. 解剖型髓内钉和股骨近端防旋髓内钉治疗老年股骨转子间骨折的疗效比较[J]. 北京大学学报(医学版), 2019, 51(2): 283-287.
[8] 刘爽,郭雨龙,杨静逸,王维,徐健. 间充质干细胞治疗系统性红斑狼疮有效性的meta分析[J]. 北京大学学报(医学版), 2018, 50(6): 1014-1021.
[9] 魏滨,张华,徐懋,李民,王军,张利萍,郭向阳,赵一鸣,周方. 不同麻醉方法对髋部骨折老年患者术后转归的影响[J]. 北京大学学报(医学版), 2017, 49(6): 1008-1013.
[10] 石慧峰, 张敬旭, 张嵘, 王晓莉. 中国0~6岁儿童孤独症谱系障碍患病率的meta分析[J]. 北京大学学报(医学版), 2017, 49(5): 798-806.
[11] 张伯松, 李文毅, 刘兴华, 危杰, 贺良, 王满宜. 肱骨干骨折手术与非手术治疗的比较[J]. 北京大学学报(医学版), 2017, 49(5): 851-854.
[12] 马燕燕,章晶晶,高雪梅. 不同下颌前伸度口腔矫治器治疗阻塞性睡眠呼吸暂停低通气综合征的系统评价[J]. 北京大学学报(医学版), 2017, 49(4): 691-699.
[13] 张树,张继源,杨杜明,杨明,张培训. 矢状位不稳定转子间骨折的形态特征和复位技术[J]. 北京大学学报(医学版), 2017, 49(2): 236-241.
[14] 张权,孙宁,黄强,朱仕文. 应用肩峰前外侧小切口治疗肱骨近端骨折[J]. 北京大学学报(医学版), 2017, 49(2): 242-245.
[15] 赵春鹏,王军强,苏永刚,韩巍,周力,王满宜. 机器人辅助经皮螺钉内固定治疗骨盆和髋臼骨折[J]. 北京大学学报(医学版), 2017, 49(2): 274-280.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
[1] 张三. 中文标题测试[J]. 北京大学学报(医学版), 2010, 42(1): 1 -10 .
[2] 赵磊, 王天龙 . 右心室舒张末期容量监测用于肝移植术中容量管理的临床研究[J]. 北京大学学报(医学版), 2009, 41(2): 188 -191 .
[3] 万有, , 韩济生, John E. Pintar. 孤啡肽基因敲除小鼠电针镇痛作用增强[J]. 北京大学学报(医学版), 2009, 41(3): 376 -379 .
[4] 张燕, 韩志慧, 钟延丰, 王盛兰, 李玲玲, 郑丹枫. 骨骼肌活组织检查病理诊断技术的改进及应用[J]. 北京大学学报(医学版), 2009, 41(4): 459 -462 .
[5] 林红, 王玉凤, 吴野平. 学校生活技能教育对小学三年级学生行为问题影响的对照研究[J]. 北京大学学报(医学版), 2007, 39(3): 319 -322 .
[6] 丰雷, 程嘉, 王玉凤. 注意缺陷多动障碍儿童的运动协调功能[J]. 北京大学学报(医学版), 2007, 39(3): 333 -336 .
[7] . 书讯[J]. 北京大学学报(医学版), 2007, 39(3): 225 -328 .
[8] 牟向东, 王广发, 刁小莉, 阙呈立. 肺黏膜相关淋巴组织型边缘区B细胞淋巴瘤一例[J]. 北京大学学报(医学版), 2007, 39(4): 346 -350 .
[9] 张宏文, 丁洁, 王芳, 杨惠霞. 一例X连锁Alport综合征女性妊娠期随访[J]. 北京大学学报(医学版), 2007, 39(4): 351 -354 .
[10] 燕太强, 杨荣利, 郭卫, 沈丹华. 胫骨平滑肌肉瘤伴全身多发骨转移一例[J]. 北京大学学报(医学版), 2007, 39(4): 369 -373 .