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

doi:10.19723/j.issn.1671-167X.2019.03.017

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

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^△()

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^△()

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/Abstract

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

张祎然,饶烽,皮伟,张培训,姜保国. 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[J]. 北京大学学报（医学版）, 2019, 51(3): 493-500.

Yi-ran ZHANG,Feng RAO,Wei PI,Pei-xun ZHANG,Bao-guo JIANG. Proximal femoral nails antirotation and dynamic hip screws for fixation of unstable intertrochanteric fractures of femur: A meta-analysis[J]. Journal of Peking University(Health Sciences), 2019, 51(3): 493-500.

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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

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

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

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