Chinese Journal of Tissue Engineering Research ›› 2013, Vol. 17 ›› Issue (4): 736-743.doi: 10.3969/j.issn.2095-4344.2013.04.026
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Wang Ben1, Ge Zhen-xin1, Yang Guo-yue2, Zhang Dong-zheng1, Zhang Yin-guang3, Tian Wei3, Liu Zhao-jie3, Jia Jian3
Received:
2012-10-13
Revised:
2012-10-27
Online:
2013-01-22
Published:
2013-01-22
Contact:
Wang Ben★, Studying for master’s degree, Physician, Graduate School of Tianjin Medical University, Tianjin 300200, China
5421120@qq.com
About author:
Wang Ben★, Studying for master’s degree, Physician, Graduate School of Tianjin Medical University, Tianjin 300200, China
5421120@qq.com
CLC Number:
Wang Ben, Ge Zhen-xin, Yang Guo-yue, Zhang Dong-zheng, Zhang Yin-guang, Tian Wei, Liu Zhao-jie, Jia Jian. Intramedullary nails versus extramedullary fixation in the repair of intertrochanteric fractures: A Meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(4): 736-743.
2.1 检索结果分析 初检文献1 856篇,通过阅读标题、摘要后排除明显不符合要求文献1681篇,阅读全文排除文献44篇,最终纳入分析文献31篇[5-35],计5 217例患者,详细资料见表1。 2.2 纳入研究的方法学质量评估 所有纳入文献均为随机对照试验,其中12篇文献通过采用计算机或者随机数字表的方法来随机分配,17篇文献通过密闭信封来确保分配隐藏,仅4篇文献提到盲法,25篇文献对失访进行了描述。根据修改后Jadad质量评分量表进行评价,19 篇文献为高质量,12篇文献质量较低。见表2。 2.3 Meta分析结果 本文纳入的所有研究均为随机对照试验,文献间异质性检验用卡方检验分析各研究结果间的统计学异质性,以I2值判断异质性大小,若I2 < 50%认为各研究间不存在异明显的异质性,采用固定效应模型;I2 > 50%则认为各研究间存在明显的异质性,采用随机效应模型;各结局指标如为二分变量则效应值采用RR,如为连续变量,效应值则采用MD。 Gamma钉与滑动髋螺钉各项结局指标比较:共13项随机对照研究 (n=2 656)对Gamma钉和滑动髋螺钉进行了比较[5-17]。12项研究(n=2 278)显示Gamma钉组术中股骨骨折风险明显高于滑动髋螺钉组(RR=4.00, 95%CI:1.80-8.86,P < 0.01),见图1。13项研究结果显示Gamma钉组术后股骨骨折(RR=3.57,95%CI:1.68-7.60,P < 0.01),内固定切出风险(RR =1.61, 95%CI:1.02-2.52,P =0.04)高于滑动髋螺钉组,见图2,3。12项研究报道了再固定情况,Gamma钉组(n =1 195)共67例患者进行了二次固定,明显多于滑动髋螺钉组(n=1 234)的43例(RR=1.58,95%CI:1.09-2.30,P=0.02),见图4,Gamma钉组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。两组在手术时间(MD=2.42,95%CI:-3.71-8.55,P=0.44)、术中失血(MD=83.25,95%CI:-171.21-337.70,P=0.52)、骨折不愈合率(RR=0.49,95%CI:0.22-1.12;P=0.09)、伤口感染(RR=0.92,95%CI:0.48-1.77,P=0.80)、死亡率(RR=1.03,95%CI:0.87-1.22,P=0.71)、平均住院时间(MD=1.50, 95%CI:-0.53-3.53,P=0.15)无明显差异。 股骨近端髓内钉与滑动髋螺钉各项结局指标比较:有6项研究(n=1面礼257)对股骨近端髓内钉与滑动髋螺钉进行了比较[17-22],两组患者在手术时间(MD=-1.45,95%CI:-8.48-5.59,P=0.69)、术中失血量(MD=-172.32, 95%CI:-426.91-82.26,P=0.18)、术中暴露于放射线时间(MD=0.90,95%CI:-0.03-1.83,P=0.06)、固定中及术后股骨骨折、内固定切出(RR=1.27, 95%CI:0.57-2.85,P=0.56)、骨折不愈合(RR=0.50,95%CI:0.09-2.68,P=0.42)、伤口感染(RR=1.43,95%CI:0.78-2.62,P=0.24)、二次固定(RR=1.43,95%CI:0.81-2.53,P=0.22)、死亡率(RR=1.11,95%CI:0.65-1.87,P=0.70)、平均住院时间(MD=0.27, 95%CI:-0.76-1.30,P=0.60)方面无明显差异。 股骨近端抗旋髓内钉与滑动髋螺钉各项结局指标比较: 共3项随机对照研究(n=307)比较了股骨近端抗旋髓内钉与滑动髋螺钉[23-25]。股骨近端抗旋髓内钉组平均失血量为185.9 mL,少于滑动髋螺钉组的438.9 mL[23]。髋关节功能Harris评分股骨近端抗旋髓内钉组(81分)优于滑动髋螺钉组(76分),但固定中放射时间股骨近端抗旋髓内钉组(5.1 min)明显长于滑动髋螺钉组(MD=2.11, 95%CI:1.78-2.43,P < 0.01)。两组患者手术时间(MD=-14.50,95%CI:-66.44-37.44,P=0.58)、固定中及术后股骨骨折[24-25]、内固定切出[23-25]、骨折不愈合[23-25]、二次固定风险[25]、伤口感染[23-24]、死亡率(RR=1.00,95%CI:0.39-2.58,P=1.00)、平均住院时间无明显差异[24]。"
髓内髋螺钉与滑动髋螺钉各项结局指标比较:共3项随机对照研究(n=347)比较了髓内髋螺钉与滑动髋螺钉[26-28]。髓内髋螺钉组平均术中失血245 mL,少于滑动髋螺钉组的340 mL[26]。术中暴露于放射线时间髓内髋螺钉组为3.3 min,明显长于滑动髋螺钉组的2.1 min (MD=1.20,95%CI: 0.88-1.52,P < 0.01)。两组患者在手术时间(MD=6.10,95%CI:-21.34-33.53,P=0.66)、固定中(RR=3.69,95%CI: 0.61-22.16,P=0.15)及术后股骨骨折(RR=5.12,95%CI: 0.61-43.33,P=0.13)、内固定切出(RR=1.01,95%CI: 0.21-4.90,P=0.99)、二次固定风险[28]、骨折不愈合(RR=1.71,95%CI: 0.23-12.72,P=0.60)、伤口感染[28]、死亡率(RR=0.90,95%CI: 0.62-1.30,P=0.58)、髋部或大腿残留疼痛(RR=1.02,95%CI: 0.66-1.58,P=0.92)等方面无明显差异。 7项随机对照研究(n=689)对一些其他常见髓内固定器与髓外固定器各项指标进行比较[29-35]。Gamma钉与PCCP、Gamma钉与90°度角钢板疗效与安全性相似[29-30]。股骨近端髓内钉组手术时间短于动力髁螺钉(DCP)组[31]。股骨近端抗旋髓内钉组平均手术时间为 65.4 min,明显缩短[32]。滑动髋螺钉组手术时间、术中暴露于放射线时间少于Holland钉,但术中失血也更多,且最终髋关节功能评分Holland钉组也更好一些[33]。髓内髋螺钉组患者不仅手术时间、术中失血少于滑动髋螺钉组患者,且固定后开始有效负重时间也更早[34]。K-Y髓内钉与滑动髋螺钉在各主要方面无明显差异[35]。"
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