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

doi:10.3969/j.issn.2095-4344.2013.04.026

Abstract

Abstract:

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.

Key words: bone and joint implants, evidence-based medicine of bone and joint implants, intertrochanteric fractures, Gamma nail, dynamic hip screw, intramedullary nail of proximal femur, proximal femoral nail antirotation, fracture fixation, Meta-analysis, tissue engineering

CLC Number:

R318

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.

Figures/Tables 7

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]。"

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