Plating versus intramedullary nail fixation for the treatment of humeral shaft fractures in adults: A systematic review update

doi:10.3969/j.issn.2095-4344.2013.39.017

Abstract

Abstract:

BACKGROUND: There is controversial on which method is preferred for the treatment of humeral shaft fractures, plate or intramedullary nail fixation? Some studies have compared the effect of those two methods, but the results are different. While the results of the systematic research and the Meta-analysis on the comparative studies is also different due to the differences in the number and the extraction of the researches.
OBJECTIVE: To systematically evaluate the efficacy of plating versus intramedullary nail fixation in the treatment of adult humeral shaft fracture.
METHODS: A computer-based retrieve was conducted in PubMed database, MEDLINE database, Cumulative Index to Nursing & Allied Health Literature, Evidence-Based Medicine database, CBM database, Wanfang database and CNKI database for the randomized or quasi-randomized controlled trials on the comparison of plating and intramedullary nail fixation in the treatment of adult humeral shaft fracture. The quality of these trials was critically assessed according to Jadad. The effective data were extracted for Meta-analysis by Stata 12.0 software.
RESULTS AND CONCLUSION: Totally, 15 randomized or quasi-randomized controlled trials were collected including four quasi-randomized controlled trials and 11 randomized controlled trials. The results showed that intramedullary nail fixation may increase the risk of complications (odds ratio=0.37(0.19, 0.59), P=0.00). Bias Egger’s test of P=0.91 showed there was no significant publication bias. The risk of re-operation of intramedullary nail fixation was increased (odds ratio=0.28(0.14, 0.57), P=0.00) with the Egger’s test of P=0.69. The incidence of shoulder impingement of intramedullary nail fixation was significantly higher than that of pate fixation (odds ratio=0.13(0.05, 0.35), P=0.00), and there were no significant differences in postoperative infection, nonunion, implant failure, iatrogenic nerve palsy, operation time and bone union time between two methods. The results showed that compared with plate fixation, intramedullary nail fixation may increase the incidence of shoulder impingement, complications and re-operation, while there were significant differences in postoperative infection, nonunion, implant failure, iatrogenic nerve palsy, operation time and bone union time between two methods.

Key words: fracture fixation, intramedullary, internal fixators, fracture fixation, humeral fractures, Meta-analysis

CLC Number:

R318

Li Lian-hua, Wang Hao, Zhang Yan, Cai Yan-hong, Zhang Hao, Liu Zhi, Sun Tian-sheng. Plating versus intramedullary nail fixation for the treatment of humeral shaft fractures in adults: A systematic review update[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(39): 6970-6977.

Figures/Tables 6

2.1 检索结果分析及基线质量评价共查到相关文献312篇。按纳入标准进行筛选后获取15篇文献[8-22]。其中研究地点3篇在中国大陆[15, 21-22]，1篇在中国台湾省[12]；11篇在其他国家[8-11,13-14,16-20]，13 篇为英文[8-20]，2 篇为中文[21-22]。各纳入研究的基本情况见表1。 2.2 Meta分析结果 2.2.1 主要结果指标并发症：实验关注的并发症主要是指肱骨干骨折中、肱骨干骨折后发生医源性神经损伤、肱骨干骨折后感染、内固定失效、肩部撞击及活动受限、骨不连等事件发生的总和。有13个研究报告了钢板与髓内针治疗成人肱骨干骨折后并发症的发生率[9-14, 16-22]，共866例患者，其中钢板固定420例，髓内针固定446例，钢板固定组发生并发症108例，髓内针固定组发生并发症169例。各研究间异质性明显(P=0.00，I2=55%)，应用敏感性分析及累积Meta分析，见图2，3，均未找到异质性来源。将髓内针类型、钢板类型、研究性质、研究地点分别进行Meta回归分析，结果显示，钢板类型、髓内针类型、研究性质、研究地点的P值分别为0.34，0.02，0.96，0.76。这说明髓内针类型对异质性的影响较为明显，究其原因可能与不同髓内针的手术操作复杂程度及固定效果对并发症的发生造成影响。为消除髓内针类型对Meta分析造成的异质性，实验按照髓内针类型进行亚组Meta分析，分析模型采用随机模型，如图4所示，总体的Meta分析结果显示OR=0.49(0.26，0.92)，P=0.01，髓内针发生并发症的风险要高于钢板。由于OR可信区间的上限0.92接近1，因此在接受这一结论还需要谨慎。再看亚组分析结果，弹性髓内针、膨胀髓内针与交锁髓内针亚组OR分别为1.72(0.61-4.83)，5.09(0.88，29.27)及0.37(0.19，0.59)，对应的P值分别为0.30，0.07及0.00。"

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