手术与非手术治疗锁骨中段骨折的Meta分析
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摘要
目的系统评价手术与非手术治疗锁骨中段骨折的有效性和安全性。方法计算机检索Pub Med、The Cochrane Library、EMbase、MEDLINE(Ovid)、CBM、CNKI和Wan Fang Data数据库,搜索手术与非手术治疗成人锁骨中段骨折的随机对照试验(R C T)和前瞻性队列研究,检索时限均从建库至2017年6月3日。由2位研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Rev Man 5.2软件进行Meta分析。结果共纳入14个RCT和5个前瞻性队列研究,合计1 543例患者。Meta结果分析显示:与非手术组相比,手术组能明显提高上肢Constant评分[SMD=0.76,95%CI(0.40,1.13),P<0.000 1]并改善肩肘手DASH评分[SMD=–0.49,95%CI(–0.91,0.06),P=0.02]。此外,手术组的骨折不愈合率[RR=0.17,95%CI(0.10,0.30),P<0.000 01]及畸形愈合率[RR=0.20,95%CI(0.12,0.33),P<0.000 01]显著降低,患者满意度[RR=1.39,95%CI(1.13,1.71),P=0.002]明显提高。结论当前证据显示,手术治疗锁骨中段骨折能够改善上肢功能,提高患者满意度,降低骨折不良愈合率。但受纳入研究数量和质量的限制,上述结论还需更多高质量研究予以证实。
Objective To systematically review the safety and efficacy of operative versus non-operative treatment for displaced midshaft clavicle fractures. Methods Databases including Pub Med, The Cochrane Library,EMbase, MEDLINE(Ovid), CBM, CNKI and Wan Fang Data were searched to collect randomized controlled trials(RCTs)and cohort studies about operation versus non-operation for displaced midshaft clavicle fractures from inception to June3 rd, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies.Then meta-analysis was performed by Rev Man 5.2 software. Results A total of 14 RCTs and 5 prospective cohort studies involving 1 543 patients were included. The results of meta-analysis showed that operation was superior to non-operation in the Constant score(SMD=0.76, 95%CI 0.40 to 1.13, P<0.000 1), DASH score(SMD=–0.49, 95%CI –0.91 to 0.06,P=0.02), nonunion rate(RR=0.17, 95%CI 0.10 to 0.30, P<0.000 01), malunion(RR=0.20, 95%CI 0.12 to 0.33, P<0.000 01)and patients' satisfaction rate(RR=1.39, 95%CI 1.13 to 1.71, P=0.002), respectively. Conclusion Current evidence shows that operation could improve the function of the upper limbs, reduce nonunion and malunion, and improve the satisfaction of the patients with midshaft clavicle fractures. Due to the limited quality of the included studies, more large-scale, high-quality studies are required to verify the above conclusion.
Objective To systematically review the safety and efficacy of operative versus non-operative treatment for displaced midshaft clavicle fractures. Methods Databases including Pub Med, The Cochrane Library,EMbase, MEDLINE(Ovid), CBM, CNKI and Wan Fang Data were searched to collect randomized controlled trials(RCTs)and cohort studies about operation versus non-operation for displaced midshaft clavicle fractures from inception to June3 rd, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies.Then meta-analysis was performed by Rev Man 5.2 software. Results A total of 14 RCTs and 5 prospective cohort studies involving 1 543 patients were included. The results of meta-analysis showed that operation was superior to non-operation in the Constant score(SMD=0.76, 95%CI 0.40 to 1.13, P<0.000 1), DASH score(SMD=–0.49, 95%CI –0.91 to 0.06,P=0.02), nonunion rate(RR=0.17, 95%CI 0.10 to 0.30, P<0.000 01), malunion(RR=0.20, 95%CI 0.12 to 0.33, P<0.000 01)and patients' satisfaction rate(RR=1.39, 95%CI 1.13 to 1.71, P=0.002), respectively. Conclusion Current evidence shows that operation could improve the function of the upper limbs, reduce nonunion and malunion, and improve the satisfaction of the patients with midshaft clavicle fractures. Due to the limited quality of the included studies, more large-scale, high-quality studies are required to verify the above conclusion.
引文
1Nordqvist A,Petersson C.The incidence of fractures of the clavicle.Clin Orthop Relat Res,1994,(300):127-132.
2 Postacchini F,Gumina S,De Santis P,et al.Epidemiology of clavicle fractures.J Shoulder Elbow Surg,2002,11(5):452-456.
3van der Meijden OA,Gaskill TR,Millett PJ.Treatment of clavicle fractures:current concepts review.J Shoulder Elbow Surg,2012,21(3):423-429.
4Pecci M,Kreher JB.Clavicle fractures.Am Fam Physician,2008,77(1):65-70.
5 Andersen K,Jensen PO,Lauritzen J.Treatment of clavicular fractures.Figure-of-eight bandage versus a simple sling.Acta Orthop Scand,1987,58(1):71-74.
6Eskola A,Vainionp??S,Myllynen P,et al.Outcome of clavicular fracture in 89 patients.Arch Orthop Trauma Surg,1986,105(6):337-338.
7 李洪飞,潘朝晖.手术和非手术治疗锁骨中段移位骨折的效果比较.中国当代医药,2015,22(5):20-22.
8Wang XH,Guo WJ,Li AB,et al.Operative versus nonoperative treatment for displaced midshaft clavicle fractures:a meta-analysis based on current evidence.Clinics(Sao Paulo),2015,70(8):584-592.
9 Kong L,Zhang Y,Shen Y.Operative versus nonoperative treatment for displaced midshaft clavicular fractures:a metaanalysis of randomized clinical trials.Arch Orthop Trauma Surg,2014,134(11):1493-1500.
10Stengel D.Operative versus nonoperative treatment for displaced midshaft clavicular fractures:a meta-analysis of randomized clinical trials.Unfallchirurg,2012,115(11):1041-1043.
11 Smeeing DPJ,van der Ven DJC,Hietbrink F,et al.Surgical versus nonsurgical treatment for midshaft clavicle fractures in patients aged 16 years and older:a systematic review,meta-analysis,and comparison of randomized controlled trials and observational studies.Am J Sports Med,2017,45(8):1937-1945.
12Stang A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in metaanalyses.Eur J Epidemiol,2010,25(9):603-605.
13 Balshem H,Helfand M,Schünemann HJ,等(高霑译).GRADE指南:Ⅲ.证据质量分级.中国循证医学杂志,2011,11(4):451-455.
14Smekal V,Irenberger A,Struve P,et al.Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized,controlled,clinical trial.J Orthop Trauma,2009,23(2):106-112.
15 Canadian Orthopaedic Trauma Society.Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.a multicenter,randomized clinical trial.J Bone Joint Surg Am,2007,89(1):1-10.
16夏长所,邹云雯,叶发刚.锁骨中段骨折的两种治疗方法比较.中国骨伤,2004,17(4):231-232.
17 葛友平.锁骨中段移位骨折手术治疗与非手术治疗效果比较.中外医疗,2009,28(21):70-70.
18龚骏.手术与非手术治疗锁骨中段移位骨折的效果对比.当代医学,2015,21(32):52-53.
19 高峰.切开复位钢板内固定及非手术方法治疗成人锁骨中段1/3移位骨折疗效分析.淮海医药,2016,34(6):654-655.
20卢耀开,王锡雄.老年性锁骨中段骨折保守治疗与手术治疗的效果对比.中国实用医药,2016,11(34):33-35.
21 Woltz S,Stegeman SA,Krijnen P,et al.Plate fixation compared with nonoperative treatment for displaced midshaft clavicular fractures:a multicenter randomized controlled trial.J Bone Joint Surg Am,2017,99(2):106-112.
22Shetty SK,Chandran R,Ballal A,et al.To operate or not to operate the mid-shaft fractures of the clavicle:a comparative study of functional outcomes of the two methods of management.J Clin Diagn Res,2017,11(1):R1-R3.
23 Robinson CM,Goudie EB,Murray IR.Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures:a multicenter,randomized,controlled trial.J Bone Joint Surg Am,2013,95(17):1576-1584.
24Mirzatolooei F.Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle.Acta Orthop Traumatol Turc,2011,45(1):34-40.
25 Virtanen KJ,Remes V,Pajarinen J,et al.Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures:a randomized clinical trial.J Bone Joint Surg Am,2012,94(17):1546-1553.
26Judd DB,Pallis MP,Smith E,et al.Acute operative stabilization versus nonoperative management of clavicle fractures.Am J Orthop(Belle Mead NJ),2009,38(7):341-345.
27 Chen QY,Kou DQ,Cheng XJ,et al.Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail.Chin J Traumatol,2011,14(5):269-276.
28Khorami M,Fakour M,Mokarrami H,et al.The comparison of results of treatment of midshaft clavicle fracture between operative treatment with plate and non-operative treatment.Arch Bone Jt Surg,2014,2(3):210-214.
29 Dhakad RK,Panwar M,Gupta S,et al.Plating versus conservative treatment in mid shaft fractures of clavicle:a comparative study.J Clin Orthop Trauma,2016,7(Suppl 2):166-170.
30Kulshrestha V,Roy T,Audige L.Operative versus nonoperative management of displaced midshaft clavicle fractures:a prospctive cohort study.J Orthop Trauma,2011,25(1):31-38.
31 Naveen BM,Joshi GR,Harikrishnan B.Management of mid-shaft clavicular fractures:comparison between non-operative treatment and plate fixation in 60 patients.Strategies Trauma Limb Reconstr,2017,12(1):11-18.
32van der Ven Denise JC,Timmers TK,Flikweert PE,et al.Plate fixation versus conservative treatment of displaced midshaft clavicle fractures:functional outcome and patients'satisfaction during a mean follow-up of 5 years.Injury,2015,46(11):2223-2229.
33 Xu CP,Li X,Cui Z,et al.Should displaced midshaft clavicular fractures be treated surgically?A meta-analysis based on current evidence.Eur J Orthop Surg Traumatol,2013,23(6):621-629.
34Mc Kee MD.Clavicle fractures in 2010:sling/swathe or open reduction and internal fixation?Orthop Clin North Am,2010,41(2):225-231.
35Drosdowech DS,Manwell SE,Ferreira LM,et al.Biomechanical analysis of fixation of middle third fractures of the clavicle.J Orthop Trauma,2011,25(1):39-43.
36 Smekal V,Irenberger A,Struve P,et al.Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized,controlled,clinical trial.J Orthop Trauma,2009,23(2):106-112.
2 Postacchini F,Gumina S,De Santis P,et al.Epidemiology of clavicle fractures.J Shoulder Elbow Surg,2002,11(5):452-456.
3van der Meijden OA,Gaskill TR,Millett PJ.Treatment of clavicle fractures:current concepts review.J Shoulder Elbow Surg,2012,21(3):423-429.
4Pecci M,Kreher JB.Clavicle fractures.Am Fam Physician,2008,77(1):65-70.
5 Andersen K,Jensen PO,Lauritzen J.Treatment of clavicular fractures.Figure-of-eight bandage versus a simple sling.Acta Orthop Scand,1987,58(1):71-74.
6Eskola A,Vainionp??S,Myllynen P,et al.Outcome of clavicular fracture in 89 patients.Arch Orthop Trauma Surg,1986,105(6):337-338.
7 李洪飞,潘朝晖.手术和非手术治疗锁骨中段移位骨折的效果比较.中国当代医药,2015,22(5):20-22.
8Wang XH,Guo WJ,Li AB,et al.Operative versus nonoperative treatment for displaced midshaft clavicle fractures:a meta-analysis based on current evidence.Clinics(Sao Paulo),2015,70(8):584-592.
9 Kong L,Zhang Y,Shen Y.Operative versus nonoperative treatment for displaced midshaft clavicular fractures:a metaanalysis of randomized clinical trials.Arch Orthop Trauma Surg,2014,134(11):1493-1500.
10Stengel D.Operative versus nonoperative treatment for displaced midshaft clavicular fractures:a meta-analysis of randomized clinical trials.Unfallchirurg,2012,115(11):1041-1043.
11 Smeeing DPJ,van der Ven DJC,Hietbrink F,et al.Surgical versus nonsurgical treatment for midshaft clavicle fractures in patients aged 16 years and older:a systematic review,meta-analysis,and comparison of randomized controlled trials and observational studies.Am J Sports Med,2017,45(8):1937-1945.
12Stang A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in metaanalyses.Eur J Epidemiol,2010,25(9):603-605.
13 Balshem H,Helfand M,Schünemann HJ,等(高霑译).GRADE指南:Ⅲ.证据质量分级.中国循证医学杂志,2011,11(4):451-455.
14Smekal V,Irenberger A,Struve P,et al.Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized,controlled,clinical trial.J Orthop Trauma,2009,23(2):106-112.
15 Canadian Orthopaedic Trauma Society.Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.a multicenter,randomized clinical trial.J Bone Joint Surg Am,2007,89(1):1-10.
16夏长所,邹云雯,叶发刚.锁骨中段骨折的两种治疗方法比较.中国骨伤,2004,17(4):231-232.
17 葛友平.锁骨中段移位骨折手术治疗与非手术治疗效果比较.中外医疗,2009,28(21):70-70.
18龚骏.手术与非手术治疗锁骨中段移位骨折的效果对比.当代医学,2015,21(32):52-53.
19 高峰.切开复位钢板内固定及非手术方法治疗成人锁骨中段1/3移位骨折疗效分析.淮海医药,2016,34(6):654-655.
20卢耀开,王锡雄.老年性锁骨中段骨折保守治疗与手术治疗的效果对比.中国实用医药,2016,11(34):33-35.
21 Woltz S,Stegeman SA,Krijnen P,et al.Plate fixation compared with nonoperative treatment for displaced midshaft clavicular fractures:a multicenter randomized controlled trial.J Bone Joint Surg Am,2017,99(2):106-112.
22Shetty SK,Chandran R,Ballal A,et al.To operate or not to operate the mid-shaft fractures of the clavicle:a comparative study of functional outcomes of the two methods of management.J Clin Diagn Res,2017,11(1):R1-R3.
23 Robinson CM,Goudie EB,Murray IR.Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures:a multicenter,randomized,controlled trial.J Bone Joint Surg Am,2013,95(17):1576-1584.
24Mirzatolooei F.Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle.Acta Orthop Traumatol Turc,2011,45(1):34-40.
25 Virtanen KJ,Remes V,Pajarinen J,et al.Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures:a randomized clinical trial.J Bone Joint Surg Am,2012,94(17):1546-1553.
26Judd DB,Pallis MP,Smith E,et al.Acute operative stabilization versus nonoperative management of clavicle fractures.Am J Orthop(Belle Mead NJ),2009,38(7):341-345.
27 Chen QY,Kou DQ,Cheng XJ,et al.Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail.Chin J Traumatol,2011,14(5):269-276.
28Khorami M,Fakour M,Mokarrami H,et al.The comparison of results of treatment of midshaft clavicle fracture between operative treatment with plate and non-operative treatment.Arch Bone Jt Surg,2014,2(3):210-214.
29 Dhakad RK,Panwar M,Gupta S,et al.Plating versus conservative treatment in mid shaft fractures of clavicle:a comparative study.J Clin Orthop Trauma,2016,7(Suppl 2):166-170.
30Kulshrestha V,Roy T,Audige L.Operative versus nonoperative management of displaced midshaft clavicle fractures:a prospctive cohort study.J Orthop Trauma,2011,25(1):31-38.
31 Naveen BM,Joshi GR,Harikrishnan B.Management of mid-shaft clavicular fractures:comparison between non-operative treatment and plate fixation in 60 patients.Strategies Trauma Limb Reconstr,2017,12(1):11-18.
32van der Ven Denise JC,Timmers TK,Flikweert PE,et al.Plate fixation versus conservative treatment of displaced midshaft clavicle fractures:functional outcome and patients'satisfaction during a mean follow-up of 5 years.Injury,2015,46(11):2223-2229.
33 Xu CP,Li X,Cui Z,et al.Should displaced midshaft clavicular fractures be treated surgically?A meta-analysis based on current evidence.Eur J Orthop Surg Traumatol,2013,23(6):621-629.
34Mc Kee MD.Clavicle fractures in 2010:sling/swathe or open reduction and internal fixation?Orthop Clin North Am,2010,41(2):225-231.
35Drosdowech DS,Manwell SE,Ferreira LM,et al.Biomechanical analysis of fixation of middle third fractures of the clavicle.J Orthop Trauma,2011,25(1):39-43.
36 Smekal V,Irenberger A,Struve P,et al.Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized,controlled,clinical trial.J Orthop Trauma,2009,23(2):106-112.