成人肱骨干骨折髓内钉固定与加压钢板固定的系统评价
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摘要
目的:分析髓内钉对比加压钢板治疗成人肱骨干骨折的疗效及并发症比较。方法我们检索了Cochrane liabrary(CCTR)以及Cochrane协作网肌骨组专业试验数据库,MEDLINE(1966-2006),EMBASE(1980-2006),PUBMED NRR(http://www.update-software.com/National/),CCT(http://www.controlled-trials.com)。国内包括中国生物医学文献数据库(CBM),手工检索中文骨科文献。收集髓内钉对比加压钢板治疗成人肱骨干骨折的临床随机对照试验,并评价纳入研究的方法学质量。统计软件采用Cochrane协作网提供的RevMan 4.2.8。结果:共纳入髓内钉对比钢板治疗成人肱骨干骨折的临床随机对照试验3篇共215例病人。Meta分析表明,髓内钉对比钢板治疗成人肱骨干骨折,其术后并发症引起的二次手术率高[OR=2.68,95%CI(1.19,6.04),p=0.02],术后肩部疼痛及肩关节活动范围减少较钢板组明显[OR=13.02,95%CI(2.23,75.95),p=0.004],及[OR=18.60,95%CI(1.01,341.83),p=0.05]。而骨折不愈合率,医源性桡神经损伤率及感染率上两者无太大差异。骨折愈合时间因文献未提供详细数据未做Meta分析。结论:与钢板内固定相比较,髓内钉固定治疗成人肱骨干骨折其二次手术率更高,造成肩部疼痛及肩关节活动障碍更明显。而在骨折不愈合率,医源性桡神经损伤率及感染率上,髓内钉固定对比加压钢板固定,其差异无统计学意义。因本系统评价纳入的病例数较少,结论有待进一步确认,我们尚需更多设计严格的大样本随机对照研究以增加证据的强度
Objective:To determine the effect of intramedulllary nailing versus compression plates in adults on the rates of secondary surgery,the rates of nonunion,the rates of infection,the rates of iatrogenic radial nerve injury,and the time of union,the influence of shoulder and elbow joint.Methods:we searched the specialized trials registered in Cochrane muscle bone group,Cochraneliabrary(CCTR),MEDLINE(1966-2006), EMBASE(1980-2006),PUBMEB(1966-2006),NRR(http://www.update-software.com/ National/),CCT(http://www.controlled-trials.com),and CBMdisc(1979-July2006),and we handsearched some Chinese orthoopaedics Journals.Data were extracted and evaluated by two reviewers independently of each other.Randomized controlled trials of intramedullary nailing versus compression plates for humeral shaft fractures in adults were included.The quality of trials was critical assessed.RevMan 4.2.8 software was used for data analysis.Result:Three RCTS of intramedullary nails versus compression plates for humeral shaft fractures in adults were included.Three studies including a total of 215 patients met the inclusion criteria for the review.The results of meta-analysis showed that intramedullary nails for humeral shaft fractures in adults increased the rates of secondary surgery[OR=2.68,95%CI(1.19,6.04),p=0.02],increased the pains in shoulder[OR=13.02,95%CI(2.23,75.95),p=0.004],and increased rates of decreased range of motion of shoulder[OR=18.60,95%CI(1.01,341.83),p=0.05].In aspects of complications,including the rates of nonunion,the rates of infection,the rates of iatrogenic radial nerve injury,intramedullary nails versus compression plates,there are no evident differences in statistics.The time of union was not used for Meta-analysis because included trials did not offer detailed data.Conclusion:compared with compression plates for humeral shaft fractures in adults,intramedullary nails increased the rates of secondary surgery,increased the pains in shoulder,increased rates of decreased range of motion of shoulder,there are no statistical difference in the rates of nonunion,the rates of infection, the rates of iatrogenic radial nerve injury,however,because the systematic review included few patients,further studies are needed to determine the effects of intramedulla- ry nails and compression plates on these outcomes.
Objective:To determine the effect of intramedulllary nailing versus compression plates in adults on the rates of secondary surgery,the rates of nonunion,the rates of infection,the rates of iatrogenic radial nerve injury,and the time of union,the influence of shoulder and elbow joint.Methods:we searched the specialized trials registered in Cochrane muscle bone group,Cochraneliabrary(CCTR),MEDLINE(1966-2006), EMBASE(1980-2006),PUBMEB(1966-2006),NRR(http://www.update-software.com/ National/),CCT(http://www.controlled-trials.com),and CBMdisc(1979-July2006),and we handsearched some Chinese orthoopaedics Journals.Data were extracted and evaluated by two reviewers independently of each other.Randomized controlled trials of intramedullary nailing versus compression plates for humeral shaft fractures in adults were included.The quality of trials was critical assessed.RevMan 4.2.8 software was used for data analysis.Result:Three RCTS of intramedullary nails versus compression plates for humeral shaft fractures in adults were included.Three studies including a total of 215 patients met the inclusion criteria for the review.The results of meta-analysis showed that intramedullary nails for humeral shaft fractures in adults increased the rates of secondary surgery[OR=2.68,95%CI(1.19,6.04),p=0.02],increased the pains in shoulder[OR=13.02,95%CI(2.23,75.95),p=0.004],and increased rates of decreased range of motion of shoulder[OR=18.60,95%CI(1.01,341.83),p=0.05].In aspects of complications,including the rates of nonunion,the rates of infection,the rates of iatrogenic radial nerve injury,intramedullary nails versus compression plates,there are no evident differences in statistics.The time of union was not used for Meta-analysis because included trials did not offer detailed data.Conclusion:compared with compression plates for humeral shaft fractures in adults,intramedullary nails increased the rates of secondary surgery,increased the pains in shoulder,increased rates of decreased range of motion of shoulder,there are no statistical difference in the rates of nonunion,the rates of infection, the rates of iatrogenic radial nerve injury,however,because the systematic review included few patients,further studies are needed to determine the effects of intramedulla- ry nails and compression plates on these outcomes.
引文
铩颷1]Chiu,Fang-Yao MD;Chen.,Chuan-Mu MD;Lin,Chien-Fu Jeff MD,ClosedHumeral Shaft Fractures:A Prospective Evaluation of Surgical Treatment,thejournal of trauma Volume 43(6),December 1997,pp 947-951
[2]Balfour GW,Mooney V,Ashby ME.Diaphyseal fractures of the humerus treatedwith a ready-made fracture brace.J Bone Joint Surg Am.1982;64:11-13.[ContextLink]
[3]Hunter SG.The closed treatment of fractures of the humeral shaft.Clin Orthop.1982;164:192-198.Bibliographic Links Library Holdings[Context Link]
[4]Klenerman L.Fractures of the shaft of the humerus.J Bone Joint Surg Am.1966;48:105-111.[Context Link]
[5]Naver L,Aalberg JR.Humeral shaft fractures treated with a ready-made fracturebrace.Arch Orthop Trauma Surg.1986;106:20-22.Bibliographic Links LibraryHoldings[Context Link]
[6]Sarmiento A,Horowitch A,Aboulafia A,Vangsness CT Jr.Functional bracing forcomminuted extra-articular fractures of the distal third of the humerus.J Bone JointSurg Br.1990;72:283-287.Bibliographic Links Library Holdings[Context Link]
[7]Zagorski JB,Latta LL,Zych GA,Finnieston AR.Diaphyseal fractures of thehumerus.J Bone Joint Surg Am.1988;70:607-610.[Context Link]
[8]Bell MJ,Beauchamp CG,Kellam JK,McMurty RY.The results of plating humeralshaft fractures in patients with multiple injuries:the Sunnybrook experience.J BoneJoint Surg Br.1985;67:293-296.[Context Link]
[9]Christiansen NO.Kuntscher intramedullary reaming and nail fixation for nonunionof the humerus.Clin Orthop.1976;116:222-226.[Context Link]
[10]Griend RV,Tomasin J,Ward EF.Open reduction and internal fixation of humeralshaft fracture.J Bone Joint Surg Am.1986;68:430-433.[Context Link]
[11]Modabber MR,Jupiter JB.Operative management of diaphyseal fractures of thehumerus:plate versus nail.Clin Orthop.1998;347:93-104.Ovid Full TextBibliographic Links[Context Link]
[12]Chapman,Jens R.;Henley,M.Bradford;Agel,Randomized Prospective Study ofHumeral Shaft Fracture Fixation:Intramedullary Nails Versus Plates.J OrthopTrauma.Volume 14(3),March/April 2000,pp162-166
[13]DeLong TB Jr,Born CT,Marcelli E,et al.Ender nail fixation in long bone fractures: experience in a Level Ⅰ trauma center.J Trauma.1989;29:571.Bibliographic Links
Library Holdings[Context Link]
铩颷14]Durbin RA,Gottesman MJ,Saunders KC.Hackethal stacked nailing of humeralshaft fractures:experience with 30 patients.Clin Orthop.1983;179:168.[ContextLink]
[15]Hall RF Jr,Pankovich AM.Ender nailing of acute fractures of the humerus:a studyof closed fixation by intramedullary nails without reaming.J Bone Joint Surg Am.1987;69:558.[Context Link]
[16]Henley MB,Chapman JR,Claudi BF.Closed retrograde Hackethal nail stabilizationof humeral shaft fractures.J Orthop Trauma.1992;6:18.Bibliographic Links LibraryHoldings[Context Link]
[17]Reudi T,Moshfegh A,Pfeiffer KM,et al.Fresh fractures of the shaft of the humerus:conservative or operative treatment? Reconstr Surg Traumatol.1974;14:65.[ContextLink]
[18]Chacha PB.Compression plating without bone grafts for delayed and non-union ofhumeral shaft fractures.Injury.1974;5:283.Bibliographic Links Library Holdings[Context Link]
[19]Naiman PT,Schein AJ,Siffert RS.Use of ASIF compression plates in selected shaftfractures of the upper extremity:a preliminary report.Clin Orthop.1970;71:208.Bibliographic Links Library Holdings[Context Link]
[20]R.G.McCormack,MD,D.Brien,MD,R.E.Buckley,MD,Fixation of fractures ofthe shaft of the humerus by dynamic compression plate or intramedullary nail JBone Joint Surg BR 2000;82-B:336-9
[21]Crates J,Whittle AP.Antegrade interlocking nailing of acute humeral shaft fractures.Clin Orthop 1998;350:40-50.Ovid Full Text Bibliographic Links Library Holdings[Context Link]
[22]Lin J.Treatment of humeral shaft fractures with humeral locked nail andcomparison with plate fixation.J Trauma 1998;44:859-864.Ovid Full TextBibliographic Links Library Holdings[Context Link]
[23]倪东亮 祝云利!林平 钢板及交锁髓内钉治疗肱骨干骨折疗效对比.中国矫形外科杂志 2000年12月第7卷第12期
[24]彭海洲!刘明礼!罗睿髓内钉与钢板治疗肱骨干骨折疗效比较 骨与关节损伤杂志 2004年12月第19卷第12期
铩颷1]Chiu,Fang-Yao MD;Chen,Chuan-Mu MD;Lin,Chien-Fu Jeff MD,ClosedHumeral Shaft Fractures:A Prospective Evaluation of Surgical Treatment,the journalof trauma Volume 43(6),December 1997,pp 947-951
[2]Balfour GW,Mooney V,Ashby ME.Diaphyseal fractures of the humerus treatedwith a ready-made fracture brace.J Bone Joint Surg Am.1982;64:11-13.[ContextLink]
[3]Hunter SG.The closed treatment of fractures of the humeral shaft.Clin Orthop.1982;164:192-198.Bibliographic Links Library Holdings[Context Link]
[4]Klenerman L.Fractures of the shaft of the humerus.J Bone Joint Surg Am.1966;48:105-111.[Context Link]
[5]Naver L,Aalberg JR.Humeral shaft fractures treated with a ready-made fracturebrace.Arch Orthop Trauma Surg.1986;106:20-22.Bibliographic Links LibraryHoldings[Context Link]
[6]Sarmiento A,Horowitch A,Aboulafia A,Vangsness CT Jr.Functional bracing forcomminuted extra-articular fractures of the distal third of the humerus.J Bone JointSurg Br.1990;72:283-287.Bibliographic Links Library Holdings[Context Link]
[7]Zagorski JB,Latta LL,Zych GA,Finnieston AR.Diaphyseal fractures of thehumerus.J Bone Joint Surg Am.1988;70:607-610.[Context Link]
[8]Bell MJ,Beauchamp CG,Kellam JK,McMurty RY.The results of plating humeralshaft fractures in patients with multiple injuries:the Sunnybrook experience.J BoneJoint Surg Br.1985;67:293-296.[Context Link]
[9]Christiansen NO.Kuntscher intramedullary reaming and nail fixation for nonunion ofthe humerus.Clin Orthop.1976;116:222-226.[Context Link]
[10]Griend RV,Tomasin J,Ward EF.Open reduction and internal fixation of humeralshaft fracture.J Bone Joint Surg Am.1986;68:430-433.[Context Link]
[11]Modabber MR,Jupiter JB.Operative management of diaphyseal fractures of thehumerus:plate versus nail.Clin Orthop.1998;347:93-104.Ovid Full TextBibliographic Links[Context Link]
[12]Chapman,Jens R.;Henley,M.Bradford;Agel,Randomized Prospective Study ofHumeral Shaft Fracture Fixation:Intramedullary Nails Versus Plates.J OrthopTrauma.Volume 14(3),March/April 2000,pp 162-166
[13]DeLong TB Jr,Born CT,Marcelli E,et al.Ender nail fixation in long bone fractures: experience in a Level Ⅰ trauma center.J Trauma.1989;29:571.Bibliographic Links
Library Holdings[Context Link]
铩颷14]Durbin RA,Gottesman MJ,Saunders KC.Hackethal stacked nailing of humeral shaftfractures:experience with 30 patients.Clin Orthop.1983;179:168.[Context Link]
[15]Hall RF Jr.,Pankovich AM.Ender nailing of acute fractures of the humerus:a studyof closed fixation by intramedullary nails without reaming.J Bone Joint Surg Am.1987;69:558.[Context Link]
[16]Henley MB,Chapman JR,Claudi BF.Closed retrograde Hackethal nail stabilizationof humeral shaft fractures.J Orthop Trauma.1992;6:18.Bibliographic Links LibraryHoldings[Context Link]
[17]Reudi T,Moshfegh A,Pfeiffer KM,et al.Fresh fractures of the shaft of the humerus:conservative or operative treatment? Reconstr Surg Traumatol.1974;14:65.[ContextLink]
[18]R.G.McCormack,MD,D.Brien,MD,R.E.Buckley,MD,Fixation of fractures ofthe shaft of the humerus by dynamic compression plate or intramedullary nail J BoneJoint Surg BR 2000;82-B:336-9
[19]倪东亮,祝云利,林平.钢板及交锁髓内钉治疗肱骨干骨折疗效对比.中国矫形外科杂志,2000,7(12)
[20]彭海洲,刘明礼,罗睿髓内钉与钢板治疗肱骨干骨折疗效比较.骨与关节损伤杂志,2004,19(12)
[2]Balfour GW,Mooney V,Ashby ME.Diaphyseal fractures of the humerus treatedwith a ready-made fracture brace.J Bone Joint Surg Am.1982;64:11-13.[ContextLink]
[3]Hunter SG.The closed treatment of fractures of the humeral shaft.Clin Orthop.1982;164:192-198.Bibliographic Links Library Holdings[Context Link]
[4]Klenerman L.Fractures of the shaft of the humerus.J Bone Joint Surg Am.1966;48:105-111.[Context Link]
[5]Naver L,Aalberg JR.Humeral shaft fractures treated with a ready-made fracturebrace.Arch Orthop Trauma Surg.1986;106:20-22.Bibliographic Links LibraryHoldings[Context Link]
[6]Sarmiento A,Horowitch A,Aboulafia A,Vangsness CT Jr.Functional bracing forcomminuted extra-articular fractures of the distal third of the humerus.J Bone JointSurg Br.1990;72:283-287.Bibliographic Links Library Holdings[Context Link]
[7]Zagorski JB,Latta LL,Zych GA,Finnieston AR.Diaphyseal fractures of thehumerus.J Bone Joint Surg Am.1988;70:607-610.[Context Link]
[8]Bell MJ,Beauchamp CG,Kellam JK,McMurty RY.The results of plating humeralshaft fractures in patients with multiple injuries:the Sunnybrook experience.J BoneJoint Surg Br.1985;67:293-296.[Context Link]
[9]Christiansen NO.Kuntscher intramedullary reaming and nail fixation for nonunionof the humerus.Clin Orthop.1976;116:222-226.[Context Link]
[10]Griend RV,Tomasin J,Ward EF.Open reduction and internal fixation of humeralshaft fracture.J Bone Joint Surg Am.1986;68:430-433.[Context Link]
[11]Modabber MR,Jupiter JB.Operative management of diaphyseal fractures of thehumerus:plate versus nail.Clin Orthop.1998;347:93-104.Ovid Full TextBibliographic Links[Context Link]
[12]Chapman,Jens R.;Henley,M.Bradford;Agel,Randomized Prospective Study ofHumeral Shaft Fracture Fixation:Intramedullary Nails Versus Plates.J OrthopTrauma.Volume 14(3),March/April 2000,pp162-166
[13]DeLong TB Jr,Born CT,Marcelli E,et al.Ender nail fixation in long bone fractures: experience in a Level Ⅰ trauma center.J Trauma.1989;29:571.Bibliographic Links
Library Holdings[Context Link]
铩颷14]Durbin RA,Gottesman MJ,Saunders KC.Hackethal stacked nailing of humeralshaft fractures:experience with 30 patients.Clin Orthop.1983;179:168.[ContextLink]
[15]Hall RF Jr,Pankovich AM.Ender nailing of acute fractures of the humerus:a studyof closed fixation by intramedullary nails without reaming.J Bone Joint Surg Am.1987;69:558.[Context Link]
[16]Henley MB,Chapman JR,Claudi BF.Closed retrograde Hackethal nail stabilizationof humeral shaft fractures.J Orthop Trauma.1992;6:18.Bibliographic Links LibraryHoldings[Context Link]
[17]Reudi T,Moshfegh A,Pfeiffer KM,et al.Fresh fractures of the shaft of the humerus:conservative or operative treatment? Reconstr Surg Traumatol.1974;14:65.[ContextLink]
[18]Chacha PB.Compression plating without bone grafts for delayed and non-union ofhumeral shaft fractures.Injury.1974;5:283.Bibliographic Links Library Holdings[Context Link]
[19]Naiman PT,Schein AJ,Siffert RS.Use of ASIF compression plates in selected shaftfractures of the upper extremity:a preliminary report.Clin Orthop.1970;71:208.Bibliographic Links Library Holdings[Context Link]
[20]R.G.McCormack,MD,D.Brien,MD,R.E.Buckley,MD,Fixation of fractures ofthe shaft of the humerus by dynamic compression plate or intramedullary nail JBone Joint Surg BR 2000;82-B:336-9
[21]Crates J,Whittle AP.Antegrade interlocking nailing of acute humeral shaft fractures.Clin Orthop 1998;350:40-50.Ovid Full Text Bibliographic Links Library Holdings[Context Link]
[22]Lin J.Treatment of humeral shaft fractures with humeral locked nail andcomparison with plate fixation.J Trauma 1998;44:859-864.Ovid Full TextBibliographic Links Library Holdings[Context Link]
[23]倪东亮 祝云利!林平 钢板及交锁髓内钉治疗肱骨干骨折疗效对比.中国矫形外科杂志 2000年12月第7卷第12期
[24]彭海洲!刘明礼!罗睿髓内钉与钢板治疗肱骨干骨折疗效比较 骨与关节损伤杂志 2004年12月第19卷第12期
铩颷1]Chiu,Fang-Yao MD;Chen,Chuan-Mu MD;Lin,Chien-Fu Jeff MD,ClosedHumeral Shaft Fractures:A Prospective Evaluation of Surgical Treatment,the journalof trauma Volume 43(6),December 1997,pp 947-951
[2]Balfour GW,Mooney V,Ashby ME.Diaphyseal fractures of the humerus treatedwith a ready-made fracture brace.J Bone Joint Surg Am.1982;64:11-13.[ContextLink]
[3]Hunter SG.The closed treatment of fractures of the humeral shaft.Clin Orthop.1982;164:192-198.Bibliographic Links Library Holdings[Context Link]
[4]Klenerman L.Fractures of the shaft of the humerus.J Bone Joint Surg Am.1966;48:105-111.[Context Link]
[5]Naver L,Aalberg JR.Humeral shaft fractures treated with a ready-made fracturebrace.Arch Orthop Trauma Surg.1986;106:20-22.Bibliographic Links LibraryHoldings[Context Link]
[6]Sarmiento A,Horowitch A,Aboulafia A,Vangsness CT Jr.Functional bracing forcomminuted extra-articular fractures of the distal third of the humerus.J Bone JointSurg Br.1990;72:283-287.Bibliographic Links Library Holdings[Context Link]
[7]Zagorski JB,Latta LL,Zych GA,Finnieston AR.Diaphyseal fractures of thehumerus.J Bone Joint Surg Am.1988;70:607-610.[Context Link]
[8]Bell MJ,Beauchamp CG,Kellam JK,McMurty RY.The results of plating humeralshaft fractures in patients with multiple injuries:the Sunnybrook experience.J BoneJoint Surg Br.1985;67:293-296.[Context Link]
[9]Christiansen NO.Kuntscher intramedullary reaming and nail fixation for nonunion ofthe humerus.Clin Orthop.1976;116:222-226.[Context Link]
[10]Griend RV,Tomasin J,Ward EF.Open reduction and internal fixation of humeralshaft fracture.J Bone Joint Surg Am.1986;68:430-433.[Context Link]
[11]Modabber MR,Jupiter JB.Operative management of diaphyseal fractures of thehumerus:plate versus nail.Clin Orthop.1998;347:93-104.Ovid Full TextBibliographic Links[Context Link]
[12]Chapman,Jens R.;Henley,M.Bradford;Agel,Randomized Prospective Study ofHumeral Shaft Fracture Fixation:Intramedullary Nails Versus Plates.J OrthopTrauma.Volume 14(3),March/April 2000,pp 162-166
[13]DeLong TB Jr,Born CT,Marcelli E,et al.Ender nail fixation in long bone fractures: experience in a Level Ⅰ trauma center.J Trauma.1989;29:571.Bibliographic Links
Library Holdings[Context Link]
铩颷14]Durbin RA,Gottesman MJ,Saunders KC.Hackethal stacked nailing of humeral shaftfractures:experience with 30 patients.Clin Orthop.1983;179:168.[Context Link]
[15]Hall RF Jr.,Pankovich AM.Ender nailing of acute fractures of the humerus:a studyof closed fixation by intramedullary nails without reaming.J Bone Joint Surg Am.1987;69:558.[Context Link]
[16]Henley MB,Chapman JR,Claudi BF.Closed retrograde Hackethal nail stabilizationof humeral shaft fractures.J Orthop Trauma.1992;6:18.Bibliographic Links LibraryHoldings[Context Link]
[17]Reudi T,Moshfegh A,Pfeiffer KM,et al.Fresh fractures of the shaft of the humerus:conservative or operative treatment? Reconstr Surg Traumatol.1974;14:65.[ContextLink]
[18]R.G.McCormack,MD,D.Brien,MD,R.E.Buckley,MD,Fixation of fractures ofthe shaft of the humerus by dynamic compression plate or intramedullary nail J BoneJoint Surg BR 2000;82-B:336-9
[19]倪东亮,祝云利,林平.钢板及交锁髓内钉治疗肱骨干骨折疗效对比.中国矫形外科杂志,2000,7(12)
[20]彭海洲,刘明礼,罗睿髓内钉与钢板治疗肱骨干骨折疗效比较.骨与关节损伤杂志,2004,19(12)