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中华肩肘外科电子杂志

中华肩肘外科电子杂志 ›› 2019, Vol. 07 ›› Issue (04) : 319 -328. doi: 10.3877/cma.j.issn.2095-5790.2019.04.006

所属专题： 专题评论； 文献；

论著

老年复杂肱骨近端骨折的治疗选择：保守治疗，切开复位还是肱骨头置换？系统评价及Meta分析
金开基1, 邢志利1,†(), 安帅2   
  1. 1. 102206　北京大学国际医院骨科
    2. 100053　北京，首都医科大学宣武医院骨科
  • 收稿日期:2018-03-16 出版日期:2019-11-05
  • 通信作者: 邢志利
  • 基金资助:
    北京市严重创伤区域性救治体系建设项目(2016-1-4081)

Treatment options for complex proximal humeral fractures in the elderly: conservative treatment, open reduction or humeral head replacement? A systematic reviews and Meta analysis

Kaiji Jin1, Zhili Xing1,†(), Shuai An2   

  1. 1. Department of Orthopedics, Peking University International Hospital, Beijing 102206, China
    2. Department of Orthopedics, Xuan Wu Hospital Affiliated to Capital Medical University, Beijing 100053, China
  • Received:2018-03-16 Published:2019-11-05
  • Corresponding author: Zhili Xing
  • About author:
    Corresponding author: Xing Zhili, Email:
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引用本文：

金开基, 邢志利, 安帅. 老年复杂肱骨近端骨折的治疗选择：保守治疗，切开复位还是肱骨头置换？系统评价及Meta分析[J]. 中华肩肘外科电子杂志, 2019, 07(04): 319-328.

Kaiji Jin, Zhili Xing, Shuai An. Treatment options for complex proximal humeral fractures in the elderly: conservative treatment, open reduction or humeral head replacement? A systematic reviews and Meta analysis[J]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2019, 07(04): 319-328.

目的

对已发表的随机对照试验进行Meta分析，以期得到证据等级水平更高的关于老年复杂肱骨近端骨折治疗的临床指南。

方法

通过检索Pubmed、EMBASE和Cochrane General Register of Controlled Trials，搜索符合纳入标准并报道功能评分和并发症的随机对照试验，对文献进行证据等级评价并提取功能评分及并发症数据，采用Revman 5.0软件进行Meta分析。

结果

本研究共纳入4篇包含215例患者的随机对照试验，其中2篇（105例患者）比较了肱骨近端Neer 4部分骨折保守治疗和肱骨头置换的Constant功能总体评分、分组评分及并发症情况。Meta分析结果显示对于Neer 4部分骨折，与肱骨头置换相比，保守治疗短期Constant总体评分（WMD =5.69, 95% CI: 0.34~11.03, P=0.04）更高，术后1年肱骨头置换可明显改善疼痛评分（WMD =-2.75, 95% CI: -4.45~-1.04, P=0.002），但总体功能评分与保守治疗无明显差别（WMD =-2.46 , 95% CI: -8.88~-3.96, P=0.14）。另外2篇文献（110例患者）比较了Neer 3、4部分骨折保守治疗和锁定钢板治疗的Constant功能评分和并发症情况，Meta分析显示对于两者在改善功能评分和并发症方面无明显差别。其中1篇文献研究显示对于Neer 3部分骨折，锁定钢板可能改善患者总体功能评分。

结论

对于Neer 4部分骨折短期内保守治疗功能评分更高，肱骨头置换长期可改善疼痛，但无法改善总体功能评分。锁定钢板对于Neer 3部分骨折患者可能改善总体功能评分。

关键词: 肱骨近端骨折, 保守治疗, 锁定钢板, 内固定, 肱骨头置换, 功能评分, 并发症
Background

Proximal humeral fractures are one of the most common fractures, accounting for 4%-5% of total body fractures, and their incidence increases with age. Neer classification is the most widely used classification system, and it divides the proximal humeral fracture into four parts: humeral head, greater tuberosity, lesser tuberosity and humeral shaft. According to the fracture displacement (>1 cm) and angulation (>45°) , proximal humeral fracture is divided into 1 to 4-part. For non-displaced or slightly displaced proximal humeral fractures, conservative treatment can usually achieve satisfactory clinical outcomes. However, the treatment of complex proximal humeral fractures (Neer 3 or 4-part fractures and fracture-dislocations) is more difficult. Conservative treatment, locking plate and humeral head replacement are the most commonly used treatments in clinic, but there is still debate about their clinical efficacy. Conservative treatment mainly involves proper manual reduction and fixation by suspension or other means. It is theoretically difficult to perform satisfactory fracture reduction and reliable fixation, and may bring a relatively high rate of malunion and other complications. Neer et al, first proposed humeral head replacement for treatment of displaced 3 or 4-part fractures and fracture-dislocations, and reported higher patient satisfaction. However, humeral head replacement is more traumatic with complex surgical technique, long postoperative recovery time and more complications, which often leads to poor function. Later studies have reported poor functional results as well. Locking plate fixation is also a classic treatment for displaced proximal humeral fractures. Plate with angle-stabilized screws is used for fracture fixation as a whole. Theoretically, complications such as internal fixation failure and screw penetration can be significantly reduced. Currently, there have been many systematic reviews on the proximal humeral fractures, but the included literatures are mostly retrospective studies with low levels of evidence. Objective This study conducted a meta-analysis of currently published randomized controlled trials to obtain a higher level of evidence for clinical guidelines in the treatment of complex proximal humeral fractures in the elderly.

Methods

The randomized controlled trials that met the inclusive criteria and reported functional scores and complications were searched on Pubmed, EMBASE and Cochrane General Register of Controlled Trials. The evidence levels of literatures were evaluated for the extraction of functional scores and complications. Metaman 5.0 software was used for meta-analysis.

Results

A total of 4 randomized controlled trials involving 215 patients were included in the study. Two of the literatures (105 patients) compared the overall and group Constant scores and complications between conservative treatment and humeral head replacement of Neer part-4 proximal humeral fractures. The meta-analysis showed a higher short-term overall Constant score (WMD =5.69, 95% CI: 0.34-11.03, P=0.04) of conservative treatment compared with humeral head replacement for Neer part-4 proximal humeral fractures. The VAS score (WMD =-2.75, 95% CI: -4.45- -1.04, P= 0.002) was significantly improved one year after humeral head replacement, but the there was no significant difference compared with conservative treatment (WMD =-2.46 , 95% CI: -8.88-3.96, P=0.45) . Another two literatures (110 patients) compared Constant scores and complications between conservative treatment and locking plate fixation of Neer part-3 and part-4 proximal humeral fractures. The meta-analysis showed no significant difference in the improvement of functional scores and complications between them. One of the studies showed that for Neer part-3 fractures, locking plate fixation may improve the overall functional score of the patient.

Conclusions

The functional score was higher for conservative treatment of Neer part-4 fractures in the short term. The humeral head replacement can improve long-term pain, but it cannot improve the overall functional score. Locking plate fixation may improve overall functional scores in patients with Neer part-3 fractures.

Key words: Proximal humeral fracture, Conservative treatment, Locking plate, Internal fixation, Humeral head replacement, Functional score, Complication
图1 文献筛选流程图
表1 文献基本信息
作者 年份 例数 女性（%） 年龄（岁） 骨折类型 随访时间（年） 功能评分 手术入路 内植物类型
保守治疗 手术治疗 保守治疗 手术治疗 保守治疗 手术治疗
Boons等[9] 2012 25 25 92 96 79.9 76.4 4部分 1 Constant评分 三角肌胸大肌入路 Global Fx" prosthesis
Olerud等[10] 2011 28 27 86 85 77.5（60~92） 75.8（58~90） 4部分 1 Constant评分 三角肌胸大肌入路 Global Fx" prosthesis
Olerud等[11] 2011 30 30 83 80 74.9 （58~88） 72.9 （56~92） 3部分 1 Constant评分 三角肌胸大肌入路 Philos钢板
Fjalestad等[12] 2012 25 25 96 80 73.1 （60~88） 72.2 （60~86） 3、4部分 1 Constant评分 三角肌胸大肌入路 LCT钢板
表2 文献质量评价
作者 年份 随机分配方法 分配方案隐藏 盲法 结果数据的完整性 选择性报告研究结果 基线平衡 其他偏倚来源
临床疗效、并发症 死亡、再手术
Boons等[9] 2012 低风险 低风险 高风险 不清楚 低风险 不清楚 低风险 低风险
Olerud等[10] 2011 低风险 低风险 高风险 不清楚 低风险 不清楚 低风险 低风险
Olerud等[11] 2011 低风险 低风险 高风险 不清楚 低风险 不清楚 低风险 不清楚
Fjalestad等[12] 2012 低风险 低风险 高风险 不清楚 低风险 不清楚 不清楚 低风险
图2 3~4个月时肱骨头置换术和保守治疗总体Constant评分的均值差和95%置信区间的森林图
图3 3~4个月时肱骨头置换术和保守治疗Constant疼痛评分的均值差和95%置信区间的森林图
图4 3~4个月时肱骨头置换术和保守治疗Constant ADL评分的均值差和95%置信区间的森林图
图5 3~4个月时肱骨头置换术和保守治疗Constant ROM评分的均值差和95%置信区间的森林图
图6 3~4个月时肱骨头置换术和保守治疗Constant力量评分的均值差和95%置信区间的森林图
图7 12个月时肱骨头置换术和保守治疗总体Constant评分的均值差和95%置信区间的森林图
图8 12个月时肱骨头置换术和保守治疗Constant ADL评分的均值差和95%置信区间的森林图
图9 12个月时肱骨头置换术和保守治疗Constant ROM评分的均值差和95%置信区间的森林图
图10 12个月时肱骨头置换术和保守治疗Constant力量评分的均值差和95%置信区间的森林图
图11 12个月时肱骨头置换术和保守治疗Constant疼痛评分的均值差和95%置信区间的森林图
图12 12个月时肱骨头置换术和保守治疗不良事件的比值比和95%置信区间的森林图
图13 12个月时锁定钢板和保守治疗总体Constant评分的均值差和95%置信区间的森林图
图14 12个月时锁定钢板和保守治疗不良事件的比值比和95%置信区间的森林图
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