Gao Yu, Zhang Wei, Duan Xin, Yang Jing, Al-Qwbani Mohammed, Lv Jingtong, Xiang Zhou
Department of Orthopedics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.
Cochrane Database Syst Rev. 2013 May 31(5):CD008987. doi: 10.1002/14651858.CD008987.pub2.
Radial head fractures are the most common type of elbow fracture and can severely affect the function of the elbow. There is uncertainty and controversy about when surgery is indicated as well as what type of surgical intervention is best.
To assess the effects of surgical interventions for treating radial head fractures in adults. We aimed to compare surgical versus non-surgical treatment, and different methods of surgical intervention.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library; 2012 Issue 4), MEDLINE (1946 to May 2012), EMBASE (1980 to 2012 Week 19) and trial registers (November 2011). No language restrictions were applied.
All randomised and quasi-randomised controlled trials evaluating surgical interventions for treating radial head fractures.
Two review authors independently selected trials, assessed risk of bias and extracted data. Where appropriate, results were pooled.
We included three randomised controlled trials, involving a total of 251 participants. All three trials were at high risk of performance bias reflecting the fact that surgeons could not be blinded. One trial was at low risk of selection bias but was undermined by a high attrition bias, in part resulting from post-randomisation exclusions. There were incomplete details of methodology for the other two trials, which usually resulted in unclear risk of bias judgements.Two trials compared radial head replacement with open reduction and internal fixation (ORIF) for treating Mason type III radial head fractures. The trial authors reported outcomes at a mean of 2.8 years and 15 months respectively. There were significant differences between the two groups in favour of radial head replacement in the Broberg and Morrey elbow scores (92.1 versus 72.4, mean difference (MD) 19.70; 95% confidence interval (CI) 15.64 to 23.76; one trial, 45 participants), excellent or good Broberg and Morrey elbow scores (33/36 versus 16/31, risk ratio (RR) 1.88; 95% CI 1.27 to 2.77; two trials), and overall adverse events (6/36 versus 15/31, RR 0.33; 95% CI 0.14 to 0.77; two trials). No statistically significant difference was found between the two groups in any of the reported individual adverse events.One trial compared biodegradable pins with standard metal screws in treating radial head fractures of AO-classification 21 B2. The two types of fixation devices yielded similar results, with no significant between-group differences in the Broberg and Morrey scores (93.3 versus 90.9, MD 2.40; 95% CI -0.10 to 4.90), excellent or good Broberg and Morrey elbow scores (72/74 versus 56/61, RR 1.06; 95% CI 0.97 to 1.15), and adverse events (13/82 versus 16/82, RR 0.81; 95% CI 0.42 to 1.58) at two-year follow-up.
AUTHORS' CONCLUSIONS: Only tentative conclusions can be drawn from the available evidence in this review. Compared with ORIF, there was some evidence that radial head replacement had better elbow function and fewer adverse events for Mason type III radial head fractures in the short term. However, the evidence is of low quality and it is unknown whether these results would apply in the longer term or more generally. Using biodegradable implants may be as good as metallic implants for fixation of some usually more stable fractures but more evidence is needed to confirm this. There is a need for good quality evidence for addressing the areas of uncertainty for the surgical treatment of radial head fractures.
桡骨头骨折是最常见的肘部骨折类型，可严重影响肘部功能。对于何时进行手术以及哪种手术干预方式最佳存在不确定性和争议。
评估手术干预治疗成人桡骨头骨折的效果。我们旨在比较手术治疗与非手术治疗，以及不同的手术干预方法。
我们检索了Cochrane骨、关节和肌肉创伤组专业注册库（2012年5月）、Cochrane对照试验中央注册库（Cochrane图书馆；2012年第4期）、MEDLINE（1946年至2012年5月）、EMBASE（1980年至2012年第19周）和试验注册库（2011年11月）。未设语言限制。
所有评估手术干预治疗桡骨头骨折的随机和半随机对照试验。
两位综述作者独立选择试验、评估偏倚风险并提取数据。在适当情况下，对结果进行合并。
我们纳入了三项随机对照试验，共涉及251名参与者。所有三项试验均存在较高的实施偏倚风险，这反映了外科医生无法实施盲法这一事实。一项试验存在较低的选择偏倚风险，但因较高的失访偏倚而受到影响，部分原因是随机分组后的排除。另外两项试验的方法学细节不完整，这通常导致偏倚风险判断不明确。两项试验比较了桡骨头置换术与切开复位内固定术（ORIF）治疗Mason III型桡骨头骨折的效果。试验作者分别报告了平均2.8年和15个月时的结果。两组之间在Broberg和Morrey肘部评分方面存在显著差异，支持桡骨头置换术（92.1对72.4，平均差（MD）19.70；95%置信区间（CI）15.64至23.76；一项试验，45名参与者）、Broberg和Morrey肘部评分优秀或良好（33/36对16/31，风险比（RR）1.88；95%CI 1.27至2.77；两项试验）以及总体不良事件（6/36对15/31，RR 0.33；95%CI 0.14至0.77；两项试验）。在任何报告的个体不良事件中，两组之间均未发现统计学上的显著差异。一项试验比较了可生物降解钢针与标准金属螺钉治疗AO分类21 B2型桡骨头骨折的效果。两种固定装置产生了相似的结果，在两年随访时，两组在Broberg和Morrey评分方面无显著组间差异（93.3对90.9，MD 2.40；95%CI -0.10至4.90）、Broberg和Morrey肘部评分优秀或良好（72/74对56/61，RR 1.06；95%CI 0.97至1.15）以及不良事件（13/82对16/82，RR 0.81；95%CI 0.42至1.58）。
本综述中的现有证据只能得出初步结论。与切开复位内固定术相比，有一些证据表明，在短期内，桡骨头置换术对于Mason III型桡骨头骨折具有更好的肘部功能和更少的不良事件。然而，证据质量较低，且这些结果是否适用于更长期或更广泛的情况尚不清楚。对于一些通常更稳定的骨折，使用可生物降解植入物进行固定可能与金属植入物一样好，但需要更多证据来证实这一点。需要高质量证据来解决桡骨头骨折手术治疗中存在不确定性的领域。
