Elgayar Lugman, Arnall Frances, Barrie Jim
Clinical Research Fellow, Trauma and Orthopaedic Department, University Hospital of Wales, Cardiff, United Kingdom.
Consultant Physiotherapist, School of Health and Society, University of Salford, Manchester, United Kingdom.
J Foot Ankle Surg. 2019 Sep;58(5):933-937. doi: 10.1053/j.jfas.2018.12.017.
Nine percent of all fractures affect the ankle, with an annual incidence of 122/100,000 in Edinburgh, UK. While unstable fractures are usually treated surgically, there has been no recent systematic review of the evidence supporting this decision. In this systematic review, relevant electronic databases (such as MEDLINE and CINHAL) were searched from inception to February 2017. Five randomized controlled trials that examined surgical versus conservative interventions in 951 adults with closed ankle fractures, with follow-up for at least 6 months, were selected for further synthesis of evidence. The risk of selection bias in all selected trials was relatively low. However, most of the trials had a high risk of performance and detection bias. Three of the 5 selected trials used the validated functional Olerud Molander Ankle Score. One trial (n = 43), reported a statistically better score for the surgical group at 27-month follow-up, whereas a second (n = 81) and a third (n = 620) trial found no significant difference at 12 and 6 months, respectively. No significant differences between surgical and conservative treatments were reported in 2 trials (n = 111) and (n = 96) in nonvalidated functional outcome measures. Other outcomes were malunion (9/334 [2.6%] versus 48/301 [15.9%], p < .0001) and nonunion (3/408 [0.7%] versus 28/383 [7.3%], p < .0001) and were considerably higher in the conservatively treated group. Early treatment failure was significantly lower with surgery (7/435 [1.6%] versus 70/419 [16.7%], p < .0001). The risk of malunion, nonunion, and loss of reduction were greater in nonoperative care. However, the 2 treatment approaches provided equivalent functional outcomes.
所有骨折中9%累及踝关节，在英国爱丁堡其年发病率为122/10万。虽然不稳定骨折通常采用手术治疗，但最近尚无支持这一决策的证据的系统评价。在本系统评价中，检索了从建库至2017年2月的相关电子数据库（如MEDLINE和CINHAL）。选取了5项随机对照试验，这些试验对951例闭合性踝关节骨折成人进行了手术与保守干预对比研究，随访至少6个月，以进一步综合证据。所有入选试验的选择偏倚风险相对较低。然而，大多数试验存在较高的实施和检测偏倚风险。5项入选试验中有3项使用了经过验证的Olerud Molander踝关节功能评分。一项试验（n = 43）报告手术组在27个月随访时评分在统计学上更好，而第二项试验（n = 81）和第三项试验（n = 620）分别在12个月和6个月时未发现显著差异。在2项试验（n = 111）和（n = 96）中，未经验证的功能结局测量指标显示手术与保守治疗之间无显著差异。其他结局包括畸形愈合（9/334 [2.6%] 对比48/301 [15.9%]，p <.0001）和骨不连（3/408 [0.7%] 对比28/383 [7.3%]，p <.0001），保守治疗组的发生率明显更高。手术治疗的早期治疗失败率显著更低（7/435 [1.6%] 对比70/419 [16.7%]，p <.0001）。非手术治疗中畸形愈合、骨不连和复位丢失的风险更大。然而，两种治疗方法提供了相当的功能结局。
