Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.
Syst Rev. 2020 Aug 13;9(1):179. doi: 10.1186/s13643-020-01424-4.
A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.
We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.
Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.
Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.
PROSPERO CRD42015020805.
尽管对于临床实践中的共同决策而言，综合概述各种常见骨折的治疗方法非常重要，但目前仍然缺乏这方面的内容。本研究旨在确定手术治疗与非手术治疗成人创伤性骨骼骨折的疗效和安全性。
我们检索了 Medline、Embase、CINAHL、Web of Science 和 CENTRAL 数据库，检索时间截至 2018 年 11 月，以获取比较手术治疗与非手术治疗成人骨折的随机试验。对于安全性结局，仅纳入在 2000 年或以后入组患者的试验，而对疗效结局没有时间限制。两名审查员独立评估研究的纳入情况、从全文试验中提取数据，并进行偏倚风险评估。主要结局指标为自我报告的疼痛、功能和生活质量，以及严重不良事件（SAEs）。采用随机效应模型（Hedges'g）进行分析。
在筛选出的 28375 条记录中，我们纳入了 61 项试验，并对 11 个部位的 12 种骨折类型进行了荟萃分析：跟骨、锁骨、股骨、肱骨、踝骨、掌骨、跖骨、桡骨、肋骨、舟骨和胸腰椎。另外还有 7 种其他骨折类型仅有 1 项试验。对于桡骨远端骨折，功能的标准化均数差（SMD）为 0.31（95%CI 0.10 至 0.53，n = 378 名参与者），手术治疗更优，然而，手术组的严重不良事件风险更高（RR = 3.10（1.42 至 6.77），n = 436）。对于关节内移位的跟骨骨折，功能的 SMD 为 0.64（0.13 至 1.16，n = 244），生活质量的 SMD 为 0.19（0.01 至 0.36，n = 506），手术治疗更优。对于关节外移位的锁骨中段骨折，与非手术治疗相比，手术治疗的严重不良事件风险更小（RR = 0.62（0.42 至 0.92），n = 1394）。其他比较均未显示出统计学意义上的差异，大多数常见骨折类型的可用数据不足。
在有多项试验的 12 种骨折类型中，仅有两种类型（桡骨远端骨折和关节内移位的跟骨骨折）的疗效倾向于手术治疗，其中一种（桡骨远端骨折）的手术组安全性结局更差。我们的研究结果突出了目前高质量随机试验对于常见骨折类型的缺乏，以及部分现有试验存在较大的异质性和偏倚风险。
PROSPERO CRD42015020805。
