Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Fort Lauderdale, FL, USA.
Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL, USA.
Arch Orthop Trauma Surg. 2024 Jun;144(6):2527-2538. doi: 10.1007/s00402-024-05359-6. Epub 2024 May 14.
Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs.
A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion.
Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26 min (95% CI - 28.60 to - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33 s, 95% CI - 84.441 to - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found.
The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.
入点选择是股骨顺行钉固定的关键环节，会影响钉的适配性，进而影响骨折复位。在成人中，标准的入点是梨状肌窝和大转子尖端。之前的系统评价比较了这两种技术，但没有仅限于随机对照试验（RCT），也没有一致地纳入相同的可用 RCT。
对比较股骨顺行钉入点选择的研究进行了系统检索，共在 7 个数据库中进行了检索。只有比较转子下入点和梨状肌下入点治疗转子间或股骨干骨折的前瞻性 RCT 才有资格纳入。
最终，只有 6 项 RCT 符合纳入标准。6 项纳入研究中有 5 项报告了手术时间。结果表明，使用转子下入点的手术时间平均减少约 21.26 分钟（95%CI-28.60 至-13.92，p<0.001），差异有统计学意义。有 4 项研究报告了透视曝光情况，但由于报告方法不同，只有 2 项研究纳入分析。转子下入点的透视曝光量明显少于梨状肌下入点（MD-50.33 秒，95%CI-84.441 至-16.22，p=0.004）。未发现对线不良率、延迟愈合率、不愈合率、疼痛评分或并发症发生率的显著差异。
在手术时间和透视时间方面的显著差异与其他研究一致。虽然我们无法对功能结局评分的数据进行汇总，但纳入的研究中没有一项在最后随访时发现评分有显著差异。两种方法均显示出类似的功能结局和安全性特征，表明入点的选择应根据术者的技术熟悉程度和骨折特点来决定。
