TRAUMA
A Meta-analysis of Reamed Versus Unreamed Intramedullary Nailing for the Treatment of Closed Tibial Fractures
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2014;2(13):35 Orthopedics. 2014 Apr 1;37(4):e332-8Nine studies (randomized controlled trials or quasi-RCTs) were included in this meta-analysis comparing reamed and unreamed intramedullary nailing for closed tibial fractures. Of note, pooled nonunion rate was significantly lower for reamed intramedullary nailing vs. unreamed nailing. Additionally, rates of secondary surgeries, particularly implant exchange and dynamization, were also lower with reamed nailing. Pooled incidences of infection, compartment syndrome, and postoperative knee pain were similar between reamed and unreamed intramedullary nailing.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
はい = 1
不確実＝0.5
無関係 = 0
いいえ = 0
報告基準評価では、著者が出版物内で試験の方法論的特徴や試験特性を報告する際の透明性を評価します。評価は以下の5つのカテゴリーに分類されます。
4/4
Introduction
4/4
Accessing Data
2/4
Analysing Data
3/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
Fragility Indexは、重要な所見の解釈を助けるツールで、結果の強さの尺度を提供します。Fragility Indexは、その所見が有意でなくなるために、二項対立の結果に追加する必要がある連続した事象の数を表します。数値が小さいほど弱い所見を表し、数値が大きいほど強い所見を表します。
なぜ今この研究が必要なのですか？
Debate exists between intramedullary nailing with and without reaming in tibial fractures. Cited advantages of reaming include stability with expedited union, although disadvantages include high risk of complications such as bone necrosis, compartment syndrome and infection. Unreamed intramedullary nailing has been suggested to avoid these complications and reduce operative time, but has been associated with poor mechanical stability and longer time to union. Previous meta-analysis have addressed this comparison, although have been limited by their inclusion of both closed and open tibial fractures. Therefore, this study aimed to investigate outcomes in closed fractures specifically.
主な研究課題は何ですか？
How does intramedullary nailing with and without reaming compare in the treatment of closed tibial fractures?
重要な知見は？
- Nine studies with 1229 tibial fractures (643 reamed; 586 unreamed) were included in the study. Eight outcomes were pooled: Rates of nonunion, delayed union, malunion, secondary surgery, implant failure, infection, compartment syndrome, and knee pain.
- A significantly higher rate of nonunion was observed with unreamed nailing (3 studies; OR 0.43 [95%CI 0.21, 0.28]; p=0.02). The rates of delayed union (2 studies; OR 0.53 [95%CI 0.20, 1.41]; p=0.20) and malunion (2 studies; OR 0.48 [95%CI 0.13, 1.81]; p=0.28) were similar between groups.
- Overall, rate a secondary surgery was significantly lower with unreamed nailing (OR 0.53 [95%CI 0.35, 0.81]; p=0.003). By surgery type, implant exchange (OR 0.37 [95%CI 0.16, 0.81]; p=0.01) and dynamization (OR 0.57 [95%CI 0.34, 0.98]; p=0.04) were significantly lower. The incidence of bone graft as a secondary procedure did not significantly differ between groups (OR 1.33 [95%CI 0.26, 6.80]; p=0.73).
- Rate of implant failure was significantly lower with reamed nailing (OR 0.34 [95%CI 0.21, 0.57]; p<0.0001). This was predominantly due to failure of the screws (Reamed 20/514; Unreamed 54/498) (OR 0.32 [95%CI 0.19, 0.55]; p<0.0001) as opposed to failure of the nail (p=0.94).
- There were no significant differences observed in rates of infection (7 studies; OR 1.36 [95%CI 0.70, 2.65]; p=0.36), compartment syndrome (5 studies; OR 0.69 [95%CI 0.31, 1.53]; p=0.36) or knee pain (2 studies; OR 0.97 [95%CI 0.47, 2.00]; p=0.93).
最も覚えておくべきことは？
Reamed intramedullary nailing exhibited a lower rate of nonunion than unreamed nailing following fixation of closed tibial fractures, along with lower rates of secondary implant exchange and dynamization. Incidence of screw failure in reamed nailing was also significantly lower than in unreamed nailing. Other complications (infection, compartment syndrome, postoperative knee pain) did not significantly differ between groups.
それが私の患者ケアにどのように影響するか？
The results from this analysis suggest that reamed intramedullary nailing may offer a more advantageous outcome than unreamed nailing in treatment of closed fractures of the tibia with respect to nonunion and associated secondary surgeries. Inconsistent with previous literature, there did not appear to be an increased risk of complications with reamed nailing, as pooled rates of infection, compartment syndrome and knee pain were similar between methods. Unfortunately, current literature still lacks sufficient data to conduct comparisons on other pertinent complications, such as fat embolism and pulmonary embolism. These are topics that should be considered in future studies.
免責事項
このページに記載されている内容は、情報提供のみを目的としたものであり、専門的な医療アドバイス、診断、治療の代わりとなるものではありません。治療が必要な場合は、必ず医師の診断を仰ぐか、最寄りの救急外来を受診してください。このページに記載されている内容に関して個人が表明した意見、信念、見解は、OrthoEvidenceの意見、信念、見解を反映するものではありません。
0の4 月間無料記事のロック解除
