Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes.
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Abstract
Purpose: Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.
Methods: A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.
Results: Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.
Conclusions: An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.
目的：儿童股骨骨干骨折与发病风险相关。已经开发了各种固定方法，但只有有限的证据支持它们的使用。本系统综述评估了使用钢板内固定或柔性髓内钉治疗儿童闭合性股骨干骨折的临床结果。方法：进行PROSPERO注册、符合PRISMA的系统回顾和荟萃分析。MEDLINE、Embase和Web of Science（WoS）数据库从成立到2023年2月进行了搜索。纳入标准包括临床研究报告使用钢板固定和柔性髓内钉手术治疗儿童闭合性股骨干骨折后的不良结果。ROBINS-I和RoB2工具评估了偏倚的风险。结果：13篇论文（2项前瞻性随机对照试验和11个回顾性队列）报道了801名儿童（559名男性，242名女性）的805例闭合性股骨干骨折。共有360个钢板固定器和445个柔性髓内钉。报告两例骨髓炎和一例骨不连。荟萃分析显示，钢板内固定术发生软组织感染的风险较低（相对风险0.26（95%置信区间0.07-0.92））。以下结果无差异：畸形愈合（相对风险0.68（95%可信区间0.32-1.44））；非计划性再手术（相对风险0.59（95%置信区间0.31-1.14））和腿长差异（相对风险1.58（95%可信区间0.66-3.77））。所有研究中偏倚的风险都很高。结论：即使证据质量较低，对805例骨折的荟萃分析差异最小的分析也被认为是高质量的。研究结果受到已发表文献中方法论的重要缺陷的限制。需要使用标准化核心结果进行精心设计的多中心前瞻性研究，以提出治疗建议。证据级别：三。
期刊介绍：
Aims & Scope
The Journal of Children’s Orthopaedics is the official journal of the European Paediatric Orthopaedic Society (EPOS) and is published by The British Editorial Society of Bone & Joint Surgery.
It provides a forum for the advancement of the knowledge and education in paediatric orthopaedics and traumatology across geographical borders. It advocates an increased worldwide involvement in preventing and treating musculoskeletal diseases in children and adolescents.
The journal publishes high quality, peer-reviewed articles that focus on clinical practice, diagnosis and treatment of disorders unique to paediatric orthopaedics, as well as on basic and applied research. It aims to help physicians stay abreast of the latest and ever-changing developments in the field of paediatric orthopaedics and traumatology.
The journal welcomes original contributions submitted exclusively for review to the journal. This continuously published online journal is fully open access and will publish one print issue each year to coincide with the EPOS Annual Congress, featuring the meeting’s abstracts.
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