Kuo Liang Tseng, Chi Ching-Chi, Chuang Ching-Hui
Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, No. 6, West Sec. Chia-Pu Road Putz, Chiayi, Taiwan, 613.
Cochrane Database Syst Rev. 2015 Mar 30;2015(3):CD010261. doi: 10.1002/14651858.CD010261.pub2.
The distal tibial metaphysis is located in the lower (distal) part of the tibia (shin bone). Fractures of this part of the tibia are most commonly due to a high energy injury in young men and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain.
To assess the effects (benefits and harms) of surgical interventions for distal tibial metaphyseal fractures in adults. We planned to compare surgical versus non-surgical (conservative) treatment, and different methods of surgical intervention.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 12), MEDLINE (1946 to November Week 3 2014), EMBASE (1980 to 2014 Week 48), the Airiti Library (1967 to 2014 Week 8), China Knowledge Resource Integrated Database (1915 to 2014 Week 8), ClinicalTrials.gov (February 2014) and reference lists of included studies.
We included randomised and quasi-randomised controlled clinical studies comparing surgical versus non-surgical (conservative) treatment or different surgical interventions for treating distal tibial metaphyseal fractures in adults. Our primary outcomes were patient-reported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes.
Two authors independently selected studies, assessed the risk of bias in each study and extracted data. We resolved disagreement by discussion and, where necessary, in consultation with a third author. Where appropriate we pooled data using the fixed-effect model.
We included three randomised trials that evaluated intramedullary nailing versus plating in 213 participants, with useable data from 173 participants of whom 112 were male. The mean age of participants in individual studies ranged from 41 to 44 years. There were no trials comparing surgery with non-surgical treatment. The three included trials were at high risk of performance bias, with one trial also being at high risk of selection, detection and attrition bias. Overall, the quality of available evidence was rated as very low for all outcomes, meaning that we are very unsure about the estimates for all outcomes.The results of two large ongoing trials of nailing versus plating are likely to provide sufficient evidence to address this issue in a future update.
AUTHORS' CONCLUSIONS: Overall, there is either no or insufficient evidence to draw definitive conclusions on the use of surgery or the best surgical intervention for distal tibial metaphyseal fractures in adults. The available evidence, which is of very low quality, found no clinically important differences in function or pain, and did not confirm a difference in the need for re-operation or risk of complications between nailing and plating.The addition of evidence from two ongoing trials of nailing versus plating should inform this question in future updates. Further randomised trials are warranted on other issues, but should be preceded by research to identify priority questions.
胫骨干骺端位于胫骨（小腿骨）的下部（远端）。该部位的骨折在年轻男性中最常见于高能损伤，在老年女性中则最常见于骨质疏松。胫骨干骺端骨折的最佳手术干预方法仍不确定。
评估成人胫骨干骺端骨折手术干预的效果（益处和危害）。我们计划比较手术治疗与非手术（保守）治疗，以及不同的手术干预方法。
我们检索了考克兰骨、关节和肌肉创伤小组专业注册库（2014年12月9日）、考克兰对照试验中央注册库（2014年第12期）、MEDLINE（1946年至2014年11月第3周）、EMBASE（1980年至2014年第48周）、华艺数位图书馆（1967年至2014年第8周）、中国知网（1915年至2014年第8周）、ClinicalTrials.gov（2014年2月）以及纳入研究的参考文献列表。
我们纳入了比较手术治疗与非手术（保守）治疗或不同手术干预方法治疗成人胫骨干骺端骨折的随机和半随机对照临床研究。我们的主要结局是患者报告的功能，以及因不良结局而需要二次手术、翻修手术或实质性物理治疗的情况。
两位作者独立选择研究、评估每项研究的偏倚风险并提取数据。我们通过讨论解决分歧，必要时与第三位作者协商。在适当情况下，我们使用固定效应模型合并数据。
我们纳入了三项随机试验，评估了213名参与者的髓内钉固定与钢板固定，173名参与者有可用数据，其中112名是男性。各研究中参与者的平均年龄在41至44岁之间。没有比较手术与非手术治疗的试验。纳入的三项试验存在较高的实施偏倚风险，其中一项试验还存在较高的选择、检测和失访偏倚风险。总体而言，所有结局的现有证据质量均被评为极低，这意味着我们对所有结局的估计非常不确定。两项正在进行的关于髓内钉固定与钢板固定的大型试验结果可能会在未来更新中提供足够的证据来解决这个问题。
总体而言，没有或没有足够的证据就成人胫骨干骺端骨折的手术使用或最佳手术干预得出明确结论。现有证据质量极低，未发现功能或疼痛方面有临床重要差异，也未证实髓内钉固定与钢板固定在再次手术需求或并发症风险方面存在差异。两项正在进行的关于髓内钉固定与钢板固定的试验的证据补充应会在未来更新中为这个问题提供信息。有必要就其他问题进行进一步的随机试验，但在此之前应先进行研究以确定优先问题。
