Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland.
Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland.
Injury. 2021 Mar;52(3):345-357. doi: 10.1016/j.injury.2020.10.026. Epub 2020 Oct 14.
Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores).
A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.
A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union.
Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.
治疗胫骨远端干骺端或骨干骨折具有挑战性，最佳手术策略仍存在争议。本研究旨在比较钢板固定与髓内钉固定在手术时间、骨不连、愈合时间、畸形愈合、感染、后续再次干预以及功能结果（生活质量评分、膝关节和踝关节评分）方面的差异。
在 PubMed/Embase/CINAHL/CENTRAL 中对所有比较钢板固定与髓内钉固定的研究设计进行了检索。使用 RevMan 对数据进行汇总，并以比值比（OR）、风险差（RD）、加权均数差（WMD）或加权标准化均数差（WSMD）表示，置信区间（95%CI）为 95%。所有分析均根据研究设计进行分层。
共分析了 15 项研究，包括 10 项 RCT（n=873）和 5 项观察性研究（n=459），共纳入 1332 例患者。髓内钉固定可缩短愈合时间（WMD：0.4 个月，95%CI：0.1 - 0.7）、完全负重时间（WMD：0.6 个月，95%CI：0.4 - 0.8）和手术时间（WMD：15.5 分钟，95%CI：9.3 - 21.7）。钢板固定可降低畸形愈合的风险（RD：-10%，OR：0.4，95%CI：0.3 - 0.6），但感染的风险更高（RD：8%，OR：2.4，95%CI：1.5 - 3.8）。两组骨不连（RD：1%，OR：0.7，95%CI：0.3 - 1.7）、后续再次干预（RD：4%，OR：1.3，95%CI：0.8 - 1.9）和功能结果（WSMD：-0.4，95%CI：-0.9 - 0.1）无显著差异。除愈合时间和畸形愈合外，RCT 和观察性研究的效应估计值在所有结局上均一致。
钢板固定和髓内钉固定治疗胫骨远端关节外骨折均可获得满意的结果。然而，髓内钉固定可导致更高的畸形愈合率和前膝痛，而钢板固定则会增加感染的风险。本研究为个体化治疗提供了指导，并有助于在胫骨远端关节外骨折的手术治疗中做出共同决策。最佳治疗方法应基于具体病例，并与患者的具体需求相匹配，以最大限度地降低并发症风险。
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