Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia.
Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia.
Foot Ankle Surg. 2022 Oct;28(7):809-816. doi: 10.1016/j.fas.2021.11.007. Epub 2021 Nov 17.
The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF).
A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.
A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis.
In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.
关节外中远端胫骨骨折的手术治疗主要集中在降低不愈合和畸形愈合的发生率，保持髋膝踝对线，改善功能结果。腓骨骨折常伴发于此类损伤，固定腓骨的作用也越来越受到重视。本系统评价和荟萃分析旨在确定在关节外中远端胫骨骨折固定（AO/OTA 42 和 43-A）时，与不固定腓骨（NF）相比，同时固定腓骨（FF）是否会改变畸形愈合、不愈合和术后并发症的风险。
对 MEDLINE（通过 OvidSP）、PubMed、Embase 和 Cochrane 对照试验中心注册数据库（CENTRAL）从成立日期开始进行系统文献检索，纳入随机和非随机对照试验。纳入所有发表于英文的研究。使用非随机研究的偏倚风险（ROBINS-I）和推荐评估、制定与评价（GRADE）框架进行评估。二分类结局采用相对风险（RR），连续性变量采用均数差（MD），均采用 95%置信区间。α 值设为 0.05。
共纳入 10 项研究，1174 例患者纳入分析。FF 组的总体畸形愈合风险明显低于 NF 组（11.8% vs 21.9%，RR 0.63，95%CI：0.41-0.98，p=0.04），这一结果在仅纳入随机对照试验的敏感性分析中得到支持（21.8% vs 40.3%，RR 0.37，95%CI：0.18-0.76，p=0.006）。两组间不愈合率无统计学差异（p>0.05）。总体而言，两组间糖尿病、开放性骨折和吸烟史的发生率相似（p>0.05）。关于胫骨固定方法的详细信息无法进行亚组分析。
总之，在关节外中远端胫骨（AO/OTA 42 和 43-A）骨折固定中，附加腓骨固定（FF）似乎显著降低了总体畸形愈合的风险（RR，0.37，95%CI：0.18-0.76，p=0.006），而不增加不愈合的风险。鉴于胫骨固定方法缺乏亚组分析，这些结果应谨慎解释。因此，未来应进行高质量的随机对照试验，以区分胫骨固定的类型。
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