Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
Tanta University, Tanta, Egypt.
Foot Ankle Surg. 2022 Oct;28(7):986-994. doi: 10.1016/j.fas.2022.02.005. Epub 2022 Feb 12.
This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost.
comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded.
After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I=0%).
Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.
本研究旨在提供一项关于经皮锁定髓内钉（IMN）与切开复位内固定（ORIF）治疗胫腓骨远端骨折的疗效和并发症的系统评价和荟萃分析，以避免类似已发表文献的局限性。
根据系统评价和荟萃分析的首选报告项目（PRISMA）指南，两名独立的团队成员在 2021 年 5 月期间使用以下关键词及其同义词在 MEDLINE（PubMed）、EMBASE、Google Scholar、SCOPUS 和 Cochrane 数据库中进行电子搜索：“踝关节骨折固定”和“切开复位内固定”、“锁定髓内钉”或“并发症”。主要结局是（1）功能结局，（2）并发症，和（3）再次手术，次要结局是：（1）愈合率，和（2）成本。
比较经皮 ORIF 与锁定髓内钉治疗胫腓骨远端骨折的疗效和并发症的研究，至少报告以下参数之一：功能结局、并发症（感染、裂开、再次手术等）、愈合和成本。不包括报告非锁定髓内腓骨钉的研究。
去除重复项后，共识别出 1461 项研究。在筛选这些记录后，仍有 63 项研究进行了全文评估。其中，四项具有 262 例踝关节骨折的比较研究符合本荟萃分析的纳入标准。有两项研究报告了 12 个月的术后 Olerud 和 Molander 踝关节评分（OMAS），具有统计学意义的优势倾向于 IMN（MD=6.72，CI：3.77-9.67，p<0.001，I=94%）。在 ORIF 组中，总的并发症发生率为 39/134（29.1%），而在 IMN 组中为 10/128（7.8%），具有统计学意义的优势倾向于 IMN 组（RR=3.23，CI：1.71-6.11，p<0.001，I=34%）。在 ORIF 组中，总的感染率为 11/134（8.2%），而在 IMN 组中没有感染，具有统计学意义的优势倾向于 IMN 组（RR=8.05，CI：1.51-42.82，p=0.01，I=0%）。在 ORIF 组中，总的再次手术率为 10/134（7.5%），而在 IMN 组中为 6/128（4.7%），两组之间无统计学差异（RR=1.49，CI：0.60-3.70，p=0.39，I=0%）。
与切开复位内固定相比，经皮锁定髓内钉固定腓骨远端骨折可提供更好的功能结局和更低的并发症发生率。尽管踝关节骨折的发生率很高，但文献中高质量的比较研究数量仍然有限，特别是关于新型锁定腓骨钉的研究，需要进行大型多中心临床试验，才能推荐锁定髓内钉作为治疗腓骨远端骨折的新标准。
