Meta analysis of intramedullary nail versus plate fixation in treatment of extra-articular distal tibial fractures

doi:10.3969/j.issn.2095-4344.2013.48.011

Abstract

Abstract:

BACKGROUND: Intramedullary nail and traditional steel plate fixation have been widely used in the treatment of distal tibial (extra-articular) fractures, but these two kinds of methods have shortcomings. Some control studies attempt to answer the advantages and disadvantages of the issue on the treatment of extra-articular distal tibial fractures with intramedullary nail and steel plate fixation, but the conclusions are different.
OBJECTIVE: To determine the efficiency and safety of intramedullary nail and plate fixation in the treatment of extra-articular distal tibial fractures by Meta analysis.
METHODS: PubMed, Embase, Cochrane Library, CBMdisc, Weipu information database and Wanfang were searched by computer, and relevant Chinese and English orthopedic journals were hand-searched. Controlled trials related to intramedullary nail and plate fixation in the treatment of extra-articular distal tibial fracture were included. The quality of trials was critically assessed. RevMan 5.0 software was used for data analysis．
RESULTS AND CONCLUSION: Four articles were included. Meta analysis showed that compared with the plate fixation, the malunion rate of the intramedullary nail for extra-articular distal tibial fractures increased. There was no statistical difference in the rate of nonunion rate, delayed fracture healing, and infection rate after operation. These indicate that intramedullary nail and plate fixation both have good effects on fracture healing.

Key words: fractures, bone, tibial fractures, bone nails, internal fixators

CLC Number:

R318

Li Jian-gang, Wang Lei, Dong Zhe, Wang Feng-feng, Ma Gai-ping, Liu Mei-mei, Hu Fang . Meta analysis of intramedullary nail versus plate fixation in treatment of extra-articular distal tibial fractures[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(48): 8361-8367.

Figures/Tables 3

2.2 Meta分析结果 2.2.1 髓内钉与钢板内固定治疗胫骨远端关节外骨折后不愈合的差异 4个纳入的文献研究中有2个对胫骨远端骨折治疗后骨折的不愈合进行了研究，共有215例患者，其中接受髓内钉治疗131例，钢板治疗84例，各研究间具有同质性(P=0.81，I2=0%)，根据以上统计学方法采用固定效应模式进行Meta分析，结果显示差异没有显著性意义[RR 2.05，95%CI(0.53，7.96)]，即钢板与髓内钉治疗胫骨远端关节外骨折在骨折不愈合方面无差异，见图1。 2.2.2 髓内钉与钢板内固定治疗胫骨远端关节外骨折后畸形愈合的差异 4个纳入的文献研究中有3篇文献对胫骨远端关节外骨折治疗后畸形愈合进行了研究，共计有239例患者，其中接受髓内钉治疗143例，钢板治疗96例，Meta分析结果见图2。各研究具有同质性(P=0.50，I2=0%)，采用固定效应模式进行Meta分析，结果显示差异有显著性意义[RR 4.02，95%CI(1.75，9.21)]。这表明与钢板治疗了胫骨远端骨折相比，髓内钉治疗有较高的畸形愈合率。但3篇文献中有2篇是回顾性研究，而且只有Vallier等的文章为随机对照研究，分成亚组进行进一步分析，用2篇回顾性研究再做比较，共计135例，其中接受髓内钉治疗87例，钢板治疗48例，Meta分析结果见图3。各研究间没有异质性(P=0.25，I2=23%)，根据以上统计学方法采用固定效应模式进行Meta分析，结果这2种疗法差异有显著性意义[RR 4.69，95%CI(1. 47，14.91)]。表明与钢板治疗相比，髓内钉治疗的胫骨远端关节外骨折后畸形愈合率较高。 2.2.3 髓内钉与钢板内固定治疗胫骨远端关节外骨折后延迟愈合的差异 4个纳入的文献研究中有3篇文献研究对胫骨远端(关节外)骨折治疗后骨折的延迟愈合进行了研究，共计有193例患者，其中髓内钉组有115例，钢板组78例，Meta分析结果见图4。各研究间具有同质性(P=0.74，I2=0%)，采用固定效应模式进行Meta分析，结果显示差异没有显著性意义[RR 3.09，95%CI(0.75，12.69)]。这表明与钢板治疗胫骨远端骨折相比，髓内钉治疗没有区别。 2.2.4 髓内钉与钢板内固定治疗胫骨远端关节外骨折后深部感染的差异 4个研究有2个报道了胫骨远端骨折治疗后的深部感染，共计215例患者，其中接受髓内钉治疗131例，钢板治疗84例，Meta分析结果见图5。各研究间具有同质性(P=0.55，I2=0%)，根据固定效应模式进行Meta分析，结果显示差异没有显著性意义[RR 1.81，95%CI(0.33，4.28)]。这说明髓内钉与钢板在治疗了胫骨远端关节外骨折术后深部感染方面相比没有区别。 2.2.5 髓内钉与钢板内固定治疗胫骨远端关节外骨折的住院时间、手术时间、负重时间和关节功能的差异 4个纳入文献中只有Kasper等报道了住院时间、手术时间和负重时间，其余3篇都没有报道，分别为髓内钉组住院时间为9.8(4-20) d，手术时间为123(75-195) min；钢板组住院时间为9.5(4-15) d，手术时间为107(60-195) min。髓内钉组胫骨远端关节外骨折患者住院及手术时间均比钢板组长(P < 0.01)。而2组胫骨远端关节外骨折患者的负重时间的差异无显著性意义(髓内钉组3.3个月，钢板组3.8个月，P=0.14)。但因只有1篇文献对住院时间、手术时间和负重时间进行了研究，故不能对统计量进行Meta分析。对于骨折愈合时间，Vallier等(2011)没有报道，其余3篇文献分别为髓内钉组19(14-32)周、13.6±2.8(10-16)周、3.3个月，钢板组21(13-28)周、9-16(13.2±2.6)周、3.5个月。两组在骨折愈合时间上差异没有显著性意义(P > 0.05)。由于Kasper等和Vallier等(2008)只提供了骨折愈合时间的均数，未提供2组骨折愈合时间的标准差，故不合并统计量进行Meta分析。对于治疗后关节功能，4个研究中只有Kasper等进行了报道，髓内钉组和钢板组患者治疗后的美国膝关节学会膝关节功能评分中跪地痛评分分别为43(0-100)和7(0-50)，差异有显著性意义(P < 0.05)；蹲坐疼痛评分分别为29(0-95)和9(0-50)，差异也有显著性意义(P < 0.05)，即髓内钉在治疗胫骨远端骨折有较高的术后膝关节疼痛率，但因其只有1篇文献，故不能对统计量进行Meta分析。"

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