Abstract: OBJECTIVE:  There are still controversies about the postoperative complications of circular external fixation and open reduction and internal fixation with steel plates for the treatment of tibial plateau fractures. Evidence-based medicine methods are needed to evaluate the pros and cons of the two treatments. This article compared the clinical effects of circular external fixation and open reduction and internal fixation with steel plate in the treatment of tibial plateau fractures.
METHODS: Computer was used to to collect articles on relevant internal and external fixation for the treatment of complex tibial plateau fractures in PubMed, EMbase, Cochrane Library, CNKI, Wanfang and other databases. Two independent investigators screened the literature and collected the literature according to the standards. The Cochrane scoring standard was used to evaluate the quality of the randomized controlled trials, and the NOS scale was used to evaluate the quality of the cohort study. After relevant data were extracted, the RevMan 5.3 software was used for meta-analysis.  
RESULTS:  (1) Finally, 14 articles were included: 3 articles were randomized controlled trials, and 11 articles were cohort studies, with a total of 882 patients. 436 cases in the observation group received internal fixation with steel plate, and 446 cases in the control group received circular external fixation. (2) Literature quality evaluation results showed that 3 randomized controlled trials were all medium-and high-quality literature. Among 11 cohort studies, 3 were high-quality literature; 7 were higher-quality literature; and 1 was medium-quality literature. (3) Meta-analysis results showed that compared with external fixation, open reduction and internal fixation could significantly reduce the total postoperative infection rate (OR=0.31, 95%CI: 0.17-0.57, P=0.000 1) and the superficial infection rate (OR=0.28, 95%CI:0.13-0.58, P=0.000 7) and fracture malunion rate (OR=0.40, 95%CI:0.21-0.75, P=0.004) and adverse event rate (OR=0.26, 95%CI:0.16-0.42, P < 0.000 01); but did not reduce the deep infection rate (OR=0.64, 95%CI:0.34-1.19, P=0.16), the incidence of secondary osteoarthritis (OR=0.66, 95%CI:0.39-1.12, P=0.12), the rate of secondary operations (OR=0.69, 95%CI:0.39-1.22, P=0.20), postoperative knee stiffness incidence (OR=0.92, 95%CI:0.32-2.67, P=0.89), postoperative nerve injury rate (OR=0.38, 95%CI:0.10-1.45, P=0.16), postoperative thrombosis rate (OR=0.29, 95%CI: 0.08-1.08, P=0.06) and fracture nonunion rate (OR=0.80, 95%CI:0.19-3.35, P=0.76). The results of subgroup analysis of fracture malunion showed that Hoffmann external fixation was more likely to cause articular surface malunion (OR=0.13, 95%CI: 0.04-0.39, P=0.000 3).  
CONCLUSION: In the treatment of tibial plateau fractures, plate internal fixation is superior to circular external fixation in terms of superficial infection, fracture malunion and total infection rate. However, Hoffman external fixation is more likely to cause abnormal healing of the articular surface.

Key words: bone, tibia, fracture, tibial plateau fracture, external fixation, internal fixation, meta-analysis, system evaluation