Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (30): 4889-4897.doi: 10.3969/j.issn.2095-4344.2835
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A meta-analysis of efficacy and complications of 3D printing-assisted surgery for Schatzker IV-VI tibial plateau fractures
Weng Nengyuan1, Zhang Tao1, Li Kainan2, Lan Hai2, Zhang Jinli1, Fu Xuefei1, Liu Qixin1, Lin Qingyun3
- 1Department of Traumatic Knee (Part 1), Tianjin Hospital, Tianjin 300202, China; 2Department of Orthopedics, Affiliated Hospital of Chengdu University, Chengdu 610081, Sichuan Province, China; 3Chengdu University of Information Technology, Chengdu 610225, Sichuan Province, China
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Received:2019-12-26Revised:2020-01-04Accepted:2020-02-19Online:2020-10-28Published:2020-09-22 -
Contact:Zhang Tao, Master, Chief physician, Department of Traumatic Knee (Part 1), Tianjin Hospital, Tianjin 300202, China -
About author:Weng Nengyuan, Master candidate, Department of Traumatic Knee (Part 1), Tianjin Hospital, Tianjin 300202, China -
Supported by:the National Key Research and Development Plan, No. 2018YFB1307803; the Tianjin Science and Technology Plan Project, Nos. 18PTLCSY00080, and 18YFSDZC00010
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Cite this article
Weng Nengyuan, Zhang Tao, Li Kainan, Lan Hai, Zhang Jinli, Fu Xuefei, Liu Qixin, Lin Qingyun. A meta-analysis of efficacy and complications of 3D printing-assisted surgery for Schatzker IV-VI tibial plateau fractures[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(30): 4889-4897.
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2.1 文献检索的基本特征及质量评价 通过数据库初步检索得到相关文献121篇，检索参考文献获得文献8篇，去除重复发表的文献24篇，通过仔细阅读题目和文章摘要，必要时详读全文，根据其研究目的、方法学进行筛选，排除不符合筛选标准的文献90篇，此次研究无外文文献纳入因患者骨折类型或无对照组等不符合纳入标准，最终纳入15篇中文文献[6-20]，文献筛选流程见图1。 "
总计纳入758例患者，其中342例使用3D打印技术辅助手术，416例行传统手术治疗。科研设计方面，7篇是随机对照试验[7，10，12-14，16，20]，其余为前瞻性和回顾性队列研究。队列研究采用NOS评分标准，其中8篇队列研究均为8分；随机对照试验采用改良Jadad评分标准[21]，其中3篇6分，2篇5分，2篇4分。最终纳入文献的基本信息详见表1-3。 "
总计纳入758例患者，其中342例使用3D打印技术辅助手术，416例行传统手术治疗。科研设计方面，7篇是随机对照试验[7，10，12-14，16，20]，其余为前瞻性和回顾性队列研究。队列研究采用NOS评分标准，其中8篇队列研究均为8分；随机对照试验采用改良Jadad评分标准[21]，其中3篇6分，2篇5分，2篇4分。最终纳入文献的基本信息详见表1-3。 "
总计纳入758例患者，其中342例使用3D打印技术辅助手术，416例行传统手术治疗。科研设计方面，7篇是随机对照试验[7，10，12-14，16，20]，其余为前瞻性和回顾性队列研究。队列研究采用NOS评分标准，其中8篇队列研究均为8分；随机对照试验采用改良Jadad评分标准[21]，其中3篇6分，2篇5分，2篇4分。最终纳入文献的基本信息详见表1-3。 "
2.2.1 手术时间 共有13篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折手术的手术时间进行描述[6-10，12-15，17-20]。 各研究结果间具有明显统计学异质性(SMD=-2.023，95%CI=-2.418至-1.628，I2=73.6%，P=0.000)，6篇随机对照试验显示，3D打印组手术时间明显比传统组短(SMD=-1.869，95%CI=-2.300至-1.437，I2=42.8%，P=0.000)，同时在病例对照研究里发现更高的异质性(SMD=-2.122，95%CI=-2.760至-1.484，I2= 83.3%，P=0.000)；敏感性分析发现去除袁功武等[6]的文章以后，队列研究和随机对照试验亚组异质性分别降至67.9%和42.8%，总体异质性下降至61.9%。Begg’s检验漏斗图和Egger’s检验漏斗图均显示无明显发表偏倚，文章结论较稳健(P > 0.05)。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印组患者的手术时间短于传统组，其差异有显著性意义(SMD=-2.080，95%CI=-2.291至-1.869，I2=61.9%，P=0.000)，详见图2-5。 "
2.2.1 手术时间 共有13篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折手术的手术时间进行描述[6-10，12-15，17-20]。 各研究结果间具有明显统计学异质性(SMD=-2.023，95%CI=-2.418至-1.628，I2=73.6%，P=0.000)，6篇随机对照试验显示，3D打印组手术时间明显比传统组短(SMD=-1.869，95%CI=-2.300至-1.437，I2=42.8%，P=0.000)，同时在病例对照研究里发现更高的异质性(SMD=-2.122，95%CI=-2.760至-1.484，I2= 83.3%，P=0.000)；敏感性分析发现去除袁功武等[6]的文章以后，队列研究和随机对照试验亚组异质性分别降至67.9%和42.8%，总体异质性下降至61.9%。Begg’s检验漏斗图和Egger’s检验漏斗图均显示无明显发表偏倚，文章结论较稳健(P > 0.05)。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印组患者的手术时间短于传统组，其差异有显著性意义(SMD=-2.080，95%CI=-2.291至-1.869，I2=61.9%，P=0.000)，详见图2-5。 "
2.2.1 手术时间 共有13篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折手术的手术时间进行描述[6-10，12-15，17-20]。 各研究结果间具有明显统计学异质性(SMD=-2.023，95%CI=-2.418至-1.628，I2=73.6%，P=0.000)，6篇随机对照试验显示，3D打印组手术时间明显比传统组短(SMD=-1.869，95%CI=-2.300至-1.437，I2=42.8%，P=0.000)，同时在病例对照研究里发现更高的异质性(SMD=-2.122，95%CI=-2.760至-1.484，I2= 83.3%，P=0.000)；敏感性分析发现去除袁功武等[6]的文章以后，队列研究和随机对照试验亚组异质性分别降至67.9%和42.8%，总体异质性下降至61.9%。Begg’s检验漏斗图和Egger’s检验漏斗图均显示无明显发表偏倚，文章结论较稳健(P > 0.05)。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印组患者的手术时间短于传统组，其差异有显著性意义(SMD=-2.080，95%CI=-2.291至-1.869，I2=61.9%，P=0.000)，详见图2-5。 "
2.2.1 手术时间 共有13篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折手术的手术时间进行描述[6-10，12-15，17-20]。 各研究结果间具有明显统计学异质性(SMD=-2.023，95%CI=-2.418至-1.628，I2=73.6%，P=0.000)，6篇随机对照试验显示，3D打印组手术时间明显比传统组短(SMD=-1.869，95%CI=-2.300至-1.437，I2=42.8%，P=0.000)，同时在病例对照研究里发现更高的异质性(SMD=-2.122，95%CI=-2.760至-1.484，I2= 83.3%，P=0.000)；敏感性分析发现去除袁功武等[6]的文章以后，队列研究和随机对照试验亚组异质性分别降至67.9%和42.8%，总体异质性下降至61.9%。Begg’s检验漏斗图和Egger’s检验漏斗图均显示无明显发表偏倚，文章结论较稳健(P > 0.05)。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印组患者的手术时间短于传统组，其差异有显著性意义(SMD=-2.080，95%CI=-2.291至-1.869，I2=61.9%，P=0.000)，详见图2-5。 "
2.2.2 手术出血量 共有14篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折的手术出血量进行描述[6-10，12-20]。各研究结果间具有明显统计学异质性(SMD=-1.981，95%CI=-2.489至-1.474，I2=86.5%，P=0.000)，7篇随机对照试验显示3D打印组手术出血量明显比传统组小(SMD=-2.326，95%CI=-3.166至-1.486，I2=87.3%，P=0.000)，同时在临床对照试验里发现更高的异质性(SMD=-1.753，95%CI=-2.436至-1.069，I2= 87.7%，P=0.000)；敏感性分析发现去除张擎柱等[8]的文章以后，队列研究和随机对照试验亚组异质性分别降至79.0%和87.3%，总体异质性下降至83.6%。进行Begg’s检验显示无发表偏倚存在(P=0.127)，而Egger’s检验则显示存在发表偏倚(P=0.002)，再进行剪补法后显示无文章增补结论，剪补法前后文献变量估值均为0.576，文章结论较稳健。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印手术组患者的手术出血量较传统组患者减少，其差异有显著性意义(SMD=-1.804，95%CI=-2.276至-1.333，I2=83.6%，P=0.0001) ，详见图6-10。 "
2.2.2 手术出血量 共有14篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折的手术出血量进行描述[6-10，12-20]。各研究结果间具有明显统计学异质性(SMD=-1.981，95%CI=-2.489至-1.474，I2=86.5%，P=0.000)，7篇随机对照试验显示3D打印组手术出血量明显比传统组小(SMD=-2.326，95%CI=-3.166至-1.486，I2=87.3%，P=0.000)，同时在临床对照试验里发现更高的异质性(SMD=-1.753，95%CI=-2.436至-1.069，I2= 87.7%，P=0.000)；敏感性分析发现去除张擎柱等[8]的文章以后，队列研究和随机对照试验亚组异质性分别降至79.0%和87.3%，总体异质性下降至83.6%。进行Begg’s检验显示无发表偏倚存在(P=0.127)，而Egger’s检验则显示存在发表偏倚(P=0.002)，再进行剪补法后显示无文章增补结论，剪补法前后文献变量估值均为0.576，文章结论较稳健。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印手术组患者的手术出血量较传统组患者减少，其差异有显著性意义(SMD=-1.804，95%CI=-2.276至-1.333，I2=83.6%，P=0.0001) ，详见图6-10。"
2.2.2 手术出血量 共有14篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折的手术出血量进行描述[6-10，12-20]。各研究结果间具有明显统计学异质性(SMD=-1.981，95%CI=-2.489至-1.474，I2=86.5%，P=0.000)，7篇随机对照试验显示3D打印组手术出血量明显比传统组小(SMD=-2.326，95%CI=-3.166至-1.486，I2=87.3%，P=0.000)，同时在临床对照试验里发现更高的异质性(SMD=-1.753，95%CI=-2.436至-1.069，I2= 87.7%，P=0.000)；敏感性分析发现去除张擎柱等[8]的文章以后，队列研究和随机对照试验亚组异质性分别降至79.0%和87.3%，总体异质性下降至83.6%。进行Begg’s检验显示无发表偏倚存在(P=0.127)，而Egger’s检验则显示存在发表偏倚(P=0.002)，再进行剪补法后显示无文章增补结论，剪补法前后文献变量估值均为0.576，文章结论较稳健。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印手术组患者的手术出血量较传统组患者减少，其差异有显著性意义(SMD=-1.804，95%CI=-2.276至-1.333，I2=83.6%，P=0.0001) ，详见图6-10。"
2.2.2 手术出血量 共有14篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折的手术出血量进行描述[6-10，12-20]。各研究结果间具有明显统计学异质性(SMD=-1.981，95%CI=-2.489至-1.474，I2=86.5%，P=0.000)，7篇随机对照试验显示3D打印组手术出血量明显比传统组小(SMD=-2.326，95%CI=-3.166至-1.486，I2=87.3%，P=0.000)，同时在临床对照试验里发现更高的异质性(SMD=-1.753，95%CI=-2.436至-1.069，I2= 87.7%，P=0.000)；敏感性分析发现去除张擎柱等[8]的文章以后，队列研究和随机对照试验亚组异质性分别降至79.0%和87.3%，总体异质性下降至83.6%。进行Begg’s检验显示无发表偏倚存在(P=0.127)，而Egger’s检验则显示存在发表偏倚(P=0.002)，再进行剪补法后显示无文章增补结论，剪补法前后文献变量估值均为0.576，文章结论较稳健。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印手术组患者的手术出血量较传统组患者减少，其差异有显著性意义(SMD=-1.804，95%CI=-2.276至-1.333，I2=83.6%，P=0.0001) ，详见图6-10。"
2.2.2 手术出血量 共有14篇文献对传统组和3D打印组行SchatzkerⅣ-Ⅵ型胫骨平台骨折的手术出血量进行描述[6-10，12-20]。各研究结果间具有明显统计学异质性(SMD=-1.981，95%CI=-2.489至-1.474，I2=86.5%，P=0.000)，7篇随机对照试验显示3D打印组手术出血量明显比传统组小(SMD=-2.326，95%CI=-3.166至-1.486，I2=87.3%，P=0.000)，同时在临床对照试验里发现更高的异质性(SMD=-1.753，95%CI=-2.436至-1.069，I2= 87.7%，P=0.000)；敏感性分析发现去除张擎柱等[8]的文章以后，队列研究和随机对照试验亚组异质性分别降至79.0%和87.3%，总体异质性下降至83.6%。进行Begg’s检验显示无发表偏倚存在(P=0.127)，而Egger’s检验则显示存在发表偏倚(P=0.002)，再进行剪补法后显示无文章增补结论，剪补法前后文献变量估值均为0.576，文章结论较稳健。在除外临床异质性因素后采用随机效应模型进行统计学分析，结果显示3D打印手术组患者的手术出血量较传统组患者减少，其差异有显著性意义(SMD=-1.804，95%CI=-2.276至-1.333，I2=83.6%，P=0.0001) ，详见图6-10。"
2.2.3 术中透视次数 3篇文献对术中透视次数进行了比较[6-7，9]。Meta分析结果显示各研究间具有明显异质性，所以采用随机效应模型进行合并，结果发现3D打印组较传统组术中透视次数更少(SMD=-3.183，95%CI=-5.758至-0.608，I2=94.7%，P=0.015)。详见图11。 "
2.2.4 骨折平均愈合时间 4篇文献对骨折平均愈合时间进行了比较[10，13，15，17]。Meta分析结果显示各研究间具有明显异质性，所以采用随机效应模型进行合并，结果发现3D打印组较传统组骨折术后愈合时间更短(SMD=-0.797，95%CI=-1.504至-0.090，I2=82.3%，P=0.027)，详见图12。 "
2.2.5 Rasmussen评分优良率 5篇文献对Rasmussen评分优良率进行了比较[7，9，11-12，16]。采用固定效应模型合并分析发现各项研究无明显统计学异质性。Meta分析结果显示3D打印组术后Rasmussen评分优良率大于传统组(RR=1.178，95%CI= 1.037-1.338，I2=0.0%，P=0.012)，详见图13。 "
2.2.7 术后6个月HSS功能评分 4篇文献对术后6个月HSS功能评分进行了比较[13，15-17]。Meta分析结果显示各研究间无明显异质性，所以采用固定效应模型进行合并，结果显示3D打印组术后6个月HSS功能评分大于传统组(RR=0.779，95%CI= 0.510-1.048， I2=0.0%，P=0.000 1)，详见图14。 "
2.2.9 并发症 9篇文献对并发症进行了比较[7-12，17-19]。Meta分析结果显示，各研究间无明显异质性，所以采用固定效应模型进行合并，结果显示3D打印组有更少的并发症出现(RR=0.383，95%CI=0.215-0.680，I2=0.0%，P= 0.001)，详见图15。 "
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