PDF(Pubmed)
Abstract：
Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPO and interlocking IMN techniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.
摘要：
髓内钉（IMN）和微创经皮钢板内固定（MIPPO）都是治疗胫骨远端骨折的可行方法。IM钉在更短的操作时间方面具有优势，更快的联盟，降低感染率，然而，它可能导致对准问题和残余的膝盖疼痛。相反，MIPPO固定提供了更好的对准和最大限度地减少膝盖不适，但伴随着较高的软组织并发症和硬件刺激的风险。值得注意的是,这篇综述表明，MIPPO与更大的风险相关，这两种肤浅的风险(15%与IMN为7%）和深部感染（14%与IMN为6.3%）。本研究旨在通过比较MIPPO和交锁IMN技术治疗胫骨远端关节外骨折的临床和功能结果，全面评估胫骨远端骨折的最佳手术方法。关键结果参数包括手术持续时间，工会时间,不结合的发生，马氏症病例,感染率,二次手术干预，和功能结果，如生活质量和踝关节评分所示。关于工会并发症，值得注意的是，IMN表现出更高的马氏畸形发生率，影响14.7%的患者，而MIPPO固定组为8.8%。有趣的是,两种治疗方法都表现出相似的不愈合发生率，发生在两组患者的3.5%。此外，在评估工会时间时，IMN固定明显实现了更短的结合时间，在AO43A骨折类型和闭合性骨折中尤其明显。IMN的平均愈合时间为18周，而MIPPO固定的平均愈合时间为20周。在我们对涉及813名患者的9项研究的分析中，报告的手术时间显示,IMN和MIPPO固定的总加权平均手术时间分别为74.1分钟(56.4~124分钟)和85.4分钟(51.4~124分钟).值得注意的是,与MIPPO相比，IMN的手术时间明显缩短，显示加权平均差(WMD)为-11.24分钟，95%置信区间(CI)为-15.44~-7.05(P<0.05)。这种差异表现出显著的中等异质性(I2=68%)。鉴于这项全面的研究，对于解决胫骨远端关节外骨折的功能结局,MIPPO和IMN都是同样有效的治疗选择.虽然IMN提供了几个优点，包括较低的感染率，减少植入物的刺激，更短的操作时间，和早期的负重和联合，它与畸形愈合和前膝疼痛的风险增加有关。因此,植入物的选择应根据具体情况而定。感染风险升高的患者，源于因素，比如高龄，合并症,吸烟,或严重的软组织损伤，更适合指甲治疗。相反，MIPPO固定可能为年轻人提供更有利的选择，活跃,健康的病人,考虑到它能够减轻膝盖疼痛和畸形愈合的风险。
