背景:胫骨平台骨折,这是膝关节的关节内损伤,通常难以治疗,并发症发生率高,包括早发性骨关节炎.复杂胫骨平台骨折最常见的治疗方法是手术固定。此外,骨科医生经常使用骨缺损填充剂来解决骨缺损造成的损伤。目前,对于最佳的固定方法以及是否需要骨缺损填充剂尚无共识。
目的:评估不同手术干预和骨缺损填充剂治疗胫骨平台骨折的益处和危害。
方法:我们搜索了CENTRAL,MEDLINE,Embase,和截至2023年3月的审判登记处。我们还搜索了会议记录和灰色文献。
方法:我们纳入了随机对照试验(RCT)和准RCT,比较了治疗胫骨平台骨折的手术干预和不同类型的骨缺损填充剂。
方法:两位综述作者独立筛选了搜索结果,选定的研究,提取的数据,并评估偏见的风险。我们计算了二分结果的风险比(RR)和连续结果的平均差(MD)或标准化平均差(SMD),95%置信区间(CI)。我们的主要结果(以及我们认为最相关的具体措施)是一般生活质量(36项短期健康调查(SF-36)中的一般健康评分),患者报告的下肢功能(特殊外科医院(HSS)评分),和不良事件(计划外再手术的频率)。我们使用等级来评估证据的确定性。
结果:我们在综述中纳入了15项试验,共有948名成人参与者。九项试验比较了不同类型的固定,六项试验评估了不同类型的骨移植替代品。所有15项试验都很小,有很高的偏倚风险。我们认为大多数现有证据的确定性非常低,这意味着我们对结果几乎没有信心。只有有限的合并是可能的。一项试验比较了82例开放性或闭合性SchatzkerV型或VI型胫骨平台骨折患者的圆形固定结合经皮螺钉插入(混合固定)与标准切开复位内固定(ORIF)。在24个月的随访中,与ORIF相比,混合固定可能对SF-36一般健康评分影响很小或没有影响(MD高6分,95%CI低7.7点,高19.7点;66名参与者),患者根据HSS评分报告的下肢功能(MD高7分,95%CI低2.4点,高16.4点;66名参与者),或计划外再次手术的频率(RR0.78,95%CI0.45至1.32;83骨折(82名参与者))。然而,这三种结果的证据都很不确定.三项试验(242名参与者)比较了单电镀ORIF和双电镀ORIF。接受单钢板ORIF的患者与接受双钢板ORIF的患者相比,在24个月的随访中,患者报告的下肢功能(HSS评分)可能几乎没有差异(MD高0.2分,95%CI2.12点降低至2.52点;1项研究,84名参与者),但是证据非常不确定。在24个月随访时,没有关于生活质量或计划外再手术的数据。六项试验(包括368名参与者)比较了骨替代物与自体骨移植物(自体骨移植物)在治疗骨缺损方面的作用。没有试验报告SF-36一般健康评分,HSS得分,或24个月随访时计划外再手术的频率。
结论:没有足够的证据来确定胫骨平台骨折患者手术期间的最佳固定方法或解决骨缺损的最佳方法。进一步精心设计的RCT具有更大的样本量是必要的。
Tibial plateau fractures, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. The most common treatment for complex tibial plateau fractures is surgical fixation. Additionally, orthopaedic surgeons often use bone defect fillers to address bone defects caused by the injury. Currently, there is no consensus on the best method of fixation and on whether bone defect fillers are necessary.
To assess the benefits and harms of different surgical interventions and bone defect fillers for treating tibial plateau fractures.
We searched CENTRAL, MEDLINE, Embase, and trial registries up to March 2023. We also searched conference proceedings and the grey literature.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical interventions for treating tibial plateau fractures and different types of filler for bone defects.
Two review authors independently screened search results, selected studies, extracted data, and assessed risk of bias. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Our primary outcomes (and the specific measures we considered most relevant) were generic quality of life (general health score in the 36-item Short-Form Health Survey (SF-36)), patient-reported lower limb function (Hospital for Special Surgery (HSS) score), and adverse events (frequency of unplanned reoperation). We used GRADE to assess the certainty of evidence.
We included 15 trials in the review, with a total of 948 adult participants. Nine trials compared different types of fixation, and six trials evaluated different types of bone graft substitutes. All 15 trials were small and at high risk of bias. We considered most available evidence to be of very low certainty, meaning we have very little confidence in the results. Only limited pooling was possible. One trial compared circular fixation combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in 82 people with open or closed Schatzker types V or VI tibial plateau fractures. At 24 months\' follow-up, hybrid fixation compared with ORIF may have little or no effect on SF-36 general health score (MD 6 points higher, 95% CI 7.7 points lower to 19.7 points higher; 66 participants), patient-reported lower limb function according to the HSS score (MD 7 points higher, 95% CI 2.4 points lower to 16.4 points higher; 66 participants), or frequency of unplanned reoperation (RR 0.78, 95% CI 0.45 to 1.32; 83 fractures (82 participants)). However, the evidence for all three outcomes is very uncertain. Three trials (with 242 participants) compared single-plating ORIF versus double-plating ORIF. There may be little to know difference in patient-reported lower limb function (HSS score) at 24 months\' follow-up in people who undergo single-plating ORIF compared with those who undergo double-plating ORIF (MD 0.2 points higher, 95% CI 2.12 points lower to 2.52 points higher; 1 study, 84 participants), but the evidence is very uncertain. There were no data for quality of life or unplanned reoperation at 24 months\' follow-up. Six trials (including 368 participants) compared bone substitute versus autologous bone graft (autograft) for managing bone defects. No trials reported SF-36 general health score, HSS score, or frequency of unplanned reoperation at 24 months\' follow-up.
There is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery in people with tibial plateau fractures. Further well-designed RCTs with larger sample sizes are warranted.