髌下与髌上入路髓内钉固定胫骨骨折的荟萃分析

A meta- analysis on intramedullary nailing through infrapatellar approach versus suprapatellar approach for tibial shaft fractures

摘要:

[目的] 比较髌下入路和髌上入路髓内钉固定胫骨骨折的临床疗效。[方法] 检索 PubMed、Embase、Cochrane li- brary、万方数据库、维普科技期刊数据库、中国知网数据库，截止 2021 年 8 月发表的髌上入路和髌下入路髓内固定胫骨骨折的相关文献，采用 Review Manager 5.3 软件对文献中二分类变量 (骨折畸形愈合、骨折不愈合、术后感染) 和连续性变量 (手术时间、术中出血量、进针点位置、放射剂量、VAS 评分以及 Lysholm 评分)进行数据分析。[结果]13 篇文献纳入研究，共包括 1 112 例胫骨骨折病例。在骨折畸形愈合 (OR=5.43, 95%CI：2.16~13.65)、精确置钉 (正位 MD=1.74, 95%CI：1.22~2.27) (侧位 MD=2.25, 95%CI：1.35~3.16)、术后疼痛评分 (MD=0.81, 95% CI：0.64~0.98) 以及 Lysholm 评分 (MD=-5.26, 95% CI：- 6.52~4.00) 髌上组均显著优于髌下组。而两组在骨折不愈合 (OR=0.95, 95%CI：0.55~1.65)、术后感染 (OR=0.62, 95%CI： 0.25~1.57)、术中出血量 (MD=0.18, 95%CI：-1.71~2.07) 和术中射线曝露剂量 (MD=8.72, 95%CI：-6.24~23.68) 的差异均无统计学意义。[结论] 髌上组在降低骨折畸形愈合、提高精确置钉、减少术后疼痛以及术后膝关节恢复功能方面要优于髌下组，特别是在治疗胫骨近端以及远端骨折时优势更加明显。

Abstract:

[Objective] To compare the clinical outcomes of intramedullary nailing through infrapatellar approach versus suprapatellar approach for tibial shaft fractures. [Methods] The literatures on comparison of suprapatellar and infrapatellar intramedullary nailing for tibi- al shaft fractures published before August 2021 was searched in databases, including PubMed, EMBASE, Cochrane Library, Wanfang data- base, Weipu database and CNKI. The meta-analysis was conducted by using Review Manager 5.3 software, involving the binary variables, such as fracture malunion, fracture nonunion, postoperative infection, and continuous variables, such as operation time, intraoperative bleeding, location of needle entry point, radiation dose, VAS score and Lysholm score. [Results] A total of 13 literatures were included in the study, involving 1 112 cases of tibial shaft fractures. As consequences of the meta-analysis, the suprapatellar approach proved signifi- cantly superior to the infrapatellar approach in terms of fracture malunion (OR=5.43, 95%CI: 2.16~13.65) , accuracy of nail placement (an- teroposterior MD=1.74, 95%CI: 1.22~2.27 and lateral MD=2.25, 95%CI: 1.35~3.16) , postoperative pain score (MD=0.81, 95%CI: 0.64~ 0.98) and Lysholm score (MD=-5.26, 95%CI: 6.52~4.00) . However, there were no statistically significant differences between the two groups in terms of non-union of fracture (OR=0.95, 95%CI: 0.55~1.65) , postoperative infection (OR=0.62, 95%CI: 0.25~1.57) , intraopera- tive blood loss (MD=0.18, 95%CI: 1.71~2.07) and intraoperative radiation exposure dose (MD=8.72, 95%CI: -6.24~23.68) . [Conclusion] The suprapatellar approach is considerably superior to the infrapatellar approach in reducing fracture malunion, improving accuracy of nail placement, reducing postoperative pain and enhancing function recovery after operation, especially for the proximal and distal tibial shaft fractures.