分期切开复位内固定与外固定架结合有限内固定治疗B、C型Pilon骨折的Meta分析

背景：关于Pilon骨折的处理是目前争议较多的热点问题，但至今仍无权威性的临床指导。目前对软组织的重视和保护已为大家共识，而最近的主导治疗策略基本分为分期切开复位内固定和外固定结合有限内固定两种思路。大量回顾性研究都证实了这两种策略的有效性，但是证据等级都比较低。两种治疗方法孰优孰劣，目前仍无结论。目的：收集关于B、C型Pilon骨折不同治疗方法疗效分析的文献，进行Meta分析以找出不同术式的利弊差异。方法：通过数据库检索及手工查找有关Pilon骨折分期切开复位内固定与外固定架结合有限内固定疗效分析的文章，检索词为“tibia fractures，surgery，therapy，pilon”，要求文献发表时间为1977/2008，选取软组织感染率、骨髓炎发生率、骨不愈合及畸形愈合发生率、关节融合发生率作为评价指标，以RevMan4.2软件进行Meta分析，观察森林图显示的分析特征和结果。结果与结论：分期切开复位内固定方案的软组织感染风险较外固定并有限内固定组低，而切开复位内固定能够为Pilon骨折提供更加可靠的复位准确性和稳定性，理论上对于保证骨折在正确解剖位置上愈合有较为确切的优势。Meta分析的结果仅得到了与此推论相近似的结果，但是没有表现出统计学证据。而两种治疗方案的深部感染风险、骨折不愈合及关节融合的发生率没有差别。

Meta analysis of types B and C Pilon fracture treatment by staged open reduction and internal fixation versus external fixation combined with limited internal fixation

BACKGROUND: Treatment of Pilon fracture has always been a controversial topic, but there is no authoritative clinical instruction at present. Currently, more attention has been paid to the soft tissue and its protection. The main treatment strategy has been focused on staged open reduction and internal fixation or external fixation combined with limited internal fixation. There is no favorable evidence to prove the effectiveness of these two strategies, though a large amount of retrospective studies have been reported. It is still unknown which strategy is better. OBJECTIVE: To find out the differences in advantages and disadvantages of different operation methods by Meta analysis, followed by collection of the literatures addressing the effectiveness of different treatments for Pilon fracture of types B and C.METHODS: The relevant literatures about the effectiveness analysis of staged open reduction plus internal fixation and external fixation combined with limited internal fixation were collected through database retrieval and manual search, with tibia fractures, surgery, therapy and pilon as index words and 1977-2008 as publishing date limit. Soft tissue infection rate, myelitis incidence rate, bone nonunion and malunion incidence rate, joint fusion incidence rate were taken as evaluation indicators, analyzed with RevMan4.2 software, and followed by observation of the analyzing features and results indicated by forest plots. RESULTS AND CONCLUSION: The risk of soft tissue infection following staged open reduction and internal fixation was lower than external fixation combined with limited internal fixation, and staged open reduction and internal fixation provided a more reliable, accurate and stable reduction to Pilon fracture. Theoretically, it owns obvious advantage in fracture healing at the right anatomy site. The result of Meta analysis is in accord with the hypothesis, but there is no statistic evidence. No difference is found in the risk of deep infection, nonunion, and joint fusion between the two methods.