Interlocking Intramedullary Nail Versus MIPPO In The Treatment Of Diaphyseal And Distal Tibial Fracture In Adults:a Meta Analysis

BackgroundDiaphyseal and distal tibial fracture is a common fractures in clinic, about10%in the long bone fractures. Because of the less soft tissue,the limited supply of epiphyseal artery and periosteum artery, the incidence of union or nonunion is increasing, about5%to17%. In addition, this fracture are often combined with fibula fractures, resulting in poor stability, so the selection of surgery program is very difficult.But conservative treatmentcan often leads to serious complications, for example,local wound infection or necrosis, the stiffness of knee and ankle joint, pin tract infection, delayed healing, malunion complications,and so on. The treatment of the traditional open reduction and internal fixation are able to achieve better anatomic reduction, but needs to expose widely, stripp periosteal,then leads to a larger incision and severer soft tissue injuried. At last, there will be serious impact on the fracture of the biology environment, cause to nonunion and delayed healing. In the treatment of fractures of the diaphyseal and distal tibial fracture, Interlocking intramedullary nail is a relatively new type of internal fixation in the past two decades. It has many advantages, for example,less trauma, less bleeding, reliable fastness,the low degree of stress barrier,the higher rate of fracture healing,the lower rate of raterefracture and early ambulation.when locked, the bone pin and locked nail will become a whole, and this will prevent the shortening and rotational displacement of the fracture fragments, conducive to the healing of the fracture.The axis of the fixation has less interference of environment of the limb biology in line with the biological fixation principle, maybe the patients will do functional exercise and weight earlily.It has become one of the main ways for the fixation of the tibial fracture in clinical practice, but also has some shortcomings, such as infection, osteomyelitis, broken nails, fat embolism,the rate of the postoperative fracture malunion is very higher. Mast First introduced a idea of indirect reduction techniques which can reduce the damage of the blood supply,nonunion,delayed healing and the infectious complications in1989.Subsequently, Kretteke proposed the concept of minimally invasive surgical techniques and bridging bone plate technology in1997, MIPPO technology is a new type of internal fixation technology, developed on the basis of the theory of biological fixation.Inserting bridge-plate into the subcutaneous or intramuscular crossing the fracture fragments,and using proximal screws to fix both sides of the fracture fragments,the effective fixation of the fracture will be obtained.This maybe avoid direct exposure of the fracture fragments and obtain to the maximum protection of the fracture fragments and soft tissue blood supplied,also provide the basic biology environment of fracture healing. It is one of the good method of fixation, also for comminuted fractures extending to the articular surface. Its core content including indirect reduction and invisiable surgical operation to obtain good fracture position on the line and the state downstream. Using fixed mount as a fixed principle to bridging the fracture fragments. At the same time we can reduce soft tissue irritation to protect the blood supply of fracture fragments.Nowsday,The interlocking intramedullary nail and MIPPO are the mainly minimally invasive treatment of the fracture of the diaphyseal and distal tibial.Both of all can provide a better stability of the fracture fragments and reduce the irritation of soft tissue,attain the greatest degree of the protection of the blood supply among the fracture fragments, that will promote the healing of fractures. Although the interlocking intramedullary nail is viewed as the "gold standard" in the traditional concept for the treatment of tibial fractures, but there is no sufficient evidence which way is more advantage. Therefore, put into the inspection in foreign language database, and select the standard-compliant literature in order to operate the meta-analysis,to find the pros and cons of these two different surgical differences by means of this evaluation.Objective1. According to the evidence-based medicine method, to provide a reliable basis for the diagnosis and treatment by comparing to the clinical effects of interlocking intramedullary nail and MIPPO in the treatment of diaphyseal and distal tibial fracture in adults2. To find the efficacy and safety of the treatment of the diaphyseal and distal tibial fracture in adults by the minimally invasive percutaneous fixation techniques.Methods1.According to the PICO program in the evidence-based medicine (Participant, Intervention, Comparator, Outcome),to develop appropriate search,then to determine the detail inclusion and exclusion criteria, we would gain much more relative literature.The type of literature would be limited to a randomized controlled trials(RCTs) or quasi-randomized controlled trials(Quasi-RCTs) or controlled clinical trials (CCT).2. The search strategy would be set through the system, searching the English databases by computer:MEDLINE (1997to December,2012), EMbase (1997to December,2012), Coehrane Library (December,2012). And Chinese database: VIP,Chinese Biomedical Database,CNKI, Wanfang Full Text Database and so on.we also searched relevant reference and some Chinese orthopedic journals by hand and seeked valuable unpublished literature as much as possible to gain RCTs, Quasi-RCTs and CCTs according with inclusion and exclusion criteria.3.First according to the standards proposed by Joni, we evaluated the included literature by methodological quality evaluation,includng four aspects as follows.:(1) whether to adopt the randomized controlled trials.②whether to adopt random hidden.③whether to adopt blinded.④whether to describe the test quit lost. We will extracted data independently by two reviewers. If there were differences, we would ask the3rd person for help and discuss this. After evaluation,according to the Cochrane literature evaluation criteria and the Cochrane Systematic Review’s manual recommended quality grading,we would classify the quality of the literature into three grades:A,B and C.4. We would extract data from the related articles after evaluating strict, especially with the main data extracted from outcome measure,then carry out Meta-analysis using the the Cochrane Collaboration RevMan5.0statistical software.For each study,relative risk(RR) were calculated for dichotomous outcomes, weighted mean differences(WMD) were calculated for measurement data.We would consider clinical heterogeneity before each trial of outcome measures were pooled.If interventions of each trial were different, subgroup analysis should be applied. A fixed effects model analysis would be used if there was no significant heterogeneity in the various data,or the random effects model analysis would be used.Then we would describe the qualitative evaluation for the measure which was quantified synthetic or very low event rate.Results1、Search resultsAccording to the search strategy and the data collection methods,167of the relevant literature were retrieved ultimately.68of paper were screened out by reading the titles and abstracts,including22in Pubmed,15in EMBS,9in the other literature such as abstracts, conference record.22were wrote in chinese. Seven studies were screened out ultimately after reading detail,including5of RCTs and Quasi-RCTs,3of CCTs,and a total of433patients (216cases in intramedullary nail group,217cases in plate group).Time was limited between2005to2012, more than10months of follow-up time. All studies are in the form of full-text.2. Meta-analysis result2.1Operation time:4studies refered to the surgical operation time,including247patients,128cases in interlocking intramedullary nail group,119cases in MIPPO group. META analysis showed that there was no statistically significant between the two groups in operation time (P=0.97)2.2Losing blood:3studies refered to losing blood,including172patients,89cases in interlocking intramedullary nail group,83cases in MIPPO group. META analysis showed that there was no statistically significant between the two groups in losing blood (P=0.56)2.3Healing time of the fracture:5studies refered to the healing time,including272patients,135cases in interlocking intramedullary nail group,172cases in MIPPO group. META analysis showed that there was no significant between the two groups in healing time(P=0.35)2.4The incidence of adverse events related bone healing:Healing time of the fracture:7studies refered to the incidence of adverse events,including377patients,188cases in interlocking intramedullary nail group,189cases in MIPPO group. META analysis showed that there was statistically significant between the two groups in operation time,healing time (P=0.04),and the MIPPO group the was lower relatively in the incidence of adverse events related bone healing2.5The incidence of adverse events related soft tissue:6studies refered to the incidence of adverse events related soft,including292patients,144cases in interlocking intramedullary nail group,148cases in MIPPO group. META analysis showed that there was no statistically significant between the two groups in the incidence of adverse events related soft tissue (P=0.11)2.6The excellent rate of postoperative function evaluation(J-W Standard):5studies refered to the excellent rate of postoperative function evaluation, including231patients,119cases in interlocking intramedullary nail group,112cases in MIPPO group. META analysis showed that there was no statistically significant between the two groups in the excellent rate of postoperative function evaluation (P=0.63)Conclusion1.The difficulty of operation with the interlocking intramedullary nail is fundamentally the same as the minimally invasive percutaneous bridging plate,and both of all can better follow the minimally invasive principle,so they have lower incidence of adverse events related soft tissue.2.MIPPO group have same advantages in the healing time of fracture and the bone tissue healing. 3.According to the existing clinical data, the clinical effects of boperation with the interlocking intramedullary nail is fundamentally the same as the minimally invasive percutaneous bridging plate although they have some differences between the two groups.4.1n order to gain the better and accurate clinical evidence, we need to develop a well-designed, higher methodological quality of randomized controlled trials, as well as a large sample,multi-center randomized controlled trial.All these will increase the strength of the evidence.