Injury：关节外胫骨远端骨折的手术选择：MIPPO vs ORIF

MIPPO技术作为一种新近流行的骨折内固定技术已经为越来越多的骨科医生所接受，MIPPO技术在应用过程中所具有的减少骨折断端软组织破坏，保留局部血运，促进骨折愈合等优点已经为广大骨科医生所熟知。但其在闭合胫骨远端骨折患者中作为桥接钢板使用和开放内固定技术相比是否存在技术优势目前仍无相关报道，日前来自上海交大附属六院的创伤骨科医生Zou Jian，Zhang Wei等人就MIPPO及ORIP技术在胫骨远端骨折治疗中的功能预后等进行了较长时间的对比随访研究，相关结论发表在3月21日在线发表的injury杂志上。
研究共纳入2005年10月-2007年7月间住院手术治疗的胫骨远端骨折患者94例，平均年龄46.0岁。所有患者在确定骨折AO分型前进行治疗方法的随机划分（42例ORIF，52例MIPPO）。ORIF组42例患者，12例接受锁定钢板固定，其余30例为非锁定钢板固定；MIPPO组52例患者，41例接受锁定钢板固定，其余11例接受非锁定钢板固定（图1）。两组患者术前及术后的治疗措施相同。术后平均随访时间分别为14.0月及15.0月。比较手术时间，手术失血，术后并发症（骨折不愈合，延迟愈合，畸形愈合，感染）等相关发生率。

图1：典型桥接钢板应用示意图。a图示24岁男性，交通伤，右胫腓骨B3型骨折，A图，B图术前X片，C图，D图，MIPPO术后图片；E图，F图，术后2月X片；b图，44岁女性，交通伤，右胫骨A1型骨折，A图，术前X片，B图MIPPO技术术后4月X片；c图，38岁女性，交通伤，右胫腓骨A2型骨折，A图术前X片，B图MIPPO术后X片，C图术后4月X片。

研究结果如表1所示。组间主要统计指标无显著差异，仅手术时间及并发症发病率如感染，骨折不愈合，骨折畸形愈合等存在差异。

表1：ORIF VS MIPPO：人口统计学，骨折分型，手术时间、失血，术后并发症

 

对骨折类型按AO亚型进行分类比较后发现，AO C型骨折两组固定方法术后骨折愈合时间存在差异（ORIF 10月，MIPPO 6.0月，p=0.032），如图2。

图2：不同内固定技术对AO骨折分型愈合时间的影响

研究者分析：闭合复位可以减少对骨折断端骨周膜的破坏，但复位后骨折断端接触减少；开放复位可以保证骨折断端的完全接触，但对骨周膜破坏增加，对简单类型的骨折，如AO A1/A2型或B型骨折，两种方法没有绝对的优势点；对OA A3型骨折，骨折通常为高能量损伤，在骨折断端有骨周膜或软组织的嵌入，闭合复位时虽然减少了软组织的损害，但却不能完全清除骨折间隙内的软组织或骨膜，从而影响骨折愈合，该类型骨折推荐行ORIF；对C型骨折而言，骨折虽然为高能量损伤，但其暴力作用较为分散，骨周膜完整，进行ORIF时不仅会破坏软组织和骨周血运，同时会导致小骨折碎块剥离，从而影响骨折愈合，此时采用MIPPO技术是更恰当的选择。
据上述结果，研究者认为尽管MIPPO技术在治疗胫骨远端C型骨折时较绝对固定技术更有优势，但在治疗简单骨折时不能完全忽略直接开放内固定复位。目前仍需要较多研究对MIPPO技术的治疗优势进行相关研究。
与胫骨相关的拓展阅读：

• ACR：并存髌骨疾病可加重胫骨关节炎患者的病情
• 胫骨髓内钉开髓点取骨植骨治疗胫骨骨折不愈合效果良好
• Injury：胫骨远端骨折MIPO手术如何防止大隐静脉/隐神经损伤
• 不同方法治疗胫骨近端骨折的疗效比较
• 关节镜下缝线固定胫骨髁间骨折疗效确实 更多信息请点击：有关胫骨更多资讯

Comparison of minimally invasive percutaneous plate osteosynthesis with open reduction and internal fixation for treatment of extra-articular distal tibia fractures.
INTRODUCTION
Minimally invasive percutaneous plate osteosynthesis (MIPPO) has become a widely accepted technique to treat distal tibia fractures. However, it remains unclear whether this strategy of biological osteosynthesis with a bridge plate is superior to that of absolute stability with traditional open reduction and internal fixation (ORIF).
METHODS
In this pilot study, patients with distal tibia fractures, aged from 18 years to 60 years, were included from October 2005 to June 2007. Patients were randomly assigned to a closed group (the patients were treated by MIPPO) or an open group (the patients were treated by traditional ORIF) before they were categorised by AO fracture type. Wound healing was assessed at 2 weeks, 4 weeks, and 3 months postoperatively. Follow-up was performed once a month until the fractures achieved clinical union based on the standard criterion (pain-free full weight-bearing). Evaluation was performed for ankle range of motion, limb rotation, fracture healing, and radiographic alignment.
RESULTS
Forty-two patients were randomised to the open group and 52 to the closed group. According to AO/OTA classification, fractures were classified as Types A (55.3%), B (25.5%), and C (9.1%). The median follow-up time was 14.0 months for the open group and 15.0 months for the closed group. There was no significant difference between the groups in healing time for Type A and Type B fractures; however, for Type C fractures, there was a trend towards shorter healing time in the closed group compared with the open group.
CONCLUSIONS
Our findings suggest that the strategy of biological osteosynthesis with a bridge plate might be superior to that of absolute stability for treating Type C tibia fractures. Further studies are needed to confirm our findings.