不同手术入路MIPO技术治疗肱骨干骨折时医源性桡神经损伤的风险研究

Effect of MIPO in iatrogenic radial nerve injury in treating humeral diaphyseal fractures: A systematic review on different surgical approaches

目的系统评价不同手术入路微创钢板接骨术(minimally invasive plating osteosynthesis,MIPO)治疗肱骨干骨折医源性桡神经损伤风险。方法采用主题词和自由词结合的方法,通过计算机检索Pubmed、考克兰数据库,检索起止时间为从建库至2016年7月。收集MIPO技术治疗肱骨干骨折的临床报道。选择医源性桡神经损伤和前臂外侧皮神经损伤的发生率、神经损伤的恢复时间和恢复状态作为结局指标。采用Fisher's exact检验比较不同手术入路MIPO技术医源性桡神经损伤发生率的差别,P<0.05表示差异有统计学意义。结果共纳入40项研究984例骨折患者。纳入的病例共出现28例的医源性桡神经损伤(2.85%)。687例远端前方入路的病例中出现12例医源性桡神经损伤(1.75%);228例远端外侧入路的病例中出现11例医源性桡神经损伤(4.82%);69例后侧入路的病例中出现5例医源性桡神经损伤(7.25%)。统计分析结果表明,远端前方入路比其他两种入路损伤发生率低(P=0.015和0.014),远端外侧入路组与后侧入路无显著差别(P=0.541)。结论 MIPO技术治疗肱骨干骨折,医源性桡神经损伤的风险与髓内钉相近,比ORIF低。远端前方入路比远端外侧入路和后方入路发生医源性桡神经损伤的风险低。

Objective To critically evaluate the effect of minimally invasive plating osteosynthesis （MIPO） in iatrogenie radial nerve injury in treating humeral diaphyseal fractures, and the differences between anterior, lateral, and posterior approach. Methods PubMed and Cochrane databases were searched from their inception to July 2016. Studies reported on the use of MIPO in treating humeral diaphyseal fractures were chosen. The following post-operative outcomes of in- terest were included in the systematic review： the incidence of iatrogenic radial nerve and lateral cutaneous nerve of forearm; the duration and status of recovery of the injury. Results A total of 984 humeral shaft fractures treated by MIPO were reviewed from 40 studies. There were 12（1.75%） injuries in 687 fractures treated through distal anterior approach, 11 （4.82%） injuries in 228 fractures treated through distal lateral approach, and 5（7.25%） injuries in 69 fractures treated through posterior approach. The incidence in distal anterior approach is lower than distal lateral （P=0.015） and posterior approach （P=0.014）. There was no si.gnificant difference between distal lateral and posterior approach group （P=0.541）. Conclusion The incidence of iatrogenic radial nerve injury in humeral shaft fractures treated by MIPO is comparable to intramedullary nails （IMN）, and is lower than open reduction internal fixation with plates （ORIF）. As regard to surgical approaches, MIPO through distal anterior biceps-brachialis interval approach with brachialis splitting is superior to dis- tal lateral and posterior approaches in reducing iatrogenic radial nerve injury.