關(guān)節(jié)鏡下異體肌腱單束與雙束重建后交叉韌帶的療效比較及Meta分析
發(fā)布時(shí)間：2018-12-11 21:30
【摘要】：隨著社會(huì)的發(fā)展和人民生活水平的提高,運(yùn)動(dòng)系統(tǒng)疾病越來(lái)越受到人們的重視,雖然不是致命性的損傷,但患者生活質(zhì)量變差,會(huì)影響家庭和睦及社會(huì)和諧。我們普遍定義的膝關(guān)節(jié)韌帶損傷是一大類(lèi)疾病,相較于前交叉韌帶損傷,后交叉韌帶(Posterior cruciate ligament,PCL)損傷的發(fā)病率約占其中的3.4%-20%[1],是比較少見(jiàn)的。但是,如果不積極治療,仍舊會(huì)引起關(guān)節(jié)內(nèi)其它結(jié)構(gòu)的繼發(fā)改變。根據(jù)解剖學(xué)研究,后交叉韌帶并不是獨(dú)立的單條韌帶,而是由兩部分組成,即前外側(cè)束(AB)和后內(nèi)側(cè)束(PB),這其中AB束的功能又更為重要一些[2-4]。在膝關(guān)節(jié)屈曲時(shí),85%以上的后負(fù)荷由后交叉韌帶承擔(dān)。研究顯示當(dāng)PCL斷裂后,90°屈膝位時(shí),脛骨可產(chǎn)生最大20mm的后向位移,患者表現(xiàn)出明顯的膝關(guān)節(jié)不穩(wěn)。前外側(cè)束在關(guān)節(jié)屈曲時(shí)緊張,伸直時(shí)松弛;而后內(nèi)側(cè)束的松緊狀態(tài)(屈曲松弛,伸直緊張)與前外側(cè)束相反[5]。這種生物力學(xué)特性理論上暗示了PCL損傷的患者很難通過(guò)單束重建法來(lái)恢復(fù)正常的膝關(guān)節(jié)功能。但是,2001年Bergfeld等人經(jīng)過(guò)研究,認(rèn)為不談理論優(yōu)勢(shì),單在臨床療效上雙束重建法并沒(méi)有表現(xiàn)出其應(yīng)有的優(yōu)勢(shì)。并且相較于單束重建,雙束重建法有著一系列難以克服的缺陷(技術(shù)難度大、患者花費(fèi)高、手術(shù)時(shí)間長(zhǎng)等)。到底雙束重建與單束重建孰優(yōu)孰劣?目前學(xué)界還沒(méi)有給出一個(gè)統(tǒng)一的答案[6-8]。支持單束重建者認(rèn)為單束重建已經(jīng)恢復(fù)了后交叉韌帶的大部分功能,且手術(shù)技術(shù)成熟,療效可靠,應(yīng)為后交叉韌帶損傷的首選術(shù)式。而支持雙束重建者認(rèn)為雙束重建才能最大程度模擬PCL的解剖形態(tài),達(dá)到最接近于正常膝關(guān)節(jié)功能的臨床療效[9-10]。第一部分關(guān)節(jié)鏡下異體肌腱單雙束重建后交叉韌帶的療效比較目的應(yīng)用流行病學(xué)中前瞻性隊(duì)列研究的方法,比較異體肌腱單雙束重建PCL的療效差異。方法研究對(duì)象為2008年1月至2013年1月期間,304醫(yī)院收治的PCL損傷患者,樣本含量42例。按照隨機(jī)數(shù)字表法[11]將患者隨機(jī)分為A組(n=22例,采用單束重建)及B組(n=20例,采用雙束重建)。觀察指標(biāo)有8項(xiàng),分別為住院周期、手術(shù)時(shí)長(zhǎng)、術(shù)后發(fā)熱天數(shù)、需要關(guān)節(jié)穿刺的數(shù)量、膝關(guān)節(jié)穩(wěn)定性、Lysholm評(píng)分、IKDC評(píng)分及Tegner評(píng)分。結(jié)果B組患者手術(shù)用時(shí)及住院天數(shù)顯著高于A組(P0.05);B組患者Lysholm評(píng)分要優(yōu)于A組,差異有統(tǒng)計(jì)學(xué)意義(P0.05));兩組術(shù)后膝關(guān)節(jié)穩(wěn)定性、IKDC評(píng)分及Tegner評(píng)分較術(shù)前均有提高(P0.05),但組間差異沒(méi)有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論關(guān)節(jié)鏡下異體肌腱單雙束重建后交叉韌帶均是治療PCL損傷的安全有效的方法。雙束重建手術(shù)雖然用時(shí)長(zhǎng)、創(chuàng)傷大,但術(shù)后Lysholm評(píng)分顯示恢復(fù)膝關(guān)節(jié)功能較好,所以我們保守地認(rèn)為對(duì)于技術(shù)成熟、經(jīng)驗(yàn)豐富的臨床醫(yī)生,選擇雙束重建更優(yōu)。第二部分關(guān)節(jié)鏡下異體肌腱單束與雙束重建后交叉韌帶的Meta分析目的通過(guò)Cochrane系統(tǒng)評(píng)價(jià)研究異體肌腱單雙束重建PCL的臨床效果,比較兩種方法的優(yōu)劣。方法嚴(yán)格按照“Cochrane協(xié)作網(wǎng)統(tǒng)一工作手冊(cè)”進(jìn)行研究�？茖W(xué)制定納入與排除標(biāo)準(zhǔn):研究類(lèi)型為臨床RCT試驗(yàn),失訪率20%及隨訪時(shí)間小于12個(gè)月的研究排除;研究對(duì)象為經(jīng)關(guān)節(jié)鏡或MRI檢查確診單純PCL損傷,且年齡≥14歲(骨發(fā)育成熟)需行PCL重建的患者;排除伴有其它膝關(guān)節(jié)內(nèi)部結(jié)構(gòu)損傷的病例,如骨折、ACL損傷、骨關(guān)節(jié)炎及其他全身疾病不能手術(shù)者;干預(yù)措施均為關(guān)節(jié)鏡下異體肌腱單雙束重建PCL,移植物的固定方式不做限制,移植物的種類(lèi)為異體肌腱,不納入單純研究重建技術(shù)的文獻(xiàn);主要結(jié)局指標(biāo)有膝關(guān)節(jié)Lysholm評(píng)分、IKDC評(píng)價(jià)系統(tǒng)、關(guān)節(jié)動(dòng)度儀測(cè)量結(jié)果、術(shù)后長(zhǎng)期膝關(guān)節(jié)疼痛、手術(shù)副作用和術(shù)后并發(fā)癥,次要指標(biāo)有是否恢復(fù)傷前運(yùn)動(dòng)水平、Tegner評(píng)分、Lachman test、Drawer test、術(shù)后膝關(guān)節(jié)活動(dòng)度、術(shù)后復(fù)發(fā)的膝關(guān)節(jié)軟組織傷。檢索過(guò)程為計(jì)算機(jī)檢索Pubmed、Embase、The Cochrane Library、Ovid、CBM、Cnki、萬(wàn)方、維普等數(shù)據(jù)庫(kù),手工檢索8個(gè)月內(nèi)相關(guān)專(zhuān)業(yè)醫(yī)學(xué)雜志,納入所有關(guān)于關(guān)節(jié)鏡下單雙束重建PCL療效比較的臨床RCT試驗(yàn)(Rondomized controlled trails),并對(duì)文獻(xiàn)質(zhì)量進(jìn)行評(píng)價(jià),數(shù)據(jù)的提取和分析使用Review Manager 5.1軟件。結(jié)果共篩選出3篇文獻(xiàn),總樣本量151例。研究結(jié)果顯示:雙束組術(shù)后Lysholm評(píng)分優(yōu)于單束組(WMD=2.20,95%CI(0.56,3.83),P=0.008),膝關(guān)節(jié)穩(wěn)定性有2篇文獻(xiàn)結(jié)果顯示雙束重建法更優(yōu)(P0.05);而Tegner評(píng)分、IKDC評(píng)分、膝關(guān)節(jié)活動(dòng)度組間差異沒(méi)有統(tǒng)計(jì)學(xué)意義(P0.05);關(guān)于術(shù)后并發(fā)癥的資料缺乏,不予討論。結(jié)論1.單雙束重建PCL均能很好地恢復(fù)膝關(guān)節(jié)功能,其中雙束重建法療效更優(yōu)。2.目前關(guān)于單雙束重建PCL療效對(duì)比的質(zhì)量較高的RCT試驗(yàn)較少,且樣本量偏小,因而還需多中心大樣本臨床試驗(yàn)修正本結(jié)論。
[Abstract]:With the development of the society and the improvement of the people's living standard, the system of movement system is more and more important, although not the fatal injury, the quality of life of the patient is deteriorated, and the family harmony and social harmony will be affected. The commonly defined injury of the knee ligament is a major type of disease. The incidence of the injury of the anterior cruciate ligament and the posterior cruciate ligament (PCL) is about 3.4% to 20%[1], which is rare. However, if not actively treated, secondary changes in other structures within the joint can still be caused. According to the anatomical study, the posterior cruciate ligament is not a separate single ligament, but consists of two parts, the front outer side bundle (AB) and the back inner side bundle (PB), in which the function of the AB beam is more important[2-4]. At the time of flexion of the knee, more than 85% of the posterior load is assumed by the posterior cruciate ligament. The study shows that, when the PCL is broken, the tibia can produce a posterior displacement of up to 20 mm, and the patient shows an obvious instability of the knee. The anterior lateral beam is tense and relaxed when the joint is flexed, and then the tension of the inner bundle (flexion and relaxation, straightening tension) is opposite to the anterior lateral bundle[5]. This biomechanical property theory suggests that it is difficult for patients with PCL injury to return to normal knee function by single-beam reconstruction. However, Bergfeld et al., in 2001, did not consider the theoretical advantage, and the double-beam reconstruction method in clinical efficacy did not show its due advantages. and the two-beam reconstruction method has a series of difficult defects (large technical difficulty, high patient expense, long operation time, and the like) compared with the single-beam reconstruction. Which two-beam reconstruction and single-beam reconstruction are inferior? The current academic circle has not given a unified answer[6-8]. The support of the single-beam reconstructor is that the single-beam reconstruction has restored most of the function of the posterior cruciate ligament, and the surgical technique is mature and the curative effect is reliable. It should be the first choice for the posterior cruciate ligament injury. and the two-beam reconstructor is supported to believe that the double-beam reconstruction can simulate the anatomical shape of the PCL to the maximum extent, and the clinical curative effect of the function of the normal knee joint is achieved[9-10]. The purpose of this study was to compare the efficacy of the first partial arthroscopic reconstruction of the double-beam reconstruction of the PCL with the method of the prospective cohort study in the epidemiology. Methods From January 2008 to January 2013, there were 42 cases of PCL injury and 42 samples from 304 hospitals. The patients were randomly divided into group A (n = 22, single-beam reconstruction) and group B (n = 20, with double-beam reconstruction) according to the random number table method[11]. The number of joint puncture, the stability of the knee joint, the Lysholm score, the IKDC score and the Tegner score were required for 8 items of the observation index, the length of the hospital, the number of days after the operation, the number of joint puncture, the stability of the knee joint, the Lysholm score, the IKDC score and the Tegner score. Results In group B, the number of patients in group B was significantly higher than that in group A (P0.05). The scores of Lysholm in group B were better than that of group A (P <0.05). The stability of knee joint, IKDC and Tegner score in group B were higher than that in group A (P0.05). However, there was no significant difference between the groups (P0.05). Conclusion It is a safe and effective method for the treatment of PCL injury. Although the double-beam reconstruction operation is long and the wound is large, the postoperative Lysholm score shows that the function of restoring the knee joint is good, so we conservatively believe that the selection of the double-beam reconstruction is better for the mature and experienced clinician. The purpose of this study was to evaluate the clinical effect of the double-beam reconstruction of the tendon by the Cochrane system and compare the advantages and disadvantages of the two methods. The method was conducted in strict accordance with the 鈥淐ochrane Collaboration Network Unified Workbook鈥，
本文編號(hào)：2373252
[Abstract]:With the development of the society and the improvement of the people's living standard, the system of movement system is more and more important, although not the fatal injury, the quality of life of the patient is deteriorated, and the family harmony and social harmony will be affected. The commonly defined injury of the knee ligament is a major type of disease. The incidence of the injury of the anterior cruciate ligament and the posterior cruciate ligament (PCL) is about 3.4% to 20%[1], which is rare. However, if not actively treated, secondary changes in other structures within the joint can still be caused. According to the anatomical study, the posterior cruciate ligament is not a separate single ligament, but consists of two parts, the front outer side bundle (AB) and the back inner side bundle (PB), in which the function of the AB beam is more important[2-4]. At the time of flexion of the knee, more than 85% of the posterior load is assumed by the posterior cruciate ligament. The study shows that, when the PCL is broken, the tibia can produce a posterior displacement of up to 20 mm, and the patient shows an obvious instability of the knee. The anterior lateral beam is tense and relaxed when the joint is flexed, and then the tension of the inner bundle (flexion and relaxation, straightening tension) is opposite to the anterior lateral bundle[5]. This biomechanical property theory suggests that it is difficult for patients with PCL injury to return to normal knee function by single-beam reconstruction. However, Bergfeld et al., in 2001, did not consider the theoretical advantage, and the double-beam reconstruction method in clinical efficacy did not show its due advantages. and the two-beam reconstruction method has a series of difficult defects (large technical difficulty, high patient expense, long operation time, and the like) compared with the single-beam reconstruction. Which two-beam reconstruction and single-beam reconstruction are inferior? The current academic circle has not given a unified answer[6-8]. The support of the single-beam reconstructor is that the single-beam reconstruction has restored most of the function of the posterior cruciate ligament, and the surgical technique is mature and the curative effect is reliable. It should be the first choice for the posterior cruciate ligament injury. and the two-beam reconstructor is supported to believe that the double-beam reconstruction can simulate the anatomical shape of the PCL to the maximum extent, and the clinical curative effect of the function of the normal knee joint is achieved[9-10]. The purpose of this study was to compare the efficacy of the first partial arthroscopic reconstruction of the double-beam reconstruction of the PCL with the method of the prospective cohort study in the epidemiology. Methods From January 2008 to January 2013, there were 42 cases of PCL injury and 42 samples from 304 hospitals. The patients were randomly divided into group A (n = 22, single-beam reconstruction) and group B (n = 20, with double-beam reconstruction) according to the random number table method[11]. The number of joint puncture, the stability of the knee joint, the Lysholm score, the IKDC score and the Tegner score were required for 8 items of the observation index, the length of the hospital, the number of days after the operation, the number of joint puncture, the stability of the knee joint, the Lysholm score, the IKDC score and the Tegner score. Results In group B, the number of patients in group B was significantly higher than that in group A (P0.05). The scores of Lysholm in group B were better than that of group A (P <0.05). The stability of knee joint, IKDC and Tegner score in group B were higher than that in group A (P0.05). However, there was no significant difference between the groups (P0.05). Conclusion It is a safe and effective method for the treatment of PCL injury. Although the double-beam reconstruction operation is long and the wound is large, the postoperative Lysholm score shows that the function of restoring the knee joint is good, so we conservatively believe that the selection of the double-beam reconstruction is better for the mature and experienced clinician. The purpose of this study was to evaluate the clinical effect of the double-beam reconstruction of the tendon by the Cochrane system and compare the advantages and disadvantages of the two methods. The method was conducted in strict accordance with the 鈥淐ochrane Collaboration Network Unified Workbook鈥，
本文編號(hào)：2373252
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