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中华关节外科杂志(电子版) ›› 2021, Vol. 15 ›› Issue (02) : 199 -208. doi: 10.3877/cma.j.issn.1674-134X.2021.02.011

所属专题： 文献；

荟萃分析

胫骨高位开放截骨与闭合截骨临床疗效的Meta分析
刘丙根1,†(), 张催1, 雷昱1, 李俊宁1, 雷鸣1, 张功恒1, 甘心荣1   
  1. 1. 336000　宜春市人民医院骨二科病区
  • 收稿日期:2019-05-29 出版日期:2021-04-01
  • 通信作者: 刘丙根

Meta-analysis on clinical results of open versus closed wedge osteotomies in treatment of medial compartment osteoarthritis

Binggen Liu1,†(), Cui Zhang1, Yu Lei1, Junning Li1, Ming Lei1, Gongheng Zhang1, Xinrong Gan1   

  1. 1. Yi chun people′s hospital, Orthopedic ward 2, Yichun 336000, China
  • Received:2019-05-29 Published:2021-04-01
  • Corresponding author: Binggen Liu
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引用本文：

刘丙根, 张催, 雷昱, 李俊宁, 雷鸣, 张功恒, 甘心荣. 胫骨高位开放截骨与闭合截骨临床疗效的Meta分析[J]. 中华关节外科杂志(电子版), 2021, 15(02): 199-208.

Binggen Liu, Cui Zhang, Yu Lei, Junning Li, Ming Lei, Gongheng Zhang, Xinrong Gan. Meta-analysis on clinical results of open versus closed wedge osteotomies in treatment of medial compartment osteoarthritis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(02): 199-208.

目的

用Meta分析的方法对国内外已发表较高质量的有关比较内侧开放胫骨高位楔形截骨(OWHTO)与外侧闭合胫骨高位楔形截骨(CWHTO)治疗内侧间室骨关节炎患者的临床疗效进行综合定量分析，为内侧间室骨关节炎患者提供一种较好的外科选择方法。

方法

计算机检索Cochrane图书馆(2017年6期)、Pudmed、Ovid、Spinger Link、Elsevier、Medline等数据库。检索从1970年1月1日至2017年6月30日，有关胫骨高位开放截骨治疗(OWHTO)与闭合截骨治疗(CWHTO)治疗内侧间室骨关节炎患者包括并发症、手术时间、膝关节HSS评分、髌骨下降、平均矫正角度、胫骨平台后倾角及机械轴等文献，筛选出符合纳入标准的文献，并对其进行严格的质量评价。利用Cochrane协作网提供的RevMan 5.0软件对纳入研究结果进行Meta分析，并对数据进行异质性检验。

结果

符合纳入标准的文献13篇，总样本量1 237例。其中OWHTO治疗组666例，CWHTO治疗组571例。OWHTO治疗组与CWHTO治疗组的比较，OWHTO治疗组在术后髌骨高度Caton-Deschamps(CD)测量指数、术后胫骨平台后倾角度及手术时间差异有统计学意义[标准化加权均数差(WMD)＝-0.11，95%置信区间(CI)(-0.17，-0.05)，P<0.0001，WMD＝2.61，95% CI(2.13，3.10)，P<0.0001]，CWHTO治疗组在术前机械轴角度改变差异有统计学意义[WMD＝0.82，95% CI(0.04，1.59)，P＝0.04]，OWHTO治疗组与CWHTO治疗组在并发症[WMD＝1.55 95% CI(0.35，6.93)，P＝0.57]、视觉模拟评分法(VAS)[WMD＝0.46，95% CI(-0.15，1.06)，P＝0.14]、术前美国特种外科医院膝关节评分(HSS)[WMD＝1.72，95% CI(-1.27，4.71)，P＝0.26]、HSS[WMD＝0.70，95%CI(-1.48，2.89)，P＝0.69]、术后平均矫正角度[WMD＝2.61，95% CI(2.13，3.10)，P<0.0001]、术后机械轴[WMD＝0.21，95% CI(-0.67，1.09)，P＝0.64)、术前髌骨高度Blackburne-Peel (BP)测量指数[WMD＝0.03，95%CI(-0.01，0.07)，P＝0.12]、术后髌骨高度BP测量指数[WMD＝-0.03，95% CI(-0.02，0.07)，P＝0.31]、术前髌骨高度Insall-Salvati测量指数(ISI)[WMD＝0.02，95% CI(-0.08，0.02)，P＝0.31]、术后髌骨高度ISI[WMD＝-0.02，95% CI(-0.06，0.02)，P＝0.31]及术前胫骨平台后倾角度[WMD＝0.58，95% CI(-0.06，1.23)，P＝0.08]中差异无统计学意义。

结论

与CWHTO相比，OWHTO治疗内侧间室骨关节炎能增加胫骨平台后倾角，降低髌骨高度和矫正机械轴角度及缩短手术时间，在治疗单间室骨关节炎方面是一种较好的选择。

关键词: 骨关节炎, 膝, 胫骨, 截骨术, Meta分析
Objective

To evaluate the clinical efficacy of open wedge high tibial osteotomy (OWHTO)and closed wedge high tibial osteotomy(CWHTO) in the medial compartment osteoarthritis of patients with high quality by meta-analysis, in order to give some evidences for the choice of method dealing with the medial compartment osteoarthritis of patients.

Methods

Cochrane Central Register of Controlled Trials (Issue 6 2017), Pubmed, Ovid, Spinger Link, Elsevier, Medline were searched (time range: 1970-01-01 to 2017-6-30). OWHTO and the CWHTO were used in treating the medial compartment osteoarthritis of patients in the literature. The related literatures including complications, operating time, Hospital for Special Surgery(HSS) knee score, patellar height, mean correction angle, posterior tibial slope angle and hip-knee-ankle angle were explored.A strict quality assessment was performed to screen the literatures which met the inclusion criteria. The analysis was performed with software RevMan5.0 from the Cochrane collaboration. Additionally, the heterogeneity of data was also checked.

Results

Thirteen relevant articles were included in the standard, and the total sample size was 1 237 cases, including OWHTO group of 666 cases, 571 cases of the CWHTO group. Comparing the OWHTO group with the CWHTO group, there were significant differences in the postoperative patellar height Caton-Deschamps measurement index, postoperative posterior tibial slope angle and operation time[weighted mean difference (WMD)=0.11, 95% confidence interval (CI)(-0.17, -0.05), P<0.0001], [WMD=2.61, 95%CI(2.13, 3.10), P<0.0001]. There was significant difference in the peroperative hip-knee-ankle angle changes of the CWHTO group [WMD=0.82, 95%CI(0.04, 1.59), P=0.04]. There was no significant difference between the OWHTO group and the CWHTO group in complications[WMD=1.55 95%CI(0.35, 6.93), P=0.57], visual analogue scale (VAS) [WMD=0.46, 95%CI(-0.15, 1.06), P=0.14], preoperative HSS score[WMD=1.72, 95%CI(-1.27, 4.71), P=0.26] and postoperative HSS score[WMD=0.70, 95%CI(-1.48, 2.89), P=0.69], postoperative mean correction angle[WMD=2.61, 95%CI(2.13, 3.10), P<0.0001], postoperative hip-knee-ankle angle [WMD=0.21, 95%CI(-0.67, 1.09), P=0.64], preoperative patellar height Blackburne-Peel(BP) measurement index[WMD=0.03, 95%CI (-0.01, 0.07), P=0.12] and postoperative patellar height BP measurement index[WMD=-0.03, 95%CI(-0.02, 0.07), P=0.31], preoperative patellar height Insall-Salvati measurement index(ISI) [WMD=0.02, 95%CI(-0.08, 0.02), P=0.31]and postoperative patellar height ISI [WMD=-0.02, 95%CI(-0.06, 0.02), P=0.31]and preoperative posterior tibial slope angle[WMD=0.58, 95%CI(-0.06, 1.23), P=0.08].

Conclusion

Compared with CWHTO, in the treatment of medial compartment osteoarthritis, OWHTO can increase the posterior tibial slope angle, reduce patella height and correct hip-knee-ankle angle and shorten operation time, which is a better choice for treatment of medial compartment osteoarthritis.

Key words: Osteoarthritis, Knee, Tibia, Osteotomy, Meta-analysis.
表1 收集文献的一般资料
研究者 研究类型 男/女 手术方式 年龄(岁) 随访时间 测量参数 质量评分
OP CW OP CW
Brouwer 2006[12] RCT 33/59 45 47 49.6(21～67) 50.8(22～64) 12个月 ①③⑤⑦⑧ 7
El-Azab 2010[13] PCS 56/38 50 50 (男)44.2±5.8 (女)46.5±4.0 12个月 ①②③④⑦ 6
Song 2012[14] PCS 22/78 50 50 57.9(46～65) 60.1(46～65) 44个月 ①④ 5
Ducat 2012[15] PMS 205/116 210 92 52±9 49.7±10.3 6个月 ④⑤ 6
Bae 2013[16] PCS 6/95 30 78 56.3±7.5 58.8±7.5 3.4年 ④⑤⑥ 6
Soleimanpour 2013[17] RCT 25/7 21 21 36.5±8.1 35.1±9.7 6个月 ③④⑤⑨ 7
Schaefer 2008[18] PCS N 90 66 46(26～46) 47(26～65) 11个月 ④⑤⑧ 6
Duivenvoorden 2014[19] RCT 51/30 36 45 49.9±7.9 49.5±9.2 7.3年 ⑤⑦⑧⑩ 7
Luites 2009[20] RCT 27/15 23 19 53(40～68) 2年 ⑤⑥ 7  
van Egmond 2014[21] RCT 31/19 25 25 47.1±8.5 50.3±7.4 8年 ②④⑤⑥⑧⑩ 7
Portner 2014[22] RCS 35/9 26 18 43.9±8.48 46.5±5.17 6个月 ③④ 7
Gaasbeek 2010[23] RCT 30/20 25 25 47.0±8.5 49.8±7.4 12个月 ②⑤⑧⑨⑩ 9
Nerhus 2015[24] RCT 36/34 35 35   N 6个月 ①③④⑤⑥ 8
图1 纳入文献的一般资料
图2 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前机械轴漏斗图
表2 Meta分析结果
测量结果 例数 效果评价值 95%CI P值 I2 P值
OP CW
术前BP指数[12,13,14,24] 180 182 0.03 (-0.01，0.07) 0.12 53% 0.10
术后BP指数[12,13,14,24] 180 182 -0.03 (-0.08，0.02) 0.23 62% 0.05
术前CD指数[13,21,23,24] 135 135 0.03 (-0.01，0.07) 0.13 0% 0.70
术后CD指数[13,21,23,24] 135 135 -0.11 (-0.17，0.05) <0.0001 64% 0.04
术前ISI指数[13,22,24] 111 103 0.02 (-0.02，0.07) 0.31 0% 0.57
术后ISI指数[13,22,24] 111 103 -0.02 (-0.06，0.02) 0.31 0% 0.66
平均娇正角度[16,20,21,24] 111 103 -0.03 (-0.97，0.36) 0.38 0% 0.51
术前PTSA[13,14,15,16,17,18,21,22,24] 537 435 0.58 (-0.06，1.23) 0.08 46% 0.06
术后PTSA[13,14,15,16,17,18,21,22,24] 537 435 2.61 (2.13，3.10) <0.0001 91% <0.0001
术前HKA[15,16,17,18,19,20,21,23,24] 495 406 0.82 (0.04，1.59) 0.04 71% <0.0001
术后HKA[12,16,17,18,19,20,21,23,24] 330 361 0.21 (-0.67，1.09) 0.64 71% <0.0001
并发症[12,18,19,21,23] 221 208 1.55 (0.35，6.93) 0.57 78% 0.01
术前HSS评分[12,19] 86 95 1.72 (-1.27，4.71) 0.26 0% 0.53
术后HSS评分[12,13,19] 131 142 0.70 (-1.48，2.89) 0.69 0% 0.53
手术时间[17,23] 46 46 -19.48 (-31.02，-7.94) <0.0001 71% 0.06
VAS疼痛评分[19,21,23] 86 95 0.46 (-0.15，1.06) 0.14 26% 0.26
图3 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后髌骨高度比较森林图
图4 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后胫骨平台后倾角度比较森林图
图5 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前机械轴比较森林图
图6 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后机械轴比较森林图
图7 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)手术时间的比较森林图
图8 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后并发症的比较森林图
图9 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前髌骨高度比较森林图
图10 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前胫骨平台后倾角度比较森林图
图11 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前BP指数比较森林图
图12 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后BP指数比较森林图
图13 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前ISI指数比较森林图
图14 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后ISI指数比较森林图
图15 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)矫正角度比较森林图
图16 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术前HSS(特种外科医院)评分比较森林图
图17 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)治疗组术后HSS(特种外科医院)评分比较
图18 OWHTO(内侧开放胫骨高位楔形截骨)与CWHTO(外侧闭合胫骨高位楔形截骨)术后疼痛评分比较森林图
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