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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (04) : 508 -519. doi: 10.3877/cma.j.issn.1674-134X.2023.04.008

荟萃分析

前交叉韧带单束联合前外侧结构重建的Meta分析
邢阳, 何爱珊, 康焱, 杨子波, 孟繁钢, 邬培慧†()   
  1. 510080　广州，中山大学附属第一医院运动医学科
  • 收稿日期:2022-11-09 出版日期:2023-08-01
  • 通信作者: 邬培慧
  • 基金资助:
    国家自然科学基金面上项目(82272449)

Meta-analysis of single-bundle reconstruction combining anterolateral reconstruction of anterior cruciate ligament

Yang Xing, Aishan He, Yan Kang, Zibo Yang, Fangang Meng, Peihui Wu†()   

  1. Department of Sports medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
  • Received:2022-11-09 Published:2023-08-01
  • Corresponding author: Peihui Wu
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引用本文：

邢阳, 何爱珊, 康焱, 杨子波, 孟繁钢, 邬培慧. 前交叉韧带单束联合前外侧结构重建的Meta分析[J]. 中华关节外科杂志(电子版), 2023, 17(04): 508-519.

Yang Xing, Aishan He, Yan Kang, Zibo Yang, Fangang Meng, Peihui Wu. Meta-analysis of single-bundle reconstruction combining anterolateral reconstruction of anterior cruciate ligament[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(04): 508-519.

目的

比较单束前交叉韧带(ACL)重建联合前外侧结构(ALS)重建与单束前交叉韧带重建两种手术方式的临床效果。

方法

检索电子数据库PubMed、荷兰医学文摘(Embase)、Web of Science、万方数据库和中国知网(CNKI)，并追溯纳入文献的相关参考文献，收集比较单束ACL重建联合ALS重建与单束ACL重建两种手术方式的临床研究，结局指标包括膝关节功能评分、国际膝关节文献委员会(IKDC)评分、Lysholm评分、Tegner评分、胫骨前位移等。排除术后随访时间小于1年、无对照组或非临床研究的相关文献。提取最终纳入的文献进行质量评价和资料，采用RevMan 5.3软件进行统计分析。

结果

最终纳入10项研究，共764例患者，其中单束ACL重建联合ALS重建的345例，单束ACL重建的419例。在胫骨前位移距离[均数差(MD)＝－0.65，95%置信区间(CI)(－0.96，－0.33)，P<0.01]、IKDC评分[MD＝3.90，95%CI(1.96，5.84)，P<0.01]、Lysholm评分[MD＝2.65，95%CI(1.73，3.57)，P<0.01]、Tegner评分[MD＝0.31，95%CI(－0.13，0.75)，P＝0.17]、轴移试验[风险比(RR)＝0.23，95%CI(0.12，0.44)，P<0.01]、Lachman试验[RR＝0.40，95%CI(0.21，0.77)，P<0.01]、减少移植物再撕裂[RR＝0.24，95%CI(0.10，0.54)，P<0.01]等方面，单束ACL重建联合ALS重建均优于单束ACL重建，而在前抽屉试验[RR＝0.67，95%CI(0.24，1.89)，P＝0.44]、重返运动[RR＝1.18，95%CI(0.93，1.48)，P＝0.17]方面两组差异无统计学意义。

结论

单束ACL重建联合ALS重建在膝关节功能评分、稳定性、降低移植物再撕裂风险方面具有一定优势。

关键词: 前交叉韧带, 关节镜检查, 膝, Meta分析
Objective

To compare the clinical outcomes of single-bundle reconstruction combined with anterolateral structure (ALS) reconstruction of anterior cruciate ligament (ACL) and single-bundle ACL reconstruction only.

Methods

A literature search was conducted in PubMed, Excerpta Medical Database (Embase), Web of Science, Wanfang database and China National Knowledge Infrastructure(CNKI). The references in the included literature were tracked, and clinical studies comparing single-bundle ACL reconstruction combined with ALS reconstruction and single-bundle ACL reconstruction were collected and compared, and the outcome indices were knee function scores, International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner score, anterior tibial shift, etc.. The studies with a postoperative follow-up of less than one year, no controlled group or those that were not clinical studies, were excluded. The quality of the final included literatures was evaluated, the data were extracted and statistically analyzed using RevMan 5.3 software.

Results

Ten studies were included, with a total of 764 patients, including 419 patients with single-bundle ACL reconstruction and 345 patients with single-bundle reconstruction combined with ALS reconstruction of ACL. The single-bundle reconstruction combined with ALS reconstruction of ACL were superior than single-bundle ACL reconstruction in the results of anterior tibial shift[mean deviation(MD)=-0.65, 95% confidence interval (CI) (-0.96, -0.33), P<0.01], IKDC score [MD=3.90, 95%CI(1.96, 5.84), P<0.01], Lysholm score [MD=2.65, 95%CI(1.73, 3.57), P<0.01], Tegner score [MD=0.31, 95%CI(-0.13, 0.75), P=0.17], pivot shift test[risk ratio(RR)=0.23, 95%CI(0.12, 0.44), P<0.01], Lachman test [RR=0.40, 95%CI(0.21, 0.77), P<0.01], and reducing the postoperative graft rerupture rate [RR=0.24, 95%CI(0.10, 0.54), P<0.01]; the differences were statistically significant. There was no statistically significant difference in anterior drawer test[RR=0.67, 95%CI(0.24, 1.89), P=0.44], or return-to-sport rate [RR=1.18, 95%CI(0.93, 1.48), P=0.17].

Conclusion

Single-bundle reconstruction combined with ALS reconstruction of ACL present advantages in terms of knee joint function score, stability and reduction of graft re-rupture rate.

Key words: Anterior cruciate ligament, Arthroscopy, Knee, Meta-analysis
图1 文献筛选流程
Figure 1 Process of including documents
表1 纳入研究基本特征
Table 1 Basic characteristics of included studies
作者(年份) 例数(ACL重建/ACL+ALS重建) 年龄(岁) 随访时间(月) ALL移植物类型 单束ACL重建联合ALS重建适应证 结局指标 证据等级/NOS评分
ACL重建 ACL+ALS重建
Ibrahim[27](2017) 103(50/53) 26 26 27 股薄肌 Ⅱ级以上轴移试验；参加高水平运动；参加扭转相关运动；慢性ACL撕裂；Segond骨折 ②③④⑤⑥⑦ Ⅱ/9
Helito[30](2018) 101(68/33) 33.9 33.1 26 股薄肌 慢性ACL撕裂 ①②④⑦⑨ Ⅲ/7
Helito[31](2019) 90(60/30) 29.9 27.0 29.6 股薄肌 多发韧带松弛 ①②④⑤⑦⑨ Ⅲ/6
Lee[32](2019) 95(43/42) 27.3 26.8 41.5 同种异体股薄肌腱 ACL重建后翻修；至少随访36个月；年龄<45岁 ①②③④⑤⑥⑦⑧⑨ Ⅲ/6
Goncharov[26](2020) 48(30/18) － － 24 半腱肌或股薄肌 每周至少运动3次；参加高水平运动；年龄16~40岁；同侧膝关节无既往手术史 ①②④⑥⑧ Ⅱ/8
Erden[29](2021) 63(33/30) 26.1 27.3 32.7 半腱肌或股薄肌 Ⅱ级以上轴移试验阳性；参加高水平运动；参加扭转相关运动；慢性ACL撕裂；Segond骨折 ①②④⑥⑦⑧⑨ Ⅲ/6
Hamido[24](2021) 102(52/50) 26 24 60 股薄肌 1.Ⅲ级轴移试验阳性；2.Segond骨折；3.参加高水平运动；4.参加扭转相关运动 ②③④⑤⑥⑦⑧⑨ Ⅰ/9
Mogo[25](2021) 55(25/32) 33.8 28.8 12 股薄肌 参加扭转相关运动；Ⅱ级以上轴移试验阳性 ①④⑦⑧⑨ Ⅰ/9
Yoon[33](2021) 39(21/18) 29.6 32.9 24 同种异体肌腱 ACL重建后翻修；Ⅱ级以上轴移试验阳性 ①②③④⑤⑥⑦⑨ Ⅲ/6
Toker[28](2022) 68(37/31) 30.1 28.1 26.7 2号Fiber Tape缝线 多发韧带松弛 ①②④⑤⑥⑦⑨ Ⅱ/6
图2 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建胫骨前位移森林图
Figure 2 Forest plot of anterior tibial shift in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图3 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建IKDC(国际膝关节文献委员会)评分森林图
Figure 3 Forest plot of IKDC scores in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图4 缺省Erden[29]研究时单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建IKDC(国际膝关节文献委员会)评分森林图
Figure 4 Forest plot of IKDC scores in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction at the absence of Erden [29] study
图5 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建Lysholm评分森林图
Figure 5 Forest plot of Lysholm scores in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图6 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建Tegner评分森林图
Figure 6 Forest plot of Tegner scores in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图7 缺省Mogo[25]研究时单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的Tegner评分森林图
Figure 7 Forest plot of Tegner scores in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction at the absence of Mogo[25] study
图8 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的轴移试验阳性率森林图
Figure 8 Forest plot of positive rate of pivot shift test in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图9 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的前抽屉试验阳性率森林图
Figure 9 Forest plot of positive rate of anterior drawer test in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图10 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的Lachman试验阳性率森林图
Figure 10 Forest plot of positive rate of Lachman test in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图11 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的重返运动率森林图
Figure 11 Forest plot of return- to- sport rate in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
图12 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建移植物再撕裂率森林图
Figure 12 Forest plot of graft re-rupture rate in single-bundle reconstruction combined with ALS reconstruction of ACL versus single bundle ACL reconstruction
表2 ACLR+ALSR与ACLR不同ALL移植物类型亚组分析
Table 2 Subgroup analysis of different ALL graft types in ACLR+ALSR and ACLR
移植物类型Graft type IKDC评分 Lysholm评分 Tegner评分 轴移试验 前抽屉试验
研究数目 MD(95%CI) 研究数目 MD(95%CI) 研究数目 MD(95%CI) 研究数目 RR(95%CI) 研究数目 RR(95%CI)
自体肌腱Autologous tendon 5 3.80(1.13, 6.47) 6 2.63(1.62, 3.64) 2 0.47(－0.10, 1.04) 7 0.23(0.10, 0.53) 2 0.52(0.15, 1.90)
异体肌腱或缝线Allogeneic tendons or sutures 3 3.76(1.37, 6.15) 3 2.75(0.50, 4.99) 2 0(－0.54, 0.54) 3 0.21(0.06, 0.68) 1 1.17(0.18, 7.47)
P值   0.98   0.93   0.24   0.88   0.49
移植物类型 Lachman试验 胫骨前位移距离 重返运动率 移植物再撕裂率
研究数目 RR(95%CI) 研究数目 MD(95%CI) 研究数目 RR(95%CI) 研究数目 RR(95%CI)
自体肌腱 4 0.37(0.14, 1.01) 6 －0.55(－0.89, －0.22) 4 1.06(0.94, 1.21) 5 0.07(0.02, 0.29)
异体肌腱或缝线 3 0.43(0.19, 1.00) 3 －0.95(－1.75, －0.14) 1 2.23(1.26, 3.96) 3 0.28(0.05, 1.51)
P值   0.83   0.38   0.01   0.20
图13 单束ACL(前交叉韧带)重建联合ALS(前外侧结构)重建与单束ACL重建的Lachman试验比较漏斗图
Figure 13 Funnel plot of Lachman test for single-bundle reconstruction combined with ALS reconstruction of ACL compared to single bundle ACL reconstruction
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