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中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 808 -817. doi: 10.3877/cma.j.issn.1674-134X.2023.06.008

荟萃分析

全膝关节置换术后下肢轻度内翻对线对疗效的影响
张思平, 刘伟, 马鹏程†()   
  1. 830000　乌鲁木齐，新疆医科大学第四临床医学院
    830000　乌鲁木齐，新疆医科大学
    250000　济南，山东省公共卫生临床中心骨创伤科
  • 收稿日期:2022-10-17 出版日期:2023-12-01
  • 通信作者: 马鹏程

Therapeutic effects of lower extremity mild varus alignment after total knee arthroplasty

Siping Zhang, Wei Liu, Pengcheng Ma†()   

  1. The Fourth Clinical Medical College of Xinjiang Medical University, Urumqi 830000, China
    Xinjiang Medical University, Urumqi 830000, China
    Department of Traumatology, Shandong Public Health Clinical Center, Jinan 250000, China
  • Received:2022-10-17 Published:2023-12-01
  • Corresponding author: Pengcheng Ma
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引用本文：

张思平, 刘伟, 马鹏程. 全膝关节置换术后下肢轻度内翻对线对疗效的影响[J/OL]. 中华关节外科杂志(电子版), 2023, 17(06): 808-817.

Siping Zhang, Wei Liu, Pengcheng Ma. Therapeutic effects of lower extremity mild varus alignment after total knee arthroplasty[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(06): 808-817.

目的

探究对于存在下肢结构性内翻并接受全膝关节置换术(TKA)的膝关节炎患者，术后下肢轻度内翻对线是否可以产生比机械对线(MA)更好的疗效。

方法

计算机检索PubMed、荷兰医学文摘数据库(Embase)、Web of Science、考克兰图书馆(the Cochrane Library)、万方、维普、中国知网文献库中比较术后下肢MA与轻度内翻对线疗效的文献，检索时间到2022年10月5日。由2名研究员根据纳入排除标准进行文献筛选及资料提取，使用纽卡斯尔－渥太华量表(NOS)评价队列研究的质量，使用改良Jadad量表评价随机对照研究(RCT)的质量，使用Revman 5.3软件进行Meta分析。

结果

将14篇文献纳入本次分析，均为高质量的队列研究。分析结果表明术后下肢轻度内翻对线组的遗忘关节评分[平均差(MD)＝8.05，95%置信区间(CI)(5.53，10.58)，P<0.01]优于MA组，差异有统计学意义。在西大略和麦克马斯特大学骨关节炎指数评分(WOMAC)[MD＝－1.34，95%CI(－2.95，0.26)，P＝0.10]、牛津膝关节评分(OKS)[MD＝0.18，95%CI(－0.37，0.73)，P＝0.52]、翻修率[比值比(OR)＝0.55，95%CI(0.22，1.35)，P＝0.19]、膝关节活动范围(ROM)[MD＝－0.84，95%CI(－2.24，0.55)，P＝0.24]以及美国膝关节协会评分(KSS)中的美国膝关节协会膝关节评分(KSKS)[MD＝0.05，95%CI(－0.59，0.69)，P＝0.87]和美国膝关节协会功能评分(KSFS)[MD＝－0.44，95%CI(－2.13，1.25)，P＝0.61]方面，术后轻度内翻对线组与MA组的预后相似，差异无统计学意义。

结论

对于存在下肢结构性内翻的膝关节炎患者，TKA术后轻度内翻对线的疗效不劣于MA。

关键词: 关节成形术，置换，膝, 下肢, 膝内翻, 预后, Meta分析
Objective

To investigate whether postoperative lower extremity mild varus alignment can generate better outcomes than postoperative lower extremity mechanical alignment (MA) in patients with structural varus of lower extremity who had received total knee arthroplasty (TKA).

Methods

PubMed, Excerpta Medica Database (Embase), Web of Science, the Cochrane Library, China Online Journals (Wanfang), China Science and Technology Journal Database (VIP) and China National Knowledge Infrastructure (CNKI) were retrieved to compare the efficacy of postoperative lower extremity MA and postoperative lower extremity mild varus alignment. The retrieval time ends by October 5, 2022. Articles screening and data extraction were completed by two researchers according to the inclusion and exclusion criteria. The quality of the cohort study was evaluated by the Newcastle-Ottawa Scale (NOS). The quality of the randomized controlled study (RCT) was evaluated using the modified Jadad scale. Meta-analysis was performed using Revman 5.3 software.

Results

Fourteen articles were included in this analysis, all of which were high-quality cohort studies. The analysis results showed that the forgotten joint score of postoperative lower extremity mild varus alignment [mean difference (MD)=8.05, 95% confidence interval (CI) (5.53, 10.58), P< 0.01] was better than that in the MA group, and the difference was statistically significant.As for the Western Ontario and McMaster University osteoarthritis index (WOMAC) [MD=-1.34, 95%CI (-2.95, 0.26), P=0.10], Oxford knee score (OKS) [MD=0.18, 95%CI (-0.37, 0.73), P=0.52], revision rate [odds ratio (OR) =0.55, 95%CI (0.22, 1.35), P=0.19], range of motion (ROM) of knee joint [MD=-0.84, 95%CI (-2.24, 0.55), P=0.24], Knee Society knee score (KSKS) of American Knee Society score (KSS) [MD=0.05, 95%CI (-0.59, 0.69), P=0.87] and Knee Society function score (KSFS) [MD=-0.44, 95%CI (-2.13, 1.25), P=0.61], the prognosis of postoperative lower extremity mild varus alignment group was similar to that of the MA group, and the difference was not statistically significant.

Conclusion

For patients with knee arthritis and structural varus of lower extremity, the effect of postoperative lower extremity mild varus alignment after TKA is not inferior to that of MA.

Key words: Arthroplasty, replacement, knee, Lower extremity, Genu varum, Prognosis, Meta-analysis
图1 文献纳入流程
Figure 1 Process diagram for included articles
表1 纳入文献的特征
Table 1 Characteristics of the included articles
作者Author 发表年Year 国家Country 组别Groups 膝样本量Knees 男/女Male/female 平均年龄(岁)Average age(year) 平均BMI(kg/m2)Average BMI 术后HKA角(°)Postoperative HKA 平均随访时间(个月)Average follow-up duration(month) 观察指标Outcomes 文献质量Quality of study
Zhang[15] 2020 中国 RV 62 12/50 67.2 26.2 175.8±0.9 64.8 ①② 8☆
MA 86 17/69 68.0 25.3 178.4±0.9 64.8
Nishida[16] 2017 日本 RV 61 11/50 73.5 NA 175.4±0.8 42.9 ①⑤ 7☆
MA 128 14/114 73.6 NA 179.4±1.6 42.9
Rajasekaran[17] 2020 印度 RV 88 14/74 64.4 NA 174.0~177.0 12.0    
MA 67 20/47 59.1 NA 177.0~183.0 12.0 ②③ 7☆
Schiffner[18] 2019 德国 RV 33 10/23 77.0 NA 175.9±1.1 48.0
MA 115 54/61 77.0 NA 179.2±1.5 48.0 ③ 7☆
Rames[19] 2017 美国 RV 60 38/22 63.2 33.3 175.7±0.9 15.6
MA 149 70/79 63.9 31.9 179.3±1.5 15.6 ③④ 7☆
Salzmann[20] 2017 德国 RV 18 7/11 69.6 29.7 175.7±0.8 24.0 ①②④⑤ 8☆
MA 104 46/58 69.5 29.8 178.6±1.0 24.0
Vanlommel[21] 2013 比利时 RV 46 19/27 74.1 31.2 175.5±0.8 86.4 ② 9☆
MA 75 17/58 74.0 29.3 179.3±1.5 86.4
Saragaglia[22] 2019 法国 RV 88 46/38 71.6 29.5 177.8±1.0 102.0 ③⑤⑥ 7☆
MA 62 30/29 71.3 30.0 181.0±1.0 102.0
Magnussen[23] 2011 法国 RV 181 53/128 71.9 30.9 <177.0 56.4 ⑤ 6☆
MA 352 113/223 71.3 29.2 177.0~183.0 56.
Ro[24] 2019 韩国 RV 64 均为女性 69.7 26.3 177.0±1.0 24.0 ①②⑥ 7☆
MA 90 均为女性 70.1 26.6 180.0±1.0 24.0
Shin[25] 2020 韩国 RV 99 7/92 72.4 27.3 176.9±1.3 46.9 ①②④ 8☆
MA 99 8/91 72.4 26.8 179.6±1.1 54.6
Oh[26] 2019 韩国 RV 176 38/598 66.9 27.4 174.0~177.0 103.4 ⑤ 8☆
MA 636 2/174 66.9 27.4 177.0~183.0 95.9
刘磊[27] 2020 中国 RV 20 6/12 65.7 27.5 175.7±0.9 18.4 ①⑥ 8☆
MA 50 11/35 66.3 26.9 179.4±1.7 18.4
钟昌恒[28] 2021 中国 RV 36 10/26 76.0 29.3 175.4±0.8 24.4 ⑥ 8☆
MA 43 4/39 78.5 27.2 179.7±2.9 24.4
图2 KSKS(膝关节协会膝关节评分)森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 2 Forest plot of Knee Society knee score
图3 KSFS(美国膝关节协会功能评分)森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 3 Forest plot of knee society function score
图4 WOMAC(西大略和麦克马斯特大学骨关节炎指数)评分森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 4 Forest plot of Western Ontario and McMaster universities osteoarthritis index
图5 OKS(牛津膝关节评分)森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 5 Forest plot of Oxford knee score
图6 遗忘关节评分森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 6 Forest plot of forgotten joint score
图7 敏感性分析前的翻修率森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 7 Forest plot of revision rate (before sensitivity analysis)
图8 敏感性分析后的翻修率森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 8 Forest plot of revision rate (after sensitivity analysis)
图9 膝关节ROM(活动度)森林图注：RV-轻度内翻对线组；MA-机械对线组
Figure 9 Forest plot of knee range of motion
图10 KSKS(膝关节协会膝关节评分)的TSA(试验序贯分析)注：蓝色曲线－累计Z值；绿色直线－传统界值；红色曲线－TSA界值；IS(红色竖线)－信息量
Figure 10 Trial sequential analysis of Knee Society knee score
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