关节镜下异体肌腱单束与双束重建后交叉韧带的疗效比较及Meta分析
发布时间：2018-12-11 21:30
【摘要】：随着社会的发展和人民生活水平的提高,运动系统疾病越来越受到人们的重视,虽然不是致命性的损伤,但患者生活质量变差,会影响家庭和睦及社会和谐。我们普遍定义的膝关节韧带损伤是一大类疾病,相较于前交叉韧带损伤,后交叉韧带(Posterior cruciate ligament,PCL)损伤的发病率约占其中的3.4%-20%[1],是比较少见的。但是,如果不积极治疗,仍旧会引起关节内其它结构的继发改变。根据解剖学研究,后交叉韧带并不是独立的单条韧带,而是由两部分组成,即前外侧束(AB)和后内侧束(PB),这其中AB束的功能又更为重要一些[2-4]。在膝关节屈曲时,85%以上的后负荷由后交叉韧带承担。研究显示当PCL断裂后,90°屈膝位时,胫骨可产生最大20mm的后向位移,患者表现出明显的膝关节不稳。前外侧束在关节屈曲时紧张,伸直时松弛;而后内侧束的松紧状态(屈曲松弛,伸直紧张)与前外侧束相反[5]。这种生物力学特性理论上暗示了PCL损伤的患者很难通过单束重建法来恢复正常的膝关节功能。但是,2001年Bergfeld等人经过研究,认为不谈理论优势,单在临床疗效上双束重建法并没有表现出其应有的优势。并且相较于单束重建,双束重建法有着一系列难以克服的缺陷(技术难度大、患者花费高、手术时间长等)。到底双束重建与单束重建孰优孰劣?目前学界还没有给出一个统一的答案[6-8]。支持单束重建者认为单束重建已经恢复了后交叉韧带的大部分功能,且手术技术成熟,疗效可靠,应为后交叉韧带损伤的首选术式。而支持双束重建者认为双束重建才能最大程度模拟PCL的解剖形态,达到最接近于正常膝关节功能的临床疗效[9-10]。第一部分关节镜下异体肌腱单双束重建后交叉韧带的疗效比较目的应用流行病学中前瞻性队列研究的方法,比较异体肌腱单双束重建PCL的疗效差异。方法研究对象为2008年1月至2013年1月期间,304医院收治的PCL损伤患者,样本含量42例。按照随机数字表法[11]将患者随机分为A组(n=22例,采用单束重建)及B组(n=20例,采用双束重建)。观察指标有8项,分别为住院周期、手术时长、术后发热天数、需要关节穿刺的数量、膝关节稳定性、Lysholm评分、IKDC评分及Tegner评分。结果B组患者手术用时及住院天数显著高于A组(P0.05);B组患者Lysholm评分要优于A组,差异有统计学意义(P0.05));两组术后膝关节稳定性、IKDC评分及Tegner评分较术前均有提高(P0.05),但组间差异没有统计学意义(P0.05)。结论关节镜下异体肌腱单双束重建后交叉韧带均是治疗PCL损伤的安全有效的方法。双束重建手术虽然用时长、创伤大,但术后Lysholm评分显示恢复膝关节功能较好,所以我们保守地认为对于技术成熟、经验丰富的临床医生,选择双束重建更优。第二部分关节镜下异体肌腱单束与双束重建后交叉韧带的Meta分析目的通过Cochrane系统评价研究异体肌腱单双束重建PCL的临床效果,比较两种方法的优劣。方法严格按照“Cochrane协作网统一工作手册”进行研究。科学制定纳入与排除标准:研究类型为临床RCT试验,失访率20%及随访时间小于12个月的研究排除;研究对象为经关节镜或MRI检查确诊单纯PCL损伤,且年龄≥14岁(骨发育成熟)需行PCL重建的患者;排除伴有其它膝关节内部结构损伤的病例,如骨折、ACL损伤、骨关节炎及其他全身疾病不能手术者;干预措施均为关节镜下异体肌腱单双束重建PCL,移植物的固定方式不做限制,移植物的种类为异体肌腱,不纳入单纯研究重建技术的文献;主要结局指标有膝关节Lysholm评分、IKDC评价系统、关节动度仪测量结果、术后长期膝关节疼痛、手术副作用和术后并发症,次要指标有是否恢复伤前运动水平、Tegner评分、Lachman test、Drawer test、术后膝关节活动度、术后复发的膝关节软组织伤。检索过程为计算机检索Pubmed、Embase、The Cochrane Library、Ovid、CBM、Cnki、万方、维普等数据库,手工检索8个月内相关专业医学杂志,纳入所有关于关节镜下单双束重建PCL疗效比较的临床RCT试验(Rondomized controlled trails),并对文献质量进行评价,数据的提取和分析使用Review Manager 5.1软件。结果共筛选出3篇文献,总样本量151例。研究结果显示:双束组术后Lysholm评分优于单束组(WMD=2.20,95%CI(0.56,3.83),P=0.008),膝关节稳定性有2篇文献结果显示双束重建法更优(P0.05);而Tegner评分、IKDC评分、膝关节活动度组间差异没有统计学意义(P0.05);关于术后并发症的资料缺乏,不予讨论。结论1.单双束重建PCL均能很好地恢复膝关节功能,其中双束重建法疗效更优。2.目前关于单双束重建PCL疗效对比的质量较高的RCT试验较少,且样本量偏小,因而还需多中心大样本临床试验修正本结论。
[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，
本文编号：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，
本文编号：2373252
本文链接：https://www.wllwen.com/yixuelunwen/waikelunwen/2373252.html
最近更新
教材专著
