关节镜联合玻璃酸钠治疗膝骨关节炎效果的Meta分析

Efficacy of arthroscopy combined with sodium hyaluronate for knee osteoarthritis:a meta-analysis

目的:膝关节镜治疗对轻中度膝骨关节炎具有良好疗效,但在术中灌洗液会带走大量原有关节液,术后通过注射玻璃酸钠补充关节液能否进一步提高疗效尚存争议。文章评价关节镜联合玻璃酸钠治疗相较于单纯关节镜治疗膝骨关节炎的疗效。方法:检索中国知网、万方、维普、CBM、PubMed、Web of Science、EMBASE及Cochrane Library数据库,检索建库至2020-03-27相关文献,纳入关节镜联合玻璃酸钠治疗膝骨关节炎的随机对照试验,对符合标准的试验采用Cochrane系统评价方法进行评价,采用Revman 5.3软件进行Meta分析。主要结局指标为Lequesne评分、Lysholm评分、WOMAC评分和目测类比评分;次要结局指标为关节液中肿瘤坏死因子α、白细胞介素1β及白细胞介素6水平。结果:共纳入31个随机对照试验,研究对象1350例。Meta分析结果显示:①联合组Lequesne评分在术后1周(MD=-0.33,95%CI:0.67至-0.00,P=0.05)、玻璃酸钠注射疗程结束后(MD=-1.00,95%CI:-1.34至-0.66,P<0.00001)、术后3个月(MD=-1.04,95%CI:-1.44至-0.64,P<0.00001)均优于对照组;②联合组Lysholm评分在术后1周(MD=5.84,95%CI:4.79-6.88,P<0.00001)、玻璃酸钠注射疗程结束后(MD=9.21,95%CI:6.93-11.49,P<0.00001)、术后3个月(MD=9.14,95%CI:6.34-11.94,P<0.00001)、术后半年(MD=10.14,95%CI:6.50-13.78,P<0.00001)、术后1年(MD=11.54,95%CI:9.92-13.16,P<0.00001)均优于对照组;③联合组WOMAC评分在术后1年(MD=-18.38,95%CI:-28.53至-8.23,P=0.0004)优于对照组;联合组目测类比评分在术后1周(MD=-0.91,95%CI:-1.11至-0.72,P<0.00001)、玻璃酸钠注射疗程结束后(MD=-0.97,95%CI:-1.23至-0.72,P<0.00001)、术后3个月(MD=-0.41,95%CI:-0.52,-0.31,P<0.00001)均优于对照组;④联合组在治疗全疗程结束后相较于注射1周后Lequense评分(MD=1.47,95%CI:1.14-1.80,P<0.00001)更优;⑤联合组更好地降低关节液中肿瘤坏死因子α、白细胞介素1β及白细胞介素6水平(P≤0.05),能更好地控制炎症情况。结论:关节镜联合玻璃酸钠治疗膝骨关节炎相较于单纯使用关节镜治疗能获得更好的短中期疗效,但上述结论尚需要更多高质量的研究进行验证。

OBJECTIVE:Knee arthroscopy has a good effect on mild to moderate knee osteoarthritis,but the lavage fluid will take away a lot of the original synovial fluid.It is still controversial whether synovial fluid can be further improved by postoperative injection of sodium hyaluronate.This study is designed to evaluate the efficacy of arthroscopy combined with sodium hyaluronate compared with arthroscopy alone for knee osteoarthritis.METHODS:The relevant literature was searched from CNKI,Wangfang,VIP,CBM,PubMed,Web of Science,EMBASE,and Cochrane Library from inception to March 27,2020.The randomized controlled trials on arthroscopy combined with sodium hyaluronate for knee osteoarthritis were included.Included studies were evaluated using the Cochrane system evaluation method.Meta-analysis was performed using RevMan 5.3 software.The primary outcomes included Lequesne score,Lysholm score,WOMAC score,and visual analogue scale score.The secondary outcomes included tumor necrosis factor-α,interleukin-1β,and interleukin-6 in synovial fluid.RESULTS:A total of 31 randomized controlled trials were included with 1350 cases.Meta-analysis results showed that in primary outcomes:(1)Lequesne score was better in the combined group than that in the control group at 1 week after surgery(MD=-0.33,95%CI:0.67 to-0.00,P=0.05),after the full treatment course(MD=-1.00,95%CI:-1.34 to-0.66,P<0.00001),3 months after surgery(MD=-1.04,95%CI:-1.44 to-0.64,P<0.00001).(2)Lysholm score was better in the combined group than that in the control group at 1 week after surgery(MD=5.84,95%CI:4.79-6.88,P<0.00001),after the full treatment course(MD=9.21,95%CI:6.93-11.49,P<0.00001),3 months after surgery(MD=9.14,95%CI:6.34-11.94,P<0.00001),half year after surgery(MD=10.14,95%CI:6.50-13.78,P<0.00001),1 year after surgery(MD=11.54,95%CI:9.92-13.16,P<0.00001).(3)WOMAC score was better in the combined group than that in the control group at 1 year after surgery(MD=-18.38,95%CI:-28.53 to-8.23,P=0.0004).Visual analogue scale score was better in the combined group than that in the control group at 1 week after surgery(MD=-0.91,95%CI:-1.11 to-0.72,P<0.00001),after the full treatment course(MD=-0.97,95%CI:-1.23 to-0.72,P<0.00001),3 months after surgery(MD=-0.41,95%CI:-0.52 to-0.31,P<0.00001).(4)Lequense score was better in the combined group after the full treatment course compared with that after only one week(MD=1.47,95%CI:1.14-1.80,P<0.00001).(5)The combined group could better reduce the contents of tumor necrosis factor-α,interleukin-1β,and interleukin-6 in the synovial fluid(P≤0.05),which could better control the inflammation.CONCLUSION:Arthroscopy combined with sodium hyaluronate can achieve a better short-and medium-term curative effect in knee osteoarthritis than arthroscopy alone.However,more high-quality studies are needed to verify the above conclusions.