两种方法治疗退行性内侧半月板后根部损伤疗效比较

Comparison of two different treatment methods for degenerative medial meniscus posterior root tears

目的对比分析关节镜下半月板成形术与保守治疗对退行性内侧半月板后根部损伤(MMPRTs)的临床疗效。方法收集2008年1月至2013年12月间内蒙古自治区人民医院收治的退行性MMPRTs患者,排除Kellgren-Lawrence分级(K-L分级)4级、非单纯性MMPRTs以及随访期不足5年患者。最终纳入53例(45~65岁),其中关节镜下半月板成形术治疗组26例,保守治疗27例。经5年随访后,根据国际膝关节评分委员会(IKDC)评分、Lysholm评分、K-L分级,以及直至末次随访为止接受全膝人工关节置换术(TKA)的比例,比较两组患者的临床疗效,并分析成形组中临床疗效欠佳患者的影响因素。术前术后评分比较采用t检验,计数资料组间比较采用卡方检验,组内各项风险因素进行COX回归分析,关节生存率比较采用Kaplan-Meier生存分析。结果关节镜下半月板成形术后26例患者随访5年以上,平均(7.6±2.3)年。末次随访平均IKDC评分为(58.7±12.4)分,平均Lysholm评分为(63.9±21.5)分,且34.6%(9/26)患者在末次随访时膝骨关节炎发生不同程度进展(K-L分级≥Ⅱ级),其中30.8%(8/26)患者在术后5年内接受了TKA手术。成形组与保守组相比,术后IKDC评分,Lysholm评分、K-L分级,以及接受TKA手术治疗的比例差异均无统计学意义(均为P>0.05)。接受成形术的患者中,女性患者最终的IKDC评分为(48.5±16.2)、男性为(58.2±11.8),差异无统计学意义(P>0.05)。女性[比值比(OR)=1.351,95%置信区间(CI)(1.062,2.003),P=0.029]、BMI较高[OR=0.143,95%CI(0.016,1.283),P=0.022]、膝内翻[OR=2.003,95%CI(1.131,6.461),P=0.035]、术前K-L分级[OR=2.051,95%CI(1.272,5.314),P=0.003]与半月板外凸[OR=0.105,95%CI(0.011,1.051),P=0.045]等多因素与末次随访时骨关节炎进展存在相关性。结论单纯行关节镜下半月板成形术治疗MMPRTs相比保守治疗而言不能有效延缓骨关节炎进展,女性、BMI增高、膝内翻以及半月板外凸这些风险因素与其预后不良有关。

Objective Toevaluate the clinical efficacy of arthroscopic partial meniscectomy to treat degenerative medial meniscus posterior root tears(MMPRTs)compared to a matched group of conservative treated MMPRTs.Methods From January 2008 to December 2013,53 patients(age 45 to 65 years)with degenerative MMPRTs treated in Inner Mongolia People’s Hospital were enrolled in this study,including 26 patients underwent arthroscopic partial meniscectomy and 27 patients received conservative treatment.The patients with K-L grade four,non-simple MMPRTs or a follow-up period of less than five years were excluded.The IKDC score,Lysholm score,Kellgren-Lawrence(K-L)grade and the ratio of total knee arthroplasty(TKA)at five years postoperatively were used for clinical evaluation.Clinical and radiographic outcomes were compared between the two groups.Analysis was performed to determine risk factors for poor clinical and radiographic outcome in the arthroscopic partial meniscectomy group alone.Preoperative and postoperative scores were compared by t test,count data were compared by chi-square test,each risk factor within the group was subjected to COX regression analysis.Joint survival rate was compared by Kaplan-Meier survival analysis.Results Twenty-six patients who underwent arthroscopic partial meniscectomy were followed for at least five years,(7.6±2.3)years on anverage.The final IKDC score was(58.7±12.4),Lysholm score was(63.9±21.5),and nine of the 26 patients(34.6%)had gradeⅡor higher level arthritis at the final follow-up than baseline.The knee osteoarthritis radiographic progression was 34.6%(8/26),and eight of the 26 patients(30.8%)were treated the operative progression by TKA.There was no significant difference in final IKDC scores,Lysholm score,K-L grades,progression to arthroplasty,or TKA rate between the arthroscopic partial meniscectomy group and conservative group(all P>0.05).In the arthroscopic partial meniscectomy group,the female patients had lower final IKDC scores(48.5±16.2)compared to the males(58.2±11.8),but there was no significant difference(P>0.05).Higher BMI[odds ratio(OR)=0.143,95%confidence interval(CI)(0.016,1.283),P=0.022],varus malalignment[OR=2.003,95%CI(1.131,6.461),P=0.035],preoperative K-L grade[OR=2.051,95%CI(1.272,5.314),P=0.003]and meniscal extrusion[OR=0.105,95%CI(0.011,1.051),P=0.045]was associated with higher rate of arthritis at final follow-up.Conclusions Compared with conservative treatment,arthroscopic partial meniscectomy for degenerative MMPRTs provides no benefit in delaying the progression of osteoarthritis.Female gender,increased BMI,and meniscus extrusion may associate with worse outcome.