胫骨内侧开放与外侧闭合截骨治疗单间室膝骨关节炎的Meta分析

Medial open-wedge tibial osteotomy versus lateral closed-wedge tibial osteotomy for unicompartmental knee osteoarthritis:a meta-analysis

目的:胫骨高位截骨是治疗膝关节内侧间室骨关节炎的有效手段,临床常用的术式有胫骨内侧开放楔形截骨和外侧闭合楔形截骨,对于两种手术选择的依据存在一些争议,文章通过Meta分析对胫骨内侧开放截骨和外侧闭合截骨的临床疗效和影像结果进行评价。方法:检索建库至2021年10月PubMed、Ovid、中国知网、万方、维普、Cochrane图书馆和EMbase数据库关于胫骨内侧开放楔形截骨和外侧闭合楔形截骨治疗单间室膝骨关节炎对比的文献。根据指定的纳入和排除标准进行文献筛选及数据整理,随机对照试验用Cochrane手册标准评估偏倚风险,队列研究使用NOS量表进行评价,使用RevMan 5.3软件对数据进行Meta分析。结果:①共纳入文献13篇,其中8项为随机对照试验,5项为队列研究,文献整体质量较高。②Meta分析结果显示,胫骨内侧开放楔形截骨和胫骨外侧闭合楔形截骨主要在术后胫骨平台后倾角(MD=2.82,95%CI:1.31-4.33,P=0.0002)、髌骨高度BPI等指数(MD=-0.09,95%CI:-0.11至-0.07,P<0.00001)、手术时间(MD=-19.48,95%CI:-31.02至-7.94,P=0.0009)上有显著差异,而在术后机械轴角度(MD=-0.01,95%CI:-0.51-0.48,P=0.96)、矫正角度(MD=-0.16,95%CI:-0.75-0.43,P=0.60)、HSS评分(MD=-0.46,95%CI:-1.47-0.55,P=0.37)、目测类比评分(MD=0.12,95%CI:-0.24-0.48,P=0.51)、Lysholm评分(MD=-0.17,95%CI:-2.53-2.19,P=0.89)和并发症(OR=0.68,95%CI:0.25-1.82,P=0.44)方面则效果相近。结论:胫骨内侧开放和外侧闭合楔形截骨治疗单间室膝骨关节炎的整体临床疗效相似,但胫骨内侧开放楔形截骨更易操作,但易导致术后胫骨平台后倾角加大以及髌骨下降;临床医生对于单间室膝骨关节炎患者需进行充分的术前影像评估及个体化选择对应术式。

OBJECTIVE:High tibial osteotomy is an effective treatment for medial compartment knee osteoarthritis,and the commonly used clinical procedures are medial open-wedge high tibial osteotomy and lateral closed-wedge high tibial osteotomy.There are some controversies about the basis of the two surgical choices.The article evaluated the clinical efficacy and imaging results of medial open-wedge high tibial osteotomy and lateral closed-wedge high tibial osteotomy by meta-analysis.METHODS:PubMed,Ovid,CNKI,Wanfang,VIP,Cochrane Library,and EMbase databases were searched for articles on the comparison of medial open-wedge tibial osteotomy and lateral closed-wedge tibial osteotomy for osteoarthritis of the knee.The retrieval period was from the database inception to October 2021.Literature screening and data compilation were conducted according to the specified inclusion and exclusion criteria.Randomized controlled trials were evaluated using Cochrane Handbook criteria to assess risk of bias,and cohort studies were evaluated using the NOS scale.RevMan 5.3 software was used for meta-analysis.RESULTS:(1)A total of 13 publications were included,of which 8 were randomized controlled trials,and 5 were cohort studies.The overall quality of the literature was high.(2)Meta-analysis results showed that medial tibial open-wedge osteotomy and lateral tibial closed-wedge osteotomy presented significant differences in postoperative posterior tibial plateau inclination(MD=2.82,95%CI:1.31-4.33,P=0.0002),patellar height BPI(MD=-0.09,95%CI:-0.11 to-0.07,P<0.00001),and operative time(MD=-19.48,95%CI:-31.02 to-7.94,P=0.0009).Postoperative mechanical axis angle(MD=-0.01,95%CI:-0.51-0.48,P=0.96),angle of correction(MD=-0.16,95%CI:-0.75-0.43,P=0.60),HSS score(MD=-0.46,95%CI:-1.47-0.55,P=0.37),visual analogue scale score(MD=0.12,95%CI:-0.24-0.48,P=0.51),Lysholm score(MD=-0.17,95%CI:-2.53-2.19,P=0.89),and complications(OR=0.68,95%CI:0.25-1.82,P=0.44)were similarly effective.CONCLUSION:The overall clinical outcomes of the two procedures are similar,and the medial tibial open-wedge osteotomy has the advantage of being easier to perform,but is prone to increased posterior tibial plateau tilt and patellar drop,so adequate preoperative imaging evaluation and individualized selection of the procedure are needed for patients with unicompartmental knee osteoarthritis.