踝关节融合术与全踝关节置换术治疗终末期踝关节炎临床疗效的Meta分析

Meta-analysis of clinical efficacy of ankle arthrodesis and total ankle arthroplasty in the treatment of end-stage ankle arthritis

目的:系统评价全踝关节置换术(total ankle arthroplasty,TAA)和踝关节融合术(ankle arthrodesis,AA)在治疗终末期踝关节炎的临床疗效。方法:文献检索PubMed、EMBASE和Cochrane图书馆数据库发表的TAA或AA治疗终末期踝关节炎的文献,检索日期从建库至2021年6月。采用偏倚风险工具进行文献质量评价。采用RevMan 5.3软件美国足对两组踝外科协会踝与后足评分(American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale,AOFAS)、视觉模拟评分(visual analog scale,VAS)、踝关节骨关节炎评分(ankle osteoarthritis scale,AOS),步态分析(步速、步频、步幅)、活动范围(range of motion,ROM),满意度、并发症和再次手术率进行Meta分析。结果:共纳入12篇文献,其中AA组1050例,TAA组3760例,共计4810例患者。Meta分析结果显示两组的AOFAS总分[MD=-3.12,95%CI(-9.02,2.96),P=0.31]、疼痛评分[MD=1.60,95%CI(-1.35,4.54),P=0.29]、对线评分[MD=-0.04,95%CI(-0.52,0.44),P=0.88]、VAS[MD=0.10,95%CI(-0.49,0.68),P=0.74]和AOS总分[MD=-4.01,95%CI(-8.28,0.25),P=0.06]比较,差异无统计学意义(P>0.05)。TAA组AOFAS功能评分较TAA组明显改善[MD=44.22,95%CI(-8.01,-0.43),P=0.03]。两组步态分析比较差异无统计学意义(P>0.05)。两组术后ROM[MD=-4.93,95%CI(-6.35,-3.52),P<0.00001]和术前到随访ROM变化[MD=-5.74,95%CI(-8.88,-2.61),P=0.0003]均有显著改善。两组的满意度比较差异无统计学意义[OR=1.011,95%CI(0.46,2.23),P=0.98]。与AA组相比,TAA组的并发症[OR=1.61,95%CI(1.26,2.06),P=0.0002]与非翻修再次手术率[OR=1.61,95%CI(1.17,2.21),P=0.003]明显更低,两组的翻修再次手术率[OR=1.02,95%CI(0.37,2.78),P=0.97]差异无统计学意义(P>0.05)。结论:AA与TAA的临床疗效相似,但TAA的非翻修再次手术率和主要手术并发症明显降低。因此,还需要进一步的高质量的方法学研究和长期的随访来证实该结论。

Objective To systematically review the clinical efficacy of total ankle arthroplasty(TAA)and ankle arthrodesis(AA)in the treatment of end-stage ankle arthritis.Methods The PubMed,EMBASE and Cochrane Library databases were searched for articles published in the treatment of end-stage ankle arthritis with AA or TAA from the establishment of the database to June 2021.Bias risk tool was used to evaluate the quality of the literature.The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale(AOFAS),visual analog scale(VAS),ankle osteoarthritis scale(AOS),gait analysis(pace,frequency,stride),range of motion(ROM),satisfaction,complications and reoperation rate were analyzed by meta-analysis between AA and TAA groups by RevMan 5.3 software.Results A total of 12 articles were included,including 1050 patients in the AA group and 3760 patients in the TAA group,totaling 4810 patients.Meta-analysis showed that the total score of AOFAS[MD=-3.12,95%CI(-9.02,2.96),P=0.31],pain score[MD=1.60,95%CI(-1.35,4.54),P=0.29],alignmentl score[MD=-0.04,95%CI(-0.52,0.44),P=0.88],VAS[MD=0.10,95%CI(-0.49,0.68),P=0.74],and AOS total score[MD=-4.01,95%CI(-8.28,0.25),P=0.06],the difference was not statistically significant(P>0.05).The score of AOFAS functional in TAA roup was significantly higher than that in TAA group[MD=44.22,95%CI(-8.01,-0.43),P=0.03].There was no significant difference in gait analysis between the two groups(P>0.05).Postoperative ROM[MD=-4.93,95%CI(-6.35,-3.52),P<0.00001]and change in ROM from preoperative to follow-up[MD=-5.74,95%CI(-8.88,-2.61),P=0.0003]between two groups,the difference was statistically significant.There was no significant difference in satisfaction between the two groups[OR=1.011,95%CI(0.46,2.23),P=0.98].Complications[OR=1.61,95%CI(1.26,2.06),P=0.0002]and non-revision reoperation[OR=1.61,95%CI(1.17,2.21),P=0.003]were significantly lower in the TAA group than in the AA group.There was no significant difference in the rate of revision and reoperation(P>0.05)between the two groups[OR=1.02,95%CI(0.37,2.78),P=0.97].Conclusion The clinical efficacy of AA is similar to that of TAA,but the non revision reoperation rate and main surgical complications of TAA are significantly reduced.Therefore,further high-quality methodological research and long-term follow-up are needed to confirm this conclusion.