微创手术与标准手术在全膝关节置换疗效中的系统评价

目的 采用系统评价的方法比较微创手术和标准手术初次全膝关节置换的早期疗效.方法 计算机检索MEDLINE(1996年6月至2010年12月)、EMBASE(1996年6月至2010年12月)、PubMed( 1996年6月至2010年12月),Cochrane图书馆(2010年第2期);手工检索中华外科等国内近10年发表的关于微创手术和标准手术初次全膝关节置换的随机对照研究、荟萃分析和系统评价.评价指标包括:手术时间及出血量、术后5d膝关节VAS疼痛评分、活动范围ROM、股四头肌功能恢复时间、术后6周膝关节KSS评分、术后并发症、影像学指标(下肢胫股角和假体对线不良).结果 与标准手术方法比较:微创手术所需时间更长[WMD 14.16,95％CI(12.61,15.71)],但出血量少[ WMD 8.31,95％ CI(6.16,10.46)].在术后3～5 d VAS疼痛评分较低[WMD 4.99,95％ CI(4.19,5.78)].术后股四头肌功能恢复时间更短[WMD 4.99,95％CI(4.19,5.78)].微创手术并发症更多[RR 1.44,95％CI(1.00,2.07)].标准手术术后假体对线不良发生率略低于微创组.但两组差异仍无统计学意义[ WMD 0.20,95％CI( -0.12,0.52);RR 1.57,95％ CI(0.88,2.83)].结论 与传统手术方法比较,微创手术术后疼痛较轻;股四头肌功能恢复更快;出血量少.但采用微创手术所需时间更长,术后并发症更多,需严格把握手术适应证.术后影像学对假体位置的评估,标准手术更精确.

Systematic reviews of mini-invasive surgery versus standard approaches for total knee arthroplasty

Objective To conduct a systematic review to compare the early efficacies of minimally invasive surgery (MIS) versus conventional approaches in TKA (total knee arthroplasty). Methods Randomized controlled trials ( RCTs) and clinical controlled trials ( CCTs) were retrieved from the databases of MEDLINE ( 1996.6 - 2010.12), EMBASE ( 1996.6 - 2010.12), PubMed ( 1996 - 2010.12) and Cochrane Library ( Issue 2,2012).Journal of Orthopedics ( from establishment to December 2010) and Orthopedic Journal of China ( from establishment to December 2010) were manually searched.Both RCTs and CCTs were included.The data were extracted by two reviewers with designed extraction form RevMan 4.2.8 software for data analysis.The criteria were as follows: (1) operative duration and reduced blood loss; (2) VAS ( visual analog scale) score; (3) faster recovery of ROM ( range of movement); (4) quadriceps muscle strength; (5)component positioning malalignement; (6) tibiofemoral angle; (7) rate of complications.Results A total of 18 RCTs were included.Compared with the standard TKA procedure,the MIS group had a longer operative duration ( WMD ( weighted mean difference) 14.16,95％ CI ( confidence interval) ( 12.61,15.71)) ; reduced blood loss ( WMD 8.31,95％ CI( 6.16,10.46)) ; lower VAS score at Days 3 -5 post-operation ( WMD 4.99,95 ％ CI(4.19,5.78)) ; better Mean Knee Society scores at Week 6 post-operation ( WMD 4.99,95％ CI ( 4.19, 5.78 )), improvement in ROM occurred more rapidly at Month 3 post-TKA ( WMD 14.59,95％ CI( 8.39,20.80)). Although the differences were not statistically significant,tibiofemoral angle was more precise in the standard group and the rate of component malalignment occurred more frequently in the MIS group ( WMD 0.20,95％ CI( - 0.12,0.52)) ( RR 1.57,95％ CI(0.88,2.83)).Conclusion MIS leads to a faster recovery than conventional surgery with a shorter operative duration,a reduced blood loss,a lower VAS score and a faster recovery of ROM and quadriceps muscle strength.However,the rates of component malalignment and complications occur more frequently in the MIS group.Potential benefits in long-term survival rate and functional improvement require further investigations.