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標題: | 後十字韌帶重建的哪些手術方法能使膝關節功能達到最佳狀態?系統文獻回顧及網絡統合分析 Which Surgical Treatments for Posterior Cruciate Ligament Reconstruction Resulted in the best knee function? A Systematic review and Network Meta-analysis |
作者: | Mei-Ting Wang 王美婷 |
指導教授: | 季瑋珠(Wei-Chu Chie) |
關鍵字: | 後十字韌帶重建,元件網絡統合分析,網絡統合分析,序貫網絡統合分析,Lysholm量表,Tegner量表, Posterior cruciate ligament reconstruction,Component network meta-analysis,Network meta-analysis,Trial sequential analysis,Lysholm knee scaling score,Tegner activity score, |
出版年 : | 2020 |
學位: | 碩士 |
摘要: | 背景 隨著交通工具的進步及高強度運動的盛行(例如橄欖球),後十字韌帶損傷的發生率隨之上升,長期追蹤後發現,保守性治療(包含復健)及手術重建皆能促進膝功能的恢復,因此接受手術治療的盛行率不高,因此實驗性隨機研究仍顯不足,因此目前哪一種後十字韌帶的重建手術術後能達到最好的功能仍有爭議。而過去觀察性研究指出,後十字韌帶損傷若不重建,則較重建組有較高的機會發生關節的退化或關節炎,因此後十字韌帶是否重建對高活動度的成人或運動員是個重要的議題。 後十字韌帶的重建有許多選擇,包括重建的時間、嫁接韌帶的數目及固定的方式,還有接枝(Graft)重建的組織來源…等,對於重建接枝數目的選擇有:單股(Single-Bundle)或雙股(Double-Bundle);遠端常見的固定方式為穿過脛骨固定(Transtibial)或鑲嵌脛骨上(Tibial Inlay),這四種方式常見於後十字韌帶的重建的討論,但選擇哪一種方法能得到較好的預後,仍沒有定論。過去在大體研究中發現,雙股或鑲嵌於脛骨的手術方式比較單股跟穿過脛骨固定有更好的生物力學表現(Biomechanical),但在功能性上的表現卻不一致,因此需要更多的研究來證實。在較少人使用手術治療的情況下,目前亦沒有同時對四種常用的手術治療成效評估與共識。 目前已有不少的傳統統合分析,針對接枝的數目(單股vs.雙股)或接枝固定的方式進行兩兩相比,但並沒有統計上顯著意義,也沒有一致性的結果,因此我們希望透過網絡統合分析,來綜合說明這樣的研究證據。 目的 後十字韌帶重建的主要術式有四種:單股-穿過脛骨、單股-鑲嵌於脛骨、雙股-穿過脛骨、雙股-鑲嵌於脛骨四種,與過去統合分析不同的是,本文希望透過網絡統合分析的方式,希望同時納入更多的術式變數來尋找最佳的重建方式,並且匯集更多研究證據包括隨機試驗研究及觀察性研究,來確認各組膝功能表現(包括Lysholm Knee Scaling Score及Tegner Activity Score)是否有優劣的差異。 研究方法 為了評估後十字韌帶重建後膝功能的表現,我們搜尋了Pubmed、Web of Science及EMBASED三個資料庫到2019年12月的文章,從中篩選出有包含上述四種手術方式(單股-穿鑿脛骨、單股-鑲嵌於脛骨、雙股-穿鑿脛骨、雙股-鑲嵌於脛骨)有兩組以上比較術後膝功能的文章,隨機控制試驗及觀察性研究的比較性文章都會被納入,共蒐集到了21篇研究總共有979名接受後十字韌帶重建的患者;其中有5篇為隨機控制試驗,16篇為觀察性世代研究,透過網路統合分析(Network Meta-Analysis)我們對四種術式進行直接與間接的比較,呈現其累積發生率以及獲得第一名的機率,並且使用元件網絡統合分析(Component Network Meta-Analysis),來對接枝的數目(單股vs.雙股)或固定的方式(穿鑿vs. 鑲嵌)進行各自效益的估計。並且透過試驗序貫分析方法(Trial Sequential Analysis)來確認未來更多的研究是否有機會獲得其優劣的差異,或者落入無效區(Futility area)。 結果 四種手術方式中,透過網絡統合分析後發現:雙股-鑲嵌脛骨在Tegner activity score的表現上顯著比單股-穿鑿脛骨優秀,且兩種量表一致的傾向為:單股-穿鑿脛骨為最差的表現。在Lysholm Knee Scaling Score中,不同的機率分析方式有不一樣的排名,而Tegner activity score則有排名一致性,優到劣依序為:雙股-鑲嵌脛骨、單股-鑲嵌脛骨、雙股穿鑿脛骨、單股-穿鑿脛骨。而元件網絡統合分析呈現;雙股比單股在Lysholm Knee Scaling Score增加0.31的效益,而鑲嵌比穿鑿增加0.70的效果,但統計上無顯著意義。而且單或雙股-穿鑿比較的試驗序貫分析方法的檢定中,檢定尚未達到最大資訊的50%,也意味著仍需更多的研究證實單雙股-穿鑿術式之間的差異。建議未來納入更多研究及干擾因子;例如手術的成本效益或住院天數來分析,或參考更多雙股-鑲嵌脛骨的研究,來選擇適合患者的手術方式。 結論 後十字韌帶損傷透過任一種後十字韌帶重建能改善膝功能表現,也可能降低未來關節炎的發生率,也沒有哪一種術式表現一致性的優秀。雙股-鑲嵌脛骨在Tegner activity score有潛在的優異性,雖然在Lysholm Knee Scaling Score使用哪種手術方式沒無顯著差異,而單純比較單雙股-穿鑿脛骨的差異上,未來仍需更多研究來比較術式之間的優劣。 BACKGROUND In recent decades with the advancement of high-intensity sports (such as American football and rugby) and transportation, the incidence of posterior cruciate ligament (PCL) has increased. The prevalence of surgical treatment is not that high and previous studies still lack more randomized-controlled trials (RCTs) to determine which kind of PCL reconstruction can achieve better knee function outcomes. Previous observational studies in the past have pointed out that if PCL injury did not repair, the chances of joint degradation or arthritis will highly increase than the reconstructed group. The most common choices of PCLR were the number of reconstruction grafts either single-bundle (SB) or double-bundle (DB), with a fixation method at the distal end of transtibial fixation or tibial inlay. At present, there has been several traditional meta-analyses comparing the numbers of grafts, or the fixed way of grafting, however, there was no statistically significant difference and no consistent results. PURPOSE The purpose of this study is to compare four main PCL reconstruction methods: single-bundle with transtibial (ST), single-bundle with tibial inlay (SI), double-bundle with transtibial (DT), and double-bundle with tibial inlay (DI). In the case of fewer people using surgical treatment, there is currently no simultaneous evaluation and consensus on the effectiveness of the four commonly used surgical treatments. Unlike previous analysis, this study will integrate a network meta-analysis and hope to incorporate more surgical variables to find the better reconstruction method. We will be gathering more research evidence including RCTs along with observational studies to confirm the performance of each group, with including Lysholm Knee Scaling Score (LKSS) and Tegner Activity Score (TAS). METHODS In this study, we searched three databases of Pubmed, Web of Science, and EMBASED all through December 2019. In order to evaluate the performance of knee function after PCL reconstruction, we selected ST, SI, DT, and DI methods from studies including randomized controlled trials and observational studies. In total, there were 21 studies that fulfilled our requirements, with 5 randomized controlled trials and 16 observational studies. A total of 979 patients underwent PCL reconstruction. Through network meta-analysis, we directly and indirectly compared these four methods, presenting their cumulative incidence and the probability of being the best. In addition, we used component network meta-analysis to estimate the respective effects of number of grafts and fixed way. Lastly, we proceeded with trials sequential analysis method to test the result will fall into its advantages, disadvantages, or futility area. RESULTS Through the network meta-analysis of the reconstruction methods, the DI has showed particularly better TAS than the ST method. And these two scales were consistent results showing that ST showed the worst performance. Compared with the LKSS, the ranking systems of TAS showed consistent results. The priority from good to bad was: DI, SI, DT, ST. The integrated analysis of component network showed that DB to SB had a 0.31 increase in LKSS, and the tibial inlay was 0.70 more effective than transtibial. In the trials sequential analysis, the result of test fell into a futility area, meaning no matter how many amounts of research is analyzed, the results of DT and ST will have no significant difference. It is recommended that future studies including more DI researches or referencing more factors such as cost-effectiveness of surgery or the length of hospital stay should be considered about deciding a suitable method for the patients. CONCLUSION PCL injuries can improve knee function and performance through reconstruction and may also reduce the risks of arthritis in the future. No significant difference was found in any of the PCLR methods. The DI has potential superiority in TAS. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/60160 |
DOI: | 10.6342/NTU202003226 |
全文授權: | 有償授權 |
顯示於系所單位: | 流行病學與預防醫學研究所 |
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