Posterior cruciate-retaining versus posterior cruciate-stabilized prostheses for total knee arthroplasty: a meta-analysis

doi:10.3969/j.issn.2095-4344.1054

Abstract

Abstract:

BACKGROUND: Total knee arthroplasty prosthesis includes the posterior cruciate ligament-retaining and the posterior cruciate-stabilized prostheses. Both prostheses can achieve the desired therapeutic effect in long-term follow-up. Both types of prosthesis have a long history of development, but whether posterior cruciate ligament retention is needed or not still remains unclear.

OBJECTIVE: To evaluate the clinical and imaging results of posterior cruciate-retaining versus posterior cruciate-stabilized in total knee arthroplasty.

METHODS: PubMed, Cochrane Library, EMbase, Web of Science, CNKI, WanFang, VIP and CBM databases were retrieved for the randomized controlled trials concerning posterior cruciate-retaining versus posterior cruciate-stabilized in total knee arthroplasty published before April 2018. Literature quality and data extraction were performed by two reviewers. Literature heterogeneity was assessed by RevMan software and meta-analysis was conducted.

RESULTS AND CONCLUSION: (1) Sixteen randomized controlled trials were enrolled involving 1 747 patients, including 899 patients undergoing total knee arthroplasty using posterior cruciate-retaining (observation group) and 848 patients using posterior-stabilized total knee arthroplasty (control group). (2) Meta-analysis results showed that no significant differences were found in the American Knee Society Score [MD=0.13, 95%CI (-0.73, 1.00)], Western Ontario and McMaster Universities Osteoarthritis Index [MD=0.59, 95%CI (0.00, 1.18)], knee extension [MD=0.04, 95%CI (-0.36, 0.45)] or posterior tibial slope [MD=-0.09, 95%CI (-0.52, 0.33)] after surgery between two groups. (3) Compared with the observation group, in the control group, the range of motion of the knee joint was significantly increased [MD=-6.78, 95%CI (-8.88, -4.67)], knee flexion was significantly increased [MD=-4.22, 95%CI (-6.03, -2.41)] and the femorotibial angle was closed to 6° [MD=0.85, 95%CI (0.46, 1.25)]. (4) There were no significant differences in the pain residual rate [OR=1.26, 95%CI (0.57, 2.78)], infection rate on the surgical site [OR=0.50, 95%CI (0.13, 1.88)] or revision rate [OR=0.59, 95%CI (0.15, 2.32)] between two groups. (5) Funnel plot revealed no significant bias in the included studies. (6) In summary, patients using posterior cruciate-stabilized prosthesis have better active range of motion of the knee joint, knee flexion and mechanical femorotibial angle than those using posterior cruciate-retaining prosthesis. Due to the operative difficulty of posterior cruciate-retaining prosthesis, the junior doctors should choose posterior cruciate-stabilized prosthesis first, and senior doctors can choose the prosthesis according to the patient’s conditions and their proficiency of the operation method.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Arthroplasty, Replacement, Knee, Prosthesis Implantation, Meta-Analysis, Tissue Engineering

CLC Number:

R459.9

Shi Junheng, Zhong Degui, Fan Zhirong, Huang Yongquan. Posterior cruciate-retaining versus posterior cruciate-stabilized prostheses for total knee arthroplasty: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(8): 1282-1290.

Figures/Tables 5

2.2 纳入文献的基本特征和文献质量评价此次研究中观察组是在全膝关节置换术中使用后交叉韧带保留型假体，对照组是在全膝关节置换术中使用后稳定型假体。共纳入16个随机对照试验[9-24]，有1 747例患者行全膝关节置换术，其中观察组的899例患者采用后交叉韧带保留型假体，对照组有848例患者采用后稳定型假体。所有纳入的随机对照试验中均报道了纳入排除标准，且方法学质量均较好，Jadad评分都在4分及以上，Jadad评分最低分是4分，最高分则达到7分。纳入研究的一般情况详见表1。 2.3 结局指标Meta分析 2.3.1 术后美国膝关节协会评分有12项研究报道了全膝关节置换术后美国膝关节协会评分[9-13，15-16，18-19，21-23]，其中后交叉韧带保留型假体组患者703例、后稳定型假体组患者572例。经异质性检验，χ2=10.84，P=0.46≥ 0.1，I2=0%，即12项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=0.13，95%CI(-0.73，1.00)]，合并效应量检验，Z=0.30，P=0.76 > 0.05，提示全膝关节置换选用后交叉韧带保留型假体与后稳定型假体术后的美国膝关节协会评分差异无显著性意义，见图2。 2.3.2 术后WOMAC评分有4项研究报道了全膝关节置换术后WOMAC评分[9，16-17，21]，其中后交叉韧带保留型假体组患者358例、后稳定型假体组患者366例。经异质性检验，χ2= 0.57，P=0.90≥ 0.1，I2=0%，即4项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=0.59，95%CI(0.00，1.18)]，合并效应量检验，Z=1.97，P=0.05≥0.05，提示全膝关节置换选用后交叉韧带保留型假体与后稳定型假体术后的WOMAC评分差异无显著性意义，见图3。 2.3.3 术后膝关节主动活动度有7项研究报道了全膝关节置换术后膝关节主动活动度[9，13，16，18，21-23]，其中后交叉韧带保留型假体组患者425例、后稳定型假体组患者203例。经异质性检验，χ2=9.14，P=0.17≥ 0.1，I2=34%，即7项纳入的研究之间存在同质性，因而应用固定效应模型合并， [MD=-6.78，95%CI (-8.88，-4.67)]，合并效应量检验，Z=6.31，P < 0.000 01，提示相较于在全膝关节置换中选用后交叉韧带保留型假体，选用后稳定型假体术后膝关节主动活动度更大，差异有显著性意义，见图4。"

2.3.4 术后膝关节伸直活动度有5项研究报道了全膝关节置换术后膝关节伸直活动度[12，14，18，21，23]，其中后交叉韧带保留型假体组患者131例、后稳定型假体组患者127例。经异质性检验，χ2=4.92，P=0.30≥ 0.1，I2=19%，即5项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=0.04，95%CI (-0.36，0.45)]，合并效应量检验，Z=0.21，P=0.84≥ 0.05，提示全膝关节置换选用后交叉韧带保留型假体与后稳定型假体术后膝关节伸直活动度的差异无显著性意义，见图5。 2.3.5 术后膝关节屈曲活动度有10项研究报道了全膝关节置换术后膝关节屈曲活动度[10，12，14-15，17-21，23]，其中后交叉韧带保留型假体组患者350例、后稳定型假体组患者346例。经异质性检验，χ2=14.04，P=0.12≥ 0.1，I2=36%，即10项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=-4.22，95%CI (-6.03，-2.41)]，合并效应量检验，Z=4.57，P < 0.000 01，提示相较于在全膝关节置换中选用后交叉韧带保留型假体，选用后稳定型假体术后膝关节屈曲活动度更大，差异有显著性意义，见图6。 2.3.6 术后机械胫股角有3项研究报道了全膝关节置换术后机械胫股角[11，17-18]，其中后交叉韧带保留型假体组患者205例、后稳定型假体组患者172例。经异质性检验，χ2= 2.36，P=0.31≥ 0.1，I2=15%，即3项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=0.85，95%CI (0.46，1.25)]，合并效应量检验，Z=4.25，P < 0.000 1，提示相较于在全膝关节置换中选用后交叉韧带保留型假体，选用后稳定型假体术后机械胫股角更小，更接近于理想的6°机械胫股角[25]，差异有显著性意义，见图7。 2.3.7 术后胫骨后倾角有4项研究报道了全膝关节置换术后胫骨后倾角[13，16-17，22]，其中后交叉韧带保留型假体组患者347例、后稳定型假体组患者346例。经异质性检验， χ2=4.27，P=0.23≥ 0.1，I2=30%，即4项纳入的研究之间存在同质性，因而应用固定效应模型合并，[MD=-0.09，95%CI (-0.52，0.33)]，合并效应量检验，Z=0.43，P=0.67，提示全膝关节置换选用后交叉韧带保留型假体与后稳定型假体术后胫骨后倾角的差异无显著性意义，见图8。 2.3.8 术后膝关节疼痛残留率有7项研究报道了全膝关节置换术后膝关节疼痛残留率[10，12-13，15-16，18，22]，其中后交叉韧带保留型假体组患者463例、后稳定型假体组患者457例，后交叉韧带保留型假体组术后出现膝关节疼痛残留14例，后稳定型假体组术后出现膝关节疼痛残留11例。经异质性检验，χ2=3.06，P=0.69≥ 0.1，I2=0%，即7项纳入的研究之间存在同质性，因而应用固定效应模型合并，[OR=1.26，95%CI (0.57，2.78)]，合并效应量检验，Z=0.56，P=0.58 > 0.05，提示全膝关节置换选用后交叉韧带保留型假体与后稳定型假体术后膝关节疼痛残留率的差异无显著性意义，见图9。"

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