Chinese Journal of Tissue Engineering Research ›› 2021, Vol. 25 ›› Issue (15): 2437-2444.doi: 10.3969/j.issn.2095-4344.3801
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Efficacy of arthroscopy combined with sodium hyaluronate for knee osteoarthritis: a meta-analysis
Li An’an1, Chen Jiayun1, Chen Jin1, Song Min1, Li Congcong1, Ye Guozhu1, Wu Gaoyi2, Lin Wenzheng2, Cai Yuning2, Liu Wengang2
- 1Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; 2Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou 510095, Guangdong Province, China
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Received:2020-04-09Revised:2020-04-16Accepted:2020-05-19Online:2021-05-28Published:2021-01-05 -
Contact:Liu Wengang, MD, Chief TCM physician, Master’s supervisor, Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou 510095, Guangdong Province, China -
About author:李安安，男，1996年生，广州中医药大学在读硕士。 -
Supported by:the Scientific Research Project of Guangdong Provincial Bureau of Traditional Chinese Medicine, No. 20183001 (to LWG); the Scientific Research Project of Guangdong Administration of Traditional Chinese Medicine, No. 20191021
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Cite this article
Li An’an, Chen Jiayun, Chen Jin, Song Min, Li Congcong, Ye Guozhu, Wu Gaoyi, Lin Wenzheng, Cai Yuning, Liu Wengang. Efficacy of arthroscopy combined with sodium hyaluronate for knee osteoarthritis: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2021, 25(15): 2437-2444.
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2.1 文献检索结果 初步检索到文献962篇，包括中文文献697篇，英文文献265篇，去除重复的文献，根据纳入和排除标准，阅读文献标题、摘要、全文后，最终纳入31篇文献[9-39]，共 1 350例研究对象，其中联合组686例，对照组664例，文献筛选流程及结果见图2。"
2.2 纳入文献的基本特征 有1篇文 献仅在关节镜手术结束时立刻在关节腔内注射1次玻璃酸钠[16]，其他30篇文献在关节腔内玻璃酸钠注射方式为1次/周，共4-6周。见表1。"
2.3 文献质量评价结果 所有随机对照试验均提出随机分配，其中9个研究采用了随机数字表法[13，14，16，17，23，26，36-38]，有1个研究采用了电脑随机数法和单盲法[10]；所有研究均未提及使用双盲法；所有研究的数据完整性良好，但均未提及分配隐藏情况、选择性报告。 纳入文献的偏倚风险评价和总结图具体见图3。"
2.4 Meta分析结果 2.4.1 Lequesne评分差异 有4篇文献报道了Lequesne评分[12，16，24，28]。各亚组内均无统计学异质性，采用固定效应模型分析。有4篇文献均报道了术后1周的评分(I2=0%，P= 0.59) [12，16，24，28]，结果显示联合组评分优于对照组(MD= -0.33，95%CI：0.67至-0.00，P=0.05)；有3篇文献报道了治疗疗程结束后的评分(I2=0%，P= 0.43)[12，24，28]，结果显示联合组评分优于对照组(MD=-1.00，95%CI：-1.34至-0.66，P < 0.000 01)；有2篇文献报道了术后3个月的评分(I2=0%，P=0.89)[16，24]，结果显示联合组评分优于对照组(MD=-1.04，95%CI：-1.44至-0.64，P < 0.000 01)，见图4。 "
2.4.2 Lysholm评分差异 有22篇文献报道了Lysholm评分[11，13-19，22-27，29-33，37-39]。因部分亚组内具有统计学异质性，故采用随机效应模型分析。有3篇文献报道了术后1周的评分(I2=0%，P=0.47) [16，24，30]，结果显示联合组评分优于对照组，差异有显著性意义(MD=5.84，95%CI：4.79-6.88，P < 0.000 01)；有14篇文献报道了治疗疗程结束后的评分(I2=94%，P < 0.000 01) [11，13-14，17，24-27，29-32，37-39]，结果显示联合组评分优于对照组(MD=9.21，95%CI：6.93-11.49，P < 0.000 01)；有8篇文献报道了术后3个月的评分(I2=93%，P < 0.000 01) [13，16，18，22-24，32，39]，结果显示联合组评分优于对照组(MD=9.14，95%CI：6.34-11.94，P < 0.000 01)；有9篇文献报道了术后半年的评分(I2=96%，P < 0.000 01) [11，13-14，17，22，27，30，32]，结果显示联合组评分高于对照组 (MD=10.14，95%CI：6.50-13.78，P < 0.000 01)；有5篇文献报道了术后1年的评分(I2=72%，P < 0.006)[15，18-19，23，33]，结果显示联合组评分优于对照组(MD=11.54，95%CI：9.92-13.16，P < 0.000 01)，见图 5。多次反复阅读全文并查验数据后，异质性来源仍较难解释，考虑为指标所使用的问卷主观性较强，易受双方影响所致，但绝大多数试验均表现出良好的疗效，不影响总体疗效判断。 "
2.4.3 WOMAC评分差异 有2篇文献报道了WOMAC评分[9-10]。各亚组内均不具有统计学异质性，采用固定效应模型分析。2篇文献均报道了术后半年的评分(I2=0%，P=0.89)，结果显示联合组评分优于对照组(MD=-6.20，95%CI： -14.72-2.32，P=0.15) [9-10]；2篇文献均报道了术后1年的评分(I2=47%，P=0.17)[9-10]，结果显示联合组评分优于对照组(MD= -18.38，95%CI：-28.53至-8.23，P=0.000 4)，见图 6。"
2.4.4 目测类比评分差异 有9篇文献报道了目测类比评分[16，20-21，24-25，31-32，34，37]。亚组内具有统计学异质性，故采用随机效应模型分析。有3篇文献报道了术后1周的评分(I2=72%，P=0.03) [16，24，32]，结果显示联合组评分优于对照组(MD= -0.91，95%CI：-1.11至-0.72，P < 0.000 01)；有7篇文献报道了治疗疗程结束后的评分(I2=96%，P < 0.000 01) [20-21，24，25，31，34，37]，逐一排查后发现异质性主要来源于1篇文 献[31]，重新分析后异质性下降(I2=74%，P=0.002)，结果显示联合组评分优于对照组(MD=-0.97，95%CI：-1.23至-0.72，P < 0.000 01)；有2篇文献报道了术后3个月的评分[16，24]，不具有统计学异质性(I2=25%，P=0.25)，结果显示联合组评分优于对照组，差异有显著性意义(MD=-0.41，95%CI：-0.52至-0.31， P < 0.000 01)，见图 7。 "
2.4.5 联合组治疗1周后与全疗程结束时各组疗效评分差异 有5篇文献既报道了术后1周也报道了玻璃酸钠注射疗程结束后的评分[12，16，24，28，30]。有3篇文献报道了Lequesne评分[12，24，28]，不具有统计学异质性(I2=0%，P=0.91)，采用固定效应模型分析，结果显示治疗全疗程后评分优于术后1周(MD=1.47，95%CI：1.14-1.80，P < 0.000 01)；有2篇文献报道了Lysholm评分[24，30]，因异质性过大，考虑为指标所使用的问卷主观性较强，易受双方影响所致，且纳入试验数量少，故采用描述性分析，结果均显示治疗全疗程后评分优于术后1周(均P < 0.05)；1篇文献报道了目测类比评分[24]，结果显示治疗全疗程后评分优于术后1周(P < 0.000 01)，见图 8。 "
2.4.6 肿瘤坏死因子α水平差异 有5篇文献报道了术后关节液中肿瘤坏死因子α的水平[17，26，35-36，38]。因其中出现2种数量级的水平，无法合并分析，推测使用了两种不同方法进行测定，故分为2个亚组，亚组内不具有统计学异质性，采用固定效应模型分析。有3篇文献结果为百级数量级pg/mL(I2=0%，P=0.92) [17，26，38]，结果显示联合组肿瘤坏死因子α水平低于对照组(MD= -84.61，95%CI：-93.25至-75.98，P < 0.000 01)；有2篇文献结果为十级数量级pg/mL(I2=36%，P=0.21) [35-36]，结果显示联合组肿瘤坏死因子α水平低于对照组(MD=-5.37，95%CI：-6.14至-4.61，P < 0.000 01)，见图9。 "
2.4.7 白细胞介素1β水平差异 有6篇文献报道了术后关节液中白细胞介素1β的水平[18，23，26，35-36，38]，差异有显著性意义(I2=99%，P < 0.000 01)，分析后发现其中存在3种范围水平，推测采用3种不同公司试剂盒，故分为3个亚组进行分析，亚组内不存在统计学异质性，采用固定效应模型分析。有2篇文献采用了方法一(I2=10%，P=0.29) [18，35]，结果显示联合组白细胞介素1β水平低于对照组(MD=-20.97，95%CI：-22.36至-19.59，P < 0.000 01)；有3篇文献采用了方法二(I2=0%，P=0.53)[23，26，38]，结果显示联合组白细胞介素1β水平低于对照组(MD=-10.58，95%CI：-12.21至-8.96，P < 0.000 01)；有1篇文献采用了方法三[36]，结果显示联合组白细胞介素1β水平低于对照组(P < 0.000 01)，见图10。 "
2.4.8 白细胞介素6水平差异 有5篇文献报道了术后关节液中白细胞介素6水平[17，26，35-36，38]。 因其中出现两种数量级的水平，无法合并分析，推测使用了不同方法进行测定，故分开分析。3篇文献结果为百级数量级pg/mL[17，26，38]，并不具有统计学异质性(I2=36%，P=0.21)，采用固定效应模型分析，结果显示联合组肿瘤坏死因子α水平低于对照组，差异有显著性意义(MD=-35.82，95%CI： -45.23至 -26.42，P < 0.000 01)。剩余2篇文献为十级数量级pg/mL[35-36]，但合并分析后仍显示异质性过大(I2=99%，P < 0.000 01)，考虑仍采取了不同测定方法，无法进行Meta分析，故采用描述性报告，两者结果均显示联合组白细胞介素6水平低于对照组(P < 0.05)，见图11。 "
2.5 发表偏倚分析 以采用Lysholm评分为指标的文献绘制漏斗图，纳入的文献呈大致对称分布，可能存在较小的潜在发表偏倚，见图12。"
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