背景:首次肩关节前脱位(FTASDs)的最佳治疗仍存在争议。因此,本研究的目的是通过对现有文献的系统评价和荟萃分析,评估FTASDs关节镜稳定手术的疗效.
方法:MEDLINE,从开始到2022年12月18日,对EMBASE和WebofScience进行了搜索,以进行单臂或比较研究,评估首次脱位后通过关节镜稳定手术管理的FTASD。合格的比较研究包括评估FTASD固定后结果的研究,或复发性脱位后的关节镜稳定。合格的证据级别为I至IV。主要结果包括肩关节再脱位的发生率,累积的肩部不稳定以及随后的肩部稳定手术。
结果:纳入了34项2,222例肩关节脱位的研究。其中,5项研究(n=408肩)是比较首次脱位后固定和关节镜Bankart修复(ABR)的随机试验.另外16项研究是非随机比较研究,评估首次脱位(ABR-F)后关节镜Bankart修复固定(研究=8,n=399肩)或复发性脱位后关节镜Bankart修复(ABR-R)(研究=8,n=943肩)。所有研究的平均随访时间为59.4±39.2个月。累计随访损失为4.7%(范围,0%-32.7%)。合并的再位错的复合率,ABR-F研究的累积不稳定性和再次手术为6.8%,11.2%和6.1%,分别。荟萃分析发现,再脱位率显着降低(OR0.09,95CI0.04-0.3,p=0.00),累积不稳定性(OR0.05,95CI0.03-0.08,p=0.00),和随后的手术(OR0.08,95CI0.04-0.15,p=0.00)当比较ABR-F固定。相对于ABR-R,ABR-F的累积不稳定率(OR0.32,95CI0.22-0.47,p=0.00)和后续手术率(OR0.27,95CI0.09-0.76,p=0.01)显着降低,对肩部再脱位率的ABR-F的影响进行点估计(OR0.59,95CI0.19-1.83,p=0.36)。与固定相比,ABR-F后达到术前水平或更高的RTS率高出3.87倍(95CI1.57-9.52,p=0.00),有限的ABR-R研究报告了这一结果。五个纳入RCTs的中位数脆弱性指数为2,这意味着仅逆转2个结局事件,使试验结果不再具有统计学意义。
结论:FTASDs的关节镜稳定手术导致较低的再脱位率,累积不稳定性,以及随后的稳定手术相对于复发后的固定或关节镜稳定手术。虽然迄今为止关于该主题的RCT数量有限,他们结论的强度受到样本量小和统计上脆弱的结果的限制。
BACKGROUND: The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature.
METHODS: MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery.
RESULTS: Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials\' findings no longer statistically significant.
CONCLUSIONS: Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.