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中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (02) : 232 -242. doi: 10.3877/cma.j.issn.1674-134X.2023.02.012

荟萃分析

不同手术方式治疗不可修复型肩袖损伤效果的Meta分析
周新, 张孝华, 周述清, 杨博文, 罗辑, 张中卒, 喻雅婷†()   
  1. 402260　重庆大学附属江津医院（重庆市江津区中心医院）骨科
    402160　重庆医科大学附属永川医院骨科
  • 收稿日期:2022-09-01 出版日期:2023-04-01
  • 通信作者: 喻雅婷
  • 基金资助:
    重庆市自然科学基金(cstc2021jcyj-msxmX0904); 国家自然科学基金(81502329)

Network meta-analysis on various surgical procedures in treatment of irreparable rotator cuff tears

Xin Zhou, Xiaohua Zhang, Shuqing Zhou, Bowen Yang, Ji Luo, Zhongzu Zhang, Yating Yu†()   

  1. Department of Orthopedics, the Centre Hospital of Jiangjin, Chongqing 402260, China
    Department of Orthopedics, the Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
  • Received:2022-09-01 Published:2023-04-01
  • Corresponding author: Yating Yu
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引用本文：

周新, 张孝华, 周述清, 杨博文, 罗辑, 张中卒, 喻雅婷. 不同手术方式治疗不可修复型肩袖损伤效果的Meta分析[J]. 中华关节外科杂志(电子版), 2023, 17(02): 232-242.

Xin Zhou, Xiaohua Zhang, Shuqing Zhou, Bowen Yang, Ji Luo, Zhongzu Zhang, Yating Yu. Network meta-analysis on various surgical procedures in treatment of irreparable rotator cuff tears[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(02): 232-242.

目的

使用网状Meta分析评价多种手术方式治疗不可修复型肩袖损伤(IRCTs)的效果。

方法

计算机检索PubMed、荷兰医学文摘数据库(Embase)、Google Scholar、循证医学数据库(Cochrane Library)、中国知网、万方和维普中文期刊数据库，参照设定的标准，筛选有关手术治疗IRCTs的随机对照试验及队列研究，排除重复发表及无可提取的肩关节功能评分数据的文献。检索时限从建库至2022年10月。纳入的随机对照试验研究风险评估使用Cochrane手册推荐的偏倚风险评估工具，队列研究使用纽卡斯尔-渥太华量表进行风险评估，数据的收集、整理及分析分别由2位研究者独立完成，对所得的数据通过Stata 15.0软件进行分析与绘图。

结果

本文共纳入17项研究，共计2 123例患者，涉及的手术方式有10种。根据累积排序概率曲线下面积(SUCRA)值的大小对不同手术方式进行排序，其标准化肩关节功能评分排序结果从优到劣依次为：肌腱转位术+肩袖部分修补术(SUCRA＝91.2)>肌腱转位术(SUCRA＝81.1)>反式肩关节置换术(SUCRA＝75.7)>上关节囊重建术(SUCRA＝70.7)>肩袖补片术(SUCRA＝65.8)>肩袖部分修补术(SUCRA＝46.5)>单纯清理术+肱二头肌肌腱切断或固定术(SUCRA＝21.9)>单纯清理术(SUCRA＝19.4)>肩峰下假体植入+肱二头肌肌腱切断或固定术(SUCRA＝15.1)>肩峰下假体植入(SUCRA＝12.6)。

结论

在IRCTs患者的各种手术方式中，肌腱转位术+肩袖部分修补术的治疗效果最好，肩峰下假体植入疗效最差，上述结论尚需开展大量设计严谨、方法科学的研究予以验证。

关键词: 外科手术，手术, 回旋套损伤, Meta分析
Objective

To evaluate the effect of various surgical procedures on the treatment of patients with irreparable rotator cuff tears (IRCTs) using a network meta-analysis.

Methods

PubMed, Excerpta Medica Database (Embase), Google Scholar, the Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP) and Wanfang Database were searched from the inception to October 2022 to search for randomised controlled trials and cohort studies of surgical procedures in treatment of IRCTs. Repeat publication and literatures without shoulder function scores were excluded. Risk assessment of the included randomised controlled trials was conducted using the risk of bias assessment tool recommended by the Cochrane Manual. The Newcastle-Ottawa scale was used for risk assessment of cohort studies. Data were analysed and plotted by Stata 15.0 software.

Results

A total of 17 studies which involved 10 surgical procedures and 2 123 patients were included in this study. According to the surface under the cumulative ranking curve (SUCRA) of standardised shoulder function scores, probability ranking in descending order is: tendon transfer with partial repair (SUCRA=91.2)>tendon transfer (SUCRA=81.1)>reverse shoulder arthroplasty (SUCRA=75.7) >superior capsular reconstruction (SUCRA=70.7)>rotator cuff patch (SUCRA=65.8)>partial repair (SUCRA=46.5)>debridement with myotenotomy or tenodesis of the biceps tendons (SUCRA=21.9)>debridement (SUCRA=19.4)>subacromial InSpace balloon implantation with myotenotomy or tenodesis of the biceps tendons (SUCRA=15.1)>subacromial InSpace balloon implantation (SUCRA=12.6).

Conclusions

This study has revealed that the tendon transfer with partial repair would deliver the best surgical outcome of an irreparable rotator cuff tear, however, the InSpace subacromial procedure delivered the worst. Further studies with multicentre and randomised controlled trials in large samples are required to find out the best possible surgical procedures in treatment of an irreparable rotator cuff tear.

Key words: Surgical procedures, operative, Rotator cuff injuries, Meta-analysis
图1 文献筛选流程图注：PubMed-美国国立医学图书馆；Embase-荷兰医学文摘数据库；The Cochrane Library-循证医学数据库；Google Scholar-谷歌学术；Scopus-斯高帕斯数据库
Figure 1 Literature screening flow chart
表1 纳入文献的基本信息
Table 1 General characteristics of the included studies
作者Author 年份Year 国家Country 研究类型Design 证据等级Level 期刊Journal 年龄(岁) Age 样本量Number of samples 干预措施Intervention 随访时间Follow-up peroid (个月) 评价指标Assessment criteria
Arm 1 Arm 2 Arm 1 Arm 2 Arm 1 Arm 2
Metcalfe[19] 2022 英国 RCT Ⅰ Lancet 66.4±7.6 67.3±7.0 56 61 单纯清理术+肱二头肌肌腱切断或固定术 单纯清理术+肱二头肌肌腱切断或固定术+肩峰下假体植入 12 CMS，OSS
Baek[20] 2022 韩国 RCS Ⅲ AM J Sport Med 63.1 64.8 51 30 肌腱转位术 上关节囊重建术 24 ASES
Ozturk[21] 2021 阿拉伯联合酋长国 RCT Ⅰ J Shouder Elb Surg 62.8±7.9 63.7±6.7 21 20 肌腱转位术 上关节囊重建术 30 ASES
Greiner[22] 2021 法国 RCS Ⅲ Orthop J Sports Med 62.5 62.1 20 20 肩袖部分修补术 上关节囊重建术 24 CMS，DASH
Kadow[23] 2021 美国 RCS Ⅲ Arch Bone Joint Surg 59.9 60 14 27 肌腱转位术 上关节囊重建术 12 ASES
Kawashima[24] 2022 日本 RCS Ⅲ Arthroscopy 71.9±7.5 67.8±2.0 10 12 肩袖部分修补术 上关节囊重建术 24 ASES，UCLA
Mori[25] 2021 日本 RCS Ⅲ AM J Sport Med 65.4±9.2 65.9±8.9 24 24 肩袖部分修补术 肩袖补片 95 CMS，ASES，UCLA
Lacheta[26] 2020 美国 RCS Ⅲ J Shouder Elb Surg 56 63 22 33 上关节囊重建术 反肩置换 24 ASES，DASH
Oh[27] 2019 韩国 RCS Ⅲ Orthop J Sports Med 61.7±8.1 65.4±5.7 17 36 单纯清理术+肱二头肌肌腱切断或固定术+肩峰下假体植入 单纯清理术+肱二头肌肌腱切断或固定术 24 CMS，ASES，DASH
Valenti[28] 2019 法国 PCS Ⅱ Int Orthop 58 53 17 14 肌腱转位术 肌腱转位术+部分 37.4 CMS
Maman[29] 2017 以色列 PCS Ⅱ Open Orthop J - - 21 21 单纯清理术+肱二头肌肌腱切断或固定术+肩峰下假体植入 单纯清理术+肩峰下假体植入 36 CMS
Klinger[30] 2005 法国 PCS Ⅱ ACTA Chir Belg 67(61~82) 67(61~82) 24 17 单纯清理术 单纯清理术+肱二头肌肌腱切断或固定术 31 CMS
Paribelli[31] 2015 意大利 PCS Ⅱ Musculoskelet Surg 64.9 62.5 20 20 肩袖部分修补术 肌腱转位术 34 UCLA
Franceschi[32] 2015 意大利 RCS Ⅲ Knee Surg Sports Traumatol Arthrosc - - 34 34 单纯清理术+肱二头肌肌腱切断或固定术 肩袖部分修补术 60 CS，UCLA
Barber[33] 2012 加拿大 RCT Ⅱ Arthroscopy 56(34~72) 56(43~69) 20 22 肩袖部分修补术 肩袖补片 24 CMS
Berth[34] 2010 法国 RCT Ⅰ J Orthopaed Traumatol - - 21 21 单纯清理术+肱二头肌肌腱切断或固定术 肩袖部分修补术 24 CMS，DASH
Favard[35] 2009 法国 RCS Ⅲ Orthop Tramatol Surg 56 ± 5.4 58.8±4.6 55 49 肩袖补片 反肩置换 24 CMS
图2 不同手术方式的网状关系图注：debridement-单纯清理术；LHB-肱二头肌肌腱切断或固定术(myotenotomy or tenodesis of the biceps tendons)；partial-肩袖部分修补术(partial rotator cuff repair)；LDT-肌腱转位术(tendon translocation)；SCR-上关节囊重建术(superior capsular reconstruction)；RTSA-反式肩关节置换术(reverse total shoulder arthroplasty)；spacer-肩峰下假体植入(InSpace subacromial balloon spacer)；patch-肩袖补片修补术(rotator cuff patch)
Figure 2 Diagram of evidence relations of different interventions
表2 纳入RCT研究的偏倚风险评价结果
Table 2 Assessment of bais risk of included RCT
作者Author 年份Year 随机方法Random methods 分配隐藏Blinded allocation 盲法Blinded trials 结果数据完整性Data integrity of outcome 选择性报告研究结果Selective report 其他偏倚来源Other bias
患者Patient 研究者Researcher 结局测量者Outcome
Metcalfe [19] 2022 计算机随机 随机序列 是 否 是 完整 否 否
Ozturk [21] 2021 随机化软件 不清楚 是 否 不清楚 完整 不清楚 不清楚
Barber [33] 2012 不清楚 密封信封 是 否 是 完整 不清楚 不清楚
Berth [34] 2010 计算机随机 不清楚 是 否 不清楚 完整 不清楚 不清楚
表3 队列研究的NOS评分
Table 3 NOS scores in cohort studies
作者Author 年份Year 研究类型Design 研究对象选择Selection of study subject 组间可比性Intergroup comparability 结果测量Outcome measurement 总分Total score
Baek [20] 2022 RCS 4 2 2 8
Greiner [22] 2021 RCS 4 1 2 7
Kadow [23] 2021 RCS 4 1 2 7
Kawashima [24] 2022 RCS 4 1 2 7
Mori [25] 2021 RCS 4 2 3 9
Lacheta [26] 2020 RCS 4 1 2 7
Oh [27] 2019 RCS 4 1 2 7
Valenti [28] 2019 PCS 4 2 2 8
Maman [29] 2017 PCS 4 2 2 8
Klinger [30] 2005 PCS 3 1 2 6
Paribelli[31] 2015 PCS 4 2 2 8
Franceschi [32] 2015 RCS 4 2 3 8
Favard [35] 2009 RCS 3 1 2 6
图3 不一致性检验
Figure 3 Inconsistency test
图4 不同手术方式疗效比较的森林图注：debridement-单纯清理术；LHB-肱二头肌肌腱切断或固定术Lesions of the long head of the biceps；partial-肩袖部分修补术partial rotator cuff repair；LDT-肌腱转位术tendon translocation；SCR-上关节囊重建术superior capsular reconstruction；RTSA-反式肩关节置换术reverse total shoulder arthroplasty；spacer-肩峰下假体植入InSpace subacromial balloon spacer；patch-肩袖补片修补术rotator cuff patch
Figure 4 Forest plot of the odds ratios with confidence intervals for different interventions
图5 不同手术方式的SUCRA(累积排序概率曲线下面积)疗效排序图注：debridement-单纯清理术；LHB-肱二头肌肌腱切断或固定术Lesions of the long head of the biceps；partial-肩袖部分修补术partial rotator cuff repair；LDT-肌腱转位术tendon translocation；SCR-上关节囊重建术superior capsular reconstruction；RTSA-反式肩关节置换术reverse total shoulder arthroplasty；spacer-肩峰下假体植入InSpace subacromial balloon spacer；patch-肩袖补片修补术rotator cuff patch
Figure 5 SUCRA efficacy ranking chart for different interventions
图6 不同手术方式漏斗图注：A-单纯清理术debridement；B-单纯清理术+肱二头肌肌腱切断或固定术debridement+LHB；C-肱二头肌肌腱切断或固定术+肩峰下假体植入ISB+LHB；D-肩袖部分修补术partial rotator cuff repair；E-肌腱转位术LDT；F-上关节囊重建术SCR；G-反肩置换RTSA；H-肌腱转位术+肩袖部分修补术LDT+partial rotator cuff repair；I-肩峰下假体植入ISB；J-肩袖补片修复术patch
Figure 6 The funnel plot of multiple surgical treatment
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