关节镜肩袖修补后早期功能锻炼的Meta分析

doi:10.3969/j.issn.2095-4344.2014.17.026

摘要/Abstract

摘要：

背景：目前关节镜肩袖修补后延期功能锻炼是否能提高肌腱的愈合率尚不清楚。关于肩袖修补后的功能锻炼时机仍无定论，且无相关系统评价发表。
目的：系统评价关节镜肩袖修补后早期与延期功能锻炼的疗效差异。
方法：检索Pubmed, EMBASE，Cochrane对照实验中心注册数据库，以及中国生物医学文献数据库、万方数据库、清华同方数据库、重庆维普数据库。英文检索词为“arthroscopy，rotator cuff，rehabilitation”，中文检索词为“肩关节镜，肩袖，康复”。对入选文献的参考文献进行二次检索。检索截止日期为2012-08-15。要求纳入文献均为关节镜肩袖修补后早期与延期功能锻炼的随机对照研究，进行方法学质量评价、筛选和异质性检验，采用REVMAN5.1软件对提取的数据进行分析。
结果与结论：共纳入3个随机对照试验，共包括237例患者，119例为早期活动组，118例为延期活动组。分析显示2组在术后1年随访时关节活动度、疼痛程度、美国肩肘外科医生评分、简明肩关节功能测试评分、肩袖再撕裂率差异均无显著性意义。提示与延期功能锻炼相比，关节镜肩袖修补后早期功能锻炼在关节功能及活动度的改善方面并无优势，但也不增加修补肩袖的再撕裂率。肩袖修补后康复方案可根据患者的实际情况进行制定。

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

全文链接：

关键词: 植入物, 关节植入物, 肩关节镜, 肩袖, 肌腱, 康复, 系统评价

Abstract:

BACKGROUND: At present, it remains unclear whether delayed functional exercises after arthroscopic rotator cuff repairs could elevate the healing rate of tendon. The opportunity of functional exercises after rotator cuff repairs is still controversial, and there is no relevant system evaluation.
OBJECTIVE: To systematically evaluate the differences in curative effects of early and delayed functional exercises after arthroscopic rotator cuff repairs.
METHODS: We searched the Pubmed, EMBASE, Cochrane Central Register of Controlled Clinical Trials, Chinese Biomedical Literature Database, Wanfang Data, China National Knowledge Infrastructure, and Chongqing VIP Database. The key words were “arthroscopy, rotator cuff, rehabilitation”. The references of the included literatures were re-retrieved. The deadline of retrieval was August 15, 2012. The included literatures were randomized controlled trials on early and delayed functional exercises after arthroscopic rotator cuff repairs. Methodological quality evaluation, screening and heterogeneous test were conducted. REVMAN5.1 software was utilized to analyze the extracted data.
RESULTS AND CONCLUSION: We included three randomized controlled trials, including 237 patients: 119 in the early movement group and 118 in the delayed movement group. During follow-up at 1 year after operation, no significant differences in range of motion, pain degree, American Shoulder and Elbow Surgeons Scale, Simple Should Test scores and re-tear rate of rotator cuff were detected between the two groups. Results confirmed that compared with delayed functional exercises, early functional exercises after arthroscopic rotator cuff repair did not have advantages on the improvement of joint function and range of motion, but also did not negatively affect cuff healing. Postoperative rehabilitation can be modified to ensure patient’s compliance.

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

全文链接：

Key words: arthroscopes, meta-analysis, range of motion, articular, randomized controlled trial

中图分类号:

R318

沈翀，唐志宏，胡军祖，邹国耀，肖荣驰，严冬雪，刘瑞端. 关节镜肩袖修补后早期功能锻炼的Meta分析[J]. 中国组织工程研究, 2014, 18(17): 2777-2782.

Shen Chong, Tang Zhi-hong, Hu Jun-zu, Zou Guo-yao, Xiao Rong-chi, Yan Dong-xue, Liu Rui-duan. Early functional exercises after arthroscopic rotator cuff repairs: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(17): 2777-2782.

图/表（结果） 6

2.1 纳入文献的特征 共检索出相关文献848篇，通过筛查，最终有3篇文章符合纳入标准^[9-11]，均为随机对照实验，共包括237例患者，119例为早期活动组，118例为延期活动组(表1)。偏倚风险如图1，2所示。综合文献，肩袖修补后3 d内行功能锻炼归为早期活动组，肩袖修补后3周后行功能锻炼为延期活动组。

2.2 关节活动度 因Cuff等^[10]的研究未提供标准差，仅合并2个研究的数据。Meta分析显示肩袖修补后6个月随访时早期活动组在前屈和外旋活动度优于延期组，肩袖修补后1年随访时2组在前屈和外旋上差异无显著性意义(P > 0.05)，见图3-6。

2.3 功能结果 美国肩肘外科医生评分和简明肩关节功能测试评分为最常用的功能结果评分。3个研究中有2个报告了以上分数，因Cuff等^[10]的研究未提供均数未能进行数据合并。Kim等^[11]发现关节镜肩袖修补后早期组和延期组的简明肩关节功能测试和美国肩肘外科医生评分分数均较术前获得显著提高，但2组间差异无显著性意义(P > 0.05)。与之相似，Cuff等^[10]的结果显示早期组与延期组的简明肩关节功能测试和美国肩肘外科医生评分分数差异无显著性意义(P > 0.05)。

2.4 疼痛分数 2个研究提供了2组术后疼痛结果。Lee等^[9]测量了休息痛和活动时疼痛，早期组和延期组术后疼痛均较术前有明显缓解，但2组在3个月、6个月、1年随访时疼痛差异均无显著性意义(P > 0.05)。相似的是，Kim等^[11]发现早期组和延期组在术后疼痛上差异无显著性意义(P > 0.05)。

2.5 愈合率 使用随机效应模型，Meta分析显示关节镜下肩袖修补后，早期活动组与延期活动组在愈合率上差异无显著性意义(P > 0.05)，见图7。

参考文献

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[4] Bey MJ, Ramsey ML, Soslowsky LJ. Intratendinous strain fields of the supraspinatus tendon: effect of a surgically created articular-surface rotator cuff tear. J Shoulder Elbow Surg. 2002;11(6):562-569.
[5] Gimbel JA, Van Kleunen JP, Williams GR, et al. Long durations of immobilization in the rat result in enhanced mechanical properties of the healing supraspinatus tendon insertion site. J Biomech Eng. 2007;129(3):400-404.
[6] Parsons BO, Gruson KI, Chen DD, et al.Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg. 2010;19(7): 1034-1039.
[7] Li S, Min SX, Zhang H, et al. Effect of continuous passive motion on basic fibroblast growth factor expression during tendon-bone repair after surgical repair of acute rupture of the supraspinatus tendon in rabbits. Nan Fang Yi Ke Da Xue Xue Bao. 2010;30(5):1020-1023.
[8] Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
[9] Lee BG, Cho NS, Rhee YG.. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy. 2012;28(1):34-42.
[10] Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012;21(11):1450-1455.
[11] Kim YS, Chung SW, Kim JY, et al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 2012;40(4):815-821.
[12] Vastamaki M, Lohman M, Borgmastars N. Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair. Clin Orthop Relat Res. 2013;471(2):554-561.
[13] Lafosse L, Brozska R, Toussaint B, et al. The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique. J Bone Joint Surg Am. 2007;89(7):1533-1541.
[14] Huijsmans PE, Pritchard MP, Berghs BM, et al. Arthroscopic rotator cuff repair with double-row fixation. J Bone Joint Surg Am. 2007;89(6):1248-1257.
[15] Boileau P, Brassart N, Watkinson DJ, et al.Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.
[16] Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86-2A: 219-224.
[17] Thomopoulos S, Williams GR, Soslowsky LJ. Tendon to bone healing: differences in biomechanical, structural, and compositional properties due to a range of activity levels. J Biomech Eng. 2003;125(1):106-113.
[18] Tashjian RZ, Hollins AM, Kim HM, et al. Factors affecting healing rates after arthroscopic double-row rotator cuff repair. Am J Sports Med. 2010;38(12):2435-2442.
[19] Goutallier D, Postel JM, Gleyze P, et al. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12(6):550-554.
[20] Sugaya H, Maeda K, Matsuki K, et al. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953-960.
[21] Mihata T, Watanabe C, Fukunishi K, et al. Functional and structural outcomes of single-row versus double-row versus combined double-row and suture-bridge repair for rotator cuff tears. Am J Sports Med. 2011;39(10):2091-2098.
[22] Tudisco C, Bisicchia S, Savarese E, et al. Single-row vs. double-row arthroscopic rotator cuff repair: clinical and 3 Tesla MR arthrography results. BMC Musculoskelet Disord.2013;14:43.
[23] Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med. 2010;38(4):835-841.
[24] Sugaya H, Maeda K, Matsuki K, et al. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation. Arthroscopy.2005; 21(11): 1307-1316.
[25] Burks RT, Crim J, Brown N, et al. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: Magnetic resonance imaging and early clinical evaluation. Am J Sports Med. 2009;37(4):674-682.
[26] Franceschi F, Ruzzini L, Longo UG, et al. Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: A randomized controlled trial. Am J Sports Med.2007;35(8):1254-1260.
[27] Charousset C, Grimberg J, Duranthon LD, et al. Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair? A prospective,nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment. Am J Sports Med.2007;35(8): 1247- 1253.
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引言

材料方法

讨论

目前广为流行的早期被动关节活动方案源于肩关节开放手术时代，开放手术需切开三角肌暴露肩峰下间隙，术后关节僵硬的发生概率较高。随着肩关节镜技术的进步和广泛应用，其减少三角肌粘连和术后瘢痕的优势也逐渐显现。关节镜微创的特性使延期康复方案有了可行性，这也对早期康复方案的必要性提出了质疑。

Parsons等^[6]将肩关节活动度前屈小于100°，外旋小于30°定义为关节僵硬。在其研究中，肩袖手术后关节僵硬发生率约23%；但1年后，关节僵硬组和非僵硬组的患者关节活动度和各项功能评分上差异均无显著性意义。本文发现术后早期活动组能更快恢复关节活动度，但仅为暂时现象，术后1年随访时早期组和延期组在前屈、外旋、美国肩肘外科医生评分、简明肩关节功能测试分数上差异均无显著性意义。这意味着，关节镜肩袖修补后，无论在降低关节僵硬发生概率或改善术后效果方面，早期活动组相比延期活动组均无优势。

肩袖修补后肌腱愈合率与临床结果关系密切^[12-14]，而术后再撕裂是常见的并发症，发生率在20%-94%^[15-16]。一些学者为提高肌腱的愈合率进行了相关研究。Bey等^[4]提出早期活动关节会导致修复处张力过高及产生微动从而妨碍愈合。Gimbel等^[5]发现术后一段时间的制动能增加修复肌腱的胶原蛋白形成，从而增强其力学性能，进而促进肌腱的愈合。Thomopoulos等^[17]分析比较鼠冈上肌肌腱修补术后在制动组和活动组的结构差异，发现制动组的肌腱弹性和结构更优。与之相反，Li等^[7]发现被动应力训练能够促进兔冈上肌腱急性断裂术后腱-骨界面修复早期碱性成纤维细胞生长因子表达，从而增进胶原合成，加快肩袖损伤术后早期腱-骨修复进程。本文结果显示，关节镜下全厚肩袖撕裂修补术后早期组和延期组在愈合率上差异无显著性意义。可以推测，康复方案并不是影响组织愈合的惟一因素，其他因素如年龄、脂肪浸润、撕裂大小、修补技术都与之有一定的关系^[18-23]。

目前肩袖修补后康复方案争议较大，无统一标准。一部分学者建议术后3周内必须固定，而大部分学者则主张早期进行被动活动^[24-27]。也有学者建议康复方案应根据术前患者的自身条件和术中情况进行制定：Accousti等^[28]建议撕裂小的稳定的患者可早期活动，而撕裂大的不稳定的患者则应支具固定6周后再开始功能锻炼。Millett等^[3]认为术后康复进行的时间和方式应根据肩袖肌腱的质量和结构完整程度来决定。综上，作者认为，对于相对年轻的撕裂较小较稳定的患者，可选用早期活动方案进行康复；对于年龄高，对疼痛耐受差，撕裂较大的患者，则选用延期活动方案更为稳妥。

本文的不足之处在于纳入文献偏少，病例数不足；优点在于所纳文献均为随机对照试验，证据等级较高。

综上所述，肩关节镜下全厚肩袖修补后早期功能锻炼与延期相比在关节功能及活动度上没有差别，但早期活动也不增加修补肩袖的再撕裂率；肩袖修补后的康复方案可根据患者的实际情况进行选择制定。

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
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