关节镜与开放手术治疗肩关节前方不稳定临床疗效的Meta分析

目的通过Meta分析比较关节镜与开放手术治疗肩关节前方不稳定的临床疗效。方法检索自1980-06—2018-07收录在PubMed、Embase、Cochrane、中国知网、万方等数据库关于比较关节镜与开放手术治疗肩关节前方不稳定临床疗效的相关文献,采用RevMan 5.3软件进行Meta分析。比较关节镜手术组和开放手术组手术时间、术中神经损伤发生率、术后肩关节前方不稳定复发率、感染发生率、再手术率、恢复运动与工作患者比例,以及末次随访时Constant评分、Rowe评分。结果纳入17篇文献,共1 588例,关节镜手术组918例,开放手术组670例。Meta分析结果显示,与开放手术组比,关节镜手术组手术时间更短,术中神经损伤发生率更低,末次随访时Constant评分更高,术后肩关节前方不稳定复发率更高,差异有统计学意义(P <0.05);但2组术后感染发生率、再手术率、恢复运动与工作患者的比例、末次随访时Rowe评分比较差异无统计学意义(P>0.05)。结论关节镜手术治疗肩关节前方不稳定术后疗效肯定,术中神经损伤发生率低,患者术后恢复快、肩关节活动度更优。     

切开与关节镜下Latarjet手术治疗肩关节前方不稳定疗效的Meta分析

目的通过Meta分析比较切开与关节镜下Latarjet手术治疗肩关节前方不稳定的临床疗效差异。 方法检索包括国内、外1954年1月至2018年1月已发表的临床对照研究。所检索的数据库包括Embase、Pubmed、Central、Cinahl、PQDT（ProQuest Dissertations and Theses）、中国知网、维普、万方、Cochrane Library、CBM （China Biology Medicine）等数据库。中文检索的关键词为切开、开放、关节镜、Latarjet,检索策略为Latarjet并且切开或关节镜或开放。英文检索的关键词为Open、Arthroscopy、Latarjet,检索策略为Latarjet AND Open OR Arthroscopic。提取数据后,采用Review Manager 5.3软件进行数据分析,比较关节镜下与开放式Latarjet手术间的疗效差异。 结果依据以上检索策略,共检索到相关文献887篇,并最终纳入7篇外文文献。通过比较发现,在Latarjet手术治疗肩关节前方不稳定时,开放式组术后Rowe评分优于关节镜下组[95% CI, （0.03, 3.25）, P=0.05],而且开放式组术后骨块移位情况[95% CI（0.12, 0.88）, P=0.03]及患者焦虑程度[95% CI（0.20, 0.75）, P=0.005]均少于关节镜下组,其差异具有统计学意义。其余结局指标术后Walch-Duplay评分[95% CI（-9.57, 10.65）, P=0.92];术后肩关节活动度[95% CI（-2.32, 7.64）, P=0.30];术中及术后各种并发症发生率[95% CI（0.42, 3.39）, P=0.74]、[95% CI（0.14, 2.49）, P=0.48]、[95% CI（0.77, 14.09）, P=0.11]、[95% CI（0.46, 4.89）, P=0.51]、[95% CI（0.12, 0.88）, P=0.03]、[95% CI（0.12, 7.22）, P=0.94] ;术后复发率[95% CI（0.21, 3.56）, P=0.85];术后视觉模拟评分（visual analogue scale,VAS） [95% CI（-0.25, 2.92）, P=0.10];手术所需时间[95% CI（-70.10, 11.81）, P=0.10]两组间差异均无统计学意义。 结论开放式与关节镜下Latarjet手术治疗肩关节前方不稳定均能取得良好的治疗效果,且并发症及复发率相当。虽然开放式组在术后Rowe评分、术后骨块移位情况和患者焦虑程度三个指标上均优于关节镜下组,但是关节镜手术仍不失为是一种安全可行的治疗选择。     

关节镜下Bankart修复术治疗肩关节复发性前脱位:手术效果及复发危险因素分析

目的 探讨关节镜下Bankart修复术(缝合锚钉技术)治疗肩关节复发性前脱位的临床效果,并对术后复发不稳的可能危险因素进行分析.方法 2002年3月至2010年3月连续收治肩关节复发性前脱位患者259例,均采用关节镜下缝合锚钉技术进行Bankart修复手术,其中188例患者获得随访.患者手术时平均年龄25.3岁(13～58岁);其中男性143例、女性45例;运动员50名、非运动员138名.随访时采用美国肩肘关节外科协会评分系统(ASES)肩关节评分、Rowe评分以及患者满意度评价手术效果.术前肩关节ASES评分平均72.6分,Rowe评分平均33.4分.对于肩关节术后不稳的复发率、关节活动范围以及术后复发不稳的危险因素进行评估.结果 188例患者术后平均随访38.6个月(12～110个月).术后肩关节ASES评分平均91.9分,与术前比较差异具有统计学意义(P＜0.001);术后Rowe评分平均81.9分,与术前比较差异具有统计学意义(P＜0.001).患者手术满意度调查显示,满意152例、基本满意16例、不满意20例,满意率为89.4%.术后有24例患者复发脱位,总体复发率为12.8%;运动员患者复发率为28.0%,非运动员复发率为7.2%.术后患者平均肩关节外展外旋为75.2°,与术前比较无明显丧失(P＞0.05).关节镜Bankart修复术后复发不稳与患者年龄及是否为运动员明显相关(P＜0.05);而与术前病程长短、锚钉类型、锚钉数目、骨性Bankart损伤、合并肩关节上盂唇撕裂损伤、合并后或下方盂唇损伤、合并肩袖撕裂、关节松弛以及肩袖间隙闭合等因素无明显相关(P＞0.05).结论 关节镜下采用缝合锚钉进行Bankart修复术是治疗肩关节复发性前脱位的有效方法,临床效果比较满意.年轻患者(≤20岁)和运动员患者是术后肩关节复发不稳的高危因素,必要时选择切开手术.

Abstract：

Objective To evaluate retrospectively the results of arthroscopic Bankart repair using suture anchors for recurrent anterior shoulder dislocation with a minimum 1-year follow-up and to assess risk factors for recurrence.Methods From March 2002 to March 2010,259 patients with recurrent anterior shoulder dislocation underwent arthroscopic Bankart repair with suture anchors.And 188 patients(50 athletes,138 nonathletes)were available for follow-up.The mean age at the time of surgery was 25.3 years (range,13-58 years).The mean follow-up was 38.6 months(range,12-110 months).All of the 188 patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Society (ASES)shoulder score and Rowe score system.The rate of recurrent instability,range of motion,and risk factors for postoperative recurrence were evaluated.The ASES score was 72.6 preoperatively,and Rowe score was 33.4.Results The ASES scores improved significantly to 91.9 postoperatively(P＜0.001).The Rowe scores improved to 81.9 postoperatively(P＜0.001).And 152 patients were greatly satisfied with the results,16 satisfied and 20 unsatisfied.The satisfactory rate was 89.4%.24 patients(12.8%)suffered a recurrence after surgery,14 athletes and 10 nonathletes.The recurrence rates were 28.0% in the athlete group and 7.2% in the nonathlete group.On average there was no significant loss of external rotation postoperatively(average,75.2° preoperatively and 67.2° postoperatively).Patients under age 20,and athlete patients were associated with recurrence(P＜ 0.05).Other factors including length of time until surgery,type of anchors,number of anchors,presence of bony Bankart lesion,presence of a superior labrum,anterior and posterior tear,presence of posterior or inferior labrum lesion,presence of rotator cuff tear,ligamentous laxity and rotator interval closure did not influence the recurrence rate(P＞0.05).Conclusions Arthroscopic Bankart repair is a good option for the treatment of recurrent anterior shoulder dislocation.Identification of risk factors for recurrence allows for consideration of open stabilization.In the series,patients under age 20 and athlete patients are the most important risk factors for recurrence.     

影响肩关节不稳术后复发因素研究进展

肩关节不稳是临床常见的疾病,随着医疗水平的提升,肩关节不稳的治疗逐步发展,从开放性手术到肩关节镜微创手术,从关节镜下软组织修复手术到骨性修复手术,但目前肩关节不稳术后仍存在较高的复发率,本文从自身因素和治疗因素对肩关节不稳术后复发的影响进行综述,旨在帮助临床医师提高对肩关节不稳的认识并选择正确的治疗方式。     

关节镜治疗肩关节前方不稳定的临床研究

肩关节不稳定是指肩关节活动时,肱骨头相对于肩胛盂出现超出生理范围的异常活动[1],多发生于年轻人或运动员.临床中,以创伤性肩关节前方不稳定(traumatic anterior shoulder instability,TASI) 最为常见[2],大部分需要接受手术治疗[3],因此本文将从解剖、生物力学以及诊断和治疗等方面对肩关节镜治疗肩关节不稳定进行综述,以期改善手术技术,提高手术效果.     

关节镜下Bankart修复术治疗复发性肩关节前脱位的中期疗效

目的 探讨关节镜下Bankart修复术治疗复发性肩关节前脱位的中期疗效。方法 回顾性分析2017年1月—2021年6月符合选择标准的107例复发性肩关节前脱位患者临床资料,均接受关节镜下Bankart修复术。男88例,女19例;患者初次脱位年龄13～48岁,平均23.3岁;脱位次数2～160次,中位次数7次;病程0.2～240.0个月,中位病程36.0个月。手术时年龄16～61岁,平均28.2岁。左肩43例,右肩64例。63例合并关节盂骨缺损,骨缺损达1.7%～16.1%,平均8.1%。MRI检查示均不合并肩袖撕裂和肩关节僵硬。术后1 d行CT三维重建检查,评估植入锚钉分布以及锚钉植入处有无关节盂劈裂骨折和拔钉等情况发生。观察术后并发症发生情况,采用疼痛视觉模拟评分（VAS）、Rowe评分、Constant-Murley评分、美国肩肘外科医师协会（ASES）评分评估患肩疼痛及功能。记录术后患者肩关节不稳复发情况、恐惧试验结果、恢复至术前运动水平患者例数以及患者自评满意度。结果 手术均顺利完成。患者均获随访,随访时间20～73个月,平均41.5个月。术后切口均Ⅰ期愈合。术后1 d CT三...     

肩关节Bankart损伤修复术后复发的因素

肩关节脱位占全身关节脱位的一半,其中以复发性前脱位为主,肩关节前脱位大部分存在Bankart损伤的可能。关节镜下修复Bankart损伤是肩关节复发性前脱位的主要治疗方法。术后复发是常见难题。研究表明Bankart损伤修复术后复发与肩关节骨量丢失、患者年龄、运动量大小、手术修复方式、术后功能康复不当以及自身疾病等有关。本文对Bankart损伤修复术后复发的因素进行综述,为临床提供参考。     

1例关节镜下清理肩关节感染及术后复发的处理

<正>患者,女,52岁,无诱因出现后颈部疼痛、灼热感,发展至右侧肩关节疼痛,急诊就诊。右肩关节X线检查,考虑为右肩关节退行性改变,给予口服消炎止痛药对症处理。患者回家后仍有疼痛不适,在当地诊所先后行5次肌注曲安耐德,肩关节疼痛缓解,但患者出现发热症状,体温最高达到38. 3℃。随后出现肩关节肿胀,局部肤温升高,剧烈疼痛。患者主诉后颈部、右侧肩关节疼痛、灼热感,向肘部放射,活动受限,体温36. 2     

肩关节前方不稳定关节镜下治疗进展

肩关节是人体诸多关节中活动度最大的关节,亦是脱位发生率最高的关节之一。肩关节的稳定性主要依靠肩关节周围肌肉、肩盂的外肜、盂唇以及关节囊、盂肱韧带等软组织结构而非骨性结构来维持,如上述软组织结构的完整性遭到破坏,则肱骨头不能在肩关节运动全程中保持于肩盂的中心位置,从而出现肩关节前方不稳定。     

SURGICAL REPAIR FOR RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER

Background : The outcome of surgical repair for recurrent anterior instability of the shoulder at the Wellington Hospital was reviewed. Methods : A retrospective review was undertaken of patients undergoing surgical repair for recurrent anterior instability of the shoulder at Wellington Hospital between October 1989 and November 1996. Patients were asked to complete two shoulder-specific questionnaires, and the range of motion, stability, and strength was evaluated clinically. Results : A total of 37 patients (38 shoulders) who had recurrent anterior dislocation of the shoulder that was unresponsive to a physician-directed rehabilitation programme were managed with open surgical repair. Procedures included the Putti–Platt, Bristow, Magnuson–Stack, Botychev, and Bankart repairs. The mean age at the time of surgery was 24 years and the male-to-female ratio was 11.3:1. Surgery was performed on the dominant side in 63.2% of shoulders. The postoperative redislocation rate was 39.4% at an average of 4.6 years follow-up. Three patients have since required revision of their surgical repair and one patient is awaiting revision. A total of 63.2% of patients were unable to return to their previous level of sports. Differences existed between the motion in the surgically treated shoulder when compared with the contralateral side. Patients reported the most functional difficulty in throwing, working overhead, pulling, and working at shoulder level. Conclusions : The results of the present study indicate a high redislocation rate, and highlight the challenges in restoring a stable, mobile, functional shoulder.     

A PROSPECTIVE STUDY OF RECURRENCE RATE AND RISK FACTORS FOR RECURRENCE AFTER A FIRST RENAL STONE

PURPOSE: We investigate further the recurrence rate and risk factors for recurrence in 300 consecutive patients who presented to our stone clinic after a first stone episode 7 to 17 years ago. MATERIALS AND METHODS: The medical records of the patients who presented consecutively with a first stone episode from 1980 to 1990 were studied and supplemented by a followup mail questionnaire and telephone interviews. At first visit serum samples were taken from all patients and 24-hour urine samples were collected for metabolic testing. RESULTS: A total of 195 patients were followed successfully, of whom 52 (27%) experienced symptomatic stone recurrence after a mean plus or minus standard deviation of 7.5+/-5.9 years. However, ultrasound examination of 36 symptom-free patients showed recurrent stones in 28%. Comparison of patients with or without recurrence confirmed that recurrence was not influenced by sex, family history of stones and urinary risk factors. However, age at onset of the disease was lower for patients who had 2 or more stones during followup than those who had only 1 stone or no recurrence. CONCLUSIONS: Stones can recur as long as 10 years after the first episode, although the rate is lower than previously reported. The metabolic evaluation after a first stone episode needs to be reappraised in terms of its cost-effectiveness, since recurrences do not seem to be predictable from standard laboratory tests.     

EVALUATION OF RISK FACTORS AFFECTING ANASTOMOTIC LEAKAGE AFTER REPAIR OF ESOPHAGEAL ATRESIA

Background:

Anastomotic leak are reported among neonates who underwent esophageal atresia.

Aim:

To find risk factors of anastomotic leakage in patients underwent esophageal repair.

Methods:

All cases with esophageal atresia were included. In this case control study, patients were classified in two groups according to presence or absence of anastomotic leaks. Duration of study was 10 years.

Results:

Sixty-one cases were included. Mean±SD age at time of surgery in patients with leakage and without leakage was 9.50±7.25 and 8.83±6.93 respectively (p=.670). Blood transfusion and two layer anastomosis had significant correlation with anastomotic leakage.

Conclusion:

Blood transfusion and double layer anastomosis are associated with higher rate of anastomotic leakage.     

肩盂骨性缺损致肩关节前方不稳定的生物力学研究

目的评价肩盂前下方骨性结构在肩关节前方稳定性中的生物力学特性和作用,为临床治疗肩盂骨性缺损提供理论依据。方法于自愿捐献的成年男性新鲜尸体取带肩胛骨的肩关节-肱骨标本10具,制备为"骨-韧带"标本;左侧4具,右侧6具。分别于肩关节外展0、90°位时,采用Instron 8874液压伺服生物力学测试系统给予肱骨头50 N的单轴压缩,每个标本按照完整肩关节、盂唇缺损、骨性缺损10%、骨性缺损20%、骨性缺损修复顺序,测量标本位移值。结果肩关节外展0°位时,完整组、盂唇缺损组、骨性缺损10%组、骨性缺损20%组、骨性缺损修复组位移分别为(10.73±2.93)、(11.43±3.98)、(13.58±4.86)、(18.53±3.07)、(12.77±3.13)mm;90°位时,分别为(8.41±2.10)、(8.55±2.28)、(9.06±2.67)、(12.49±2.32)、(8.55±2.15)mm。除骨性缺损20%组与完整组比较差异有统计学意义(P<0.05)外,其余各组与完整组比较差异均无统计学意义(P>0.05)。结论肩盂前下盂唇缺损或骨性缺损<20%时,如关节囊韧带复合体未损伤或已修复,肩关节前方稳定性无明显下降;肩盂骨性缺损≥20%时,即使修复关节囊韧带复合体,肩关节前方稳定性仍明显下降;而同时修复骨性缺损和关节囊韧带复合体可恢复肩关节前方稳定性。     

骨科教程：评估与处理肩关节不稳定的原则

在正常肩部的使用过程中．肱骨头处于肩盂及喙肩弓的中心。如在使用中肩关节不能维持其中心位．则为不稳定。不稳定的肩关节会影响整个上肢的正常功能。肩关节不稳定不同于关节松弛。关节松弛是正常关节的属性之一。它仍允许肩部进行整个幅度的功能性运动。     

胃癌术后复发的再手术治疗

目的 探讨胃癌术后复发的早期发现、早期诊断和再手术治疗问题,提高胃癌5年生存率.方法 回顾性分析1994～1997年17例胃癌术后复发再手术病例.结果 胃癌术后复发71%发生于2年之内,早期发现依赖于术后定期胃镜检查,再次手术获根治性切除者生存14个月～4年,获姑息性切除者生存6个月～22个月.结论 对胃癌术后复发病人再次手术行根治性切除者,可延长病人生存时间,术后定期纤维胃镜检查有助于早期发现和早期诊断.     

胰十二指肠切除术后发生腹部主要并发症的危险因素

目的腹部主要并发症(吻合口瘘、腹腔出血及感染)是胰十二指肠切除术后导致患者死亡的主要原因。本研究的目的是探讨发生腹部主要并发症的危险因素。方法回顾1994年12月～2003年12月间接受胰十二指肠切除术的连续123例患者的病历资料。分析变量包括临床资料、实验室数据、手术因素、病理诊断和并发症。结果腹部主要并发症的发生率为28．5％(35／123)。单变量分析表明：黄疸、手术失血量、胰肠吻合方式、术后白蛋白及血红蛋白水平为有意义的相关因素;经Logistic回归多变量分析确定了4个独立与腹部主要并发症相关的变量：黄疸(OR=4．417)、术后血红蛋白水平(OR=11．065)、手术失血量(OR=3．207)及胰肠吻合方式(OR=4．300)。结论黄疸、术后血红蛋白低于90g／L、手术失血量≥1000ml及胰肠吻合方式是胰十二指肠切除术后腹部主要并发症发生的主要危险因素。     

关节镜辅助下同种异体骨软骨移植修复膝关节剥脱性骨软骨炎

目的 评价关节镜辅助下采用同种异体骨软骨移植修复膝关节剥脱性骨软骨炎(osteochondritis dis-secans,OCD)伴大面积骨软骨缺损的可行性和有效性.方法 2004年1月-2007年5月,收治13例膝关节股骨髁OCD伴大面积骨软骨缺损患者.男7例,女6例;年龄18～59岁.左膝8例,右膝5例;病程7 d～20年,中位病程为42个月.4例有明确膝关节扭伤史.受累部位:股骨内侧髁外侧份5例,股骨内侧髁滑车面2例,股骨外侧髁6例.主动关节活动度为(95.0±13.5)°.Lysholm膝关节功能评分为(62.23±7.79)分.软骨损伤根据国际软骨修复协会分型和关节镜下的Guh1分型,均为Ⅳ型.关节镜下见骨软骨缺损面积为3～7 cm2,平均4.32 cm2;缺损深度0.8～2.0 cm,平均1.55cm.采用同种异体骨软骨块修复缺损,并联合可吸收钉固定骨软骨块.术后指导功能锻炼.结果 术后伤口均Ⅰ期愈合.13例均获随访,随访时间1年2个月～4年,平均2.2年.术后3个月2例持续活动1 h以上后膝关节疼痛,指导其功能锻炼后缓解.术后6个月2例关节摩擦感明显,关节稳定性尚好,予药物保守治疗.末次随访时主动关节活动度为(137.0±9.8)°,与术前比较差异有统计学意义(P<0.05).X线片检查示术后4～6个月移植骨软骨与受区松质骨融合,关节面平整,关节间隙正常.末次随访EMRI检查示骨软骨愈合,关节面完整;骨软骨移植物无缺损、退行性变.术后1年Lysholm膝关节功能评分为(92.08±7.64)分,与术前比较差异有统计学意义(P<0.05).结论 对于膝关节股骨髁OCD伴大面积骨软骨缺损,在关节镜辅助下采用同种异体骨软骨移植修复缺损能重建关节面的完整性和恢复关节稳定性,可取得良好的治疗效果.     

RISK FACTORS FOR OXYGEN DESATURATION DURING SLEEP, AFTER ABDOMINAL SURGERY

The postoperative period after major abdominal surgery is knownto be a period of increased episodic oxygen desaturation. Inorder to assess the risk factors for episodic desaturation,we have studied 29 surgical patients using pulse oximetry duringthe preoperative night (N_pre when they received benzodiazepinepremedication and breathed air, and also during the first threenights after operation when they received nasal oxygen supplementation.Modal oxygen saturation (Sp_o2 exceeded 95 % during all nightsstudied. The time spent at less than 90% (t90) and 85% (t85)Sp_o2 and the average Sp₂,_nadir did not differ each night. Heartrate was greater (mean 90.1 (SD 16.6) vs 65.2 (12.0) beat min^–1,P < 0.007; during the second night after operation (N2) thanduring N_pre. Before operation, the number of desaturations,t90 and t85 correlated with pharyngeal hypertrophy (P = 0.003,P = 0.002, P = 0.007, respectively). At the same time, t90 andX85 correlated with body mass index (P = 0.02 and P = 0.05,respectively). During N₂, t90 correlated with radiological lungconsolidation (P =0.05) and Spo_2nadir correlated with FEV₁,(P = 0.03). We conclude that there are several mechanisms responsiblefor oxygen de-saturation and that these mechanisms differ beforeand after surgery.