关于骨髓刺激技术在肩袖撕裂治疗作用的系统评价及Meta分析

目的评估骨髓刺激技术在改善肩袖愈合及功能恢复中的作用。 方法计算机检索Cochrane Library、PubMed、Medline、Embase、中国知网（CNKI）、维普（VIP）、万方及中国生物医学文献数据库（CBM）等数据库中关于应用骨髓刺激技术和单纯肩袖修复的比较研究,包括临床随机对照和回顾性队列研究。手工检索纳入研究的参考文献。提取各研究中指标数据,包括总体再撕裂率,大到巨大肩袖撕裂的再撕裂率,术后肩关节活动度（range of motion,ROM）,视觉模拟评分（visual analogue scale,VAS）,Constant-Murley肩关节功能评分（Constant-Murley score,CMS）,加州福尼亚大学洛杉矶分校评分（University of California, Los Angeles shoulder rating scale,UCLA）,美国肩肘外科协会评分（American shoulder and elbow surgeons score,ASES）,手臂、肩膀和手的残疾问卷（disabilities of the arm, shoulder, and hand questionnaire ,DASH）各项功能评分。运用Revman 5.3软件对其进行分析和处理。 结果共纳入2篇随机对照研究、6篇回顾性队列研究、2篇非对照回顾性研究共10篇文献进行系统回顾,Meta分析只纳入前8篇文献,患者共641例。Meta分析结果显示,与单纯肩袖修复相比,结合骨髓刺激技术能明显改善肩袖总体愈合效果OR = 0.42,95% CI（0.28,0.63）,P< 0.0001],大到巨大撕裂的肩袖修复术后再撕裂率也明显减少OR = 0.28, 95% CI（0.13, 0.58）, P = 0.0007]。而在肩关节疼痛VAS评分SMD = -0.63, 95% CI（-1.40, 0.14）, P = 0.11], ROM外旋SMD = 0.05, 95% CI（-0.22, 0.32）, P = 0.70]、前屈SMD = 0.10, 95% CI（-0.17, 0.37）, P = 0.47],CMS评分SMD = 0.12, 95% CI（-0.09, 0.32）, P = 0.26],UCLA评分SMD = -0.04, 95% CI（-0.29, 0.21）, P = 0.76],ASES评分SMD= -0.06,95% CI（-0.33, 0.21）, P = 0.67]及DASH评分SMD = -0.15, 95% CI（-0.43, 0.13）, P = 0.29]等方面的差异均无统计学意义。 结论与单纯肩袖修复相比,结合骨髓刺激技术能明显改善肩袖修复能力,尤其值得关注的是该技术能够促进大到巨大撕裂肩袖的愈合,而在术后肩关节疼痛、ROM及功能方面未见明显差异。

Systematic evaluation and meta-analysis of bone marrow stimulation techniques in the treatment of rotator cuff tear

BackgroundAdvances in arthroscopic rotator cuff repairs techniques such as single-row, double-row, transosseous-equivalent technique (also called "suture bridge" ) , margin convergence and combined patch augmentation have been extensively adopted in clinic. However, despite the advances in repairing techniques, rather high re-tear incidence especially for large to massive tears have been reported from 20% to 94% after rotator cuff repairs. Considering that rotator cuff re-tear remain a substantial implication of functional outcomes after surgical repairing, biologically based strategies to improve the quality of tendon tissue after surgical reconstruction have gained increasing interest over the last several years. Stem cells, growth factors and other tissue engineering methods are increasingly being used to improve rotator cuff healing after repair. Mesenchymal stem cells (MSCs) have been suggested to promote rotator cuff healing and should be promoted clinically. Bone marrow stimulation technologies such as micro-fracture technology and multi-channel technology have also attracted much attention. This technology is simple, direct and inexpensive, which can provide sufficient MSCs for local tendon healing and promote the occurrence of microvascularization. This technique involves perforating the musculoskeletal joint, such as the foot print area of rotator cuff, into the cartilage and locally releasing BM-MSCs to facilitate healing. In a preclinical biomechanical study, the terminal failure load of rotator cuff was significantly increased in the BMS group compared with that in the control group. Animal studies have also shown that stem cells can infiltrate into the footprint area and ultimately strengthen the rotator cuff after repair. Hernigou et al. performed a case control study comparing patients who received simple single-row repair and enhanced repair with stem cells. The stem cell group had 100% intact repair at 6 months compared to 67% of control group, and at 10 years, the rate was 87% versus 44%. Several clinical studies and meta-analyses have found that bone marrow stimulation can definitely reduce the rate of re-tear after rotator cuff repair compared with conventional repair. ObjectiveTo evaluate the role of bone marrow stimulation technique in the improvement of rotator cuff healing and function. MethodsThe Cochrane Library, PubMed, Medline, Embase, CNKI, VIP, Wanfang and CBM and other databases were retrieved on the comparative studies of using bone marrow stimulation technology and simple rotator cuff repair, including clinical randomized controlled and retrospective cohort studies. manual search of The references of included studies were manually retrieved. The index data from each study was extracted, including overall re-tear rate, re-tear rate of large rotator cuff tears, postoperative shoulder joint mobility, visual analog scale (VAS) score, Constant-Murley score (CMS) , University of California, Los Angeles shoulder rating scale (UCLA) , American shoulder and elbow surgeons score (ASES) , and disabilities of the arm, shoulder, and hand questionnaire (DASH) . The Revman 5.3 software was used for analysis and process. ResultsA total of 2 randomized controlled studies and 6 retrospective cohort studies were included in the Meta-analysis. Two uncontrolled retrospective studies and 2 uncontrolled retrospective studies and previous 8 studies were included in the systematic review. The meta-analysis only included the first 8 articles with 641 patients. The results of meta-analysis show that, compared with simple rotator cuff repair, rotator cuff repair combined with bone marrow stimulation technology can significantly improve the overall healing effect of rotator cuff OR = 0.42, 95% CI (0.28, 0.63) , P< 0.0001] . Meanwhile, the re-tear rate of large to massive rotator cuff tear after repair was also significantly reduced OR = 0.28, 95% CI (0.13, 0.58) , P = 0.0007] . In terms of shoulder VAS score SMD = -0.63, 95% CI (-1.40, 0.14) , P = 0.11] , range of motion (ROM) external rotation SMD = 0.05, 95% CI (-0.22, 0.32) , P = 0.70] ; anteflexion SMD = 0.10, 95% CI (-0.17, 0.37) , P = 0.47] , shoulder function CMS score SMD = 0.12, 95% CI (-0.09, 0.32) , P = 0.26] , UCLA score SMD = -0.04, 95% CI (-0.29, 0.21) , P = 0.76] , ASES score SMD = -0.06, 95% CI (-0.33, 0.21) , P = 0.67] , and DASH score SMD = -0.15, 95% CI (-0.43, 0.13) , P = 0.29] , there was no statistical difference. ConclusionsCompared with simple rotator cuff repair, rotator cuff repair combined with bone marrow stimulation technology can significantly improve the rotator cuff repair capability. It is particularly noteworthy that this technology can promote the healing of large to massive rotator cuff tear, and there was no significant difference in postoperative shoulder pain, ROM and function.