蔣 涵，朱 磊，解 強(qiáng)，陳 根，王志彬，李 偉，馮學(xué)會(huì)，丁 杰

運(yùn)動(dòng)員肩不穩(wěn)術(shù)后重返運(yùn)動(dòng)的研究進(jìn)展

蔣 涵1,2，朱 磊2，解 強(qiáng)1，陳 根1，王志彬1，李 偉1，馮學(xué)會(huì)1，丁 杰1

1.國(guó)家體育總局運(yùn)動(dòng)醫(yī)學(xué)研究所，北京，100061；2.曲阜師范大學(xué)體育科學(xué)學(xué)院，山東 曲阜，273100。

前肩不穩(wěn)定對(duì)年輕運(yùn)動(dòng)員來(lái)說(shuō)是一種致殘的情況，然而最佳的外科治療仍然存在爭(zhēng)議，傳統(tǒng)上，前肩不穩(wěn)定采用開(kāi)放穩(wěn)定治療。近年來(lái)，關(guān)節(jié)鏡下縫合錨釘固定Bankart修復(fù)損傷、Latarjet手術(shù)和開(kāi)放穩(wěn)定固定手術(shù)已成為公認(rèn)的技術(shù)。目前還沒(méi)有系統(tǒng)的文獻(xiàn)對(duì)關(guān)節(jié)鏡下Bankart修復(fù)手術(shù)、Latarjet手術(shù)和開(kāi)放穩(wěn)定固定手術(shù)的恢復(fù)率進(jìn)行比較。本文通過(guò)對(duì)運(yùn)動(dòng)員創(chuàng)傷性肩不穩(wěn)定后發(fā)生復(fù)發(fā)性不穩(wěn)定的研究，為了促使運(yùn)動(dòng)員盡快重返賽場(chǎng)，參考多篇文獻(xiàn)進(jìn)行分析研究。本文重點(diǎn)研究肩關(guān)節(jié)穩(wěn)定后的恢復(fù)情況，納入標(biāo)準(zhǔn)為創(chuàng)傷性肩不穩(wěn)定治療后的運(yùn)動(dòng)恢復(fù)和臨床結(jié)果，報(bào)告了初次關(guān)節(jié)鏡下Bankart修復(fù)、Latarjet手術(shù)或開(kāi)放穩(wěn)定治療后的重返運(yùn)動(dòng)率和臨床結(jié)果。研究顯示，關(guān)節(jié)鏡下Bankart修復(fù)、 Latarjet手術(shù)、開(kāi)放式修復(fù)等手術(shù)，各研究的患者人口學(xué)數(shù)據(jù)無(wú)顯著差異。關(guān)節(jié)鏡下Bankart修復(fù)術(shù)或Latarjet手術(shù)后，患者基本可恢復(fù)至損傷前的水平。不同研究中，任何水平的恢復(fù)情況和術(shù)后Rowe評(píng)分均無(wú)顯著差異。術(shù)后復(fù)發(fā)性脫位發(fā)生率明顯低于關(guān)節(jié)鏡下Bankart修復(fù)或開(kāi)放性穩(wěn)定。本研究顯示，在關(guān)節(jié)鏡下Bankart修復(fù)和Latarjet手術(shù)后，損傷前水平的恢復(fù)率比開(kāi)放穩(wěn)定手術(shù)高。盡管存在這種差異，接受治療的所有運(yùn)動(dòng)員中，大部分的人回到了受傷前的運(yùn)動(dòng)水平，治療組的其他結(jié)果指標(biāo)也類(lèi)似。因此，關(guān)節(jié)鏡下Bankart修復(fù)術(shù)、Latarjet手術(shù)和開(kāi)放性穩(wěn)定手術(shù)仍然是治療前肩不穩(wěn)定運(yùn)動(dòng)員的良好選擇。

肩不穩(wěn)；手術(shù)治療；重返運(yùn)動(dòng)

前肩不穩(wěn)定對(duì)年輕運(yùn)動(dòng)員來(lái)說(shuō)是一種致殘的狀況，對(duì)肩不穩(wěn)定的運(yùn)動(dòng)員的治療及康復(fù)后重返運(yùn)動(dòng)，在文獻(xiàn)中仍然是一個(gè)爭(zhēng)論的話(huà)題。許多患者，尤其是年輕患者的最終目標(biāo)是回到他們受傷前參加的活動(dòng)和運(yùn)動(dòng)中去。

單側(cè)前肩不穩(wěn)定最常見(jiàn)的原因是創(chuàng)傷性前肩關(guān)節(jié)脫位的后遺癥，可導(dǎo)致盂唇撕裂，造成前關(guān)節(jié)囊或關(guān)節(jié)盂損傷[1]。前肩不穩(wěn)定，特別是在老年人中，通?？梢酝ㄟ^(guò)物理治療和活動(dòng)調(diào)節(jié)來(lái)進(jìn)行非手術(shù)治療。然而，對(duì)于在年輕患者中復(fù)發(fā)性脫位的病例，對(duì)于參加接觸運(yùn)動(dòng)的患者，或那些病人有持續(xù)不穩(wěn)定的風(fēng)險(xiǎn)，手術(shù)通常是為了防止持續(xù)不穩(wěn)定的情況[2,3]。

1 資料和方法

1.1 一般資料

資料來(lái)源于2009年至2019年，對(duì)國(guó)內(nèi)外公開(kāi)發(fā)表的關(guān)于肩不穩(wěn)和重返運(yùn)動(dòng)的相關(guān)研究。

1.2 檢索方法

1.2.1 文獻(xiàn)檢索 通過(guò)中國(guó)知網(wǎng)、PubMed、Scopus、Embase和Cochrane等系統(tǒng)對(duì)文獻(xiàn)進(jìn)行電子檢索，對(duì)文獻(xiàn)進(jìn)行系統(tǒng)審查和統(tǒng)計(jì)分析[4]。搜索包括關(guān)鍵字“重返運(yùn)動(dòng)”“肩不穩(wěn)”“Bankart修復(fù)”“Latarjet手術(shù)”和“開(kāi)放穩(wěn)定”等。對(duì)每篇文章的參考文獻(xiàn)進(jìn)行查閱，并對(duì)相關(guān)文章進(jìn)行檢索。

1.2.2 納入標(biāo)準(zhǔn) 納入標(biāo)準(zhǔn)為創(chuàng)傷性肩不穩(wěn)定治療后的運(yùn)動(dòng)恢復(fù)和臨床結(jié)果。手術(shù)治療包括關(guān)節(jié)鏡下關(guān)節(jié)囊及盂唇修復(fù)術(shù)，關(guān)節(jié)鏡下的Bankart手術(shù)、Latarjet手術(shù)以及開(kāi)放穩(wěn)定術(shù)（開(kāi)放的關(guān)節(jié)囊修復(fù)術(shù)或開(kāi)放的Bankart手術(shù)）。

1.2.3 排除標(biāo)準(zhǔn) 排除標(biāo)準(zhǔn)為文獻(xiàn)回顧、專(zhuān)家意見(jiàn)、非臨床研究、病例報(bào)告和臨床研究，不排除相關(guān)病變（如盂唇損傷、肩袖撕裂）。選擇了相關(guān)文獻(xiàn)的資料進(jìn)行了分析總結(jié)。

1.3 質(zhì)量評(píng)估

嚴(yán)格參照入選標(biāo)準(zhǔn)進(jìn)行逐篇篩選，參照影響因子較高的相關(guān)文獻(xiàn)。

2 數(shù)據(jù)來(lái)源

數(shù)據(jù)提取資料包括：（1）特征研究（患者數(shù)量，證據(jù)級(jí)別）；（2）研究參與者的特征（年齡、性別、運(yùn)動(dòng)方式、占主導(dǎo)地位的肩）；（3）病理特征（運(yùn)動(dòng)期間受傷原因、次數(shù)）；（4）處理技術(shù)（關(guān)節(jié)鏡Bankart修復(fù)手術(shù)，Latarjet手術(shù)及開(kāi)放穩(wěn)定手術(shù)）；（5）臨床結(jié)果測(cè)量（受傷前的水平及恢復(fù)運(yùn)動(dòng)的比率，恢復(fù)運(yùn)動(dòng)的時(shí)間，Rowe評(píng)分）。主要的參考標(biāo)準(zhǔn)是研究參與者是否能夠在手術(shù)后恢復(fù)運(yùn)動(dòng)，其中Rowe評(píng)分也作為一種自我報(bào)告的臨床結(jié)果測(cè)量進(jìn)行討論。

3 治療方案的選擇

回顧年輕運(yùn)動(dòng)員繼續(xù)經(jīng)歷創(chuàng)傷性肩不穩(wěn)定，并經(jīng)常受到復(fù)發(fā)性不穩(wěn)定的困擾，限制他們重返運(yùn)動(dòng)。本文的目的是回顧在前肩不穩(wěn)定手術(shù)后恢復(fù)運(yùn)動(dòng)的運(yùn)動(dòng)員。最近的研究發(fā)現(xiàn)，非手術(shù)治療的運(yùn)動(dòng)員不穩(wěn)定性復(fù)發(fā)幾率較大，成功重返賽場(chǎng)的可能性也更小[5,6]。手術(shù)治療包括關(guān)節(jié)鏡下的關(guān)節(jié)囊骨膜修復(fù)和骨增強(qiáng)技術(shù)。雖然現(xiàn)代關(guān)節(jié)鏡技術(shù)提供了良好的結(jié)果，開(kāi)放技術(shù)已顯示出較低的復(fù)發(fā)率，一部分運(yùn)動(dòng)員繼續(xù)經(jīng)歷反復(fù)的不穩(wěn)定，進(jìn)一步的治療，這可能使病人在Bankart修復(fù)后面臨失敗的風(fēng)險(xiǎn)。對(duì)于盂骨丟失的患者，骨增強(qiáng)手術(shù)仍然是有利的；然而，在決定前盂唇修復(fù)還是骨增強(qiáng)時(shí)，什么是盂骨丟失的關(guān)鍵因素還在探討中[7-9]。

肩關(guān)節(jié)前不穩(wěn)定的手術(shù)治療提供了較好的結(jié)果，包括較低的復(fù)發(fā)性不穩(wěn)定和恢復(fù)運(yùn)動(dòng)，未來(lái)對(duì)患者特定危險(xiǎn)因素的研究可能有助于外科手術(shù)的決策和結(jié)果的優(yōu)化[10,11]。盡管開(kāi)放穩(wěn)定被認(rèn)為是前肩不穩(wěn)定手術(shù)治療的黃金標(biāo)準(zhǔn)，關(guān)節(jié)鏡下縫合錨定固定（關(guān)節(jié)鏡下Bankart手術(shù)）修復(fù)已成為公認(rèn)的首選治療方法。Owens等[12]強(qiáng)調(diào)關(guān)節(jié)鏡技術(shù)在治療肩不穩(wěn)定方面的應(yīng)用越來(lái)越多，在5年內(nèi)關(guān)節(jié)鏡手術(shù)增加了近20%。開(kāi)放穩(wěn)定包括直接開(kāi)放的關(guān)節(jié)囊損傷修復(fù)。另一種流行的手術(shù)是Latarjet，將喙突轉(zhuǎn)移到肩胛盂的前緣，防止肱骨頭從肩胛盂前移位并隨后脫位[2,13]。這改善了肩胛盂肱關(guān)節(jié)的固有穩(wěn)定性，脫臼需要增加偏移量，它提供了一個(gè)前下軟組織吊帶的作用[14]。關(guān)節(jié)鏡下的Bankart修復(fù)術(shù)通過(guò)直接緊縮前關(guān)節(jié)囊以及將前盂唇修復(fù)來(lái)改善穩(wěn)定性[15,16]。

在目前的文獻(xiàn)中，有數(shù)據(jù)表明關(guān)節(jié)鏡下和開(kāi)放技術(shù)，包括修復(fù)和重建以及治療前肩不穩(wěn)定的Latarjet手術(shù)，是安全有效的，無(wú)論采用何種技術(shù)，并發(fā)癥少，復(fù)發(fā)性不穩(wěn)定的發(fā)生率低[17,18]。然而，目前比較這些技術(shù)的文獻(xiàn)的重點(diǎn)主要是研究再脫位率或翻修手術(shù)之間的差異。目前還沒(méi)有系統(tǒng)的文獻(xiàn)對(duì)關(guān)節(jié)鏡下Bankart縫合錨定修復(fù)與開(kāi)放穩(wěn)定和Latarjet手術(shù)后的恢復(fù)率進(jìn)行比較，鑒于許多較小的系列評(píng)估這些技術(shù)，本文分析在關(guān)節(jié)鏡下和開(kāi)放手術(shù)治療前肩不穩(wěn)定恢復(fù)運(yùn)動(dòng)的比率。

4 分析與討論

通過(guò)對(duì)多篇關(guān)節(jié)鏡下肩穩(wěn)定術(shù)后恢復(fù)運(yùn)動(dòng)文獻(xiàn)統(tǒng)計(jì)得出，大多數(shù)患者在側(cè)臥位進(jìn)行了關(guān)節(jié)鏡下的Bankart修復(fù)，研究描述了Latarjet手術(shù)后的運(yùn)動(dòng)恢復(fù)情況和開(kāi)放肩穩(wěn)定手術(shù)后恢復(fù)運(yùn)動(dòng)。在這些研究中，隨訪(fǎng)時(shí)間的長(zhǎng)短也有所不同，從6個(gè)月到28年不等，在人群中無(wú)明顯的差異。

通過(guò)對(duì)文獻(xiàn)統(tǒng)計(jì)分析比較Bankart修復(fù)術(shù)、latarjet手術(shù)和開(kāi)放修復(fù)術(shù)的患者在損傷后恢復(fù)運(yùn)動(dòng)的比率。關(guān)節(jié)鏡下行Bankart修復(fù)術(shù)或Latarjet手術(shù)后，患者恢復(fù)到預(yù)期運(yùn)動(dòng)水平（損傷前水平），與開(kāi)放穩(wěn)定治療相比，運(yùn)動(dòng)水平更穩(wěn)定。關(guān)節(jié)鏡檢查和Latarjet手術(shù)與開(kāi)放穩(wěn)定手術(shù)相比，具有更高的水平運(yùn)動(dòng)恢復(fù)率。在關(guān)節(jié)鏡下使用帶縫錨釘?shù)腂ankart修復(fù)術(shù)與Latarjet和開(kāi)放穩(wěn)定化相比，恢復(fù)運(yùn)動(dòng)的時(shí)間更長(zhǎng)[19]。

Rowe評(píng)分是評(píng)估的文獻(xiàn)中最常見(jiàn)的報(bào)告患者預(yù)后指標(biāo)。所有3項(xiàng)開(kāi)放穩(wěn)定研究均報(bào)告了Rowe評(píng)分，術(shù)后平均分為86分。3項(xiàng)關(guān)節(jié)鏡下縫合錨定研究報(bào)告了術(shù)后Rowe評(píng)分；平均得分為79.5分。兩項(xiàng)Latarjet研究報(bào)告了術(shù)后Rowe評(píng)分；平均分?jǐn)?shù)是82.0。結(jié)果顯示與關(guān)節(jié)鏡下Bankart修復(fù)術(shù)和開(kāi)放內(nèi)固定術(shù)相比，Latarjet穩(wěn)定術(shù)后復(fù)發(fā)性脫位的可能性明顯降低[10,20,21]。

5 結(jié) 果

本系統(tǒng)對(duì)文獻(xiàn)回顧和統(tǒng)計(jì)分析顯示，在關(guān)節(jié)鏡下Bankart修復(fù)、Latarjet手術(shù)和開(kāi)放穩(wěn)定手術(shù)后，患者的重返運(yùn)動(dòng)的比率無(wú)統(tǒng)計(jì)學(xué)差異[16,22]。當(dāng)分析包括恢復(fù)到所有運(yùn)動(dòng)水平（包括比受傷前水平更低）的患者時(shí)，組間沒(méi)有發(fā)現(xiàn)差異。3種治療方案的Rowe評(píng)分差異無(wú)統(tǒng)計(jì)學(xué)意義。與關(guān)節(jié)鏡下使用縫合錨釘和開(kāi)放穩(wěn)定的Bankart修復(fù)術(shù)相比，Latarjet手術(shù)顯示了更低的整體再脫位率。

對(duì)于有外傷性肩關(guān)節(jié)脫位病史的年輕活動(dòng)期患者來(lái)說(shuō)，手術(shù)穩(wěn)定正成為一種更常見(jiàn)的操作方法，恢復(fù)活動(dòng)的比例是一個(gè)越來(lái)越重要的結(jié)果指標(biāo)[23]。關(guān)節(jié)鏡下的Bankart修復(fù)已成為許多外科醫(yī)生在最小關(guān)節(jié)盂骨丟失的治療選擇[24]。盡管如此，目前的文獻(xiàn)顯示在關(guān)節(jié)鏡穩(wěn)定與開(kāi)放穩(wěn)定的比較方面存在很大的差異[25-27]。

關(guān)節(jié)鏡鏡下的Bankart修復(fù)顯示出良好的運(yùn)動(dòng)恢復(fù)率，達(dá)到損傷前的運(yùn)動(dòng)水平[15,27-29]，在30例接受關(guān)節(jié)鏡下Bankart修復(fù)的患者中，有90%的患者恢復(fù)到損傷前水平。Gerometta等[30]報(bào)道了46名運(yùn)動(dòng)員在關(guān)節(jié)鏡穩(wěn)定后94%的各個(gè)級(jí)別的運(yùn)動(dòng)恢復(fù)率。一些研究表明，對(duì)于接觸型運(yùn)動(dòng)員（如橄欖球和曲棍球）來(lái)說(shuō)，Latarjet術(shù)后訓(xùn)練有更高的重返運(yùn)動(dòng)的比率。在關(guān)節(jié)鏡技術(shù)發(fā)展之前，開(kāi)放式穩(wěn)定是金標(biāo)準(zhǔn)治療方法[28]。Fabre等[31]在開(kāi)放穩(wěn)定手術(shù)后表現(xiàn)出了良好的長(zhǎng)期效果，82%的人回到了同樣的運(yùn)動(dòng)水平。

在前肩不穩(wěn)手術(shù)的研究中，有幾種典型的結(jié)果測(cè)量方法，包括Rowe評(píng)分、12項(xiàng)簡(jiǎn)式問(wèn)卷調(diào)查評(píng)分、美國(guó)肩關(guān)節(jié)和肘關(guān)節(jié)評(píng)分。我們的系統(tǒng)回顧顯示結(jié)果評(píng)分存在很大差異。大多數(shù)運(yùn)動(dòng)員將手術(shù)成功定義為受傷前恢復(fù)運(yùn)動(dòng)的能力，部分成功定義為恢復(fù)到某種運(yùn)動(dòng)水平。把研究的重點(diǎn)放在了球員的回歸率和再脫位率上，在高水平的競(jìng)爭(zhēng)中尤其如此[32]。

統(tǒng)計(jì)研究顯示3種手術(shù)的再脫位率相似，其中Latarjet手術(shù)稍?xún)?yōu)于關(guān)節(jié)鏡下Bankar縫合固定和開(kāi)放穩(wěn)定。盡管術(shù)后脫位率存在較大差異，但這與大多數(shù)目前發(fā)表的文獻(xiàn)一致[1,26]。Tordjman等[27]報(bào)道了關(guān)節(jié)鏡穩(wěn)定術(shù)后的再脫位率為16%，而其他的研究報(bào)道了復(fù)發(fā)性不穩(wěn)定的發(fā)生率更低。盡管有這些相似的再脫位率，在那些接受開(kāi)放性穩(wěn)定治療的患者中，在損傷前水平的恢復(fù)率較低。開(kāi)放穩(wěn)定術(shù)后，可能會(huì)發(fā)生肩部僵硬或肌力降低的現(xiàn)象發(fā)生。

6 結(jié) 論

關(guān)節(jié)鏡下行Bankart修復(fù)術(shù)或Latarjet手術(shù)后，患者恢復(fù)到預(yù)期運(yùn)動(dòng)水平（損傷前水平），與開(kāi)放固定治療相比，運(yùn)動(dòng)水平更穩(wěn)定。關(guān)節(jié)鏡檢查和Latarjet手術(shù)與開(kāi)放穩(wěn)定手術(shù)相比，具有更高的水平運(yùn)動(dòng)恢復(fù)率。在關(guān)節(jié)鏡下使用帶縫錨釘?shù)腂ankart修復(fù)術(shù)與Latarjet和開(kāi)放固定手術(shù)相比，恢復(fù)運(yùn)動(dòng)的時(shí)間更長(zhǎng)。鑒于其較高的恢復(fù)率，尤其是并發(fā)癥較小，關(guān)節(jié)鏡Bankart手術(shù)應(yīng)該考慮為運(yùn)動(dòng)員復(fù)發(fā)性肩不穩(wěn)定的選擇，Latarjet和開(kāi)放穩(wěn)定仍然是現(xiàn)代運(yùn)動(dòng)員的優(yōu)先選擇。

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Research Progress of Reactivation after Shoulder Instability

JIANG Han1,2, ZHU Lei2, XIE Qiang1, et al

1.National Institute of Sports Medicine, Dongcheng District, Beijing, 100061, China;2.School of Physical Education, Qufu Normal University, Qufu Shandong, 273100, China.

Shoulder instability is a disabling condition for young athletes; however, the best surgical treatment is still controversial. Traditionally, open stabilization treatment is used for anterior shoulder instability. In recent years, arthroscopic suture and anchor fixation for Bankart repair injuries, Latarjet surgery and open stabilization fixation surgery have become accepted technologies.Currently, there is no systematic literature to compare the recovery rate of Bankart repair surgery Latarjet and open stable fixation surgery under arthroscopy. In order to promote athletes to return to the track as soon as possible, statistical analysis is made by referring to multiple literatures.This paper focuses on the recovery of shoulder joint after stabilization.The inclusion criteria were motor recovery and clinical outcomes after treatment of traumatic shoulder instability, and the rate and clinical outcomes of re-exercise after Bankart suture anchor repair under initial arthroscopy, Latarjet surgery or open stable treatment were reported.According to the study, there was no significant difference in patient demographic data of the Bankart repair, Latarjet surgery, open repair and other surgeries with suture anchors. After arthroscopic Bankart prosthesis or Latarjet surgery, there was a statistically significant difference in patients' recovery to pre-injury levels. In different studies, there was no significant difference in recovery at any level or in postoperative Rowe scores. The incidence of recurrent dislocation after surgery was significantly lower than that of Bankart repair under arthroscopy or open and stable.This study showed that the recovery rate of the pre-injury level was higher after arthroscopic Bankart repair and Latarjet surgery than that of open and stable surgery.Despite the difference, most of the all athletes treated returned to their pre-injury activity levels, and other outcome indicators for the treatment group were similar.Therefore, arthroscopic Bankart repair, Latarjet surgery and open stabilization surgery are still good surgical options for athletes with anterior shoulder instability.

Shoulder instability; Surgical treatment; Return to sport

2019-12-14

2020-03-20

1007―6891（2021）04―0034―04

10.13932/j.cnki.sctykx.2021.04.08

G804.53

A