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Surgery for shoulder osteoarthritis

  • Review
  • Intervention

Authors


Abstract

Background

Surgical treatment including shoulder arthroplasty is a treatment option for patients with advanced osteoarthritis of the shoulder who have failed conservative treatment.

Objectives

To determine the benefit and harm of surgery in patients with osteoarthritis of the shoulder confirmed on X-ray who do not respond to analgesics and NSAIDs.

Search methods

We searched: The Cochrane Central Register of Controlled Trials (CENTRAL), via The Cochrane Library; OVID MEDLINE; CINAHL (via EBSCOHost); OVID SPORTdiscus; EMBASE; and Science Citation Index (Web of Science).

Selection criteria

All randomized clinical trials (RCTs) or quasi-randomized trials including adults with osteoarthritis of the shoulder joint (PICO- patients) comparing surgical techniques (total shoulder arthroplasty, hemiarthroplasty, implant types and fixation- intervention) versus placebo or sham surgery, non-surgical modalities, no treatment, or comparison of one type of surgical technique to another (comparison) with patient-reported outcomes (pain, function, quality of life etc.) or revision rates (outcomes).

Data collection and analysis

We reviewed titles and abstracts for inclusion, extracted study and outcomes data and assessed the risk of bias of included studies. For categorical outcomes, we calculated the risk ratio (with 95% confidence interval (CI)) and for continuous outcomes, the mean difference (95% CI).

Main results

Seven studies (238 patients) were included for analyses. None of the studies compared shoulder surgery to sham surgery, non-surgical modalities or placebo. Two studies compared hemiarthroplasty to total shoulder arthroplasty; three compared keeled and pegged humeral components; and one each compared navigation surgery to conventional and all-polyethylene to metal-backed implant. Two studies (88 patients) compared hemiarthroplasty to total shoulder arthroplasty. Patients who underwent hemiarthroplasty had statistically significantly worse functional scores on American Shoulder and Elbow Surgeons Shoulder Scale (100 point scale; higher = better) at 24 to 34 month follow-up compared to those who underwent total shoulder arthroplasty (mean difference, -10.05; 95% CI, -18.97 to -1.13; 2 studies, 88 patients), but no statistically significant differences between hemiarthroplasty and TSA were noted for pain scores (mean difference, 7.8; 95% CI, -5.33 to 20.93; 1 study, 41 patients), quality of life on short-form 36 physical component summary (mean difference, 0.80; 95% CI, -6.63 to 8.23; 1 study, 41 patients) and adverse events (Risk ratio, 1.19; 95% CI, 0.37 to 3.81; 1 study, 41 patients), respectively. A non-statistically significant trend towards higher revision rate in hemiarthroplasty compared to total shoulder arthroplasty was noted (Risk ratio, 6.18; 95% CI, 0.77 to 49.52; 2 studies, 88 patients; P = 0.09).

Authors' conclusions

Total shoulder arthroplasty seems to offer an advantage in terms of shoulder function, with no other clinical benefits over hemiarthroplasty. More studies are needed to compare clinical outcomes of surgery using different components and techniques in patients with osteoarthritis of the shoulder. There is a need for studies comparing shoulder surgery to sham, placebo and other non-surgical treatment options.

Resumen

Antecedentes

Cirugía para la osteoartritis del hombro

El tratamiento quirúrgico que incluye la artroplastia del hombro es una alternativa terapéutica para los pacientes con osteoartritis avanzada del hombro en quienes ha fracasado el tratamiento conservador.

Objetivos

Determinar los efectos beneficiosos y perjudiciales de la cirugía en los pacientes con osteoartritis del hombro confirmada por radiografía que no responden a los analgésicos ni a los AINEs.

Estrategia de búsqueda

Se hicieron búsquedas en: Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL), vía The Cochrane Library; OVID MEDLINE; CINAHL (vía EBSCOHost); OVID SPORTdiscus; EMBASE; y Science Citation Index (Web of Science).

Criterios de selección

Todos los ensayos clínicos con asignación aleatoria (ECAs) o cuasialeatorios que incluyan adultos con osteoartritis de de la articulación () del hombro y comparen técnicas quirúrgicas (artroplastia total del hombro, hemiartroplastia, tipos de implante y fijación) versus placebo o cirugía simulada, formas no quirúrgicas, ningún tratamiento o la comparación de un tipo de técnica quirúrgica con otra () con resultados informados por los pacientes (dolor, función, calidad de vida, etc.) o calificados en la revisión ().

Obtención y análisis de los datos

Se examinaron los títulos y resúmenes para la inclusión, se extrajeron los estudios y los datos de resultados y se evaluó el riesgo de sesgo de los estudios incluidos. Para los resultados categóricos se calculó el cociente de riesgos (CR) con el intervalo de confianza (IC) del 95% y para los resultados continuos se calculó la diferencia de medias (IC del 95%).

Resultados principales

Se incluyeron siete estudios (238 pacientes) en los análisis. Ningún estudio comparó la cirugía del hombro con cirugía simulada, formas no quirúrgicas o placebo. Dos estudios compararon hemiartroplastia con la artroplastia total del hombro; tres compararon la estabilización y fijación de los componentes humerales; uno comparó la cirugía de navegación con la convencional y otro un implante todo de polietileno con uno reforzado con metal. Dos estudios (88 pacientes) compararon la hemiartroplastia con la artroplastia total del hombro. Los pacientes a los que se les realizó hemiartroplastia tuvieron puntuaciones funcionales significativamente peores desde el punto de vista estadístico en la American Shoulder and Elbow Surgeons Shoulder Scale (Escala del Hombro de los Cirujanos Americanos del Hombro y el Codo) (escala de 100 puntos; mayor = mejor) a los 24 a 34 meses de seguimiento en comparación con los que recibieron artroplastia total del hombro (diferencia de medias −10,05, IC del 95%: −18,97 a −1,13; dos estudios, 88 pacientes), pero no se observaron diferencias estadísticamente significativas entre la hemiartroplastia y la artroplastia total del hombro (ATH) para las puntuaciones de dolor (diferencia de medias 7,8, IC del 95%: −5,33 a 20,93; un estudio, 41 pacientes), la calidad de vida en el resumen de componente físico del SF36 (diferencia de medias 0,80, IC del 95%: −6,63 a 8,23; un estudio, 41 pacientes) ni en los eventos adversos (cociente de riesgos 1,19, IC del 95%: 0,37 a 3,81; un estudio, 41 pacientes), respectivamente. Se observó una tendencia no estadísticamente significativa hacia una tasa mayor de revisión en la hemiartroplastia comparada con la artroplastia total del hombro (cociente de riesgos 6,18, IC del 95%: 0,77 a 49,52; dos estudios, 88 pacientes; P = 0,09).

Conclusiones de los autores

La artroplastia total del hombro parece ofrecer ventajas en cuanto a la función del hombro, sin otros beneficios clínicos sobre la hemiartroplastia. Se necesitan más estudios que comparen los resultados clínicos de la cirugía con diferentes componentes y técnicas en los pacientes con osteoartritis del hombro. Se necesitan estudios que comparen la cirugía del hombro con cirugía simulada, placebo y otras opciones de tratamiento no quirúrgico.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

摘要

背景

肩部骨關節炎的手術

對於患有嚴重肩部骨關節炎而保守治療失敗的患者而言,包含肩關節成形術的外科治療,是一項治療選擇。

目標

為了確定手術用在經過Xray證實且對於止痛劑和NSAIDs沒有反應之肩部骨關節炎患者身上的好處和壞處。

搜尋策略

我們搜尋了The Cochrane Central Register of Controlled Trials (CENTRAL) ,經由The Cochrane Library; OVID MEDLINE; CINAHL (經由 EBSCOHost); OVID SPORTdiscus; EMBASE; 以及Science Citation Index (Web of Science) 。

選擇標準

包含有肩部骨關節炎的成人 (PICO中的patients) 的所有隨機臨床試驗 (RCTs) 或半隨機試驗,比較手術方法 (全關節成形術、半關節成形術、植入物的種類和固定的介入) 和安慰劑或偽裝療法、非手術治療、沒有治療,或比較不同形式間的手術對於個案報告結果 (疼痛、功能、生活品質等) 或修正比例 (結果) 。

資料收集與分析

我們回顧包含的標題和摘要,萃取研究和結果資料,並且評估研究的偏差風險。對於某一範疇的結果,我們計算風險比例 (使用95% 的信賴區間 (CI)) 以及對於持續結果,我們計算平均數差異 (95% 信賴區間) 。

主要結論

分析7篇研究 (238位病人) 。沒有一篇研究比較肩膀手術和偽裝療法、非手術治療或安慰劑。兩篇研究比較半關節成形術和全肩關節成形術;三篇比較裝有龍骨和固定的肱骨部分;各有一篇比較導航系統和傳統的手術以及比較全聚乙烯和金屬支持的固定。兩篇研究 (88位病人) 比較半關節成形術和全肩關節成形術。和那些接受全肩關節成形術的病人相比較 (平均數差異, −10.05;95% 信賴區間, −18.97至 −1.13;兩篇研究,88位病人) ,接受半關節成形術的病人於24至34個月的後續追蹤,美國肩膀和手肘手術之肩膀量表 (100分的量表;較高分代表較好) 的功能性得分,統計學上明顯較差,但半關節成形術與全肩關節成形術的疼痛得分 (平均數差異,7.8;95% 信賴區間, −5.33至20.93;一篇研究,41位病人) ,生活品質簡易版36身體部分總結 (平均數差異,0.80;95% 信賴區間, −6.63至8.23;一篇研究,41位病人) 及不良反應 (風險比例,1.19;95% 信賴區間,0.37至3.81;一篇研究,41位病人) 在統計學上沒有明顯的差異。值得注意的是,比較半關節成形術和全肩關節成形術,前者的有較高的修正比例,但在統計學上尚未達到顯著差異 (風險比例,6.18;95% 信賴區間,0.77至49.52;兩篇研究,88位病人;P = 0.09) 。

作者結論

就肩膀功能而言,全肩關節成形術似乎較有優勢,但相對於半關節成形術,也無法提供其他臨床效益。需要更多研究比較對於肩部骨關節炎患者使用不同要素和技術的手術的臨床結果。需要有研究比較肩部手術和偽裝療法、安慰劑、及其他非手術治療方式。

翻譯人

本摘要由彰化基督教醫院鹿基分院徐瑛雅翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

肩部骨關節炎的手術:Cocharne回顧文獻的總結呈現我們所知道肩部骨關節炎的手術效果。回顧文獻指出和半關節成形術相較,肩部骨關節炎患者進行全肩關節成形術,可能可以改善疼痛,可能改善肩部生理功能,在手術期間如骨折和感染的副作用較少。關於副作用和併發症,我們經常沒有準確的訊息。尤其是雖然少見但確實會發生且嚴重的副作用。什麼是骨關節炎,以及半關節成形手術和全肩關節成形術?骨關節炎 (OA) 是關節的疾病,像是肩部。當關節失去軟骨,骨頭會增長來修復損傷。然而骨頭不正常增長反而使事情變糟。肩部骨關節炎造成肩關節疼痛、僵硬和無力。這些會影響肩膀活動程度以及一個人在家或工作時如何做日常事務。對於肩部骨關節炎的手術治療有許多形式。此文獻發現兩種手術型態的結果。肩部半關節成形術替換的關節只有一個部分 (肱骨頭) 並使用人造關節。全肩關節成形術替換的關節有多個部分使用人造關節。手術的選擇通常依據你肩關節的狀況。對於進行骨關節炎手術兩年後的患者中最常見為:疼痛:進行全肩關節成形術的患者在0 – 100分的疼痛分數量表中自評為6分。進行半關節成形術患者0 – 100分的疼痛分數量表中自評為14分。進行全肩關節成形術的患者疼痛分數在術後進步8分。 (絕對差異:8%) 。這可能是隨機發生的結果。生理功能:進行半關節成形術的患者在0 – 100分的能力量表自評為65分。進行全肩關節成形術的患者在0 – 100分的能力量表自評為77分。進行全肩關節成形術的患者自評活動能力分數在術後進步12分。 (絕對差異:10%) 。副作用:100名接受半關節成形術患者中有24名有副作用,例如感染。100名接受全肩關節成形術患者有20名有副作用,例如感染。100名接受半關節成形術而有副作用的患者多了4名。 (絕對差異:4%) 。這可能是隨機發生的結果。

Plain language summary

Surgery for Osteoarthritis of the Shoulder

This summary of a Cochrane review presents what we know from research about the effect of surgery on osteoarthritis of the shoulder.

 

The review shows that in people with osteoarthritis, total shoulder arthroplasty;

- may improve your pain compared with hemiarthroplasty

- probably does improve your shoulder physical function compared with hemiarthroplasty

- will probably lead to slightly less side effects such as fractures during surgery and infection, compared with hemiarthroplasty

 

We often do not have precise information about side effects and complications. This is particularly true for rare but serious side effects.

 

What is osteoarthritis and what are hemiarthroplasty surgery and total shoulder arthroplasty?

Osteoarthritis (OA) is a disease of the joints, such as the shoulder.   When the joint loses cartilage, the bone grows to try and repair the damage. Instead of making things better, however, the bone grows abnormally and makes things worse. Osteoarthritis (OA) of the shoulder causes pain, stiffness and weakness in the shoulder joints. This can affect how well the shoulder moves and how well a person can do routine things at home or at work.

 

There are many types of surgery for OA of the shoulder. This review found results for two types of surgery.2

Shoulder hemiarthroplasty is the surgical replacement of only one part of the joint (the humeral head) with an artificial one. Total shoulder arthroplasty is the surgical replacement of parts of the joint with artificial ones. The choice of surgery is usually based on the condition of your shoulder joint.

 

Best estimate of what happens to people with osteoarthritis two years after the surgery: 

Pain:

- people who had total shoulder arthroplasty rated their pain to be 6 on a scale of 0 to 100.

- people who had hemiarthroplasty rated their pain to be 14 on a scale of 0 to 100.

- people who had total shoulder arthroplasty rated their pain to be 8 points better after the surgery. (Absolute difference: 8%). This may be a result of chance.

 

Physical Function:

- people who had hemiarthroplasty rated their ability to be 65 on a scale of 0 to 100.

- people who had total shoulder arthroplasty rated their ability to move their shoulder to be 77 on a scale of 0 to 100 after the surgery.

- people who had total shoulder arthroplasty rated their ability to move to be 12 points better after the surgery. (Absolute difference: 10%)

 

Side effects:

- 24 people out of 100 who had hemiarthroplasty had side effects, like an infection.

- 20 people out of 100 who had total shoulder arthroplasty had side effects like an infection.

- 4 more people out of 100 had side effects with hemiarthroplasty (Absolute difference: 4%). This may be a result of chance.

 

Ancillary