隨機分派試驗結果發現關節鏡肩膀手術比開肩手術好


  Feb. 24, 2005(華盛頓)-根據一項針對軍人的前瞻性、隨機分派試驗顯示,相較於傳統開肩手術,以關節鏡手術治療關節疾病的開刀時間較短,而且所造成的不適較少。
  
  夏威夷火奴魯魯Tripler陸軍醫學中心運動醫學與骨骼手術主任Lieutenant Colonel(LTC)Craig R.Bottoni醫師表示,開肩手術曾經被認為是標準術式,然而,這種手術需要切開肌腱才能對關節進行手術;這是一種範圍相當廣泛的手術,會造成疤痕、以及使運動範圍縮小。
  
  在一項對61位連續病患(1位是女性,年齡介於24至38歲之間)的試驗中,關節鏡手術所需要的手術時間平均為52分鐘,相較於開肩手術則需耗費163分鐘(P<.001);LTC Bottoni於第72屆美國骨科外科醫師學會年會中,發表這項試驗結果。
  
  LTC Bottoni表示,試驗中的病患都是因為肩膀負載重物,例如攜帶武器,而造成肩膀脫臼;試驗的初級結果是病患多久可以回到工作崗位。
  
  在所有對肩膀不適以及功能性的評估,雖然有關節手術較佳的傾向,但較不具侵襲性的手術方式與開肩手術之間並沒有顯著差異;雖然這些軍人願意接受試驗,但他們並沒有被要求一定要參與試驗;一位病患原本被隨機分派接受關節鏡手術,但是之後他的對側肩膀卻因故接受了傳統手術,而降低了關節手術比較好的傾向。
  
  29個肩膀中,有2個(6.9%)接受開肩手術治療,而另外32個中有1個(3.1%)以關節鏡治療後,因為持續性疼痛,干擾其日常必須活動而被認為是失敗的。
  
  LTC Bottoni附帶表示,關節鏡手術恢復活動的速度較快,因為這種手術不會切斷旋轉所需肌腱,其他的優點包括我們可以看到肩膀關節的其他部位;有時候我們會遇到360度的撕裂傷,因此我們必須對頂端、後方與前方進行修補,這可以透過關節鏡做到,而不需要再依賴開肩手術。
  
  手術於2001年4月至2002年6月之間進行,61位病患目前為止沒有再度脫臼的案例,雖然有3位病患沒有持續追蹤。
  
  LTC Bottoni向Medscape表示,住院時間比較可能已經證實這2種手術方式是有差異的,但是所有病患自動地住院一天,就像一般陸軍一樣;他表示,陸軍軍醫這樣做是因為軍營沒有辦法提供照護,不像一般市民家中的家人所做的。
  
  紐澤西州Princeton大學醫學中心骨科主治醫師,同時也是會議中引言人Jeffrey S. Abrams醫師稱讚這個試驗的隨機分派設計;他認為,這是一個針對年輕人很好的試驗,但是試驗群體太過於一致;他也附帶表示在軍隊的制度下,被囑咐參與物理治療的病患順從性很高,這與一般的市民病患不同;這樣的治療順從性可能會影響治療成果。
  
  Abrams醫師與發表會中的外科醫師估計,目前為止,僅有40%至50%的肩部手術是透過關節鏡進行的,雖然有90%至100%的病例是符合適應症的;Abrams醫師與LTC Bottoni醫師預測關節鏡肩部手術將會變成治療肩部疾病的標準術式。
  
  Arthrex有限公司提供該試驗中所使用的儀器;並沒有其他重要的利害關係。

Randomized Trial Finds Arthros

By Karla Harby
Medscape Medical News

Feb. 24, 2005 (Washington) — Arthroscopic surgery for shoulder instability takes significantly less operating time and may cause less discomfort than traditional open surgery, according to a prospective, randomized trial of military personnel.

"The open technique has been considered the gold standard," said Lieutenant Colonel (LTC) Craig R. Bottoni, MD, chief of sports medicine and orthopaedic surgery at Tripler Army Medical Center in Honolulu, Hawaii. "However, this requires cutting the tendons to access the joint. This is fairly extensive exposure that can result in scarring and a limited range of motion."

In a study of 61 consecutive patients (one women), aged 24 to 38 years, arthroscopic surgery required a median time of 52 minutes compared with 163 minutes for the open procedure (P < .001). LTC Bottoni described his findings during a press conference here at the 72nd annual meeting of the American Academy of Orthopaedic Surgeons.

The patients all suffered from dislocating shoulders that prevented them from continuing activities that put heavy strain on the shoulders, such as carrying weapons, LTC Bottoni said. The primary outcome of the study was how soon the patients could return to work.

On all formal measures of shoulder discomfort and functionality, the less-invasive procedure was not statistically different from the open procedure, although there was a trend in favor of arthroscopy, LTC Bottoni reported. Participation in the study was not required of these military patients, although they readily agreed to be studied. One patient who was randomized and received arthroscopic surgery and later became a candidate for surgery on his other dislocating shoulder declined randomization in favor of arthroscopy.

Two (6.9%) of the 29 shoulders treated with an open procedure, and one (3.1%) of the 32 treated arthroscopically were assessed as failures because of persistent pain that interfered with necessary activities.

"The advantages of doing it arthroscopically include a quicker restoration of motion, because you're not cutting through the rotator cuff. The other real advantage is that we can see the rest of the shoulder joint," LTC Bottoni added. "Sometimes we get 360-degree tears. So we have to fix the top, the back, and the front, and we can do all that arthroscopically. We could never do that open."

The surgeries were performed from April 2001 to June 2002. None of the 61 patients experienced recurrent dislocations in the treated shoulder to date, although three additional treated patients were lost to follow-up.

Hospitalization time comparisons might have shown a difference between the two procedures, LTC Bottoni told Medscape, but all patients were automatically hospitalized for one night, as is commonly done in military settings. Military physicians do this because barracks do not provide the support services civilian patients would probably find in their homes, such as helpful family members, he said.

Jeffrey S. Abrams, MD, attending orthropaedic surgeon at the University Medical Center in Princeton, New Jersey, and moderator of the session at which the study was presented, praised the study's randomized design. "I think it's a wonderful study of a group of young, active people," he said. "But it's a fairly homogenous population." He also noted that in military settings, patients who are assigned to physical therapy regimens complete it, which is not true in civilian practice. Such therapy compliance could affect outcomes.

Dr. Abrams and other surgeons at the session estimated that only about 40% to 50% of shoulder surgeries, at most, are currently performed arthroscopically, when for many indications 90% to 100% could be. Both Dr. Abrams and LTC Bottoni predicted that arthroscopy will become the new gold standard procedure for shoulder instability.

Arthrex, Inc., provided devices used for this study. There are no other relevant disclosures.

AAOS 72nd Annual Meeting: Abstract 155. Presented Feb. 24, 2005.

Reviewed by Gary D. Vogin, MD

    
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