Patel Bhavik H, Lu Yining, Agarwalla Avinesh, Puzzitiello Richard N, Nwachukwu Benedict U, Cvetanovich Gregory L, Chahla Jorge, Forsythe Brian
Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, IL USA.
Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN USA.
HSS J. 2020 Dec;16(Suppl 2):534-543. doi: 10.1007/s11420-020-09773-5. Epub 2020 Sep 10.
There is increased emphasis on properly allocating healthcare resources to optimize value within orthopedic surgery. Establishing time to maximal medical improvement (MMI) can inform clinical decision-making and practice guidelines.
We sought (1) to evaluate the time to MMI as predicted by commonly used patient-reported outcome measures (PROMs) for evaluation of shoulder stabilization and (2) to evaluate typical time to return to sports and employment following surgery.
A systematic review of the Medline database was conducted to identify outcome studies reporting sequential follow-up at multiple time points, up to a minimum of 2 years after shoulder stabilization surgery. The included studies examined the outcomes of arthroscopic or open surgical techniques on anterior instability. Clinically significant improvements were evaluated utilizing the minimal clinically important difference specific to each PROM. Secondary outcomes included range of motion, return to sport/work, and recurrent instability.
Ten studies comprising 590 surgically managed cases of anterior shoulder instability were included (78% arthroscopic, 22% open). Clinically significant improvements in PROMs were achieved up to 1 year post-operatively for Rowe, Western Ontario Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. For the three most utilized tools (Rowe, WOSI, ASES), the majority of improvement occurred in the first 6 post-operative months. Clinically significant improvements in Constant Score and Oxford Shoulder Instability Score (OSIS) were achieved up to 6 months and 2 years after surgery, respectively. No clinically significant improvements were achieved on the Disabilities of the Arm, Shoulder, and Hand (DASH) tool.
Maximal medical improvement as determined by commonly utilized PROMs occurs by 1 year after operative management of anterior shoulder instability. The DASH tool does not appear to demonstrate a reliable time frame for clinically significant outcome improvement.
在骨科手术中，人们越来越强调合理分配医疗资源以优化价值。确定达到最大医学改善（MMI）的时间可以为临床决策和实践指南提供参考。
我们旨在（1）评估常用的患者报告结局测量指标（PROMs）预测的肩部稳定评估达到MMI的时间，以及（2）评估术后恢复运动和工作的典型时间。
对Medline数据库进行系统综述，以识别报告在多个时间点进行序贯随访的结局研究，随访时间至少为肩部稳定手术后2年。纳入的研究检查了关节镜或开放手术技术治疗前向不稳定的结局。利用每种PROM特有的最小临床重要差异评估临床显著改善情况。次要结局包括活动范围、恢复运动/工作情况以及复发性不稳定。
纳入了10项研究，共590例接受手术治疗的前肩不稳定病例（78%为关节镜手术，22%为开放手术）。对于Rowe评分、西安大略不稳定指数（WOSI）、美国肩肘外科医师学会（ASES）评分和简单肩部试验（SST）评分，术后1年内实现了临床显著改善。对于三种最常用的工具（Rowe评分WOSI、ASES），大部分改善发生在术后的前6个月。Constant评分和牛津肩部不稳定评分（OSIS）分别在术后6个月和2年实现了临床显著改善。上肢、肩部和手部功能障碍（DASH）工具未实现临床显著改善。
常用PROMs确定的最大医学改善在肩部前向不稳定手术治疗后第1年出现。DASH工具似乎未显示出临床显著结局改善的可靠时间框架。
