Meta-analysis Of Clinical Results Of Stemless Prosthesis And Uncemented Fixation In Shoulder Arthroplasty

Objective:Stemless humeral prosthesis is currently being used in total shoulder arthroplasty(TSA).The implant of total shoulder arthroplasty has been developed to reconstruct the anatomical structure perfectly,improve the fixation,maximize bone mass,and facilitate revision surgery.Most of the design changes of shoulder replacement implants are concentrated in the humeral stem and transition to the shorter metaphysial humeral stem,which of the prostheses may be beneficial,but it is controversial whether the results of total shoulder arthroplasty with stemless prosthesis are consistent with those of previous total shoulder arthroplasty with stemmed prostheses.In addition,cemented fixation of humeral prosthesis is recognized as the standard of shoulder arthroplasty,but uncemented fixation also has the potential advantages of providing stable fixation,reducing operation time and simplifying the process of potential revision surgery.It is not clear whether the results of uncemented fixation will have similar results and complications compare with cemented fixation.The objectives of our study are:(1)systematic evaluation of the application of the clinical efficacy of stemless prosthesis and stemmed prosthesis in the treatment of shoulder osteoarthritis in total shoulder arthroplasty;(2)whether the imaging and clinical effect of humeral prosthesis uncemented fixation is similar to that of cemented fixation in reverse total shoulder arthroplasty(RTSA).Methods:We searched Pub Med,Springer Link,Web of Science,EBSCO,The Cochrane Library,EMBASE,CNKI,Wan Fang Data and VIP by computer,and the time was limited to the periodical literature published at home and abroad from the initial time to December 2019.The authors used the Newcastle-Ottawa Scale(NOS)document quality Evaluation scale to evaluate the literature quality of the non-randomized controlled trials,and the quality evaluation criteria of Cochrane Reviewer's Handbook5.1 were used to evaluate the methodological quality and bias risk of randomized controlled trials,including random sequence generation,concealment of the allocation sequence,blinding of participants and personnel,blinding of outcome assessment,incomplete outcome,and selective reporting.Statistical analysis was performed using Stata13.0.The relative risk(RR)was used as the effect analysis statistic for the two classified variables,and the mean difference(MD)was used for the continuous variables.When the measurement methods or units of the included research indicators are inconsistent,the standardized mean difference(SMD)is used as the effect analysis statistic,and the 95%confidence interval(95%CI)of each effect quantity is given.According to the heterogeneity,we can judge whether to choose the fixed effect model or the random effect model.The size of heterogeneity was evaluated by I~2,and the higher the value of I~2,the greater the heterogeneity.Obvious clinical heterogeneity was treated by subgroup analysis or sensitivity analysis,or only descriptive analysis.P value<0.05 was considered significant.All tests were performed two-sided.Results:(1)The results of the study on stemless prosthesis group and stemmed prosthesis group showed that a total of 5 studies were included,including 2 randomized controlled trials and 3non-randomized clinical controlled studies,with a total of 190shoulders of 182 patients(shoulder count analysis).The results of Meta-analysis showed that the operation time(P=0.02)and the estimated postoperative blood loss(P=0.026)in the stemless group were less than those in the stemmed group(P=0.02);The postoperative Constant score(CS)of the stemless prosthesis group was lower than that of the stemmed prosthesis group(to-0.12),but there was no significant difference in the postoperative CS between the two groups after sensitivity analysis,using the method of"single study one by one"and excluding a low-quality study after the operation,the CS of the two group was no significant difference(SMD=-0.17;95%CI,-0.55 to0.21);There was no significant difference in activities of daily living score(SMD=0.20;95%CI,-0.10 to 0.50),strength score(SMD=0.21;95%CI,-0.10 to 0.51),pain score(SMD=-0.13;95%CI,-0.43 to 0.17),shoulder range of motion score(SMD=0.19;95%CI,-0.37 to 0.76)andflexion(SMD=0.12;95%CI,-0.54to0.78),abduction(SMD=-0.04;95%CI,-0.52 to 0.45),external rotation(SMD=0.14;95%CI,-0.15 to 0.43),internal rotation(SMD=-0.19;95%CI,-0.80 to 0.41)between the two groups.(2)The results of the study on cemented and uncemented fixation of humeral prosthesis showed that a total of 5 studies were included,all of which were non-randomized controlled studies,a total of 717patients with 720 shoulders(this article was analyzed by shoulder count).The results of Meta-analysis showed that radiological loosening rate(RR=2.61;95%CI,0.59 to11.58),postoperative shoulder instability rate(RR=1.89;95%CI,0.58 to 6.15),infection rate(RR=2.04;95%CI,0.40 to 10.41),revision rate(RR=2.06;95%CI,0.67 to 6.32)and scapular notch rate(RR=0.99;95%CI,0.48 to2.03)was no significant difference between cemented and uncemented fixation of humeral prosthesis.The incidence of radiolucent line of humeral prosthesis cemented fixation was similar to that of uncemented fixation(RR=0.67;95%CI,0.44 to 1.03).Sensitivity analysis was performed and the method of"single study one by one"was used.After excluding a study,the difference of radiolucent line between the two groups was statistically significant(RR=0.11;95%CI,0.05 to 0.25);In terms of stress shielding,the stress shielding rate of humeral prosthesis cemented fixation was significantly lower than that of uncemented fixation(RR=0.13;95%CI,0.04 to 0.46).Conclusion:1.The short and medium-term clinical effects of stemless humeral prosthesis and stemmed humeral prosthesis in the treatment of shoulder osteoarthritis are similar in total shoulder arthroplasty.2.Total shoulder arthroplasty with stemless humeral prosthesis has more advantages in shortening the operation time and reducing the estimated postoperative blood loss.3.During the short and medium-term follow-up,the common clinical complications of cemented fixation and uncemented fixation of humeral prosthesis in reverse total shoulder arthroplasty are similar.4.In short and medium-term follow-up,the use of uncemented fixation in the humeral prosthesis during reverse total shoulder arthroplasty increased the probability of stress shielding compared with cemented fixation,but further long-term follow-up data is required.