肩關(guān)節(jié)前方松解治療原發(fā)性凍結(jié)肩的回顧性研究

陳建海 劉中邸 黨育 楊明 蘆浩 張殿英 付中國

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·論著·

肩關(guān)節(jié)前方松解治療原發(fā)性凍結(jié)肩的回顧性研究

陳建海 劉中邸 黨育 楊明 蘆浩 張殿英 付中國

目的 探討肩關(guān)節(jié)鏡下肩關(guān)節(jié)前方松解對于原發(fā)性凍結(jié)肩的治療效果。方法 回顧性分析2011年1月至2012年12月收治并行肩關(guān)節(jié)鏡下肩關(guān)節(jié)前方松解的病例資料,共入組26例，男性7例，女性19例，平均年齡55歲(41～69歲)。術(shù)前進(jìn)行Constant評分、簡明肩關(guān)節(jié)評分(SST)、肩關(guān)節(jié)活動范圍檢查和疼痛視覺模擬評分(VAS)。肩關(guān)節(jié)鏡下手術(shù)松解范圍包括喙肱韌帶、肩袖間隙、盂肱中韌帶、前方關(guān)節(jié)囊及盂肱下韌帶前部。術(shù)后規(guī)范康復(fù)鍛煉。在最后一次隨訪時進(jìn)行肩關(guān)節(jié)活動范圍、Constant評分、SST評分和疼痛VAS評分。結(jié)果 獲得隨訪21例，隨訪率80.8%。平均隨訪時間31個月(29～36個月)。伴有糖尿病患者9例，占全部26例患者的34.6%。術(shù)前肩關(guān)節(jié)前屈上舉71.3°(50°～110°)，術(shù)后改善至158.9°(150°～170°)。術(shù)前體側(cè)外旋5.6°(0°～15°)，改善至術(shù)后57.5°(45°～70°)。術(shù)前Constant評分34.9分(13～71分)，術(shù)后提高到90.4分(81～100分)。術(shù)前SST評分2.4分(0～7分)術(shù)后提高到10.1分(8～12分)。術(shù)前患側(cè)肩關(guān)節(jié)疼痛VAS評分平均7.9分(5～9分)，術(shù)后提高到1.4分(0～3分)。結(jié)論 肩關(guān)節(jié)鏡下肩關(guān)節(jié)前方松解對于原發(fā)性凍結(jié)肩治療效果確切。

關(guān)節(jié)鏡；凍結(jié)肩；松解

肩關(guān)節(jié)僵硬是導(dǎo)致肩痛，影響患者生活質(zhì)量的一個常見原因，以前常常稱為“肩周炎”。Rockwood在第4版《肩》中將肩關(guān)節(jié)僵硬分為原發(fā)性凍結(jié)肩和繼發(fā)性肩關(guān)節(jié)僵硬兩類[1]。原發(fā)性凍結(jié)肩是指在沒有肩關(guān)節(jié)明確疾患的情況下，肩關(guān)節(jié)出現(xiàn)多平面的主、被動活動受限，可以伴有系統(tǒng)性疾病如糖尿病[1]。原發(fā)性凍結(jié)肩人群發(fā)生率2%～5%，70%為女性，20%～30%會出現(xiàn)對側(cè)凍結(jié)肩[2]。多數(shù)經(jīng)過保守治療可以獲得滿意的功能恢復(fù)，但仍有7%～50%患者殘留疼痛和功能受限[2]。關(guān)節(jié)鏡下肩關(guān)節(jié)松解術(shù)是對于保守治療無效的原發(fā)性凍結(jié)肩的有效治療方法[3-5]。與麻醉下手法松解相比，關(guān)節(jié)鏡下松解可以獲得更好的功能恢復(fù)、更好的疼痛緩解和更少的并發(fā)癥發(fā)生率[6]。關(guān)節(jié)鏡下松解的手術(shù)技術(shù)并沒有統(tǒng)一的標(biāo)準(zhǔn)，尤其是對于關(guān)節(jié)囊應(yīng)該松解的范圍存在爭議，有的醫(yī)生只進(jìn)行肩袖間隙松解[7]，有的進(jìn)行肩關(guān)節(jié)前方松解[8]，有的進(jìn)行肩關(guān)節(jié)前后下方松解[8]，還有進(jìn)行全關(guān)節(jié)囊松解[9]。本研究探討肩關(guān)節(jié)前方松解對于原發(fā)性凍結(jié)肩的治療效果。

資 料 與 方 法

一、一般資料

自2011年1月至2012年12月，共有37例患者以原發(fā)性凍結(jié)肩入院行肩關(guān)節(jié)鏡下松解術(shù)，患者入院前均經(jīng)過保守治療，每位患者采用的保守治療方法可能有一種或幾種，如生活方式調(diào)整、休息、激素注射、口服抗炎止痛藥物、物理治療、康復(fù)鍛煉等。保守治療無效的標(biāo)準(zhǔn)：(1) 經(jīng)上述保守方法治療后疼痛或者活動范圍沒有明顯改善；(2) 患者因疼痛或者嚴(yán)重的功能受限無法接受長期的保守治療。本研究入選標(biāo)準(zhǔn)：(1) 診斷為原發(fā)性凍結(jié)肩；(2) 術(shù)中松解范圍為肩袖間隙至6點位置；(3) 關(guān)節(jié)鏡松解前后均沒有進(jìn)行麻醉下手法松解。排除標(biāo)準(zhǔn)：(1) 術(shù)中發(fā)現(xiàn)關(guān)節(jié)內(nèi)合并其他損傷；(2) 松解范圍包含了后方關(guān)節(jié)囊；(3)同時進(jìn)行了手法松解。共有26例患者符合入選標(biāo)準(zhǔn)，其中男性7例，女性19例，平均年齡55歲(41～69歲)。

二、手術(shù)方法

手術(shù)均在全身麻醉下進(jìn)行，患者取沙灘椅體位，常規(guī)標(biāo)畫體表標(biāo)記。關(guān)節(jié)鏡常規(guī)經(jīng)后入路插入盂肱關(guān)節(jié)腔，可見關(guān)節(jié)腔容積較小，關(guān)節(jié)囊內(nèi)壁充血，滑膜增生；找到長頭肌腱后在其下方經(jīng)體外進(jìn)行針頭穿刺，建立前方工作入路?？梢娂缧溟g隙、關(guān)節(jié)囊明顯增厚(圖1)，使用射頻松解肩袖間隙，松解范圍包括長頭肌腱前緣、喙肱韌帶、肩袖間隙增生的滑膜組織(圖2)；清晰顯露出肩胛下肌腱上緣，然后將肩關(guān)節(jié)輕度外旋，可見增厚的盂肱中韌帶(圖3)，予以切斷；沿肩胛下肌后方從上到下切斷前方關(guān)節(jié)囊(圖4)和盂肱下韌帶前部(圖5，6)。確保前方關(guān)節(jié)囊松解徹底的標(biāo)準(zhǔn)是肩胛下肌在肩關(guān)節(jié)前方可以獲得清楚地顯示，一般下方松解到5-6點位置，關(guān)節(jié)鏡鞘可以順利通過盂肱關(guān)節(jié)間隙即可。下方關(guān)節(jié)囊和后方關(guān)節(jié)囊均不進(jìn)行松解。使用射頻清理關(guān)節(jié)腔內(nèi)壁充血增生的滑膜組織，并止血。將關(guān)節(jié)鏡轉(zhuǎn)入到肩峰下間隙，直視下建立前外側(cè)工作通道和后外側(cè)關(guān)節(jié)鏡第二觀察通道，進(jìn)行肩峰下滑膜清掃，均不進(jìn)行喙肩韌帶松解和肩峰前下緣成形，徹底止血。常規(guī)在盂肱關(guān)節(jié)腔和肩峰下間隙各注入復(fù)方倍他米松2 ml和利多卡因3 ml。術(shù)后康復(fù)：常規(guī)肩關(guān)節(jié)吊帶保護(hù)4周。術(shù)后第1周，進(jìn)行肩關(guān)節(jié)被動上舉、外旋活動。第2周開始，在患者可以耐受的范圍內(nèi)進(jìn)行加強(qiáng)的關(guān)節(jié)上舉、外旋、內(nèi)收的被動牽拉練習(xí)，患者可以在可耐受范圍內(nèi)進(jìn)行患肢的主動活動。術(shù)后1個月繼續(xù)關(guān)節(jié)牽拉練習(xí)，肩袖肌肉抗阻力鍛煉，肩胛帶肌肉抗阻力鍛煉，逐漸恢復(fù)日常使用。隨訪指標(biāo)：患者在術(shù)前記錄患肩被動上舉、外旋范圍，術(shù)前Constant評分和簡明肩關(guān)節(jié)評分(simple shoulder test, SST)，疼痛視覺模擬評分(Visual analogue scale,VAS)。在最后一次隨訪時進(jìn)行肩關(guān)節(jié)活動范圍、Constant評分、SST評分和疼痛VAS評分。

圖1 肩袖間隙攣縮并滑膜增生

圖2 松解肩袖間隙及喙肱韌帶

圖3 松解盂肱中韌帶

圖4 松解前方關(guān)節(jié)囊，盂肱中韌帶已經(jīng)被切斷

圖5 盂肱下韌帶前部充血并攣縮

圖6 盂肱下韌帶前部已經(jīng)松解

三、統(tǒng)計學(xué)方法

計數(shù)資料均按照平均值和最大最小值范圍描述。

結(jié) 果

26例中獲得隨訪21例，隨訪率80.8%。平均隨訪時間31個月(29～36個月)。伴有糖尿病患者9例，占26例患者的34.6%?；颊咝g(shù)前患側(cè)肩關(guān)節(jié)前屈上舉平均71.3°(50°～110°)，到最后一次隨訪時平均158.9°(150°～170°)。術(shù)前體側(cè)外旋平均5.6°(0°～15°)，到最后一次隨訪時平均57.5°(45°～70°)?；颊咝g(shù)前患側(cè)肩關(guān)節(jié)Constant評分平均34.9分(13～71分)，健側(cè)肩關(guān)節(jié)Constant評分92.8分(57～100分)；到最后一次隨訪時患側(cè)肩關(guān)節(jié)Constant評分達(dá)到90.4分(81～100分)，健側(cè)肩關(guān)節(jié)Constant評分95.6分(80～100分)?；颊咝g(shù)前SST評分平均2.4分(0～7分)，健側(cè)平均11分(4～12分)；到最后一次隨訪時患側(cè)SST平均10.1分(8～12)分，健側(cè)平均11.6分(10～12)分?；颊咝g(shù)前患側(cè)肩關(guān)節(jié)疼痛VAS評分平均7.9分(5～9分)，到最后一次隨訪時平均1.4分(0～3分)。

討 論

原發(fā)性凍結(jié)肩是中老年人群肩痛的常見原因，Binder等[2]報道人群發(fā)生率達(dá)到2%～5%。以往常常認(rèn)為原發(fā)性凍結(jié)肩是自限性疾病，但Binder等[2]的研究顯示有7%～50%存在不同程度的疼痛和功能受限。肩關(guān)節(jié)鏡下松解術(shù)是對于保守治療無效患者的一種有效治療手段[3-7,9-10]。

肩關(guān)節(jié)鏡在凍結(jié)肩治療中的應(yīng)用最初還僅是用于關(guān)節(jié)腔檢查，Neviaser根據(jù)關(guān)節(jié)鏡觀察的結(jié)果將凍結(jié)肩分為4期[11-12]。Pollock等[7]較早報道通過關(guān)節(jié)鏡對凍結(jié)肩進(jìn)行檢查，合并損傷的治療以及鏡下關(guān)節(jié)囊松解。在他的這組病例中，均是先進(jìn)行手法松解，然后再進(jìn)行關(guān)節(jié)鏡檢查和喙肱韌帶、肩袖間隙和前方關(guān)節(jié)囊松解，下方和后方關(guān)節(jié)囊都不進(jìn)行松解。Ogilvie-Harris等[6]最早報道了肩關(guān)節(jié)鏡下松解與手法松解的臨床效果，關(guān)節(jié)鏡下松解范圍包括肩袖間隙、盂肱上韌帶、肩胛下肌腱的一部分、盂肱下韌帶前部及下方關(guān)節(jié)囊。結(jié)果顯示關(guān)節(jié)鏡松解在疼痛緩解和功能恢復(fù)上都明顯優(yōu)于手法松解。Segmüller等[3]報道的關(guān)節(jié)鏡松解范圍又與前面不同，他先建立一個后下通道，進(jìn)行關(guān)節(jié)囊從前方3點到后方9點的關(guān)節(jié)囊松解，如果外旋仍有受限，繼續(xù)松解盂肱中韌帶和肩袖間隙的有限清理。Bennett[13]報道的松解范圍則從前方的肩袖間隙，喙肱韌帶，盂肱上韌帶，盂肱中韌帶，到前方關(guān)節(jié)囊，盂肱下韌帶前后部，下方關(guān)節(jié)囊直至后上方關(guān)節(jié)囊。他認(rèn)為如此廣泛的松解對原發(fā)性和繼發(fā)性凍結(jié)肩都有良好的松解效果。

對于凍結(jié)肩的手術(shù)治療，關(guān)節(jié)鏡技術(shù)已經(jīng)占據(jù)主導(dǎo)地位，但手術(shù)松解范圍沒有統(tǒng)一的標(biāo)準(zhǔn)，從局限的前方松解直至關(guān)節(jié)囊360°松解均有大量報道[14]。Chen等[8]比較了前方關(guān)節(jié)囊松解與270°關(guān)節(jié)囊松解的手術(shù)效果，其中前方關(guān)節(jié)囊松解范圍與本研究相同，結(jié)果發(fā)現(xiàn)270°松解在術(shù)后3個月時關(guān)節(jié)活動范圍優(yōu)于前方松解，在術(shù)后6個月時兩組病例關(guān)節(jié)功能沒有明顯區(qū)別。本研究結(jié)果顯示前方關(guān)節(jié)囊松解，肩關(guān)節(jié)功能可以獲得可靠的恢復(fù)。

原發(fā)性凍結(jié)肩往往表現(xiàn)為多個運動平面的活動范圍受限，如外旋、上舉和內(nèi)收。前方關(guān)節(jié)囊的松解可以顯著改善外旋，包括體側(cè)外旋和外展外旋的角度。后方關(guān)節(jié)囊松解有利于改善內(nèi)旋功能，但Snow等[15]比較前方松解與前方+后方松解的效果，并沒有發(fā)現(xiàn)對于內(nèi)旋功能恢復(fù)的差異。本項回顧性研究僅進(jìn)行前方關(guān)節(jié)囊松解，術(shù)中松解范圍從肩袖間隙到盂肱下韌帶前部，術(shù)中即可恢復(fù)正常范圍的上舉、體側(cè)外旋和外展外旋。我們選擇僅進(jìn)行前方松解的主要原因在于：(1)外旋功能受限主要由于喙肱韌帶、肩袖間隙、盂肱上、中韌帶及盂肱下韌帶前部所致，松解此范圍即可獲得術(shù)中良好的外旋恢復(fù)；(2) 從臨床指導(dǎo)患者康復(fù)訓(xùn)練來看，后方關(guān)節(jié)囊所致的水平內(nèi)收和內(nèi)旋可以比較容易通過康復(fù)鍛煉改善，術(shù)中松解后方關(guān)節(jié)囊的必要性小。

本項研究存在不足之處。首先這是一項回顧性研究，難免存在病例選擇的偏差。其次，缺乏臨床對照，前瞻性對照研究是我們下步研究的重點。有較多文獻(xiàn)報道糖尿病患者術(shù)后恢復(fù)效果差于普通患者，但本研究糖尿病患者病例數(shù)僅9例，不足以進(jìn)行有效地統(tǒng)計學(xué)比較。對于糖尿病患者術(shù)后恢復(fù)效果的研究有待開展。

結(jié)論：原發(fā)性凍結(jié)肩經(jīng)過規(guī)范保守治療無效的患者可以通過肩關(guān)節(jié)鏡松解手術(shù)獲得良好的功能恢復(fù)，肩關(guān)節(jié)前方松解可以獲得滿意療效。

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陳建海,劉中邸,黨育,等.肩關(guān)節(jié)前方松解治療原發(fā)性凍結(jié)肩的回顧性研究[J/CD]. 中華肩肘外科電子雜志,2015,3(4):227-232.

Aretrospectivestudyofanteriorarthroscopicarthrolysisfortreatmentofprimaryfrozenshoulder

ChenJianhai,LiuZhongdi,DangYu,YangMing,LuHao,ZhangDianying,FuZhongguo.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital，PekingUniversityTrafficMedicineCenter,Beijing100044,China

Correspondingauthor：FuZhongguo,Email：fuzhongguo@vip.sina.com

Background Frozen shoulder is a common cause for shoulder pain and reduced quality of life in affected patients, which is formerly referred to as “peri-arthritis of shoulder." Rockwood divided frozen shoulder cases into primary and secondary categories in the fourth edition of "The Shoulder". Primary frozen shoulder refers to the presence of active and passive activity limitation at multiple planes without clear history of shoulder disorders, which maybe accompanied by systemic diseases such as diabetes. The incidence of primary frozen shoulder is 2%-5%, with 70% of female patients and contralateral shoulder stiffness in 20%-30% of the patients. Most patients have satisfactory functional recovery after conservative treatment, but residual pain and functional limitation may remain in 7%-50% of the patients. Arthroscopic arthrolysis is an effective treatment for primary frozen shoulder with failed conservative therapies. Compared with manipulation under anesthesia, arthroscopic arthrolysis can achieve better functional recovery, pain-relief and has fewer complications. The surgical techniques for arthroscopic arthrolysis do not have uniform standards. There are controversies especially for the range of joint capsular release, while some doctors only do rotator interval release, some release anterior shoulder, some release anterior, posterior and inferior shoulder and some do a full capsular release. This study investigated the efficacy of anterior shoulder release for the treatment of primary frozen shoulder.Methods From January 2011 to December 2012, a total of 37 patients with primary frozen shoulders were hospitalized to receive arthroscopic anthrolysis. Patients all

conservative therapy before hospitalization, the main content of which include: life style adjustment, rest, steroid injection, oral non-steroid anti-inflamatory medications, physical therapy, rehabilitation and so on. Each patient may receive one or more of the above conservative therapies. Criteria for conservative therapy failure: (1) no significant improvement in pain and motion limitation after the above conservative therapies; (2) patients cannot receive long-term conservative therapy due to pain or severe functional limitations. Inclusion criteria of this study: (1) Diagnosed of primary frozen shoulder; (2) Range of surgical release is from rotator interval to 6:00 position; (3) Haven′t received manual release under anesthesia before or after arthroscopic release. Exclusion criteria: (1) intraoperative finding of other combined intra-articular injuries; (2) release range included posterior joint capsule; (3) combined with closed manipulation. A total of 26 patients met the inclusion criteria and were included in this retrospective study. Surgical methods: Surgery was performed under general anesthesia. The patient was placed at beach chair position and shoulder landmarks are marked. Arthroscopy was inserted via posterior portal into the glenohumeral joint through conventional technique, viewing small articular cavity, visible congestive synovial hyperplasia on interior walls of the joint capsule. The long head of biceps tendon was located and needle was punctured beneath from outside of the body into the joint cavity. An anterior working portal was established and radio frequency was applied to release the rotator interval. Visible thickening was seen at the joint capsule rotator interval. Arthrolysis covered leading edge of the long head tendon, coracohumeral ligament and thickened synovial tissue at the rotator interval until the edge of the subscapularis tendon could be clearly revealed, laterally rotated the shoulder joint, exposed visible thickening of the glenohumeral ligament, cut off the ligament, and cut off the anterior joint capsule and anterior glenohumeral ligament from top down along the posterior subscapularis muscles. Criteria for complete anterior joint capsule is that subscapularis muscle can be clearly seen in front of the shoulder joint. Generally, release extends downward to 5-6 o'clock position till arthroscope can pass through the glenohumeral joint smoothly. Neither the inferior nor the posterior capsule was released. Radio frequency was applied to cleanup the hyperemic and hyperplasic synovial tissue on the capsular walls and for hemostasis. Arthroscope was then moved to the subacromial space. An anterolateral working portal and a posterolateral secondary arthroscopic observation portal were established under direct vision, the subacromial space was decompressed.Coracoacromial ligament release and anterior acromioplasty were not performed. Complete hemostasis was conducted. Following routine procedure, 2 ml compound betamethasone and 3 ml lidocaine were injected into the glenohumeral joint and subacromial space, respectively. Postoperative rehabilitation: Shoulder was protected by an immobilizer for 4 weeks, passive abduction and external rotation of the shoulder was allowed in the first postoperative week. Starting from the second week, patients can perform aggressive passive stretching exercises of abduction, external rotation and adduction within a tolerable range. Patients can also perform active exercises of the shoulder within tolerable range. Capsular stretching exercises were continued since one month after operation. Anti-resistant exercises of the rotator cuff and shoulder girdle muscles were begun at 1 month after operation. Activities of daily living should be regained gradually. Follow-up indicators: Passive abduction and external rotation of the shoulder was evaluated preoperatively. Constant score, Simple Shoulder Test (SST) and VAS score were also evaluated before surgery. At the time of the last follow-up, passive range of shoulder motion,Constant score, SST score and VAS score were evaluated again.Results There were total of 26 patients in this study, among which 21 cases were followed up, accounting for a follow-up rate of 80.8%, with an average follow-up time of 31 months (29-36 months). Nine patients had concurrent diabetes, accounting for 34.6% of all 26 patients. Anterior elevation of the index shoulder was averaged in 71.3°(50°-110°) preoperatively, which was improved to an average of 158.9°(150°-170°) at the last follow-up. Preoperative average of 5.6°(0°-15°) external rotation was improved to an average of 57.5°(45°-70°) at the last follow-up. Preoperative Constant score was 34.9 points (13-71 points), and that of the contralateral shoulder was 92.8 points (57-100 points); by the time of the last follow-up, operated shoulder Constant score reached 90.4 points (81 to 100 points) while that of the contralateral shoulder was 95.6 points (80 to 100 points).Patients had a preoperative average SST score of 2.4 points (0-7 points) and contralateral shoulder average score of 11 points (4-12 points); by the time of the last follow-up, SST score of the operated shoulder was averaged in 10.1 points (8-12 points) and the contralateral side was 11.6 points (10-12 points). Preoperative VAS pain score was 7.9 points (5-9 points), which was reduced to 4 points (0-3 points) at the last follow-up.Conclusions Patients with primary frozen shoulders benefit from good functional recovery through arthroscopic release surgery after failed conservative treatment. Anterior shoulder release achieves satisfactory results.

Arthroscopy;Frozen shoulder;Arthrolysis

10.3877/cma.j.issn.2095-5790.2015.04.006

教育部創(chuàng)新團(tuán)隊項目(IRT1201)；衛(wèi)生公益性行業(yè)科研專項(201002014)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

付中國，Email：fuzhongguo@vip.sina.com

2015-10-10)