肩关节前方松解治疗原发性冻结肩的回顾性研究

A retrospective study of anterior arthroscopic arthrolysis for treatment of primary frozen shoulder

目的探讨肩关节镜下肩关节前方松解对于原发性冻结肩的治疗效果。方法回顾性分析2011年1月至2012年12月收治并行肩关节镜下肩关节前方松解的病例资料,共入组26例,男性7例,女性19例,平均年龄55岁(41~69岁)。术前进行Constant评分、简明肩关节评分(SST)、肩关节活动范围检查和疼痛视觉模拟评分(VAS)。肩关节镜下手术松解范围包括喙肱韧带、肩袖间隙、盂肱中韧带、前方关节囊及盂肱下韧带前部。术后规范康复锻炼。在最后一次随访时进行肩关节活动范围、Constant评分、SST评分和疼痛VAS评分。结果获得随访21例,随访率80.8%。平均随访时间31个月(29~36个月)。伴有糖尿病患者9例,占全部26例患者的34.6%。术前肩关节前屈上举71.3°(50°~110°),术后改善至158.9°(150°~170°)。术前体侧外旋5.6°(0°~15°),改善至术后57.5°(45°~70°)。术前Constant评分34.9分(13~71分),术后提高到90.4分(81~100分)。术前SST评分2.4分(0~7分)术后提高到10.1分(8~12分)。术前患侧肩关节疼痛VAS评分平均7.9分(5~9分),术后提高到1.4分(0~3分)。结论肩关节镜下肩关节前方松解对于原发性冻结肩治疗效果确切。

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 received 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 longterm 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 6:00position;(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 5-6o'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 4weeks,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 in71.3°(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 34.9points(13-71points),and that of the contralateral shoulder was 92.8points(57-100points);by the time of the last follow-up,operated shoulder Constant score reached 90.4points(81to 100points)while that of the contralateral shoulder was 95.6points(80to 100points).Patients had a preoperative average SST score of 2.4points(0-7points)and contralateral shoulder average score of 11points(4-12points);by the time of the last follow-up,SST score of the operated shoulder was averaged in 10.1points(8-12points)and the contralateral side was 11.6points(10-12points).Preoperative VAS pain score was 7.9points(5-9points),which was reduced to 4points(0-3points)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.