粘连性肩关节囊炎的治疗（三）
英语晨读 ·
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本次文献选自Redler LH, Dennis ER. Treatment of Adhesive Capsulitis of the Shoulder. J Am Acad Orthop Surg. 2019;27(12):e544-e554. 本次学习由阎芳副研究员主讲。
Diagnostic Imaging
Radiographs are classically normal in patients with AC. MRI in patients with AC often reveals capsular and CHL thickening, poor capsular distension, extracapsular contrast leakage, and synovial hypertrophy and scar tissue formation at the rotator interval (Figure 2). MRI findings on T2 fat-suppressed sequences in a study of 103 patients with AC correlated with pain intensity, ROM, and clinical stage. Anterior extracapsular edema was associated with degree of external rotation and abduction. Joint capsule edema in the axillary recess was associated with loss of external rotation. Joint capsule thickness was associated with pain intensity. Findings of joint capsule edema and obliteration of the subcoracoid fat triangle were more common in the early stages of AC, whereas capsular thickness markedly increased in later stages.
诊断性影像学
AC患者的x线片基本正常。AC患者的MRI常常显示关节囊和喙肱韧带增厚、关节囊延伸性不良、囊外造影剂渗漏、滑膜肥厚和肩袖间隙瘢痕组织形成（图2）。一项涉及103例AC患者的研究发现，MRI T2压脂像的表现与疼痛强度、关节活动度和肩周炎临床分期相关。前部关节囊外的水肿与外旋和外展程度有关。腋窝关节囊水肿与外旋功能丧失有关。关节囊厚度与疼痛强度相关。关节囊水肿和喙突下脂肪三角消失在AC早期更为常见，而在AC后期，关节囊厚度明显增加。
Risk Factors
The prevalence of AC is 2% to 5%, and it occurs more commonly in women and patients with diabetes. Other risk factors include hyperthyroidism; previous shoulder, breast, or cervical spine surgery; and rarely, immunizations. In a case-controlled study of 208 patients with type 2 diabetes mellitus (DM) versus 200 matched control subjects, 13% of patients in the diabetes group had AC versus 1.5% of patients in the control group (P , 0.01). Of all the patients who suffered from AC, those with diabetes were younger than those without. Additionally, the incidence of AC in the diabetes group was associated with how long they had been diabetic and had poor blood glucose control (P , 0.05). Likewise, in a meta-analysis of 18 studies, patients with diabetes were five times more likely than control subjects to have AC. From this, the overall prevalence of AC in patients with diabetes was estimated at 13.4%, whereas the prevalence of DM in patients with AC was 30%. Of note, comparison of prevalence in patients using insulin versus other treatments showed no notable difference.
风险因素
AC患病率2%～5%，女性和糖尿病患者多见。其他危险因素包括甲状腺功能亢进；曾做过肩、胸或颈椎手术；个别接受免疫接种者。在一项包含208例2型糖尿病（DM）患者与200例配对对照者的病例对照研究中，糖尿病组有13%的患者患有AC，而对照组有1.5%的患者患有AC（P＜0.01）。在所有患有AC的患者中，有糖尿病的患者比没有糖尿病的患者年龄更小。另外，糖尿病组AC的发生率与糖尿病病程及血糖控制不良有关（P＜0.05）。同样，一项包含18项研究的荟萃分析发现，糖尿病患者发生AC的可能性是对照组的5倍。据此，糖尿病患者AC的总患病率估计为13.4%，而AC患者DM的患病率为30%。值得注意的是，使用胰岛素和其他治疗方法的患者的患病率比较没有显示出显著的差异。
In a prospective, population-based, 7-year cohort study of one million participants using the Longitudinal Health Insurance Database 2005 in Taiwan, of 4,472 patients with hyperthyroidism, 162 patients experienced AC, giving a statistically significant hazard ratio of 1.22 compared with the control group, hence concluding that hyperthyroidism was an independent risk factor for developing AC.
A great deal of research has explored the incidence of AC in patients who previously had shoulder surgery. Results are mixed but range from 5% to 11% prevalence of the development of AC after shoulder surgery. In a prospective cohort study of 505 patients undergoing elective shoulder surgery, AC was identified in 11% of the patients at their 6-month follow-up and was more common in women than in men (15% versus 8%). In a retrospective analysis of 200 patients who underwent arthroscopic subacromial decompression with or without distal clavicle excision, the incidence of AC was 5.21% versus 5.71%. Ages between 46 and 60 years and previous diagnosis of AC in the contralateral side were statistically significant risk factors for the development of secondary AC. It was concluded that the risk of developing AC after arthroscopic débridement is just over 5% and not markedly affected by whether or not the distal clavicle is excised.
在一项中国台湾的基于人群的、前瞻性、耗时7年、涉及100万名参与者的队列研究中，作者发现，在4472名甲亢患者中，162名患者发生AC，与对照组相比，具有统计学意义的危险比为1.22，因此得出结论，甲亢是发生AC的独立危险因素。
大量的研究探讨了以前接受过肩部手术的患者中AC的发生率。结果是不一致的，总体来说，接受过肩关节手术的患者肩周炎的发病率在5%至11%。在一项对505名接受择期肩部手术的患者进行的前瞻性队列研究中，术后6个月的随访时，有11%的患者发生了AC，女性比男性更常见（15%对8%）。一项涉及200例关节镜下肩峰下减压术伴或不伴锁骨远端切除的患者的回顾性分析研究发现，AC的发生率分别为5.21%和5.71%。年龄在46岁到60岁之间，既往对侧发生过AC是再次发生AC的显著危险因素。结果显示，关节镜手术后发生AC的风险略高于5%，且与是否切除锁骨远端无关。