粘连性肩关节囊炎的治疗（九）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

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。

Limited Capsular Release Versus Circumferential Release

As mentioned earlier, various techniquesexist for managing the capsulotomy and rotator interval. Some authors advocatefor avoidance of an inferior release to limit axillary nerve injury. A retrospective study of 52 patients who underwent arthroscopic capsular release compared various techniques, suchas joint débridement, rotator interval opening, CHL release, variouscapsulotomies (anterior, posterior, inferior, and anterior-inferior), orsubscapularis tenotomy. All patients had improvement in pain and ROM. Patientswho underwent inferior capsulotomy as part of their release (n = 20) had the best results.

关节囊局限性松解和环周松解

如前所述，有多种技术可用于进行关节囊切开和肩袖间隙的处理。一些作者主张避免下部松解以防止腋神经损伤。有作者对52例接受关节镜下关节囊松解术的患者进行了回顾性研究，比较了各种技术，如关节固定术、肩袖间隙开放术、CHL松解术、各种关节囊切开术（前、后、下、前下）或肩胛下肌腱切开术。所有患者的疼痛和关节活动度均有改善，其中接受下囊切开术（n=20）的患者效果最好。

Lafosse et al recently described the360-capsular release technique in which the subacromial space is entered laterally,the rotator interval is opened from the outside in, and a 360° capsular release and biceps tenotomy is performed. All patientsreported excellent improvement in ROM and pain scores, and no complications werepresent, including axillary nerve injury, fracture, or infection.

Lafosse等人最近描述了360度关节囊松解技术，从外侧进入肩胛下间隙，从外向内打开肩袖间隙，并进行360度关节囊松解和肱二头肌肌腱切开术。所有患者的活动度和疼痛评分都有显著改善，无腋神经损伤、骨折或感染等并发症。

Author’s Preferred Technique

The senior author prefers an interscaleneblock for sustained postoperative pain control combined with a generalanesthetic, including paralysis, to ensure that a gentle MUA can beaccomplished without undue force. Our capsular release method incorporates ananterior, anteroinferior, and posterior capsular release, with extension inferiorlyto the level of the infraspinatus and release of the rotator interval. We beginusing a posterior working portal where the rotator interval is released workingaround the labrum superiorly to the biceps laterally (Figure 5). Care is takento release all adhesions to help lateralize the humeral head and improveworking space. The superior glenohumeral interval and CHL are released withinthe rotator interval. Next, we identify the subscapularis and free up itsposterior surface. The anteroinferior capsule is released deep to subscapularistendon along with any component of contracted middle glenohumeral ligament andinferior glenohumeral ligament circumferentially to the 5 o’clock position. Next,an anterior working portal is used to perform a posterior capsule release,working inferiorly using infraspinatus fibers as landmark of adequate release(Figure 6).

作者的首选技术

作者更倾向于肌间沟阻滞以获得良好术后镇痛联合全身麻醉，以确保可以在没有过度用力的情况下温和地进行手法松解。我们的关节囊松解方法包括前囊、前下囊和后囊松解，向下应松解到冈下肌水平，并松解肩袖间隙。我们使用一个后方的工作通道，松解肩袖间隙，向上到达盂唇，向外到达肱二头肌（图5）。小心松解所有粘连，以使肱骨头能向侧方移动以使术者获得更好的操作空间。在肩袖间隙处松解上盂肱间隙和喙肱韧带。接下来，我们确定肩胛下肌的位置并松解其后表面。前下关节囊松解的深度应达到肩胛下肌腱和挛缩的中盂肱韧带和下盂肱韧带的环周直到5点钟位置。下一步，使用前路工作通道进行后关节囊松解，向下直至冈下肌纤维得到充分松解（图6）。

During the MUA, the anterior and posterior releases propagate toward each other and connect inferiorly. It is vital to grasp the patient’s arm proximally to create a short lever arm, which decreases the risk of fracture. The first step is forward elevation of the arm to 180°. This serves to release the inferior capsule in the axillary fold. Next, with the arm adducted, the shoulder is externally rotated to release the anterior capsule. Then, cross-body adduction is performed to release the posteroinferior capsule. Next, the arm is brought into abduction. In abduction, with scapular stabilization by an assistant, the glenohumeral joint is first maximally externally rotated (to continue release of the anterior capsule) and then maximally internally rotated (to release the posterior capsule). We document the patient’s forward elevation, external rotation at the side,90°ainternalrotationat bduction, and straight abduction with the camera to provide the patient and his or her therapist with photographs of the improved ROM (Figure 7). After the manipulation, a repeat arthroscopic assessment is performed to confirm circumferential release. Last, an assessment of the subacromial space is always performed. Impingement signs are not applicable on physical examination in patients with AC, and a large subacromial spur with extensive subacromial bursitis is often encountered. A standard subacromial decompression with acromioplasty is performed if warranted by intraoperative findings. Postoperatively, all patients have portable AP, lateral, and axillary radiographs in the postanesthesia care unit to ensure no fractures are present. Postoperative multimodal pain management is used, including acetaminophen 1000 mg three times daily for 7 days, gabapentin 300 mg three times daily for 3 days, diazepam 5 mg as needed for muscle spasm, and oxycodone 5 to 10 mg as needed for pain. With this regimen, we have found that patients require fewer narcotics and therefore can avoid undesirable adverse effects.

在手法松解过程中，前方和后方分别松解并过渡到下方的松解。松解时应抓住患者手臂的近端以形成一个短的力臂是至关重要的，这样可以降低骨折的风险。第一步是将手臂从前方上举到180°。这有助于松解腋窝皱襞中的下关节囊。接下来，手臂内收，肩关节外旋以松解前关节囊。然后，上臂向对侧内收以松解后下关节囊。接下来，手臂外展。外展时，应有助手协助以稳定肩关节，盂肱关节首先最大限度地外旋（继续松解前囊），然后最大限度地内旋（松解后囊）。我们用相机记录患者的前举、侧方外旋、90°外展位内旋和外展，为患者及其治疗师提供活动度改进后的照片（图7）。手法松解后，重复关节镜评估，以确认彻底松解。最后，一定要对肩峰下间隙进行评估。撞击征不适用于AC患者的体格检查，经常会碰到肩峰下大骨刺和广泛的肩峰下滑囊炎的患者。如果术中发现有必要，可以进行标准的肩峰下减压术和肩峰成形术。术后，所有患者均在麻醉后护理室接受便携式正位片、侧位片和腋窝x线片检查，以确保无骨折发生。术后采用多模式镇痛管理，包括对乙酰氨基酚1000mg，每日3次，连续7天，加巴喷丁300mg，每日3次，连续3天，肌肉痉挛时地西泮5mg，疼痛时羟考酮5～10mg。通过这个方案，我们发现病人需要更少的麻醉剂，因此可以避免不良反应。