Lehtinen J T, Belt E A, Kauppi M J, Kaarela K, Kuusela P P, Kautiainen H J, Lehto M U
Harvard Shoulder Service, Massachusetts General Hospital, Boston, MA, USA.
Ann Rheum Dis. 2001 Apr;60(4):322-6. doi: 10.1136/ard.60.4.322.
To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively.
At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space.
Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=-0.49 (95% CI -0.36 to -0.60) and r=-0.58 (95% CI -0.46 to -0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5.
Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.
对74例血清学阳性且有侵蚀性类风湿关节炎患者的队列进行前瞻性随访，评估盂肱（GH）关节的骨质破坏、向上移位和内移情况。
在15年随访时，用标准方法对148个肩部进行X线摄影。通过四种方法从X线片检查GH关节的骨质破坏，其中三种测量肱骨头的移位，一种测量肱骨头的重塑。肱骨头大结节到喙突的距离（内移距离（MD））以及到肱骨头关节面的距离（GA），此前已被用于评估类风湿性GH关节的术前偏移。最近开发了内侧移位指数（MI）和向上移位指数（UI）来评估类风湿性GH关节的破坏模式。GH关节的破坏程度采用Larsen法在0至5级范围内进行评估。研究测量值与GH关节破坏程度之间的关系。将UI与我们之前对肩峰下间隙的测量值进行比较。
MI和UI均与GH关节破坏（Larsen分级）呈负相关，r = -0.49（95%CI -0.36至-0.60）和r = -0.58（95%CI -0.46至-0.68）。UI与肩峰下间隙显著相关，r = 0.90（95%CI 0.86至0.93）。未受影响关节的平均MI和UI测量值在报告的正常变异范围内。MD的平均值在Larsen 4级（83.0 mm）和5级（65.5 mm）之间缩小。肱骨头形态从3级开始出现扁平及侵蚀，5级时检测到肱骨头内侧破坏。
内移似乎先于肱骨头向上移位，提示肩袖损伤。有症状的Larsen 3级肩部应通过临床和影像学手段进行密切随访。如果考虑行全肩关节置换术，在足够早的阶段（Larsen 3级和4级）进行骨科会诊是值得的，此时负责功能的软组织结构仍处于良好状态，手术时机可以得到很好的规划。
