Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.
General Practitioner Training Program, Utrecht, the Netherlands.
Clin Orthop Relat Res. 2021 Nov 1;479(11):2483-2489. doi: 10.1097/CORR.0000000000001803.
Shoulder injections for conditions such as adhesive capsulitis are commonly performed and can be administered through image-based or landmark-based injection approaches. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast. Landmark-based injections would be advantageous, if they were accurate, because they would save the time and expense associated with ultrasound. However, few prospective studies have compared well-described landmark-based shoulder injection techniques without ultrasound.
QUESTION/PURPOSE: Using anatomic landmarks, and without using ultrasound, is the accuracy of glenohumeral injection for adhesive capsulitis greater via the posterior approach or via a new anterior approach?
Between 2018 and 2020, we treated 108 patients potentially eligible for adhesive capsulitis treatment. These patients had clinical symptoms of aggravating shoulder pain with a duration of less than 4 months and passively impaired, painful glenohumeral ROM. Due to the exclusion of patients with other shoulder conditions (full-thickness rotator cuff ruptures and posttraumatic stiffness), 95 patients received an injection in this sequential, prospective, comparative study. Between 2018 and 2019, 41 patients (17 males and 24 females; mean age 52 ± 5 years; mean BMI 24 ± 3 kg/m2) were injected through the posterior approach, with the acromion as the anatomical landmark, during the first part of the study period. After that, between 2019 and 2020, 54 patients (20 males and 34 females; mean age 54 ± 4 years; mean BMI 23 ± 3 kg/m2) received an injection through a new anterior approach, with the acromioclavicular joint as the anatomic landmark, during the second part of the study period. Injections via both approaches were administered by two experienced shoulder specialists (both with more than 10 years of experience). Both specialists had experience with the posterior approach before this study, and neither had previous training with the new anterior approach. Injections contained a corticosteroid, local anaesthetic, and contrast medium. Radiographs were taken within 20 minutes after the injection, and a radiologist blinded to the technique determined accuracy. Accurate injections were defined as having contrast fluid limited to the glenohumeral joint, while inaccurate injections displayed leakage of contrast fluid into the soft tissue or subacromial space. All of the enrolled patients were analyzed.
In the group with the posterior approach, the accuracy was 78% (32 of 41) in contrast to 94% (51 of 54, odds ratio 0.21 [95% CI 0.05 to 0.83]; p = 0.03) in patients with the new anterior approach.
The new anterior approach without the use of ultrasound was more accurate than the posterior approach. In fact, it was nearly as accurate as previously published ultrasound-guided approaches. We recommend using the new anterior approach for intraarticular glenohumeral injections instead of ultrasound-guided injections because it will save time and costs associated with ultrasound. Still, the clinical effects (anxiety, pain, functional outcome, and adverse events) of the new anterior approach should be compared with ultrasound-guided injections in a randomized study.
Level II, therapeutic study.
对于粘连性肩关节囊炎等疾病，肩部注射是一种常见的治疗方法，可以通过基于影像或基于解剖标志的注射方法进行。超声引导下的注射因其能够实时可视化针和注入的对比剂而被广泛应用且准确。如果基于解剖标志的注射方法准确，那么它们将节省与超声相关的时间和费用，因此具有优势。然而，很少有前瞻性研究比较过没有超声的描述良好的基于解剖标志的肩部注射技术。
问题/目的：在不使用超声的情况下，通过后入路或新的前入路进行粘连性肩关节囊炎的肩峰下间隙注射，哪种方法的准确性更高？
2018 年至 2020 年期间，我们治疗了 108 例可能符合粘连性肩关节囊炎治疗条件的患者。这些患者具有以下临床症状：肩部疼痛加剧，持续时间<4 个月，且被动活动时肩肱关节活动度受限伴疼痛。由于排除了患有其他肩部疾病（全层肩袖撕裂和创伤后僵硬）的患者，因此在这项连续、前瞻性、比较研究中，95 例患者接受了注射治疗。2018 年至 2019 年期间，41 例患者（17 例男性和 24 例女性；平均年龄 52±5 岁；平均 BMI 24±3kg/m2）接受了后入路注射，以肩峰作为解剖标志，在研究的第一部分进行。在此之后，2019 年至 2020 年期间，54 例患者（20 例男性和 34 例女性；平均年龄 54±4 岁；平均 BMI 23±3kg/m2）接受了新的前入路注射，以肩锁关节作为解剖标志，在研究的第二部分进行。两种方法的注射均由两名经验丰富的肩部专家（均有 10 年以上经验）进行。两名专家在这项研究之前都有后入路注射的经验，且都没有接受过新前入路的培训。注射包括皮质类固醇、局部麻醉剂和对比剂。注射后 20 分钟内拍摄 X 光片，由一名对技术不了解的放射科医生确定准确性。准确的注射定义为对比剂仅局限于肩峰下关节，而不准确的注射显示对比剂漏入软组织或肩峰下间隙。所有入组患者均进行了分析。
在后入路组中，准确性为 78%（41 例中有 32 例），而在新前入路组中，准确性为 94%（54 例中有 51 例，优势比 0.21[95%CI 0.05 至 0.83]；p=0.03）。
与后入路相比，不使用超声的新前入路更准确。事实上，它与之前发表的超声引导方法几乎一样准确。我们建议使用新的前入路进行关节内肩峰下间隙注射，而不是超声引导注射，因为它将节省与超声相关的时间和成本。不过，还需要在随机研究中比较新前入路与超声引导注射的临床效果（焦虑、疼痛、功能结果和不良事件）。
II 级，治疗性研究。
