Warner J J, Allen A A, Marks P H, Wong P
Shoulder Service, Center for Sports Medicine, University of Pittsburgh, Pennsylvania 15213-1217, USA.
J Bone Joint Surg Am. 1997 Aug;79(8):1151-8. doi: 10.2106/00004623-199708000-00006.
A loss of motion after an operation on the shoulder often cannot be treated successfully with physical therapy or closed manipulation. Although open release techniques generally improve motion, they involve extensive dissection. We developed a technique of arthroscopic capsular release and applied it in eighteen patients who had postoperative stiffness of the shoulder. The patients were selected for the arthroscopic release technique if a conservative program of physical therapy and an attempted closed manipulation had failed to restore motion and if they had no known extra-articular contractures. Five of the thirteen patients who had had a global loss of shoulder motion had motion restored with the anterior capsular release, and six needed an additional release of the posterior aspect of the capsule--that is, a combined (anterior and posterior) capsular release. The arthroscopic procedure could not be completed in the remaining two patients because of an extra-articular scar involving the subscapularis, but those patients were managed successfully with an open release. As five patients had lost only internal rotation and flexion, they had only a posterior capsular release. For the eleven patients who had had either an anterior or a combined (anterior and posterior) capsular release, the mean improvement in the score of Constant and Murley was 43 points (range, 31 to 62 points) and all improvements in motion were significant (p < 0.01). Flexion improved a mean of 51 degrees (range, 10 to 65 degrees); external rotation in adduction and abduction, 31 degrees (range, 10 to 50 degrees) and 40 degrees (range, 5 to 80 degrees), respectively; and internal rotation in adduction and abduction, six spinous-process levels (range, three to eleven levels) and 41 degrees (range, 20 to 70 degrees), respectively. For the five patients who had an isolated posterior capsular release, the score of Constant and Murley improved a mean of 20 points (range, 5 to 35 points) and the improvements in motion also were significant (p < 0.05 and 0.005). Internal rotation in adduction and abduction improved a mean of four spinous-process levels (range, one to ten levels) and 42 degrees (range, 30 to 60 degrees), respectively. Eight patients had an arthroscopic acromioplasty for concomitant impingement disease. One patient who had had a combined (anterior and posterior) release and one who had had a posterior capsular release continued to have pain because of injury of the articular cartilage from a previous operation. We concluded that arthroscopic capsular release is a reliable method for restoring motion with minimum morbidity in carefully selected patients who have postoperative stiffness of the shoulder. When necessary, it can be converted to an open release.
肩部手术后出现的活动受限通常无法通过物理治疗或闭合手法复位成功治疗。尽管开放松解技术一般能改善活动度，但需要广泛的解剖操作。我们开发了一种关节镜下关节囊松解技术，并将其应用于18例肩部术后僵硬的患者。如果物理治疗的保守方案和尝试的闭合手法复位未能恢复活动度，且患者不存在已知的关节外挛缩，则选择这些患者进行关节镜松解技术。13例肩部整体活动丧失的患者中，5例通过前关节囊松解恢复了活动度，6例需要额外松解关节囊的后部，即联合（前和后）关节囊松解。由于肩胛下肌存在关节外瘢痕，其余2例患者无法完成关节镜手术，但这些患者通过开放松解成功得到了治疗。5例仅丧失内旋和屈曲功能的患者，仅进行了后关节囊松解。对于11例接受了前或联合（前和后）关节囊松解的患者，Constant和Murley评分的平均改善为43分（范围为31至62分），所有活动度的改善均具有显著性（p < 0.01）。屈曲平均改善51度（范围为10至65度）；内收和外展时的外旋分别改善31度（范围为10至50度）和40度（范围为5至80度）；内收和外展时的内旋分别改善6个棘突水平（范围为3至11个水平）和41度（范围为20至70度）。对于5例仅进行后关节囊松解的患者，Constant和Murley评分平均改善20分（范围为5至35分），活动度的改善也具有显著性（p < 0.05和0.005）。内收和外展时的内旋分别平均改善4个棘突水平（范围为1至10个水平）和42度（范围为30至60度）。8例患者因合并撞击症接受了关节镜下肩峰成形术。1例接受联合（前和后）松解的患者和1例接受后关节囊松解的患者因既往手术导致的关节软骨损伤仍有疼痛。我们得出结论，对于精心挑选的肩部术后僵硬患者，关节镜下关节囊松解是一种以最小发病率恢复活动度的可靠方法。必要时，可转换为开放松解。
