关节镜联合富血小板血浆治疗粘连性肩周炎的疗效

doi:10.3877/cma.j.issn.1674-134X.2023.06.002

目的

探讨关节镜下松解术联合富血小板血浆(PRP)治疗粘连性肩周炎的疗效及对转化生长因子-β(TGF-β)和基质金属蛋白酶-2(MMP-2)表达影响的研究。

方法

选择2021年1月至2022年7月珠海市人民医院脊柱骨病科收治的粘连性肩周炎患者112例。纳入标准：符合肩周炎诊断标准；至少保守治疗6个月而症状及功能无明显改善者；年龄50~70岁。排除标准：继发性肩周炎；合并肩袖损伤、骨折、脱位等其他肩部疾病；合并重要脏器功能减退；内分泌疾病等。随机数字表法分成两组，每组56例。实验组行肩关节镜松解术＋PRP注射，对照组仅行肩关节镜松解术。方差分析和t检验比较两组患者术前、术后3、6个月MMP-2、TGF-β水平，同时比较术前、术后1、3、6个月视觉模拟评分(VAS)和术前、术后3、6个月肩关节Constant评分、美国肩肘外科医师评分(ASES)评分、肩关节活动度(ROM)。

结果

两组患者的性别、年龄等一般数据的差异没有统计学意义(均为P>0.05)。两组患者术后1、3、6个月随访VAS评分显著降低，而术后3、6个月随访肩关节Constant评分、ASES评分较术前均有增高(F＝151.25、119.37、1603.87、1488.35，均为P<0.001)，且ROM活动度也明显改善(前屈F＝957.80、803.17，内旋F＝755.46、1 024.99，外展F＝506.43、626.74，均为P<0.001)，差异具有统计学意义。治疗后组间末次随访比较，实验组疼痛VAS评分、肩关节Constant评分、肩关节ASES评分改善更明显，差异有统计学意义(t＝3.223、4.612、3.583，均为P<0.05)，而ROM活动度改善也更明显，差异具有统计学意义(前屈t＝3.487，内旋t＝5.101，外展t＝3.114，均为P<0.001)。手术后3、6个月，两组患者的TGF-β、MMP-2水平较手术前降低(F＝650.28、784.41、506.37、740.33，均为P<0.05)，且实验组患者的TGF-β、MMP-2水平均低于对照组(t＝2.656、2.723、2.736、2.941，均为P<0.05)，差异均有统计学意义。实验组末次随访1例复发粘连，而对照组有4例复发肩关节粘连，采用关节腔PRP注射后均缓解。

结论

肩关节镜手术联合PRP治疗粘连性肩周炎患者的效果优于单纯关节镜清理，不仅能快速降低疼痛和功能恢复，而且可以降低患者的炎症反应程度及复发风险，并且可作为松解术后再发粘连的治疗手段。

关键词: 肩, 关节镜, 富血小板血浆, 关节周围炎, 转化生长因子β, 基质金属蛋白酶

Objective

To investigate the effect of arthroscopic release combined with platelet-rich plasma (PRP) on the expression of transforming growth factor β(TGF-β) and matrix metalloproteinase 2 (MMP-2) in the treatment of adhesive periarthritis of shoulder.

Methods

A total of 112 patients with adhesive periarthritis of shoulder admitted to Department of Orthopedics, Zhuhai People's Hospital from January 2021 to July 2022 were selected. Inclusion criteria: diagnosis of periarthritis of shoulder; non-surgical treatment for at least six months without improvement; aged from 50 to 70 years. Exclusion criteria: secondary periarthritis of shoulder; combing with rotator cuff injury, bone fracture or dislocation; vital organ dysfunction; endocrine diseases.The patients were divided into two groups by random number table, 56 cases in each group. The experimental group were treated by shoulder arthroscopic release and PRP injection, and the control group were treated only with shoulder arthroscopic release. The serum MMP-2 and TGF-β were compared between the two groups before operation, three and six months after operation, and the visual analog scale (VAS) before operation, one, three and six months after operation, the Constant score, American Shoulder Elbow Surgeons(ASES)score of shoulder joint and the range of motion (ROM) of shoulder joint were compared between the two groups before operation and three and six months after operation by analysis of variance and t test.

Results

There was no significant difference in gender, age or other general data between the two groups (all P>0.05). VAS score was significantly decreased at one, three and six months after operation, while Constant score, ASES score were increased at three and six months after operation (F=151.25, 119.37, 1603.87, 1488.35, all P<0.001), and ROM activity also improved significantly (anteflexion F=957.80, 803.17, internal rotation F=755.46, 1024.99, abduction F=506.43, 626.74, all P<0.001), the difference was statistically significant.Compared with the last follow-up between the two groups, the VAS score, the Constant score, the ASES score in the experimental group were significantly improved (t=3.223, 4.612, 3.583, all P<0.05), and ROM activity was also significantly improved(forward flexion t=3.487, internal rotation t=5.101, abduction t=3.114, all P<0.001), the differences were statistically significant.At three and six months after operation, the levels of TGF-β and MMP-2 in two groups were lower than before operation(F=650.28, 784.41, 506.37, 740.33, all P<0.05), and the levels of TGF-β and MMP-2 in experimental group were lower than those in control group(t=2.656, 2.723, 2.736, 2.941, all P<0.05), the differences were statistically significant. At the last follow-up, there was one case of recurrent adhesion in the experimental group, and fourcases of recurrent shoulder adhesion in the control group, all of which were relieved after PRP injection.

Conclusion

The effect of shoulder arthroscopic surgery combined with PRP in the treatment of adhesive shoulder periarthritis is better than that of arthroscopicdebridementalone, which can not only rapidly reduce pain and functional recovery, but also reduce the degree of inflammation and the risk of recurrence in patients, and can be used as a treatment for the recurrence of adhesions after release

Key words: Shoulder, Arthroscope, Platelet-rich plasma, Periarthritis, Transforming growth factor beta, Matrix metalloproteinases

表1 两组肩周炎患者一般资料

Table 1 General information of the patients with shoulder periarthritis

组别Groups	例数Case number	年龄[岁，(±s)]Age (year)	性别[例(%)]Gender		病程[月，(±s)]Duration(month)	患侧[例(%)]Affected side
组别Groups	例数Case number	年龄[岁，(±s)]Age (year)	男Male	女Female	病程[月，(±s)]Duration(month)	左Left	右Right
实验组Experimental group	56	59.5±5.4	36(64.3)	20(35.7)	8.3±1.7	32(57.1)	24(42.9)
对照组Control group	56	58.8±5.3	32(57.1)	24(42.9)	7.98±1.7	29(51.8)	27(48.2)
统计值Statistical value		t＝1.501	χ²＝0.599		t＝0.949	χ²＝0.324
P值		>0.05	>0.05		>0.05	>0.05

表1 两组肩周炎患者一般资料

Table 1 General information of the patients with shoulder periarthritis

组别Groups	例数Case number	年龄[岁，(±s)]Age (year)	性别[例(%)]Gender		病程[月，(±s)]Duration(month)	患侧[例(%)]Affected side
组别Groups	例数Case number	年龄[岁，(±s)]Age (year)	男Male	女Female	病程[月，(±s)]Duration(month)	左Left	右Right
实验组Experimental group	56	59.5±5.4	36(64.3)	20(35.7)	8.3±1.7	32(57.1)	24(42.9)
对照组Control group	56	58.8±5.3	32(57.1)	24(42.9)	7.98±1.7	29(51.8)	27(48.2)
统计值Statistical value		t＝1.501	χ²＝0.599		t＝0.949	χ²＝0.324
P值		>0.05	>0.05		>0.05	>0.05

表2 两组肩周炎患者肩关节VAS评分(±s)

Table 2 VAS scores of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后1个月One month after operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	6.38±0.74	3.31±0.50^a	2.12±0.31^a	1.42±0.43^a	933.89	<0.001
对照组Control group	56	6.58±0.75	4.09±0.39^a	2.74±0.25^a	1.76±0.18^a	1 483.58	<0.001
t值		0.849	5.531	7.032	3.223
P值		>0.05	<0.001	<0.001	0.03

表2 两组肩周炎患者肩关节VAS评分(±s)

Table 2 VAS scores of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后1个月One month after operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	6.38±0.74	3.31±0.50^a	2.12±0.31^a	1.42±0.43^a	933.89	<0.001
对照组Control group	56	6.58±0.75	4.09±0.39^a	2.74±0.25^a	1.76±0.18^a	1 483.58	<0.001
t值		0.849	5.531	7.032	3.223
P值		>0.05	<0.001	<0.001	0.03

表3 两组肩周炎患者肩关节Constant评分(±s)

Table 3 Shoulder Constant score of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	51.0±3.5	74.3±1.4^a	83.5±1.5^a	151.25	<0.001
对照组Control group	56	49.8±2.8	72.0±1.3^a	81.5±1.0^a	119.37	<0.001
t值		1.187	5.351	4.612
P值		>0.05	<0.001	<0.001

表3 两组肩周炎患者肩关节Constant评分(±s)

Table 3 Shoulder Constant score of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	51.0±3.5	74.3±1.4^a	83.5±1.5^a	151.25	<0.001
对照组Control group	56	49.8±2.8	72.0±1.3^a	81.5±1.0^a	119.37	<0.001
t值		1.187	5.351	4.612
P值		>0.05	<0.001	<0.001

表4 两组肩周炎患者肩关节ASES评分(±s)

Table 4 ASES score of shoulder in the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	50.8±3.1	73.4±1.3^a	84.2±1.7^a	1 603.87	<0.001
对照组Control group	56	50.4±2.7	71.5±1.3^a	82.2±1.7^a	1 488.35	<0.001
t值		0.310	5.650	3.583
P值		>0.05	<0.001	0.001

表4 两组肩周炎患者肩关节ASES评分(±s)

Table 4 ASES score of shoulder in the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	50.8±3.1	73.4±1.3^a	84.2±1.7^a	1 603.87	<0.001
对照组Control group	56	50.4±2.7	71.5±1.3^a	82.2±1.7^a	1 488.35	<0.001
t值		0.310	5.650	3.583
P值		>0.05	<0.001	0.001

表5 两组肩周炎患者血清MMP-2 [g/L，(±s)]

Table 5 Serum MMP-2 of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	41.4±4.0	24.3±2.7^a	12.5±1.5^a	506.37	<0.001
对照组Control group	56	42.5±3.1	26.7±1.7^a	13.5±0.6^a	740.33	<0.001
t值		0.94	2.656	2.723
P值		>0.05	0.011	0.010

表5 两组肩周炎患者血清MMP-2 [g/L，(±s)]

Table 5 Serum MMP-2 of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	41.4±4.0	24.3±2.7^a	12.5±1.5^a	506.37	<0.001
对照组Control group	56	42.5±3.1	26.7±1.7^a	13.5±0.6^a	740.33	<0.001
t值		0.94	2.656	2.723
P值		>0.05	0.011	0.010

表6 两组肩周炎患者血清TGF-β比较[ng/L，(±s)]

Table 6 Serum TGF-β between of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	96.0±7.8	50.6±5.9^a	30.3±2.4^a	650.28	<0.001
对照组Control group	56	98.8±16.1	56.2±7.0^a	33.0±3.3^a	783.41	<0.001
t值		0.676	2.736	2.941
P值		>0.05	0.009	0.006

表6 两组肩周炎患者血清TGF-β比较[ng/L，(±s)]

Table 6 Serum TGF-β between of the patients with shoulder periarthritis

组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
实验组Experimental group	56	96.0±7.8	50.6±5.9^a	30.3±2.4^a	650.28	<0.001
对照组Control group	56	98.8±16.1	56.2±7.0^a	33.0±3.3^a	783.41	<0.001
t值		0.676	2.736	2.941
P值		>0.05	0.009	0.006

表7 两组肩周炎患者肩关节ROM [°，(±s)]

Table 7 Shoulder ROM of the patients with shoulder periarthritis

活动度ROM	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
前屈Forward flexion	实验组Experimental group	56	42.8±4.3	123.9±4.3^a	135.8±4.5^a	957.80	<0.001
前屈Forward flexion	对照组Control group	56	41.8±1.3	121.1±3.3^a	128.5±8.2^a	803.17	<0.001
	t值		1.054	2.376	3.487
	P值		>0.05	0.023	0.001
	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
内旋Internal rotation	实验组Experimental group	56	13.5±1.6	38.0±2.9^a	40.6±2.1^a	755.46	<0.001
内旋Internal rotation	对照组Control group	56	13.7±1.0	35.3±2.4^a	37.7±1.5^a	1024.99	<0.001
	t值		0.585	3.161	5.101
	P值		>0.05	0.003	0.001
	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
外展Abduction	实验组Experimental group	56	65.2±1.2	133.2±2.4^a	136.3±2.6^a	506.43	<0.001
外展Abduction	对照组Control group	56	66.0±1.6	131.4±3.2^a	133.4±3.2^a	626.74	<0.001
	t值		1.325	2.133	3.114
	P值		>0.05	0.045	0.003

表7 两组肩周炎患者肩关节ROM [°，(±s)]

Table 7 Shoulder ROM of the patients with shoulder periarthritis

活动度ROM	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
前屈Forward flexion	实验组Experimental group	56	42.8±4.3	123.9±4.3^a	135.8±4.5^a	957.80	<0.001
前屈Forward flexion	对照组Control group	56	41.8±1.3	121.1±3.3^a	128.5±8.2^a	803.17	<0.001
	t值		1.054	2.376	3.487
	P值		>0.05	0.023	0.001
	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
内旋Internal rotation	实验组Experimental group	56	13.5±1.6	38.0±2.9^a	40.6±2.1^a	755.46	<0.001
内旋Internal rotation	对照组Control group	56	13.7±1.0	35.3±2.4^a	37.7±1.5^a	1024.99	<0.001
	t值		0.585	3.161	5.101
	P值		>0.05	0.003	0.001
	组别Groups	例数Case number	手术前Before operation	术后3个月Three months after operation	术后6个月Six months after operation	F值	P值
外展Abduction	实验组Experimental group	56	65.2±1.2	133.2±2.4^a	136.3±2.6^a	506.43	<0.001
外展Abduction	对照组Control group	56	66.0±1.6	131.4±3.2^a	133.4±3.2^a	626.74	<0.001
	t值		1.325	2.133	3.114
	P值		>0.05	0.045	0.003

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Effect of arthroscope combining platelet-rich plasma in treatment of adherent periarthritis of shoulder

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Effect of arthroscope combining platelet-rich plasma in treatment of adherent periarthritis of shoulder