粘連性肩關節囊炎的糖尿病患者手術介入治療的風險評估

中文摘要研究目的　　粘連性肩關節囊炎(adhesive capsulitis)又稱為五十肩或冰凍肩，好發於40歲到60歲的族群，一般民眾的發生率約為2~5%。臨床症狀為疼痛及漸進式的肩關節活動角度受限。確切的病理生理機轉目前尚未完全明瞭。粘連性肩關節囊炎可能的危險因子有女性、糖尿病患、甲狀腺亢進及先前接受過肩部、胸部或頸椎手術的患者。有多篇的研究已經證實有糖尿病的患者比一般民眾更容易罹患粘連性肩關節囊炎。粘連性肩關節囊炎的治療方式有非手術及手術介入等治療方式，目前並無標準的治療準則，可依患者症狀持續的時間來選擇治療方式。通常病患在接受非手術治療6個月以上無效即可考慮手術介入治療，但大部分(約89.5%)的患者採用非手術治療即可。本研究想探討在中山醫學大學附設醫院的患者中，有糖尿病的粘連性肩關節囊炎患者是否有較高的機會需要手術介入治療。研究方法及資料　　由於糖尿病為粘連性肩關節囊炎的危險因子，且粘連性肩關節囊炎的患者中有糖尿病的比例也高於一般人，因此，本研究想探討有糖尿病的粘連性肩關節囊炎患者是否有較高的機會需要手術介入治療。本研究計畫以回顧性研究方式，使用中山附醫的資料庫作為研究資料來源，收集近7年來診斷為粘連性肩關節囊炎患者資料，比較有無診斷糖尿病的患者其後續接受手術的比例，進行數據分析及統計。為了排除低估粘連性肩關節囊炎患者有無糖尿病診斷的誤差，亦設計前瞻性的研究方式來蒐集2023年7月至2024年4月期間診斷為粘連性肩關節囊炎患者資料來進行數據分析及統計，比較有糖尿病的粘連性肩關節囊炎患者是否有較高的機會需要手術介入治療。研究結果　　回顧性2016年至2022年中山附醫的患者資料庫診斷有粘連性肩關節囊炎總共有2706位，其中只有619位 (22.9%)有糖尿病的診斷。有糖尿病診斷的粘連性肩關節囊炎患者接受手術治療的有10位(1.62%)，而沒有糖尿病診斷的2087位患者中，接受手術治療的有19位(0.91%)，有糖尿病診斷的患者有較高的手術比例但無統計學上的意義(P=0.135)。前瞻性研究中收錄了2023年7月至2024年4月新診斷粘連性肩關節囊炎的患者共31位。有糖尿病診斷的患者有12位(38.7%)，只有1位(8.3%)患者接受手術治療。有19位(61.3%)患者無糖尿病的診斷，其中有2位(10.5%)患者接受手術治療，無糖尿病診斷的患者有較高的手術比例但亦無統計學上的意義(P=0.673)。結論　　由回顧性的資料來看，不管有無糖尿病的診斷的粘連性肩關節囊炎患者幾乎都只接受保守治療。有糖尿病的診斷的粘連性肩關節囊炎的患者比沒有糖尿病的診斷的患者有較高的比率接受手術治療，但無統計學上的意義。從前瞻性的研究來看，有糖尿病的診斷的粘連性肩關節囊炎患者則有較低的比率接受手術治療，亦無統計學上的意義。但前瞻性的研究收錄的病患太少目前才31位，且接受手術的患者只有3位。因此，需要收錄更多的案例來分析才能看出有無糖尿病的診斷是否會增加粘連性肩關節囊炎患者需要接受手術治療的機會。關鍵詞：粘連性肩關節囊炎、糖尿病、徒手關節授動術、關節囊鬆開術

AbstractObjective Adhesive capsulitis, also known as frozen shoulder, is a condition commonly seen in individuals aged 40 to 60, with an incidence rate of about 2-5% in the general population. Clinical symptoms include pain and progressively limited range of motion in the shoulder joint. The exact pathophysiological mechanism of adhesive capsulitis is not yet fully understood. Possible risk factors include female gender, diabetes, hyperthyroidism, and previous shoulder, chest, or cervical spine surgeries. Several studies have confirmed that individuals with diabetes have a higher likelihood of developing adhesive capsulitis compared to the general population. Treatments for adhesive capsulitis include both non-surgical and surgical interventions, but there are no standardized guidelines for treatment. The choice of treatment typically depends on the duration and severity of symptoms. Surgical intervention is usually considered if symptoms persist despite over six months of non-surgical treatment, but the majority (approximately 89.5%) of patients respond well to non-surgical treatments. This study aims to investigate whether patients with diabetes and adhesive capsulitis at Chung Shan Medical University Hospital have a higher likelihood of requiring surgical intervention.Methods and MaterialsSince diabetes is a known risk factor for adhesive capsulitis, and the prevalence of diabetes among patients with adhesive capsulitis is higher than in the general population, this study seeks to explore whether diabetic patients with adhesive capsulitis have a greater likelihood of requiring surgical treatment. A retrospective study was conducted using the database of Chung Shan Medical University Hospital, collecting data from patients diagnosed with adhesive capsulitis over the past seven years. We compared the proportion of patients with and without diabetes who subsequently underwent surgery. To minimize potential underestimation of diabetes diagnosis among adhesive capsulitis patients, a prospective study was also designed. We collected data from patients newly diagnosed with adhesive capsulitis between July 2023 and April 2024 for analysis, comparing the likelihood of surgical intervention in diabetic versus non-diabetic patients.Results From 2016 to 2022, a total of 2,706 patients diagnosed with adhesive capsulitis were identified in the hospital’s database in retrospective study. Among them, 619 patients (22.9%) had diabetes. Of the diabetic patients, 10 (1.62%) underwent surgical treatment, while among the 2,087 non-diabetic patients, 19 (0.91%) received surgery. Although diabetic patients had a higher proportion of surgical interventions, the difference was not statistically significant (P = 0.135).A total of 31 patients newly diagnosed with adhesive capsulitis were enrolled between July 2023 and April 2024 in prospective study. Of these, 12 patients (38.7%) had diabetes, with 1 (8.3%) requiring surgery. Among the 19 non-diabetic patients (61.3%), 2 (10.5%) underwent surgical intervention. Non-diabetic patients showed a slightly higher rate of surgery, but the difference was not statistically significant (P = 0.673).Conclusion The retrospective data indicated that most adhesive capsulitis patients, regardless of diabetes status, opted for conservative treatment. Diabetic patients had a higher proportion of surgical interventions compared to non-diabetic patients, but the difference was not statistically significant. In the prospective study, diabetic patients showed a lower rate of surgical intervention, though this finding was not statistically significant either. The small sample size (31 patients) and low number of surgical cases (only 3) limit the ability to draw firm conclusions. Additional cases are needed to further analyze whether the diagnosis of diabetes increases the likelihood of surgical intervention for adhesive capsulitis patients.Keywords: adhesive capsulitis, diabetes mellitus (DM), manipulation under anesthesia (MUA), capsular release