Arthroscopic arthrolysis for recalcitrant frozen shoulder: a lateral approach

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age

INTRODUCTION

The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age.

MATERIALS AND METHODS

This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS).

RESULTS

A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results.

CONCLUSIONS

Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Frozen Shoulder: Diagnosis and Management

ABSTRACT

Frozen shoulder is a common condition that causes pain and restriction of movement of the shoulder unrelated to secondary causes. It has three classic phases (freezing, frozen, and thawing), and is resolved in most cases within 1 to 2 years. Diagnosis is clinical based on global motion restriction and pain. Imaging plays an ancillary role to narrow the differential diagnosis. Physical therapy, nonsteroidal anti-inflammatories, and injection therapies are standard treatments, although none have been shown to alter the long-term course of the condition. Ultrasound guidance is recommended for injection-based therapy, although not required. Further study should focus on long-term outcomes and treatments that significantly alter the natural course of the disease.

Comparing surgical outcomes of anterior capsular release vs circumferential release for persistent capsular stiffness

Purpose

To consolidate the existing literature evaluating anterior capsular release and circumferential capsular release in the treatment of adhesive capsulitis (AC) of the shoulder.

Methods

The electronic databases PUBMED, EMBASE, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) were searched from data inception to October 8, 2020. Data are presented descriptively where appropriate. A meta-analysis was conducted for patient-reported outcomes.

Results

Overall, there were forty-six articles included. The majority of patients underwent circumferential release compared to anterior release (80.1% vs. 19.9%). Concomitant Manipulation Under Anesthesia (MUA) was employed in 25 studies, with a higher occurrence in the anterior compared to the circumferential release group (70% vs 60%). Both groups experienced significant improvements postoperatively in range of motion (ROM) and patient-reported outcomes. Complication rates were low for both anterior release (0.67%) and 360° release (0.44%).

Conclusion

Both anterior and circumferential release are effective techniques for treating AC with low complication rates. Future studies should improve documentation of patient demographics, surgical techniques and outcomes to determine an individualized treatment protocol for patients.

Level of evidence

Level IV, Systematic Review of Level I-IV studies.

Adhesive Capsulitis

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Capsulitis adhesiva del hombro. Comparación entre métodos de tratamiento conservador

Objetivo: Evaluar los resultados funcionales de tres protocolos distintos de tratamiento conservador en pacientes con capsulitis adhesiva del hombro. Materiales y Métodos: Se revisaron las historias clínicas de los pacientes tratados por capsulitis adhesivaen nuestra institución, entre enero de 2016 y enero de 2019. Se compararon tres protocolos diferentes de tratamiento: grupo 1, bloqueo del nervio supraescapular con un anestésico local y corticoide, analgésicos y fisioterapia después del alivio del dolor; grupo 2, bloqueo del nervio supraescapular con anestésico local sin corticoide, analgésicos y fisioterapia; grupo 3, analgésicos y fisioterapia, sin bloqueo del nervio supraescapular. Se determinaron los resultados funcionales con la escala ASES y el resultado subjetivo con el SSV. Resultados: Se dividió en tres grupos a 46 pacientes tratados por capsulitis adhesiva. Los pacientesdel grupo 3 tuvieron, en promedio, más sesiones de fisioterapia (30,31 ± 21,07). Los del grupo 2 recibieron la mayor cantidad promedio de bloqueos del nervio supraescapular (3,27 ± 1,22). Los resultados de los puntajes funcionales fueron: grupo 1 (15 pacientes): media 84 ASES y 84 SSV; grupo 2 (15 pacientes): media 93,40 ASES y 91,67 SSV; grupo 3 (16 pacientes): media 79,4 ASES y 80,63 SSV. Conclusiones: Las distintas formas de tratamiento conservador para la capsulitis adhesiva logran excelentesresultados. La analgesia mediante bloqueos seriados del nervio supraescapular con un anestésico y corticoide logró mejores resultados funcionales y subjetivos, y disminuyó la necesidad de administrar analgésicos y de sesiones de fisioterapia (grupo 1).Nivel de Evidencia: IV

Arthroscopic release in adhesive capsulitis of the shoulder: a retrospective study with 2 to 6 years of follow-up

Background

This study aimed to evaluate the response rate to arthroscopic release treatment in adhesive capsulitis of the shoulder (ACS) for patients with refractory to conservative treatment.

Methods

In this retrospective study, 51 patients (age mean, 49.1±5.6 years) with unilateral adherent capsule underwent arthroscopic releasing surgery for the shoulder capsule. Etiologies of the ACS in 30 patients were idiopathic: 10 patients were affected after surgery and 11 patients following trauma. The patients were evaluated in terms of shoulder function, satisfaction rate, pain intensity, and joint range of motion (ROM) based on a Constant score, a Simple Shoulder Test, the visual analog scale, and four movements, respectively.

Results

The mean Constant score before surgery was 48.2±3.5 and reached 74.4±6 and 77.0±6.3 at 6 months and the final follow-up, respectively (p<0.001). The mean scores of pain intensity, a Simple Shoulder Test, and ROM showed significant improvement at all follow-ups (p<0.001). Sex, age, and diabetes did not have any significant effect on patient recovery. However, patients who experienced ACS after surgery had poorer results than others at all follow-up points.

Conclusions

Arthroscopic releasing surgery of the shoulder in patients with ACS refractory to conservative treatment produces rare complications and an effective injury response. It seems that patients suffering ACS following surgery have a weaker response to the treatment.

Effectiveness of arthroscopic management of idiopathic shoulder stiffness: A meta-analysis

BACKGROUND

Persisting shoulder stiffness adversely affects quality of life by causing pain and motion restrictions especially in patients with diabetes.

OBJECTIVE

The aim of this study was to evaluate the outcomes of arthroscopic capsular release in patients with idiopathic shoulder stiffness.

METHOD

A literature search was conducted in electronic databases and studies were selected by following precise eligibility criteria. Random-effects meta-analyses were performed to estimate the changes at latest follow-up in scores of the Constant, American Shoulder and Elbow Surgeons (ASES), and University of California at Los Angelis (UCLA) scales, Visual Analogue Scale (VAS), and shoulder range of motion.

RESULTS

Nineteen studies were included. The follow-up duration was 42 months [95% confidence interval (CI): 32, 51]. Improvements in scores of the Constant, ASES, UCLA scales, and VAS were 48.3 [95% CI: 38.0, 58.6], 44.6 [95% CI: 24.6, 64.6], 19.3 [95% CI: 16.6, 22.0], and -6.1 [95% CI: -6.9, -5.4] respectively (P< 0.05 all). Improvements in the shoulder range of motion were: abduction 82.0 [95% CI: 65.0, 98.9]; forward flexion 75.9 [95% CI: 59.7, 92.1]; external rotation 43.2 [95% CI: 37.5, 49.0]; and internal rotation 25.4 [95% CI: 15.2, 35.5] degrees; P< 0.05 all).

CONCLUSION

Arthroscopic capsular release effectively improves shoulder function in patients with idiopathic shoulder stiffness.

[Posttraumatic shoulder stiffness]

Posttraumatic stiffness of the shoulder joint is a frequent and socioeconomically relevant result of injury; however, prior to making the diagnosis as the only cause of a persisting impairment of motion, it is necessary to rule out other sequelae of trauma. Even intensive conservative treatment is mostly accompanied by the stagnation of the impairments of movement. In many cases the treatment of choice is early arthroscopic arthrolysis with a standardized approach and intensive follow-up treatment. In the surgical treatment of proximal humeral fractures with humeral head preservation, arthroscopic arthrolysis with simultaneous implant removal is a form of planned second intervention for improvement of shoulder function in cases of persisting motion deficits after bony consolidation. Despite sometimes substantial limitations of movement, a clinically relevant and lasting improvement of shoulder function can be achieved with arthroscopic arthrolysis in posttraumatic shoulder stiffness.

Clinical Guidelines in the Management of Frozen Shoulder: An Update!

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.

Arthroscopic Outside-In Shoulder Release for Patients With an Inaccessible Glenohumeral Joint

Rotator interval release is an important procedure used in many shoulder operations. It is currently performed through an intra-articular approach, which may result in incomplete release or tissue removal. Here, we introduce an outside-in rotator interval release technique for complete rotator interval tissue removal, which is performed mainly through the lateral portal and a distal anterior portal under the coracoacromial arch. This technique can be used for many shoulder conditions, such as severe joint contracture or fibrosis, fixed shoulder dislocation, or disorders of the long head of the biceps. Our experience indicates that this technique is easy, effective, and capable of addressing even the most difficult shoulder conditions. We believe that adoption of this technique by surgeons can facilitate the success of many shoulder operations.

Arthroscopic Outside-in Shoulder Release for Patients With an Inaccessible Glenohumeral Joint

Severe shoulder contracture, which usually results from severe frozen shoulder or traumatic arthrofibrosis, is clinically quite common. This condition requires surgical release resulting from severe functional impediment. However, most surgeons are reluctant to operate on such patients because the glenohumeral joint is always inaccessible because of contracture severity. Thus, we introduced an outside-in shoulder release technique starting from the posterior side of the glenohumeral joint. This procedure includes the fabrication of posterior and inferior posterior portals, locating the glenohumeral space out of the capsule, creating working space just posterior to the posterior capsule, releasing the posterior capsule, and thereafter releasing the inferior and superior capsules. Our clinical experience indicates that this procedure can be performed safely and effectively when certain guidelines are followed and can allow for subsequent access to the glenohumeral joint in most cases. We think the introduction of this technique will provide a special surgical option for patients with severe joint contracture.

Outcomes of Arthroscopic Capsular Release in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review

Background:

Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position.

Purpose:

To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS).

Results:

A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; P = .81) or in any PRO scores between groups (P > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; P = .91), forward flexion (BC, 64.4°; LD, 79.3°; P = .73), abduction (BC, 77.8°; LD, 81.5°; P = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; P = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) (P < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) (P < .0001).

Conclusion:

Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

Arthroscopic Management of the Stiff Shoulder

Shoulder stiffness affects a diverse population of patients suffering a decrease in function and shoulder pain. Arthroscopic management of this debilitating spectrum of pathology is a safe and effective course of action in cases recalcitrant to nonoperative therapy. Arthroscopic management of the stiff shoulder has been reported to be effective in the treatment of stiffness due to adhesive capsulitis, birth palsy, stiffness in the setting of rotator cuff tears, and osteoarthritis in the posttraumatic patient, in the postoperative patient, and in the throwing athlete. Arthroscopic management is most effective in treating the stiff shoulder in the setting of adhesive capsulitis recalcitrant to nonoperative therapy or posttraumatic stiffness. Results are more guarded in the treatment of postoperative stiffness. Excessive force and trauma to the shoulder, including fracture of the humerus, can be avoided with a 360[degrees] capsular release for shoulder stiffness rather than manipulation under anesthesia.

Clinical Outcomes of Arthroscopic 360° Capsular Release for Idiopathic Adhesive Capsulitis in the Lateral Decubitus Position

PURPOSE

To report outcomes after arthroscopic 360° capsular release in the lateral decubitus position for idiopathic glenohumeral adhesive capsulitis without manipulation under anesthesia.

METHODS

A retrospective case series of patients who underwent arthroscopic capsular release in the lateral decubitus position for idiopathic adhesive capsulitis with minimum 2-year follow-up was conducted. Patient demographics, preoperative range of motion (ROM), postoperative ROM, and the postoperative outcome scores, visual analog scale for pain, Single Assessment Numeric Evaluation, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores, were recorded. Complications and reoperations were recorded. Paired t-tests were used to compare preoperative and postoperative ROM, with P < .05.

RESULTS

Overall, 43 patients were identified, of whom 10 were excluded because of post-traumatic etiology. Of the remaining 33 patients, 27 (81.8%) completed a minimum follow-up of 2 years. The mean age was 54.8 with a standard deviation of 7.4 years and 78% were female, with the duration of symptoms of 16.2 ± 21.0 (range, 3-125) months. Hypothyroidism was present in 7% and diabetes present in 30%. Active forward flexion improved from 115.0° ± 21.9° to 156.2° ± 16.1° at the final follow-up (mean difference, 41.2; 95% confidence interval [33.7, 48.7]; P < .001). Active external rotation with the arm adducted improved from 28.1° ± 16.3° preoperatively to 56.8° ± 15.7° at the final follow-up (mean difference, 27.7; 95% confidence interval [19.1, 36.3]; P < .001). Significant ROM improvements were seen even as early as 2 weeks postoperatively (P < .001). Two patients (7%) had manipulation under anesthesia postoperatively due to early recurrent stiffness 4 to 6 weeks after arthroscopic capsular release. There were no revision surgeries or complications.

CONCLUSIONS

Arthroscopic 360° capsular release in the lateral decubitus position for idiopathic adhesive capsulitis results in a significant early and lasting improvement in ROM, excellent functional outcomes, and low revision and complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Award Winning Research Recognized

One of the joys of the editorial team is selecting the annual Journal Awards. Recognizing research excellence is what we do. If a manuscript was ultimately selected for publication, it is already excellent, as we publish less than 20% of original scientific article submissions, and we received more than 1,300 such submissions in 2017. To be one of our award winners is to be truly "elite."

Indications for hydrodilatation for frozen shoulder

Frozen shoulder causes significant functional disability and pain in a population group constituted by patients who are often middle-aged and working.

Frozen shoulder remains poorly understood. The available literature is limited and often prone to bias.

A rapid, non-surgical and cost-effective treatment that reduces pain and restores function is an attractive option.

Hydrodilatation is a potential first-line treatment of frozen shoulder in secondary care.

Cite this article: EFORT Open Rev 2017;2:462–468. DOI: 10.1302/2058-5241.2.160061

Management of the Stiff Shoulder With Arthroscopic Circumferential Capsulotomy and Axillary Nerve Release

Management of the stiff shoulder is a common and frequently daunting clinical scenario. Arthroscopic capsular release is usually an option for management of severe, chronic glenohumeral joint contractures when conservative treatment fails. Technical hurdles including a thickened capsule, reduction in joint volume, and difficulty with positioning the shoulder intraoperatively can make this procedure challenging. In addition, incomplete release and recalcitrant stiffness are frequent issues. We believe a complete release of the capsule entails special attention to the axillary pouch and requires identification and protection of the axillary nerve. We present a technique for a complete arthroscopic circumferential capsulotomy and detail our approach to safely dissect and protect the axillary nerve under arthroscopic visualization.

Editorial Commentary: Recalcitrant Idiopathic Adhesive Capsulitis of the Shoulder

An investigation of recalcitrant idiopathic adhesive capsulitis of the shoulder showed good outcomes with arthroscopic capsular release. However, it is critical that future authors carefully define the term "recalcitrant idiopathic adhesive capsulitis" so that we are speaking the same language and that future authors include a control (nonsurgical) treatment group to better determine whether surgery is truly superior to nonsurgical treatment.

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background:

Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it.

Methods:

A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided.

Results:

Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option.

Conclusion:

Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Clinical evaluation of arthroscopic treatment of shoulder adhesive capsulitis

OBJECTIVE

To evaluate the results of arthroscopic releases performed in patients with adhesive capsulitis refractory to conservative treatment.

METHODS

This was a retrospective study, conducted between 1996 and 2012, which included 56 shoulders (52 patients) that underwent surgery; 38 were female, and 28 had the dominant side affected. The mean age was 51 (29-73) years. The mean follow-up was 65 (12-168) months and the mean preoperative time was 8.9 (2-24) months. According to Zukermann's classification, 23 cases were considered primary and 33 secondary. With the patient in the lateral decubitus position, circumferential release of the joint capsule was performed: joint debridement; rotator interval opening; coracohumeral ligament release; anterior, posterior, inferior, and finally antero-inferior capsulotomy. A subscapularis tenotomy was performed when necessary. All patients underwent intense physical therapy in the immediate postoperative period. In 33 shoulders, an interscalene catheter was implanted for anesthetic infusion. Functional results were evaluated by the UCLA criteria.

RESULTS

Improved range of motion was observed: mean increase of 45° of elevation, 41° of external rotation and eight vertebral levels of medial rotation. According to the UCLA score excellent results were obtained in 25 (45%) patients; good, in 24 (45%); fair, in two (3%); and poor, in two (7%). Patients who had undergone inferior capsulotomy achieved better results. Only 8.8% of patients who used the anesthetic infusion catheter underwent postoperative manipulation. Seven patients had complications.

CONCLUSION

There was improvement in pain and range of motion. Inferior capsulotomy leads to better results. The use of the interscalene infusion catheter reduces the number of re-approaches.

Serial Comparison of Clinical Outcomes After Arthroscopic Capsular Release for Refractory Frozen Shoulder With and Without Diabetes

PURPOSE

To compare serial clinical outcomes after arthroscopic treatment of refractory frozen shoulder with and without diabetes.

METHODS

Seventeen patients with diabetic frozen shoulder (diabetes group) and 20 patients with idiopathic frozen shoulder (idiopathic group) were included. The mean follow-up period was 48.4 ± 15.8 months. Visual analog scale pain score; University of California, Los Angeles score; American Shoulder and Elbow Surgeons score; and range of motion were evaluated preoperatively; at 3, 6, and 12 months after surgery; and at the final follow-up examination.

RESULTS

Both groups showed significant improvement in all clinical scores and range of motion during the serial follow-up periods (P < .001). There were no significant differences between the 2 groups in any of the assessed clinical scores, except the mean American Shoulder and Elbow Surgeons score in the diabetes group was significantly lower than that in the idiopathic group at 12 months after surgery (77.7 v 88.8, P = .025). In the diabetes group, mean forward flexion was significantly lower than that in the idiopathic group at 3 months (140.0° v 151.5°, P = .011) and 6 months (152.2° v 161.8°, P = .045) after surgery. Mean external rotation was significantly lower than that in the idiopathic group at 6 months after surgery (43.3° v 55.0°, P = .021). Mean internal rotation was significantly lower than that in the idiopathic group at 6 months (13.7 v 11.7, P = .006) and 12 months (12.2 v 9.9, P = .041) after surgery. There were no significant differences between the 2 groups in any assessed outcomes at the final follow-up examination.

CONCLUSIONS

These results provide supportive evidence suggesting that the diabetes group had slower postoperative functional recovery until 12 months postoperatively, although arthroscopic capsular release for refractory frozen shoulder with and without diabetes yielded satisfactory clinical outcomes at the final follow-up examination.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Shoulder proprioception - lessons we learned from idiopathic frozen shoulder

Background

Of all the most frequent soft tissue disorders of the shoulder, idiopathic frozen shoulder (IFS) offers the greatest potential for studying proprioception. Studies concerning the presence of proprioception dysfunctions have failed to determine the potential for spontaneous healing of passive shoulder stabilizers (anterior and posterior capsule, middle and inferior gleno-humeral ligaments), its relationship with passive (PJPS) and active (AJPS) shoulder proprioception for internal and external rotation (IR, ER), as well as the isokinetic muscle performance of the internal and external rotators. This study investigates these dependencies in the case of arthroscopic release of IFS.

Methods

The study group comprised 23 patients (average aged 54.2) who underwent arthroscopic release due to IFS and 20 healthy volunteers. The average follow-up time was 29.2 months. The Biodex system was used for proprioception measurement in a modified neutral arm position and isokinetic evaluation. The results were analysed using the T-test, Wilcoxon and interclass correlation coefficient. P-values lower than 0.05 were considered significant.

Results

Statistically significant differences were found between involved (I) and uninvolved (U) shoulders only in the cases of PJPS and AJPS, peak torque, time to peak torque and acceleration time for ER (p < 0.05). No statistically significant difference was noted between PJPS IR and PJPS ER or between AJPS IR and AJPS ER (p > 0.05) for the U shoulders.

Conclusions

The anatomical structure of anterior (capsule, middle and anterior band of inferior gleno-humeral ligament) and posterior (capsule and posterior band of inferior gleno-humeral ligament) passive shoulder restraints has no impact on the difference in PJPS values between ER and IR in a modified neutral shoulder position. The potential for spontaneous healing of the anterior and posterior passive shoulder restraints influences PJPS recovery after arthroscopic release of IFS. ER peak torque deficits negatively affect AJPS values. PJPS and AJPS of ER and IR can be measured with a high level of reproducibility using an isokinetic dynamometer with the arm in a modified neutral shoulder position. Differences greater than 15 % for PJPS and >24 % for AJPS for ER and IR can be helpful for future studies as baseline data for identification of particular passive and active shoulder stabilizers at risk.

Rates of surgery for frozen shoulder: an experience in England

AIM

the aim of this study was to identify the incidence of surgical treatment for frozen shoulder in a western population.

METHODS

patients included in this study all resided within a well-defined area in the North West of England, all had surgery for frozen shoulder over a 3-year period and were identified from theatre logbooks of two local hospitals. Cases having surgery for shoulder stiffness other than frozen shoulder were excluded. Local and national population size estimates were based on data obtained from the UK Office for National Statistics.

RESULTS

117 patients underwent surgery for frozen shoulder during the period examined; of these 101 had arthroscopic arthrolysis and 16 had manipulation under anaesthesia. The overall incidence of frozen shoulder surgery was calculated at 2.67 procedures per 10,000 general population per year, and at 7.55 for those aged 40-60.

CONCLUSION

surgical intervention for frozen shoulder is common, estimated at over 14,180 cases per year in England. Given the variation in costs associated with arthroscopic arthrolysis and manipulation under anaesthesia, comparative studies of the cost effectiveness of the two procedures would be of great value.

LEVEL OF EVIDENCE

2C (outcome research).

Effects of intra-articular steroid injection before pan-capsular release in patients with refractory frozen shoulder

PURPOSE

The purpose of the study was to retrospectively determine the effects of intra-articular steroid injection on the clinical outcome of patients who underwent arthroscopic pan-capsular release for refractory frozen shoulder.

METHODS

Between 2000 and 2010, 34 patients (20 males, 14 females) who underwent an arthroscopic pan-capsular release for frozen shoulder were included. Intra-articular steroid injections were administered from April 2006, and just before surgery and at the final follow-up, ranges of motion (ROM) and scores of the Shoulder Rating Scale of the University of California, Los Angeles (UCLA) scoring system were evaluated.

RESULTS

Intra-articular steroid injection significantly improved the UCLA scores of pain just before surgery and at the final follow-up (1.7 ± 0.5 vs. 6 ± 2, p < 0.0001). We subdivided the patients into those with and without diabetes mellitus. Steroid injection had a significant effect on the ROM in forward flexion (166.6 ± 8.6 vs. 140 ± 36.1, p = 0.026) and the scores of pain (10 vs. 9.3 ± 1.2, p = 0.046) at the final follow-up in the group without diabetes mellitus compared with those with it.

CONCLUSION

Intra-articular steroid injection improves pain just before an arthroscopic pan-capsular release and at the final follow-up in all the patients with refractory frozen shoulder. However, it improves the ROM in forward flexion and the UCLA scores of pain at the final follow-up only in those without diabetes mellitus.

LEVEL OF EVIDENCE

Therapeutic studies, Level IV.

Mid-term results following arthroscopic capsular release in patients with primary and secondary adhesive shoulder capsulitis

PURPOSE

The purpose of this study was to assess the effectiveness of arthroscopic capsular release carried out for refractory cases of both primary and secondary adhesive shoulder capsulitis that were not responsive to at least 6 months of prior conservative therapy.

METHODS

Arthroscopic 360-degree capsular release was performed on 167 patients (173 shoulders) with adhesive shoulder capsulitis. Ninety-one shoulders (52.6%) had primary and 82 shoulders (47.4%) secondary adhesive capsulitis. The median follow-up period was 36 months (range 14-67 months).

RESULTS

All patients were evaluated according to the constant score. Both groups (primary and secondary adhesive capsulitis) experienced a significant improvement for all ranges of motion immediately postoperative, as well as at the time of follow-up. The median preoperative constant score was 41 (range 18-61) points and increased significantly to a median of 83 (range 27-100) at the time of follow-up. In the group of primary adhesive capsulitis, median preoperative score was 42 points (range 19-58) and increased to 85 points (range 36-100) at follow-up. In the group of secondary adhesive capsulitis, the preoperative mean increased from 41 points (range 18-61) to 74 points (range 27-100) at the time of the follow-up. The constant score component for pain and the visual analogue scale (VAS) score were also significantly increased.

CONCLUSION

Arthroscopic capsular release in patients with primary and secondary adhesive shoulder capsulitis represents a valuable therapeutic choice with minimal complications, to effectively reduce pain and improve movement in all planes of motion.

LEVEL OF EVIDENCE

Therapeutic retrospective case series study, Level IV.