Arthroscopic capsular release for refractory shoulder stiffness: a critical analysis of effectiveness in specific etiologies

Pharmacopuncture therapy for adhesive capsulitis: A pragmatic randomized controlled pilot study

Background

Although several studies have reported the effectiveness of acupuncture treatment for adhesive capsulitis (AC), research on pharmacopuncture therapy for AC remains limited. We compared the effectiveness and safety of pharmacopuncture and physiotherapy for AC.

Methods

This pragmatic, randomized, controlled, parallel-group pilot study enrolled patients with limitations of shoulder movement and a numeric rating scale (NRS) score for shoulder pain ≥5 randomized (1:1) to the pharmacopuncture therapy (PPT) and physiotherapy (PT) groups. Treatment sessions were administered twice weekly for 6 weeks, and the participants were followed up for 13 weeks after randomization. The primary outcome was the NRS score for shoulder pain, and the secondary outcomes were the visual analog scale (VAS), Shoulder Pain and Disability Index (SPADI), range of motion (ROM), patient global impression of change (PGIC), EuroQol 5-Dimension 5-Level (EQ-5D-5L), and Short Form 12 Health Survey (SF-12) scores. The intention-to-treat (ITT) analysis was set as the primary analysis.

Results

Among 50 participants, for the primary endpoint (week 7) the PPT group showed a significantly superior improvement in NRS, VAS, SPADI, ROM for flexion, ROM for abduction, and EQ-5D-5L scores. The ROM for extension, ROM for adduction, physical component summary, and patient global impression of change were significantly better in the PPT than in the PT group, and these effects were sustained until week 13.

Conclusion

In this pilot study, PPT showed better effects than PT, confirming the feasibility of a follow-up main study.

Trial registration

Clinicaltrials.gov (NCT05292482) and cris.nih.go.kr (KCT0007198).

Arthroscopic Lysis of Adhesions for Stiffness After Surgical Management of Proximal Humerus Fractures Leads to Satisfactory Outcomes in Most Patients

Purpose

To report patient-reported outcomes (PROs), range of motion (ROM), and satisfaction, in patients who underwent arthroscopic lysis of adhesions for stiffness after open reduction with internal fixation (ORIF) or reverse shoulder arthroplasty (RSA) for fracture.

Methods

A retrospective review was performed to identify patients with stiffness who underwent arthroscopic lysis of adhesions following ORIF or RSA for proximal humerus fracture at a single institution between 2012 and 2021 with minimum 1-year follow-up. PROs including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value (SSV), as well as active ROM including forward flexion (FF), external rotation (ER), internal rotation (IR), were collected pre- and postoperatively. Attempted nonoperative treatment before arthroscopic lysis of adhesions was documented. Complications and satisfaction were also recorded.

Results

A total of 21 patients met the study criteria (4 RSA, 17 ORIF), with an average age of 66.7 ± 8 years. The study sample comprised mostly of female patients (90%). The mean time from the index surgery to arthroscopy was 9 months, and mean follow-up post-lysis was 17 months. Patients with ORIF reported significant pain relief (VAS, Δ -3.2) and improvement in range of motion (FF, Δ 36°; ER, Δ 20°; IR Δ 3 spinal levels) and PROs (ASES, Δ 34.7; SSV Δ 44.8) (P < .01) after lysis. Patients with RSA had significant improvement in ASES (Δ 21.8; P = .04), SSV (Δ 8.8; P = .04), and FF (Δ 38; P = .02) but did not have significant improvement in VAS (Δ -2; P = .2), ER (Δ 0°; P = 1.0), and IR (Δ 1 spinal level; P = .2). Satisfaction was 100% in the RSA cohort and 82% in the ORIF cohort. No complications were observed.

Conclusions

Arthroscopic lysis of adhesions for stiffness after surgical management of proximal humerus fracture leads to satisfactory outcomes in most patients. Post-ORIF, patients may achieve improvement in PROs and global ROM, whereas post-RSA, patients may achieve improvement in PROs and FF but do not necessarily improve in rotational ROM.

Level of Evidence

Level IV, therapeutic case series.

Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis

Background

Adhesive capsulitis of the shoulder is a painful and debilitating condition. While the majority of patients improve with conservative treatment, those who do not improve require surgery such as arthroscopic capsular release (ACR) for symptom relief. However, there is limited literature regarding the optimal timeframe to proceed with surgery.

Methods

This retrospective cohort evaluated 134 Hispanic patients who underwent ACR for the treatment of adhesive capsulitis. Patients were divided into an early and a delayed treatment group that included all patients. Patients were then divided into diabetic and idiopathic subgroups. Early vs. delayed treatment outcomes (forward flexion, external rotation, Visual Analog Scale pain scores, and recurrence requiring reoperation) were assessed in all patients and in each subgroup.

Results

No statistically significant differences were found between the early and delayed release groups in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up in the all-patient group. In the idiopathic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up. In the diabetic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month and 6 months of follow-up visits.

Conclusions

There was no difference in outcomes following ACR for adhesive capsulitis between patients who underwent early release vs. delayed release. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus.

Alteration of chronic inflammatory status by transarterial embolization in frozen shoulder evaluated by 18-fluorine-fluoro-2-deoxyglucose positron-emission tomography/computed tomography

BACKGROUND

Frozen shoulder (FS) is speculated to have an inflammatory etiology. On angiography, abnormal angiogenesis is observed around the affected shoulder, suggesting a possible source of inflammation and pain. The effectiveness and safety of transarterial embolization (TAE) targeting abnormally proliferating blood vessels have been reported. This study investigated changes in chronic inflammatory and hypoxic status before and after TAE in FS by 19-fluorine-fluoro-2-deoxyglucose (FDG) positron-emission tomography/computed tomography as a possible mechanism of the therapeutic response to TAE.

METHODS

Fifteen patients with unilateral FS, persistent for more than 6 months, who were refractory to conservative treatments, underwent TAE using the temporary embolic agent imipenem/cilastatin. Patients underwent positron-emission tomography/computed tomography with FDG (as a biomarker of inflammation) before and 8 weeks after TAE. Regional uptake was evaluated by the maximum standardized uptake value. The lesion-side-to-(contralateral-) normal-side uptake ratio was also calculated. Pain and functional scales, range-of-motion, and laboratory tests, including white blood cell, C-reactive protein, interleukin 6, vascular endothelial growth factor, and tumor necrosis factor α were evaluated.

RESULTS

On FDG-PET, the average maximum standardized uptake value of the lesion-side was significantly greater than that of the normal-side (maximum standardized uptake value before TAE: 3.11 ± 1.25 vs 1.95 ± 1.15, P = .0001; 8-weeks post-TAE: 2.36 ± 0.74 vs 1.78 ± 0.69, P = .0002). The mean lesion-side-to-(contralateral-) normal-side uptake ratios before TAE (1.71 ± 0.60) decreased after TAE (1.37 ± 0.29, P = .011). The decrease of FDG uptake (-21.1 ± 12.2%) showed a significant correlation with the change in the pain scale score (r = -0.56, P = .039) and extension score (r = -0.59, P = .026).

CONCLUSION

Chronic inflammation in FS, as demonstrated by FDG uptake, was decreased after TAE. Thus, chronic inflammation is likely to be an underlying mechanism that should be targeted for symptomatic improvement of frozen shoulder.

Arthrofibrosis Nightmares: Prevention and Management Strategies

Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.

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.

Does the timing of surgical intervention impact the clinical outcomes and overall duration of symptoms in frozen shoulder?

BACKGROUND

The optimal timing of arthroscopic capsular release in patients with frozen shoulder is controversial. Some surgeons delay surgery in the belief that early surgical intervention results in a poorer prognosis. However, whether early surgical intervention causes inferior clinical outcomes and a longer duration of symptoms in frozen shoulder remains unclear. The objective of this study was to compare the clinical outcomes and overall duration of symptoms in frozen shoulder between patients who underwent early surgical intervention and those subjected to late surgical intervention. Our hypotheses were that (1) early surgical intervention would provide significant improvement in symptoms but inferior clinical outcomes because of more severe synovitis compared with late surgical intervention and (2) early surgical intervention would shorten the overall duration of symptoms compared with late surgical intervention.

METHODS

We reviewed 60 consecutive patients with frozen shoulder who underwent arthroscopic capsular release. We compared clinical outcomes and the overall duration of symptoms between 2 groups: Group I comprised 27 patients who underwent surgery <6 months after onset (mean, 3.8 months), whereas group II comprised 33 patients who underwent surgery ≥6 months after onset (mean, 11.1 months). The severity of glenohumeral synovitis at the time of surgery was evaluated. Patient-reported pain, shoulder function, and range of motion, as well as the presence of sleep disturbance, were assessed preoperatively and at 3 and 6 months after surgery.

RESULTS

Both groups showed significant improvements in the visual analog scale pain score, Japanese Orthopaedic Association score, American Shoulder and Elbow Surgeons score, and prevalence of sleep disturbance after surgery (P < .001), although the glenohumeral synovitis score was significantly higher in group I than in group II (P < .0001). Forward flexion at 6 months after surgery was significantly greater in group I than in group II (P = .007). The overall duration of symptoms was shorter in group I than in group II (P < .0001). Neither the pain score, functional score, prevalence of sleep disturbance, nor postoperative recovery time differed between groups.

CONCLUSIONS

Arthroscopic capsular release provided significant pain relief and improvement in shoulder function in patients with frozen shoulder regardless of the timing of surgery. Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes when compared with late surgical intervention. Surgeons do not need to delay surgical intervention for patients who have intolerable pain and/or nocturnal pain with sleep disturbance.

[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.

Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies

Adhesive capsulitis of the shoulder (ACS) is a condition with significant clinical and economic implications. The etiology of adhesive capsulitis is not clearly understood and there remains lack of consensus in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of ACS are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences, and can range from conservative options to surgical intervention. The aim of this review is to summarize the pathophysiology and clinical presentation of ACS and to discuss the evidence base for various management strategies employed today.

Frozen shoulder (FS) is a relatively common condition characterized by pain and stiffness of the shoulder joint. The exact cause of primary FS is unknown and in some patients the condition can persist for several years. Treatment strategies vary depending on stage of presentation, patient factors and clinician preferences. This review gives a summary of the clinical presentation of FS and an overview of the current evidence for both surgical and conservative treatment options for the condition.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial

BACKGROUND

This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures.

METHODS

Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up).

RESULTS

One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742).

CONCLUSION

The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Capsular release following total shoulder arthroplasty: an analysis of early outcomes

BACKGROUND

The purpose of this study is to analyze the outcomes of open and arthroscopic capsular release following total shoulder arthroplasty.

METHODS

Over 15 years, 19 patients experienced persistent shoulder stiffness after anatomic total shoulder arthroplasty refractory to nonoperative treatment, requiring either open (n = 5) or arthroscopic (n = 14) capsular release. There were seven (39%) patients who had a prior diagnosis of stiffness before the primary arthroplasty.

RESULTS

At a follow-up of 2.3 years (1-5.5), there were changes in range of motion, including forward flexion (77°-117°), abduction (49°-98°), external rotation (9°-19°), internal rotation at 0° (Sacrum to L1), and pain (4.1-2.3) scores (p < 0.01). There were seven (37%) patients that required a reoperation following the initial capsular release. The survival-free of reoperation at 2 and 5 years was 76% and 53%, respectively, while the survival-free of revision surgery at 2 and 5 years was 83%. Furthermore, three (16%) patients required a repeat capsular release. Overall, there were 11 (58%) complications, including stiffness (n = 9), infection (n = 1), subscapularis rupture (n = 2), glenoid loosening (n = 3), and pain with weakness requiring reoperation (n = 1).

CONCLUSIONS

Shoulder stiffness after total shoulder arthroplasty is a very difficult pathology to treat, with high rates of complications and reoperations after capsular release. Overall, in patients that do not develop glenoid loosening, capsular release does improve the patient's pain and shoulder motion. Furthermore, when patients develop stiffness, it is critical to rule out other etiologies, such as glenoid loosening, prior to proceeding with capsular release.

LEVEL OF EVIDENCE IV

Retrospective case series.

Convalescence after arthroscopic capsular release in frozen shoulder

Introduction

To determine if arthroscopic capsular release (ACR) shortens duration of illness in frozen shoulder (FS) in comparison to the depicted natural course of 30.1 months and to identify risk factors for persisting complaints.

Materials and methods

A consecutive group of 71 shoulders in 70 patients with mean age of 54 (37-74) years with FS were treated by ACR and enrolled in our study with follow-up investigation at 1, 3, 6 and finally 32 (19-49) months postoperatively.

Results

Patients had complaints for 8 (3-60) months preoperatively. 8 shoulders (11%) were classified as primary and 63 (89%) shoulders as secondary type FS. 6 patients were lost to follow-up. Relative Constant score increased significantly from 31% before surgery to 103% at last follow-up. 55 patients (85%) achieved subjective remission after 7 (1.5-18) months, postoperatively. Overall duration of illness was 16 (5-72) months. All patients with primary FS achieved remission and all patients with persisting symptoms had secondary FS.

Conclusion

Duration of illness was shortened by more than 12 months compared with the natural time course defined by Reeves. Secondary FS, especially ac-joint pathologies, previous surgery, diabetes and more than 12 months preoperative illness duration were identified as risk factors for persisting complaints. Hypothesis of worse outcome in secondary FS was confirmed.

What is the optimal surgical intervention for patients with frozen shoulder and a concomitant partial-thickness rotator cuff tear?

Background

Patients with recalcitrant frozen shoulder traditionally undergo arthroscopic capsular release. Some patients may have a concomitant partial-thickness rotator cuff tear (PTT). There is limited evidence if these PTT require repair at the same setting. We aim to compare if patients undergoing concomitant rotator cuff repair do better than patients undergoing capsular release alone. Secondarily, we aim to determine if outcomes after arthroscopic capsular release differ for patients with and without PTT.

Methods

A retrospective review of patients with frozen shoulders undergoing arthroscopic capsular release between 2012 and 2016 was performed. Patients with partial-thickness tears and patients without rotator cuff tears were included. Clinical outcomes were collected preoperatively and at 3, 6, 12 months after operation.

Results

There were 33 patients with PTT—15 underwent capsular release without repair (CR group), whereas 18 underwent capsular release with rotator cuff repair (RCR group). A total of 62 control patients without rotator cuff tears (No Tear) underwent arthroscopic capsular release only. For patients with PTT, there were no significant differences in preoperative demographics and function between the CR and RCR group. The CR group had significantly worse preoperative pain. At 1-year follow-up, the RCR group had significantly better internal rotation, lesser pain, and better function than the CR group. For patients undergoing capsular release only, the No Tear group had better internal rotation, lesser pain, and better function at 1 year compared with the CR group.

Conclusion

Patients with a stiff, frozen shoulder and concomitant PTT do benefit from arthroscopic rotator cuff repair with capsular release. The benefit is evident at 1-year follow-up.

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.

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review

INTRODUCTION

Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.

HYPOTHESIS

Different aetiological groups yield variable outcomes following arthroscopic capsular release.

MATERIALS AND METHODS

A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.

RESULTS

Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.

LEVEL OF EVIDENCE

IV, systematic review.

Arthrofibrosis and large joint scarring

Large joint arthrofibrosis and scarring, involving the shoulder, elbow, hip, and knee, can result in the loss of function and immobility. The pathway of joint contracture formation is still being elucidated and is due to aberrations in collagen synthesis and misorientation of collagen fibrils. Novel antibodies are being developed to prevent arthrofibrosis, and current treatment methods for arthrofibrosis include medical, physical, and surgical treatments. This article describes the biology of joint contracture formation, along with current and future pharmacologic, biologic, and medical interventions.

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.

Management of Failed Rotator Cuff Repair in Young Patients

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Contact pressure of the coracoacromial arch in shoulders with joint contracture: A cadaveric study

BACKGROUNDS

There have been many reports describing that the capsular fibrosis of the shoulder joint is the main cause of frozen shoulder, whereas others reported the significance of subacromial impingement as an etiological factor. The purpose of this study was to investigate the contact pressure between the coracoacromial arch and the rotator cuff tendons to clarify the contact phenomenon in shoulders with joint contracture.

METHODS

Fourteen fresh-frozen cadaveric shoulders were used. Specimens were divided into two groups: normal group (8 shoulders, definition: more than 61° of flexion and abduction and more than 21° of external rotation) and joint contracture group (6 shoulders, definition: less than 60° of flexion and abduction and less than 20° of external rotation). Contact pressure and area beneath the coracoacromial arch were measured by a flexible force sensor during flexion, abduction, internal and external rotation in adduction and abduction, extension and horizontal extension motions.

RESULTS

The peak contact pressure under the acromion was observed at 90° in flexion and abduction in the normal group, whereas that in the contracture group was observed at 30° in flexion (P = 0.037) and at 30° in abduction (P = 0.041). Contact pressure in the contracture group was significantly higher than that in the normal group at 20° and 30° of abduction (P = 0.043, P = 0.041, respectively). There were no significant differences of contact pressure during other motions. Although no significant differences of contact pressure beneath the coracoacromial ligament were observed, contact area significantly increased in extension and horizontal extension motion.

CONCLUSION

The contact between the acromion and the rotator cuff was observed in lower angles of flexion and abduction in shoulders with contracture than in those without. When treating patients with shoulder contracture, we need to perform rehabilitation taking such an abnormal movement into consideration.

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.

Clinical correlation of metabolic parameters on 18F-FDG PET/CT in idiopathic frozen shoulder

Objective

Because positron emission tomography/computed tomography (PET/CT) using fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) can be used to visualize inflammation of the musculoskeletal system, it may help elucidate the pathophysiology of frozen shoulder (FS). The purpose of this study was to characterize the uptake pattern on ¹⁸F-FDG PET/CT in patients with idiopathic FS and to determine if there is a correlation between its metabolic parameters and clinical findings.

Methods

¹⁸F-FDG PET/CT was conducted to 35 patients with unilateral idiopathic FS. Clinical data including pain, functional scores, and passive range of motion (ROM) were collected. Maximum standardized uptake values (SUVmax) were measured at the four regions of interest (ROIs): rotator interval (RI), anterior joint capsule (AJC), axillary recess (AR), and posterior joint capsule (PJC) from the attenuation-corrected axial images.

Results

Mean SUVmax values for four ROIs of the affected shoulder were significantly higher than those of the unaffected shoulder. Mean SUVmax values of RI and AR were significantly higher than those of AJC and PJC and mean SUVmax of AJC was significantly higher than that of PJC in the affected side. Three recognizable patterns of increased uptake were noted: (1) AR dominant type (15 patients); (2) RI dominant type (9 patients); (3) both RI and AR dominant type (11 patients). The SUVmax of AR showed negative correlation with abduction and forward flexion. The SUVmax of RI showed negative correlation with external rotation and internal rotation. The SUVmax of AJC showed negative correlation with all ROMs. However, there was no significant correlation between the SUVmax of PJC and any ROM.

Conclusion

Our study demonstrates that the anterior–inferior capsular portion, including RI and AR, is the main pathologic site of idiopathic FS and reveals significant correlations between ROM and metabolic parameters on ¹⁸F-FDG PET/CT. These results imply that AR and RI lesions are related to elevational limitations and rotational limitations, respectively.

Range of motion of diabetic frozen shoulder recovers to the contralateral level

Objective

To determine whether frozen shoulder heals equally well in patients with and without diabetes and whether dependency on insulin affects the outcome.

Methods

We retrospectively examined 178 patients with idiopathic frozen shoulder; 27 patients had diabetes. We evaluated range of motion, pain, and functional results. The mean follow-up was 9.7 years (SD, 7.1 years).

Results

In the presence of frozen shoulder, range of motion did not differ between patients with and without diabetes. At follow-up, range of motion in all directions of both the affected and unaffected shoulders of patients with diabetes was inferior to that of patients without diabetes. Among patients with diabetes, range of motion of the once-frozen shoulder reached the level of the unaffected shoulder. Patients with and without diabetes experienced similar pain except during exertion. The Constant–Murley score was not significantly different between the two groups, and insulin dependency did not lead to worse outcomes.

Conclusion

Frozen shoulder heals well in patients with diabetes.

Locked bucket-handle type bony Bankart lesion resulting from manipulation

A patient who underwent manipulation for stiffness accompanying a rotator cuff tear experienced a complication consisting of a bony Bankart lesion connected to the superior and inferior labrum. This lesion was displaced posteriorly, locked behind the humeral head and blocking the reduction. Attachment of the labrum to this fragment made reduction and fixation easier. This bony Bankart lesion was fixed successfully by arthroscopic placement of knotless suture anchors. Level of evidence Case report, Level IV.

Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial

BACKGROUND

Intra-articular corticosteroid injection is a common therapy for adhesive capsulitis, but there is a lack of prospective randomized controlled studies analyzing the efficacy of single injections applied blindly to accelerate improvement in pain and function.

HYPOTHESIS

In patients with adhesive capsulitis, a single intra-articular corticosteroid injection without image control applied before the beginning of a physical therapy program will accelerate pain relief and recovery of function compared with oral nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 74 patients with primary adhesive capsulitis in the freezing stage were randomized to receive either intra-articular injections with betamethasone or oral NSAIDs. Clinical outcome was documented at baseline and after 2, 4, 8, and 12 weeks and comprised a visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the abbreviated Constant-Murley score, and the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score for function. Passive range of motion was measured with a goniometer.

RESULTS

Patients treated with corticosteroid injections achieved faster pain relief compared with control patients during the first 8 weeks after treatment (P < .001). However, no significant difference in pain was observed among the groups at final follow-up. Likewise, shoulder function and motion improved significantly in both groups at all follow-up points. Shoulder function scores and most motion parameters improved faster in the injection group up to week 8 (P < .001). Again, no significant differences in function or motion were seen at final follow-up.

CONCLUSION

In patients with adhesive capsulitis, a single corticosteroid injection applied without image control provides faster pain relief and earlier improvement of shoulder function and motion compared with oral NSAIDs.

Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder

BACKGROUND

In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates.

METHODS

This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention.

RESULTS

Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention.

CONCLUSIONS

A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.

Arthroscopic treatment of refractory adhesive capsulitis of the shoulder

OBJECTIVE

to evaluate the results of arthroscopic treatment of refractory adhesive capsulitis of the shoulder associated as for improved range of motion after a minimum follow up of six years.

METHODS

from August 2002 to December 2004, ten patients with adhesive capsulitis of the shoulder resistant to conservative treatment underwent arthroscopic surgery. One interscalene catheter was placed for postoperative analgesia before the procedure. All were in Phase II, with a minimum follow up of two years. The mean age was 52.9 years (39-66), predominantly female (90%), six on the left shoulder. The time between onset of symptoms and surgical treatment ranged from six to 20 months. Four adhesive capsulitis were found to be primary (40%) and six secondary (60%).

RESULTS

the preoperative mean of active anterior elevation was 92°, of external rotation was 10.5° of the L5 level internal rotation; the postoperative ones were 149°, 40° and T12 level, respectively. Therefore, the average gain was 57° for the anterior elevation, 29.5° for external rotation in six spinous processes. There was a significant difference in movements' gains between the pre and post-operative periods (p<0.001). By the Constant Score (range of motion), there was an increase of 13.8 (average pre) to 32 points (average post).

CONCLUSION

the arthroscopic treatment proved effective in refractory adhesive capsulitis of the shoulder resistant to conservative treatment, improving the range of joint movements of patients evaluated after a minimum follow up of six years.

Management of complications after rotator cuff surgery

Rotator cuff repair (RCR) is a common procedure performed by orthopedic surgeons via arthroscopic, open, or mini-open techniques. While this surgery is considered to be of low morbidity, several potential complications can arise either intraoperatively or during the postoperative time period. Some of these complications are related to the surgical approach (arthroscopic or open), while others are patient dependent. Many of these complications can be managed through nonoperative means; however, early recognition and timely treatment is essential in limiting the long-term sequela and improving patient outcome. There are several different ways to classify complications after RCR repair: timing, severity, preventability, whether or not the pathology is intra- or extra-articular, and the type of treatment necessary. It is essential that the surgeon is cognizant of the etiology contributing to the failed RCR surgery in order to provide timely and proper management.

Arthroscopic treatment of adhesive capsulitis of the shoulder with minimum follow up of six years

OBJECTIVE

To evaluate the results of the arthroscopic treatment of adhesive capsulitis of the shoulder with six to nine years of follow up.

METHODS

From August 2002 to December 2004, ten patients underwent arthroscopic capsular release for adhesive capsulitis refractory to conservative treatment. An interscalene catheter was used for postoperative analgesia, before the procedure. All were in stage II, with a minimum follow up of six years. The mean age was of 52.9 years old (range, 39 to 66), with female predominance (90%) and six left shoulders. The time between the onset of symptoms and surgery varied from six to 20 months. There were four patients in the primary form (40%) and six in the secondary (60%).

RESULTS

In the preoperative evaluation, the mean active anterior elevation was 92°, 10.5° of external rotation, and internal rotation level L5. Postoperatively, the mean active elevation was 149°, 40° of external rotation and internal level T12, respectively. Thus, the average gains were 57° in forward active elevation, 29.5° in external rotation and six spinous processes, these values being statistically significant (p <0.001). According to the Constant functional score (arc of movements), the value increased from 13.8 (preoperative mean) to 32 points (postoperative mean).

CONCLUSION

Arthroscopic treatment of adhesive capsulitis of the shoulder refractory to conservative treatment allows effective gain of range of motion of this joint.

The management of secondary frozen shoulder after anterior shoulder dislocation - The results of manipulation under anaesthesia and injection

INTRODUCTION

Patients with secondary frozen shoulder following anterior dislocation were treated with manipulation under anaesthesia (MUA) and injection.

METHODS

Ten patients included in study. Oxford Shoulder Scores (OSS), range of motion (ROM) and need for any further treatment measured.

RESULTS

Mean follow-up of 93 weeks. OSS and ROM improved in all patients. Three patients required repeat MUA. Two patients developed recurrent instability.

DISCUSSION

Secondary frozen shoulder may be more recalcitrant. Recurrent instability is a risk following anterior shoulder dislocation. It is feasible that by performing an MUA to maximise mobility, stability may be sacrificed. It should be performed with caution.

[Arthroscopic release for shoulder stiffness]

OBJECTIVE

Arthroscopic capsular release for refractory shoulder stiffness to recreate active and passive shoulder joint mobility.

INDICATIONS

Adhesive capsulitis of the shoulder (primary and secondary frozen shoulder) after receiving at least 3 months of conservative treatment.

CONTRAINDICATIONS

Boney-related stiffening of the shoulder joint, joint infection, freezing phase of the primary frozen shoulder and shoulder stiffness after reconstructive surgery.

SURGICAL TECHNIQUE

Opening of the lower shoulder joint capsule over a gentle unidirectional manipulation under general anesthesia. A diagnostic arthroscopy in lateral position with extension of the arm is then performed. The release is completed with incision of the ventral and the dorsal part of the capsule under arthroscopic control.

POSTOPERATIVE MANAGEMENT

While still in the operation room, the anesthetist places an interscalene brachial plexus catheter, thus, delivering the best possible analgesia. This enables full range of active and passive movement of the shoulder joint for at least 3 days. Outpatient continuation of physiotherapy with anti-inflammatory and analgesic medication.

RESULTS

The literature shows good functional results with age- and gender-related Constant scores greater than 75 %. Our retrospective inquiry of 37 cases with a mean follow-up of 40 months confirms this outcome. The disease duration was shortened by arthroscopic release. Ability to work was achieved after a mean of 1.9 months; treatment ended 3.6 months after operation. In 10 cases with secondary shoulder stiffness, residual symptoms remained.

Functional results and patient satisfaction after arthroscopic capsular release of idiopathic and post-traumatic stiff shoulder

PURPOSE

The purpose of this prospective study was to compare the functional results and patient satisfaction after arthroscopic shoulder capsular release in patients with idiopathic and posttraumatic stiff shoulder.

METHODS

The study included 50 patients who underwent arthroscopic capsular release after failure of conservative treatment. The etiology of stiffness was either idiopathic (25 patients) or post-traumatic (25 patients). There were 28 women and 22 men with an average age of 49 years (range, 32-70 years). All patients were treated with physical therapy for a mean of six months (range, 3-12 months) before surgery. Range of motion was measured three times: 48 hours after surgery, then one month and six months after surgery.

RESULTS

Constant score showed improvement for both groups of patients in the period of six months after surgery. In the group with idiopathic stiffness the score increased from 36 to 86, while in the group with post-traumatic stiff shoulder the score advanced from 32 to 91. The idiopathic stiff shoulder group had an improved active forward flexion from 90 to 161°, external rotation from 10 to 40°, and internal rotation from L5 to L1. In the post-traumatic stiff shoulder groupthe forward flexion was improved from 95 to 170°, external rotation from 13 to 40° and internal rotation from L4 to L1.

CONCLUSION

There was an improvement of range of motions and patients' satisfaction after arthroscopic shoulder capsular release and manipulation under anesthesia, equally in idiopathic and post-traumatic stiff shoulder, compared to the situation before surgery. Post-traumatic contracture patients expressed higher level of satisfaction with their shoulder function than the idiopathic stiff shoulder patients.

Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation

INTRODUCTION

The aim of this prospective study was to assess the immediate and long-term effectiveness of arthroscopic capsular release in a large cohort of patients with a precise and isolated diagnosis of stage II idiopathic frozen shoulder.

METHODS

All patients underwent a preoperative evaluation. Patients with secondary frozen shoulder and those with concurrent pathology at arthroscopy were excluded. This left 136 patients with a stage II arthroscopically confirmed idiopathic frozen shoulder. At each postoperative attendance, a record was made of pain, function and range of motion. At 12 months, the Oxford shoulder score was calculated, and pain and range of motion were assessed.

RESULTS

Fifty per cent achieved good pain relief within a week and eighty per cent within six weeks of arthroscopic capsular release. The mean preoperative visual analogue scale pain score was 6.6 and the mean postoperative score was 1.0. The mean time to achieving good pain relief was 16 days following surgery. No patient could sleep through the night prior to surgery while 90% reported having a complete night's sleep at a mean of 12 days after surgery. The mean postoperative Oxford shoulder score was 38/48 and the mean improvement was 19.2.

CONCLUSIONS

This large series demonstrates that arthroscopic capsular release is a safe procedure, with rapid improvement in pain and a marked improvement in range of motion.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

Adhesive capsulitis: review of imaging and treatment

Adhesive capsulitis is one of the most common conditions affecting the shoulder; however, early clinical diagnosis can be challenging. Treatment is most effective when commenced prior to the onset of capsular thickening and contracture; consequently, the role of imaging is increasing. The aim of this review is to demonstrate the typical imaging appearances of adhesive capsulitis and to examine some of the evidence regarding each of these imaging modalities. An evaluation of the various management options available to the clinician is also presented.

Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review

BACKGROUND

It is currently unclear as to whether there is a difference in the clinical effectiveness of an arthroscopic capsular release compared to a manipulation under anaesthesia (MUA) in patients with recalcitrant idiopathic adhesive capsulitis.

METHODS

A systematic review was performed using computerized keyword searches of MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported outcomes data following either a manipulation under regional or general anaesthesia or an arthroscopic capsular release in patients with idiopathic adhesive capsulitis were included. Data on clinical measures of shoulder range of motion and subjective outcome measures were extracted and summarized.

RESULTS

Twenty-two studies (21 studies provided level IV evidence) including 989 patients were included resulting in a comparison of 9 MUA and 17 capsular release groups. Patients were 60% female with a median age of 52 years old (range, 24-91 years). Median duration of symptoms and follow-up were 9 months (range, 3-50) and 35 months (range, 3-189), respectively. There were minimal differences in the median changes in abduction, flexion, and external rotation range of motion (ROM), and final Constant score between the MUA and capsular release groups.

CONCLUSION

The quality of evidence available is low and the data available demonstrate little benefit for a capsular release instead of, or in addition to, an MUA. A high quality study is required to definitively evaluate the relative benefits of these procedures.

The effect of biceps adhesions on glenohumeral range of motion: a cadaveric study

BACKGROUND

Previous studies have demonstrated that the humerus slides along the long head of the biceps tendon (LHBT). Blocking this motion may result in decreased glenohumeral (GH) range of motion (ROM). The goal of the study was to characterize the excursion of the LHBT and measure the effect of biceps adhesions on GH ROM.

MATERIALS AND METHODS

A custom biomechanical testing setup was used to measure the excursion of the LHBT and rotation of the humerus at 0°, 15°, 30°, 60°, and 90° of GH abduction in the scapular plane. An in situ biceps tenodesis with the biceps anchor still intact, thus simulating biceps adhesions, was sequentially performed in 2 positions: 0° abduction and maximum external rotation, followed by 0° abduction and maximum internal rotation. The effect of tenodesis on ROM was measured.

RESULTS

There was an average excursion of 19.4 ± 5.4 mm of the LHBT as the humerus was taken through ROM in the scapular plane. Tenodesis in 0° abduction and maximum internal rotation resulted in a significant decrease in GH external rotation of 47.3° ± 12.2° (P = .007) with the arm in 0° abduction.

CONCLUSIONS

Tenodesis in maximum internal rotation limited rotation significantly, such that in situ tenodesis without proximal tenotomy should not be performed. Furthermore, in situations where the biceps is at risk for scarring, such as proximal humeral fractures, shoulder arthroplasty, and the stiff shoulder, the biomechanical consequence of biceps adhesions may be similar to in situ tenodesis and may limit ROM and clinical outcomes.

[Shoulder stiffness]

Primary shoulder stiffness is idiopathic. Due to coincidence with other diseases, a systemic genesis with hormonal influence is discussed. The result of chronic inflammation with fibroblastic proliferation is a fibrotic capsule, atrophy of ligaments, and muscular dysbalance. The main symptom is painful restricted passive and active shoulder motion. There is a high rate of unsatisfactory courses. Therapy depends on the phase and duration of shoulder stiffness. Primary treatment of choice is oral steroid therapy, followed by physical and physiotherapy. Steroids can be applied intraarticular, as an alternative. If conservative treatment fails after a period of 6 months, arthroscopic arthrolysis is indicated. Secondary shoulder stiffness often results from traumatization or operation of the shoulder. Primary treatment is also conservative, but operative intervention should be performed early after unsuccessful therapy. Intensive, passive mobilization is necessary after arthrolysis.

Miniopen coracohumeral ligament release and manipulation for idiopathic frozen shoulder

In the management of idiopathic frozen shoulder, manipulation under anaesthesia is known to have serious potential complications including fractures and intra-articular injuries. Arthroscopy is a safer treatment modality but requires special instruments, experience, and involves added cost. The aim of this work was to study the use of miniopen Coracohumeral ligament release and manipulation of the shoulder as a safe and simple method of treating idiopathic frozen shoulder that could be performed as a quick procedure under short duration anaesthesia obtaining a significant improvement of shoulder function while avoiding complications that are feared to occur with the use of manipulation under anaesthesia. Miniopen Coracohumeral ligament release is performed through a 3-cm incision. The Coracohumeral ligament is divided, and then the shoulder is manipulated without undue force. A case series including fifteen patients (19 shoulders) with idiopathic frozen shoulder operated by this technique is described. Miniopen Coracohumeral ligament release and manipulation is a quick procedure that may be performed under short duration anaesthesia obtaining a significant improvement of shoulder function meanwhile avoiding complications that are feared to occur with the use of manipulation under anaesthesia.

Shoulder stiffness and rotator cuff repair

INTRODUCTION

Shoulder stiffness is a frequent complication of surgical repair of rotator cuff tears. Post-operative stiffness negatively affects surgical outcomes leading to a substantial comorbidity and to the failure of surgical treatment. Also, a stiff shoulder could commonly be concomitant with an rotator cuff tear (RCT).

SOURCES OF DATA

We performed a comprehensive search of CINAHL, Embase, Medline and the Cochrane Central Registry of Controlled Trials, from inception of the database to 31 July 2011. Sixteen articles published in peer-reviewed journals were included in this comprehensive review.

AREAS OF CONTROVERSY

The management of shoulder stiffness is still controversial. The role of rehabilitation programs (standard versus early passive mobilization) after RCT repair on the development of stiffness is not clear, while the role of arthroscopic capsular release for post-operative stiffness is better defined, although a threshold of decreased the range of movement for which capsular release is advised has not been identified.

AREAS OF AGREEMENT

Several factors have been identified to predispose the development of shoulder stiffness. There is also evidence in favor of surgical management of RCTs even when accompanied by shoulder stiffness, and there are strong evidences that arthroscopic capsular release is reliable and effective in managing shoulder stiffness.

GROWING POINTS

The post-operative rehabilitation protocol remains controversial. We are still far from definitive guidelines for the management of pre- and post-operative stiffness, and prospective double-blinded randomized clinical trials are needed to obtain evidence allowing to establish a reliable and effective management plan for shoulder stiffness.