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Zhao Y, Yang T, Feng C, Li L, Pang L, Zhao S. Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis. Orthop Surg 2024; 16:1517-1529. [PMID: 38747000 PMCID: PMC11216839 DOI: 10.1111/os.14077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVE Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. METHODS A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). RESULTS A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. CONCLUSIONS In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.
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Affiliation(s)
- Yanmin Zhao
- Outpatient Department, West China HospitalSichuan UniversityChengduPeople's Republic of China
- West China School of NursingSichuan UniversityChengduPeople's Republic of China
| | - Ting Yang
- West China School of NursingSichuan UniversityChengduPeople's Republic of China
- Operating Room of Anesthesia Surgery Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Chenchen Feng
- Outpatient Department, West China HospitalSichuan UniversityChengduPeople's Republic of China
- West China School of NursingSichuan UniversityChengduPeople's Republic of China
| | - Lang Li
- Department of OrthopedicsHospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.)ChengduPeople's Republic of China
| | - Long Pang
- Sports Medicine Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Shuzhen Zhao
- Outpatient Department, West China HospitalSichuan UniversityChengduPeople's Republic of China
- West China School of NursingSichuan UniversityChengduPeople's Republic of China
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Galasso O, Mercurio M, Luciano F, Mancuso C, Gasparini G, De Benedetto M, Orlando N, Castricini R. Arthroscopic capsular release for frozen shoulder: when etiology matters. Knee Surg Sports Traumatol Arthrosc 2023; 31:5248-5254. [PMID: 37702747 PMCID: PMC10598184 DOI: 10.1007/s00167-023-07561-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder. METHODS A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, β = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release. CONCLUSION High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, V.le Europa, 88100, Catanzaro, Italy
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, V.le Europa, 88100, Catanzaro, Italy
| | - Francesco Luciano
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, V.le Europa, 88100, Catanzaro, Italy
| | - Claudia Mancuso
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, V.le Europa, 88100, Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, V.le Europa, 88100, Catanzaro, Italy.
| | | | - Nicola Orlando
- Division of Orthopaedic and Trauma Surgery, "Villa Verde", 63900, Fermo, Italy
| | - Roberto Castricini
- Division of Orthopaedic and Trauma Surgery, "Villa Verde", 63900, Fermo, Italy
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Li D, Zhang C, Xiang X, Cheng Y, Zhang L, Ma K. The Effect of Arthroscopic Extra-Articular Entire Coracohumeral Ligament Release for Patients with Recalcitrant Frozen Shoulder. Orthop Surg 2023; 15:1975-1982. [PMID: 36345115 PMCID: PMC10432473 DOI: 10.1111/os.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/21/2022] [Accepted: 09/21/2022] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE The thickened coracohumeral ligament (CHL) is an important part of the typical manifestations and magnetic resonance imaging of frozen shoulder. However, only a few clinical studies with limited cases on arthroscopic extra-articular entire CHL release exist in the literature. This study was to evaluate the effect of arthroscopic extra-articular entire CHL release for patients with recalcitrant frozen shoulder. METHODS From February 2014 to February 2020, 81 cases of recalcitrant frozen shoulder patients treated with surgery in a single-center shoulder department and followed for more than 2 years were analyzed. Arthroscopic 360° capsular release was performed with intra-articular partial release (IPR group) or additional extra-articular entire release (IPR + EER group) of CHL. The same rehabilitation program was performed after surgery in both groups. Visual analogue scale (VAS) for pain, range of motion (ROM), and the Constant-Murley scoring system was evaluated before operation, at 3 months after operation, 6 months after operation, and the final follow-up. T-test, Mann-Whitney U-test and chi-squared test were used to compared data. RESULTS There were 39 patients in the IPR group, with an average follow-up of 29.2 months. A total of Forty-two patients in the IPR + EER group completed a mean follow-up of 25.7 months. All incisions healed in stages. There were significant differences in Constant-Murley shoulder score, VAS score, and ROM before operation and at the final follow-up in both groups (both P < 0.001). The VAS score of the IPR + EER group was lower than that of the IPR group at 3 months after surgery (P < 0.05), and 6 months after operation (P < 0.05). External rotation, internal rotation, and abduction of ROMs and Constant-Murley shoulder score were significantly greater in the IPR + EER group at 3 months (P < 0.001, P < 0.05, P < 0.001, P < 0.05, respectively) and 6 months after operation (P < 0.001, P < 0.05, P < 0.001, P < 0.05, respectively). At the last follow-up, there was no significant difference in forward flexion, internal rotation, and abduction of ROMs, VAS, and the Constant-Murley shoulder score between the IPR and IPR + EER groups. The external rotation of the IPR + EER group was still greater than that of the IPR group at the last follow-up (P < 0.001). CONCLUSION Arthroscopic extra-articular entire coracohumeral ligament release could solve early pain of shoulder joint, recover shoulder joint functions effectively, and achieve a satisfactory efficacy in the treatment of recalcitrant frozen shoulder.
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Affiliation(s)
- Dan‐mei Li
- Shoulder and Elbow Surgery CenterLuoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan ProvinceLuoyangChina
| | - Chuan Zhang
- Shoulder and Elbow Surgery CenterLuoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan ProvinceLuoyangChina
| | - Xian‐Xiang Xiang
- Department of Orthopedic SurgeryAffiliated Zhongshan Hospital of Dalian UniversityDalianChina
| | - Yong‐Feng Cheng
- Department of Orthopedic SurgeryXiangtan Hospital of Traditional Chinese MedicineXiangtanChina
| | - Lai‐Fu Zhang
- Shoulder and Elbow Surgery CenterLuoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan ProvinceLuoyangChina
| | - Kun Ma
- Shoulder and Elbow Surgery CenterLuoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan ProvinceLuoyangChina
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Sudah SY, Menendez ME, Moverman MA, Puzzitiello RN, Little D, Nicholson AD, Garrigues GE. The role of the anterior shoulder joint capsule in primary glenohumeral osteoarthritis. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:21-27. [PMID: 37588061 PMCID: PMC10426523 DOI: 10.1016/j.xrrt.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The pathogenesis of primary glenohumeral arthritis (GHOA) is mediated by a complex interaction between osseous anatomy and the surrounding soft tissues. Recently, there has been growing interest in characterizing the association between the anterior shoulder joint capsule and primary GHOA because of the potential for targeted treatment interventions. Emerging evidence has shown substantial synovitis, fibrosis, and mixed inflammatory cell infiltrate in the anterior capsule of osteoarthritic shoulders. In addition, increased thickening of the anterior shoulder joint capsule has been associated with greater posterior glenoid wear and humeral head subluxation. While these findings suggest that anterior capsular disease may play a causative role in the etiology and progression of eccentric GHOA, further studies are needed to support this association. The purpose of this article is to review the pathogenesis of primary GHOA, contextualize current hypotheses regarding the role of the anterior capsule in the disease process, and provide directions for future research.
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Affiliation(s)
- Suleiman Y. Sudah
- Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA
| | | | - Michael A. Moverman
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University, Boston, MA, USA
| | - Richard N. Puzzitiello
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University, Boston, MA, USA
| | - Dianne Little
- Department of Basic Medical Sciences and the Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
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Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes. J Clin Med 2021; 10:jcm10215185. [PMID: 34768705 PMCID: PMC8584489 DOI: 10.3390/jcm10215185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/23/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
This retrospective study compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy. The patients who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy (Group I, n = 30) or received only corticosteroids injection and physiotherapy (Group II, n = 29) were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later. The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome. Group I had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.
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Wang YD, Ming YX, Pang YH, Chen WN, Zong XH, Wu JY, Deng YK. Effectiveness of arthroscopic management of idiopathic shoulder stiffness: A meta-analysis. J Back Musculoskelet Rehabil 2021; 34:565-572. [PMID: 33554887 DOI: 10.3233/bmr-200267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Matson A, Kunkel Z, Bernal-Crespo V, Chainani A, Chainani M, Finley S, Friedman L, Little D, Garrigues G. The histopathology of the humeral head in glenohumeral osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2021; 3:100147. [DOI: 10.1016/j.ocarto.2021.100147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/16/2022] Open
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Abstract
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.
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Schleip R, Klingler W. Active contractile properties of fascia. Clin Anat 2019; 32:891-895. [PMID: 31012158 DOI: 10.1002/ca.23391] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/19/2019] [Accepted: 04/21/2019] [Indexed: 12/16/2022]
Abstract
The ubiquitous network of fascial tissues in the human body is usually regarded as a passive contributor to musculoskeletal dynamics. This review aims to highlight the current understanding of fascial stiffness regulation. Notably the ability for active cellular contraction which may augment the stiffness of fascial tissues and thereby contribute to musculoskeletal dynamics. A related narrative literature search via PubMed and Google Scholar reveals a multitude of studies indicating that the intrafascial presence of myofibroblasts may enable these tissues to alter their stiffness. This contractile tissue behavior occurs not only in several pathological fibrotic contractures but has also been documented in normal fasciae. When viewed at time frames of seconds and minutes the force of such tissue contractions is not sufficient for exerting a significant effect on mechanical joint stability. However, when viewed in a time-window of several minutes and longer, such cellular contractions can impact motoneuronal coordination. In addition, over a time frame of days to months, this cellular activity can induce long-term and severe tissue contractures. These findings tend to question the common clear distinction between active tissues and passive tissues in musculoskeletal dynamics. Clin. Anat. 32:891-895, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Robert Schleip
- Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Guenzburg, Germany.,Department of Sports Medicine and Health Promotion, Friedrich Schiller University Jena, Jena, Germany.,Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
| | - Werner Klingler
- Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany.,Faculty of Health School - Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
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Lu Z, Wang J, Xu B, You W, Wang J. [Effectiveness of arthroscopic capsular release to treat primary severe frozen shoulder through trans cuff portal]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:773-777. [PMID: 29798518 DOI: 10.7507/1002-1892.201702012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To assess the effectiveness of arthroscopic capsular release to treat primary severe frozen shoulder through trans cuff portal. Methods Between June 2012 and January 2015, 28 patients with primary severe frozen shoulder were enrolled in the study. There were 8 males and 20 females with an average age of 57 years (range, 42-81 years). The left shoulder was involved in 16 cases and the right one in 12 cases. The mean disease duration was 11 months (range, 7-21 months). Six patients had diabetes. All patients underwent arthroscopic capsular release by trans cuff portal. The range of motion (ROM) of the shoulder were measured at preoperation and at 6 weeks and 24 months after operation; the scores of American Shoulder and Elbow Surgeons (ASES) and visual analogue scale (VAS) were used to evaluate the shoulder function and pain. Results Primary healing of incision was obtained, and no complications of infection, shoulder instability, and nerve injury were found. All patients were followed up 24 months. Pain of the shoulder was obviously relieved; VAS score was significantly lower at 6 weeks and 24 months after operation than preoperation ( P<0.05), and at 24 months than 6 weeks ( P<0.05). ROM of the shoulder and ASES score at 6 weeks and 24 months after operation were significantly increased when compared with preoperative ones ( P<0.05); significant difference was found in ROM of forward flexion and external rotation and the ASES score between at 6 weeks and 24 months ( P<0.05). And internal rotation in-creased from trochanter (9 cases), hip (6 cases), sacrum (7 cases), and L 4 vertebral level (6 cases) before operation to the T 12-T 6 vertebral level at 6 weeks and 24 months after operation, which were close to normal side. Conclusion Arthroscopic capsular release through trans cuff portal is an effective and safe management for primary severe frozen shoulder.
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Affiliation(s)
- Zhenfei Lu
- Department of Orthopedics, Wuxi Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Wuxi Jiangsu, 214000, P.R.China
| | - Jianhua Wang
- Department of Orthopedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200092, P.R.China
| | - Bing Xu
- Department of Orthopedics, Wuxi Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Wuxi Jiangsu, 214000, P.R.China
| | - Weijia You
- Department of Orthopedics, Wuxi Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Wuxi Jiangsu, 214000, P.R.China
| | - Jianwei Wang
- Department of Orthopedics, Wuxi Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Wuxi Jiangsu, 214000,
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