Arthroscopic Anterior Capsular Release for Idiopathic FrozenShoulder

Arthroscopic anterior capsular release for idiopathic frozenshoulder

Abheek Kar

ABSTRACT

Introduction: Frozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both activeand passive loss of motion. Zuckerman et al further classified Frozen shoulder into primary and secondary groups.Primary or idiopathic frozen shoulder has by definition no clear cause. The initial treatment consists of conservativemanagement with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation underanaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation underanaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has beendone providing excellent functional outcome and reproducible results.

Aim: The purpose of this study was to prospectively evaluate the efficacy of arthroscopic anterior capsular release forpatients with refractory idiopathic adhesive capsulitis.

Methods: 26 patients (sixteen males, ten females) with a mean age of 58.4 years (range; 44-72 years) were followedup at our institution. Arthroscopic anterior capsular release was done using two portals. Synovectomy was done usinga shaver and capsular release was done using radiofrequency ablator.

Results: The functional outcome was evaluated using ASES (American Shoulder and Elbow Society) and Constantand Murley scoring system. At 12 months, mean improvement in ASES score was 38 points and Constant and Murleyscore was 40.5 points. Out of 26 patients 22 said that they would recommend the procedure to someone

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Frozen shoulder, Refractory idiopathic adhesive capsulitis, Intra-articular steroids

INTRODUCTION AND AIM

Frozen shoulder (Adhesive capsulitis) has been defined asa condition characterized by both active and passive lossof motion. Zuckerman et al further classified1 frozenshoulder into primary and secondary groups. Primary oridiopathic frozen shoulder has by definition no clear cause.Secondary frozen shoulder has intrinsic causes (fractures,tendonitis, rotator cuff tears or degenerative arthritis),extrinsic causes (Parkinsonism, cervical radiculopathy,cardiovascular accidents and head injuries) and systemiccauses (Diabetes mellitus, thyroid dysfunction andmyositis).

Primary (Idiopathic) frozen shoulder goes through threestages. The freezing phase (from few weeks up to 9 months),frozen phase (3e12 months) and thawing phase (5e26months). The initial treatment consists of conservativemanagement with NSAID, Physiotherapy, intra-articularsteroids or saline and in some instances manipulation underanaesthesia.

Once in a while there are cases which are refractory toconservative treatment and manipulation under anaesthesiahas its risks2 like fractures and rotator cuff tears. Manipula-tion also doesn’t treat the primary pathology in this condi-tion, which is synovitis. Arthroscopic capsular release ofstiff shoulders has been done providing excellent functional

Consultant, Shoulder and Sports Medicine Unit, Apollo Gleneagles Hospitals, Kolkata 700054, India.email: abheekkar@gmail.comReceived: 30.7.2012; Accepted: 13.8.2012; Available online 27.8.2012Copyright � 2012, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2012.08.007

Apollo Medicine 2012 DecemberVolume 9, Number 4; pp. 303e306 Original Article

outcome and reproducible results. The purpose of this studywas to prospectively evaluate the efficacy of arthroscopicanterior capsular release for patients with refractory idio-pathic adhesive capsulitis.

METHODS

Between January 2009 and February 2011, 26 patients(sixteen males, ten females) with a mean age of 58.4 years(range; 44e72 years) were followed up at our institution.The mean duration between the onset of symptoms andsurgery was 6.2 months. All patients had tried conservativetreatment including intra-articular steroids, physical therapyand 14 patients had undergone manipulation under anaes-thesia prior to Arthroscopy. All the patients had severe nightpain, stiffness and restricted usage of the arm for day to dayactivities. Exclusion criteria included diabetes mellitus,trauma, arthritis, thyroid dysfunction, cervical radiculopathy,cerebro-vascular accident, cardiac surgery and majorsystemic illness. Radiographs were unremarkable. Thesurgery was done under general anaesthesia in beach chairposition. Hypotensive anaesthesia (mean BP e 90 mmHg)was used along with Artho-pump to minimize intra-articularbleeding and facilitate clear visualization. At first the poste-rior portal is made. To facilitate entry of the arthroscopytrocar and cannula into the tight joint some saline may beinjected into the joint to distend it. Also the posterior portalis 0.5 cm higher than the usual posterior portal. Entry intothe joint is made using a blunt trocar to avoid joint damage.The anterior portal is also made high up, just supero-lateralto the coracoid process close to the biceps tendon. A5.5 mm plastic cannula is used for smooth passage of instru-ments through the anterior portal. The first step of the surgery

Fig. 1 Synovectomy of the rotator interval and superiorcapsule.

Fig. 2 Release of superior, middle and inferior gleno-humeralligaments and capsule using the radiofrequency probe.

Fig. 3 After the complete release, the shiny subscapular istendon can be seen.

Table 1 Chart showing the improvement in the range ofmotion.

304 Apollo Medicine 2012 December; Vol. 9, No. 4 Kar

is removal of the synovitis of the rotator interval usinga motorized shaver (3.5 mm) (Fig. 1). The next step is thecapsular release using the radio frequency ablation device.3

The release is done of the capsule along with the superior,middle and inferior gleno-humeral ligaments3 (Fig. 2). Theprobe should be close to the glenoid edge when it reachesinferiorly to avoid injuring the axillary nerve. The tendonof subscapularis should be seen clearly after the release(Fig. 3). Post-operative pain relief was given using routineanalgesics depending on the pain score of the patient. Post-operative physiotherapy was done for a period rangingfrom 3 to 12 weeks. All patients were discharged on theevening of the surgery or the next morning .The functionaloutcome was evaluated using ASES (American Shoulderand Elbow Society) and Constant and Murley scoringsystem.

RESULTS

All the patients showed significant improvement in therange of motion (Table 1) and relief of pain in the imme-diate post-operative period. At 12 months, mean improve-ment in ASES score was 38 points and Constant andMurley score was 40.5 points. The complications in ourseries were, two transient axillary nerve paraesthesias

(which resolved within three days), excessive swelling ofthe joint due to fluid extravasations in all the cases (whichsubsided within 24 h) and one patient developed anteriorportal superficial infection (which subsided with regulardressings and antibiotics). None of the patients had anyinstability post-operatively. Out of 26 patients 22 saidthat they would recommend the procedure to someone.

CONCLUSIONS

Arthroscopic release showed promising results with reliableincrease in range of motion, early relief of symptoms andconsequent early return to work (Fig. 4). It is sufficient toperform anterior release only2 without the need for poste-rior release as there was no residual internal rotation stiff-ness and pain during follow up. Arthroscopic anteriorcapsular release is highly recommended in properlyselected patients. It should be done in mid stage of thedisease (frozen state). Post-operative physiotherapy isextremely important.

CONFLICTS OF INTEREST

The author has none to declare.

Fig. 4 Restoration of normal joint function at 2 months follow up.

Arthroscopic anterior capsular release Original Article 305

REFERENCES

1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus defini-tion. J Shoulder Elbow Surg. 2011 Mar;20(2):322e325. Epub2010 Nov 4.

2. Beaufils P, Prévot N, Boyer T, et al. Arthroscopic release of theglenohumeral joint in shoulder stiffness: a review of 26 cases.

French Society for Arthroscopy. Arthroscopy. 1999 JaneFeb;15(1):49e55.

3. Musil D, Sadovský P, Stehlík J, Filip L, Vodicka Z.Arthroscopic capsular release in frozen shoulder syndrome.Acta Chir Orthop Traumatol Cech. 2009 Apr;76(2):98e1032.

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