Arthroscopic Anterior Capsular Release for Idiopathic Frozen Shoulder

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Frozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both active
and 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 conservative
management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under
anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under anaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has been done providing excellent functional outcome and reproducible results.

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Arthroscopic Anterior Capsular Release for Idiopathic Frozen Shoulder

  1. 1. Arthroscopic Anterior Capsular Release for Idiopathic Frozen Shoulder
  2. 2. Arthroscopic anterior capsular release for idiopathic frozen shoulder Abheek Kar ABSTRACT Introduction: Frozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both active and 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 conservative management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under anaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has been done providing excellent functional outcome and reproducible results. Aim: The purpose of this study was to prospectively evaluate the efficacy of arthroscopic anterior capsular release for patients 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 followed up at our institution. Arthroscopic anterior capsular release was done using two portals. Synovectomy was done using a shaver and capsular release was done using radiofrequency ablator. Results: The functional outcome was evaluated using ASES (American Shoulder and Elbow Society) and Constant and Murley scoring system. At 12 months, mean improvement in ASES score was 38 points and Constant and Murley score 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 as a condition characterized by both active and passive loss of motion. Zuckerman et al further classified1 frozen shoulder into primary and secondary groups. Primary or idiopathic 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 systemic causes (Diabetes mellitus, thyroid dysfunction and myositis). Primary (Idiopathic) frozen shoulder goes through three stages. The freezing phase (from few weeks up to 9 months), frozen phase (3e12 months) and thawing phase (5e26 months). The initial treatment consists of conservative management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under anaesthesia has 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 of stiff shoulders has been done providing excellent functional Consultant, Shoulder and Sports Medicine Unit, Apollo Gleneagles Hospitals, Kolkata 700054, India. email: abheekkar@gmail.com Received: 30.7.2012; Accepted: 13.8.2012; Available online 27.8.2012 Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.08.007 Apollo Medicine 2012 December Volume 9, Number 4; pp. 303e306 Original Article
  3. 3. outcome and reproducible results. The purpose of this study was to prospectively evaluate the efficacy of arthroscopic anterior 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 and surgery was 6.2 months. All patients had tried conservative treatment including intra-articular steroids, physical therapy and 14 patients had undergone manipulation under anaes- thesia prior to Arthroscopy. All the patients had severe night pain, stiffness and restricted usage of the arm for day to day activities. Exclusion criteria included diabetes mellitus, trauma, arthritis, thyroid dysfunction, cervical radiculopathy, cerebro-vascular accident, cardiac surgery and major systemic illness. Radiographs were unremarkable. The surgery was done under general anaesthesia in beach chair position. Hypotensive anaesthesia (mean BP e 90 mmHg) was used along with Artho-pump to minimize intra-articular bleeding and facilitate clear visualization. At first the poste- rior portal is made. To facilitate entry of the arthroscopy trocar and cannula into the tight joint some saline may be injected into the joint to distend it. Also the posterior portal is 0.5 cm higher than the usual posterior portal. Entry into the joint is made using a blunt trocar to avoid joint damage. The anterior portal is also made high up, just supero-lateral to the coracoid process close to the biceps tendon. A 5.5 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 superior capsule. Fig. 2 Release of superior, middle and inferior gleno-humeral ligaments and capsule using the radiofrequency probe. Fig. 3 After the complete release, the shiny subscapular is tendon can be seen. Table 1 Chart showing the improvement in the range of motion. 304 Apollo Medicine 2012 December; Vol. 9, No. 4 Kar
  4. 4. is removal of the synovitis of the rotator interval using a motorized shaver (3.5 mm) (Fig. 1). The next step is the capsular 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). The probe should be close to the glenoid edge when it reaches inferiorly to avoid injuring the axillary nerve. The tendon of subscapularis should be seen clearly after the release (Fig. 3). Post-operative pain relief was given using routine analgesics depending on the pain score of the patient. Post- operative physiotherapy was done for a period ranging from 3 to 12 weeks. All patients were discharged on the evening of the surgery or the next morning .The functional outcome was evaluated using ASES (American Shoulder and Elbow Society) and Constant and Murley scoring system. RESULTS All the patients showed significant improvement in the range 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 and Murley score was 40.5 points. The complications in our series were, two transient axillary nerve paraesthesias (which resolved within three days), excessive swelling of the joint due to fluid extravasations in all the cases (which subsided within 24 h) and one patient developed anterior portal superficial infection (which subsided with regular dressings and antibiotics). None of the patients had any instability post-operatively. Out of 26 patients 22 said that they would recommend the procedure to someone. CONCLUSIONS Arthroscopic release showed promising results with reliable increase in range of motion, early relief of symptoms and consequent early return to work (Fig. 4). It is sufficient to perform 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 anterior capsular release is highly recommended in properly selected patients. It should be done in mid stage of the disease (frozen state). Post-operative physiotherapy is extremely 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
  5. 5. REFERENCES 1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus defini- tion. J Shoulder Elbow Surg. 2011 Mar;20(2):322e325. Epub 2010 Nov 4. 2. Beaufils P, Prévot N, Boyer T, et al. Arthroscopic release of the glenohumeral 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. 306 Apollo Medicine 2012 December; Vol. 9, No. 4 Kar
  6. 6. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/

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