Surgical intervention in periarthritis shoulder


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Surgical intervention in periarthritis shoulder

  1. 1. Periarthritis of Shoulder When To Intervene Surgically And How Dr.G.Ramesh M.S(Ortho.) Asst.Professor, Dept. of Orthopaedics Gandhi Medical College and Hospital
  2. 2. Introduction • Common problem • Difficult to treat • Non-surgical management • What to do with failure of non-surgical management
  3. 3. Alternate names • Duplay -1872: “Periarthritis scapulo-humerale” • Codman -1934: “Frozen shoulder” • Neviaser -1945: “Adhesive capsulitis” “A condition of uncertain etiology characterized by significant restriction of both active and passive motion that occurs in the absence of a known intrinsic shoulder disease” -American Academy of Orthopaedic Surgeons-1992:
  4. 4. Etiology and pathogenesis “Chronic inflammatory process involving the capsule of the shoulder causing a thickening and contracture of the capsule which secondarily becomes adherent to the humeral head”. -Neviaser
  5. 5. Natural History Phase I : Freezing or painful phase Pain around the shoulder, worst at night Duration 2 to 9 months Phase II : Frozen or adhesive phase Pain present only at extremes of movements Gross restriction of movements Duration 4 to 12 months Phase III: Thawing or resolution phase Pain subsides, ROM slowly returns Return of full movements can take months to years Motion restriction often persists
  6. 6. Natural History • Believed to be self resolving • But not in all patients • Adhesive capsulitis in DM • Adhesive capsulitis with co-morbid conditions
  7. 7. Management of Frozen Shoulder Non-surgical management Freezing or painful phase Aims at pain relief Initial treatment of Choice Surgical management Frozen or thawing phase Aims at regaining the ROM
  8. 8. Surgical management • Manipulation Under Anaesthesia (MUA) considered gold standard carries risks like fracture, dislocation, nerve injuries, uncontrolled rupture of capsule injuries to soft tissues does not alter the time course of disease contraindicated in osteoporosis, in post-surgery, post-trauma stiffness • Arthroscopic capsular release
  9. 9. Arthroscopic capsular release Advantages • Allows controlled and precise capsular release • Synovectomy • Allows evaluation and possible treatment of additional pathology • Joint distention via arthroscopic inflow
  10. 10. Arthroscopic capsular release Indications Idiopathic Adhesive capsulitis Non-responders (refractory cases) Surrenders When MUA fails to restore movements Where MUA is contraindicated Recurrence of stiffness after MUA Adhesive capsulitis secondary to intrinsic shoulder pathology Adhesive capsulitis associated with diabetes Post surgical Post traumatic
  11. 11. Arthroscopic capsular release The Principle: • A tightened coraco humeral ligament and rotator interval with contracted capsule are the “essential lesions” in adhesive capsulitis. • Resection of these structures combined with appropriate exercises will restore ROM and relieves pain NORMAL SHOULDER FROZEN SHOULDER
  12. 12. Rotator interval • The principal site of pathology • Anatomy of rotator interval • Contents of rotator interval Superior Glenohumeral Ligament(SGHL) Anterior Superior Capsule Coracohumeral Ligament(CHL)
  13. 13. Arthroscopic capsular release Timing when to be advised minimum of 6months period of conservative management
  14. 14. Arthroscopic capsular release Surgical technique Anaesthesia G.A. with interscalene brachial block Position of patient lateral decubitus position Arthroscopic portals posterior portal anterior superior portal
  15. 15. Arthroscopic capsular release Rotator interval release E.R. in adduction superior gleno humeral ligament anterior superior capsule coraco humeral ligament Middle glen humeral ligament release 450 of abduction Sub scapular delineation HUMERAL HEAD HUMERAL HEAD SUB SCAPULAR TENDON SUBSCAPULAR TENDON
  16. 16. Arthroscopic capsular release Release of inferior capsule Rotations in 90 0 of abduction Release of posterior capsule Forward flexion and I.R Manipulation of shoulder HUMERAL HEAD GLENOID INFERIOR CAPSULE HUMERAL HEAD GLENOID AFTER CUTING INFERIOR CAPSULE HUMERAL HEAD GLENOID POSTERIOR CAPSULE GLENOID AFTER CUTTING POSTERIOR CAPSULE
  17. 17. Arthroscopic capsular release Post-operative management • For maintenance of gains in ROM • Shoulder kept in full abduction and external rotation • Interscalene block for 48 hrs • Aggressive physiotherapy
  18. 18. Arthroscopic capsular release Case Details Name: Yellamma Age/Sex: 50 / Female Occupation: Manual Labourer Duration of Symptoms : 9 Months Diagnosis: idiopathic adhesive Capsulitis Clinical Video Surgical Video
  19. 19. Post operative Pictures
  20. 20. Arthroscopic capsular release Authors ` No. of pts Mean age yrs M;F ratio Mean time of preop symptoms Surgical treatment Mean follow up results SEGMULLER et al 24 50 14:10 Not stated Arthroscopic release 13.5 months 88%satisfied 76% normal function Beufils et al 25 48 6:19 13 months Arthroscopic release 21 months 69% very satisfied or satisfied Watson et al 73 52 42:31 19.7 mnths Arthroscopic release 12 months Pain reduced by 2.2wks ROM 10% that of other shoulder by 5.5 wks jerosch 28 49 13:15 24 months Arthroscopic release 26 Mean constant score inrease by 41 points Benett 31 60 12:19 Min 6wks Arthroscopic release 18months Mean constant score increase 37 to 78 points Nicholson 68 50 27:41 Not stated Arthroscopic release 3yrs Increase in ASES 35.5 TO 93 points Clinical Studies
  21. 21. Conclusion Arthroscopic Capsular Release is a reliable treatment for improving ROM in patients with Refractory idiopathic Capsulitis , Secondary adhesive Capsulitis, Post traumatic and Post operative Shoulder Stiffness So the Arthroscopic Capsular Release should be in the Armamentarium of Orthopaedic Surgeon for the management of refractive adhesive Capsulitis