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

https://doi.org/10.1016/j.jse.2009.08.004Get rights and content

Hypothesis

The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology.

Materials and Methods

A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months).

Results

At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97°, 14°, and the L5 vertebral level, respectively, to 135°, 38°, and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively).

Conclusions

Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Section snippets

Materials and methods

This study was approved by the IRB of the Massachusetts General Hospital (Protocol # 2009-P-000912).

From 2000 and 2005, 115 consecutive patients (115 stiff shoulders) underwent arthroscopic release for painful shoulder stiffness unresponsive to conservative management. The etiology of stiffness was either post-traumatic, postsurgical, or idiopathic. Patients who were determined to have stiffness due to bony structural abnormalities were excluded from the study. The study was approved by the

Patient data according to specific etiology

Patients with idiopathic frozen shoulders had marked restriction of passive glenohumeral joint motion. No history of trauma was recorded. Of the patients, 41 (25 women and 16 men) met these criteria. Their mean age at the time of capsular release was 52 years (range, 36 to 81 years). The dominant arm was affected in 21 patients and the nondominant arm in 20. Of the 41 patients, 16 (39%) had diabetes mellitus and 2 (4.8%) had hypothyroidism. Operative intervention was performed after at least 9

Surgical technique

The operation was performed as previously described by the senior surgeon in 1997 with a few technical modifications added after the original description.12 All patients were operated on in the beach-chair position. After positioning of the patient in the operating room, while under anesthesia, passive range of motion was documented. The entire upper extremity was then prepared in a sterile fashion, and a mechanical arm holder was used to maintain the position of the arm. An 18-gauge spinal

Aftercare

All patients had interscalene anesthesia with an indwelling interscalene catheter. They received a bolus of 30 to 40 mL of a combination of 1.5% mepivacaine and 0.5% bupivacaine, usually in a combination of 20 mL each. Then, the infusion was run with 0.1% bupivacaine at a variable rate ranging from 10 to 20 mL/h, depending on the individual patient's degree of pain.

Patients were admitted to the hospital for 48 hours to undergo immediate physical therapy, which consisted of passive range of

Statistical analysis

To determine the statistical significance between the different groups, a 1-way analysis of variance test was used. When significant, a Tukey test was performed to identify differences between groups. The level of statistical significance was set at P = .05.

Results

At a mean follow-up of 46 months (range, 24 to 89 months), the mean pain score decreased from 7.5 (range, 4 to 10) to 1 (range, 0 to 8) (P < .0001) in all patients (Table III). Of the 115 patients, 72 (63%) reported no pain, 24 (21%) reported mild pain, 14 (12%) reported moderate pain, and 5 (4%) reported severe pain. All patients with severe pain after surgery had a similar level of pain before surgery. None of the patients had worsening pain after surgery. The mean SSV increased from 29%

Results according to etiology

When the demographic data of the groups were compared, the mean age of the patients in the postsurgical stiffness group was younger than that in the patients in both the idiopathic frozen shoulder group and the post-traumatic stiffness group (P = .0007 and P = .0001, respectively). There was no difference in the 3 groups in terms of gender and dominant side (P > .05).

In the idiopathic group, all outcome measures significantly improved after arthroscopic capsular release (Table III). One patient

Comparison of outcome between groups

The outcomes after treatment of idiopathic stiffness were better than the outcomes after treatment of postsurgical stiffness in terms of pain relief (P = .01), forward flexion (P = .02), and SSV (P = .0001). There was no significant difference between the outcomes of the idiopathic stiffness and post-traumatic stiffness groups, but shoulders with post-traumatic stiffness had better postoperative SSV scores than shoulders with postsurgical stiffness (P = .006).

Discussion

Management of shoulder stiffness continues to be challenging.17, 18, 20, 21 Although physical therapy is generally effective in the management of the stiff shoulder due to adhesive capsulitis, it may not be as effective in patients in whom stiffness develops after surgery or trauma.1, 3, 10, 26 Patients in whom there is a failure to progress after a compliant commitment to conservative treatment and who continue to have not only shoulder stiffness but also pain may benefit from operative

Conclusions

Arthroscopic capsular release is a reliable treatment option for patients with idiopathic, post-traumatic, and postsurgical shoulder stiffness. It was found to reliable not only in restoring motion but also in eliminating pain. Patients with idiopathic or post-traumatic shoulder stiffness have better outcomes than those with postsurgical stiffness. Diabetic involvement did not affect the outcome of surgical treatment.

Disclaimer

The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article and have no potential conflicts of interest related to this manuscript.

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

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      Despite partial-thickness tears being common in frozen shoulders, reported to be up to 15%,34 limited data is available on the outcomes of capsular release in this group of patients. Elhassan found no difference after arthroscopic capsular release between idiopathic and post-traumatic stiffness, but patients in his post-traumatic group included patients with shoulder fractures and dislocations.10 Our results suggest that outcomes after arthroscopic capsular release are superior in patients who have no rotator cuff tear compared with those who have a partial-thickness tear.

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