Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation

Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder

BACKGROUND

Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease.

METHODS

Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated.

RESULTS

The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases.

CONCLUSIONS

Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block

BACKGROUND

Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC.

MATERIALS AND METHODS

A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved.

RESULTS

Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness.

CONCLUSIONS

In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tear with limited shoulder movement

BACKGROUND

To determine the clinical efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tendinopathy to improve the Constant-Murley and Visual Analogue Scale (VAS) scores, and shoulder flexion.

METHODS

Fifty-one patients with full-thickness rotator cuff tears and limited shoulder movement who were admitted to our hospital from October 2017 to October 2020 were selected; all patients were treated with arthroscopic rotator cuff suture and 360° capsular release. The Constant-Murley score, VAS score, and shoulder flexion angle were used to evaluate shoulder joint function before and during follow-up. Rotator cuff healing was assessed by MRI with the Sugaya classification.

RESULTS

After treatment, the Constant-Murley score (58.98 ± 9.84) was significantly improved compared with pre-treatment (29.33 ± 9.71), the VAS score (1.23 ± 0.87) was significantly lower than pre-treatment (7.54 ± 1.22), and the shoulder flexion angle (142.67 ± 8.59°) was significantly improved compared with pre-treatment (51.50 ± 2.10°); the difference was statistically significant (P < 0.05).

CONCLUSIONS

Arthroscopic rotator cuff suture and simultaneous 360° capsular release have a significant effect on the treatment of rotator cuff tear with limited shoulder movement.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

One-stage rotator cuff repair in stiff shoulders shows comparable range of motion, clinical outcome and retear rates to non-stiff shoulders: a systematic review

BACKGROUND

One-stage treatment involving rotator cuff repair and shoulder capsule release is mainly used to treat patients with rotator cuff tears (RCTs) and concomitant shoulder stiffness. Despite the increasing attention to the efficacy and safety of one-stage treatment, controversy still remains. Therefore, this systematic review aims to summarize the indications, operation procedure and rehabilitation protocol, and compare the range of motions (ROMs), functional outcomes and retear rates of one-stage treatment for RCTs in stiff shoulders and non-stiff shoulders.

METHODS

Multiple databases (PubMed, the Cochrane Library, Embase and MEDLINE) were searched for studies that investigated outcomes after one-stage treatment for RCTs concomitant with shoulder stiffness compared with rotator cuff repair for RCTs alone, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Descriptive statistics, including range of motion, patient-reported outcome and retear rate, are presented without meta-analysis due to the heterogeneity and low levels of evidence.

RESULTS

A total of 9 cohort studies were included, with 305 patients treated with one-stage treatment involving rotator cuff repair and simultaneous shoulder capsular release and 1059 patients treated with rotator cuff repair alone. Patients in both groups had significant symptom improvement and functional recovery after the one-stage treatment for the stiffness group and standard repair for the non-stiffness group, and most patients could return to normal life and work within 6 months after the operation. The retear rate in the one-stage treatment group was not higher than that in the rotator cuff repair group. No statistically significant differences between the two groups were observed in terms of range of motion and patient-reported outcomes in the vast majority of studies at the final follow-up, including the visual analog scale for pain, the Constant score, the American Shoulder and Elbow Surgeons score, the University of California Los Angeles Shoulder Score, the Oxford shoulder score and the Simple Shoulder Test.

CONCLUSION

One-stage treatment for RCTs in stiff shoulders provides comparable ROM and patient-reported clinical outcomes as rotator cuff repair for non-stiff RCTs. In addition, the rate of postoperative retear in stiff shoulder treated with one-stage treatment was not higher than in non-stiff shoulders.

Arthroscopic Pan-Capsular and Transverse Humeral Ligament Release with Biceps Tenodesis for Patients with Refractory Frozen Shoulder

Arthroscopic capsular release allows direct visualization and release of inflamed tissues in refractory frozen shoulder. The reticular neural network in the long head of the biceps tendon (LHBT) and nerve endings of the transverse humeral ligament (THL) might be responsible for shoulder pain. We hypothesized that patients with painful refractory frozen shoulder benefited from pan-capsular release, THL release, and LHBT tenodesis. The LHBT tenodesis decreased the possibility of LHBT instability. The balance of the shoulder joint was maintained after such extensive release. From October 2013 to June 2019, patients with painful refractory frozen shoulder were enrolled consecutively at the same institute. All patients received arthroscopic pan-capsular, THL release, and suprapectoral LHBT tenodesis with a minimum of 2-year follow-up. Preoperative and postoperative shoulder range of motion (ROM), pain visual analog scale (PVAS), subjective shoulder value (SSV), constant score, LHBT score, acromio-humeral distance (AHD), and critical shoulder angle (CSA) were recorded. In total, 35 patients with an average age of 53.1 ± 9 years were enrolled. The average follow-up period was 24 ± 1.5 months. Forward elevation improved from 105.1° ± 17° to 147° ± 12° (p < 0.001), external rotation improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001), and internal rotation improved from L3 to T9 (p < 0.001), respectively, at final follow-up. PVAS improved from 7.3 ± 1.1 to 1.8 ± 0.6 (p < 0.001), constant score from 23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV from 27.7 ± 10.5 to 77.4 ± 3.8, respectively, at follow-up. No differences were found in AHD and CSA after surgery (p = 0.316, and p = 0.895, respectively). Patients with painful refractory frozen shoulder benefited from pan-capsular and THL release. A radiographically balanced shoulder joint was maintained even after such extensive release.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

Shoulder Surgery as an Effective Treatment for Shoulder-Related Sleep Disturbance: A Systematic Review

PURPOSE

The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery.

METHODS

A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance after shoulder surgery was reviewed by 2 independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented.

RESULTS

Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). In total, 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty (TSA), 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from before to after surgery. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, P < .05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, P > .05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, P < .05). All 4 RCR studies and 1 TSA study using PSQI found significant improvements in mean PSQI scores within 6 to 24 months (P < .05).

CONCLUSIONS

Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should use sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Effectiveness of arthroscopic management of idiopathic shoulder stiffness: A meta-analysis

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.

Allogenic Pure Platelet-Rich Plasma Therapy for Adhesive Capsulitis: A Bed-to-Bench Study With Propensity Score Matching Using a Corticosteroid Control Group

BACKGROUND

While platelet-rich plasma (PRP) has been widely studied for musculoskeletal disorders, few studies to date have reported its use for adhesive capsulitis (AC). Fully characterized and standardized allogenic PRP may provide clues to solve the underlying mechanism of PRP with respect to synovial inflammation and thus may clarify its clinical indications.

PURPOSE

To clinically evaluate the safety and efficacy of a fully characterized pure PRP injection in patients with AC and to assess the effects of pure PRP on synoviocytes with or without inflammation in vitro.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

For the clinical analysis, a total of 15 patients with AC received an ultrasonography-guided intra-articular PRP injection and were observed for 6 months. Pain, range of motion (ROM), muscle strength, shoulder function, and overall satisfaction in the patients were evaluated using questionnaires at 1 week as well as at 1, 3, and 6 months after the PRP injection and results were compared with the results of a propensity score-matched control group that received a corticosteroid injection (40 mg triamcinolone acetonide). For the in vitro analysis, synoviocytes were cultured with or without interleukin-1β (IL-1β) and PRP. The gene expression of proinflammatory and anti-inflammatory cytokines as well as matrix enzymes and their inhibitors was evaluated.

RESULTS

At 6-month follow-up, pure PRP significantly decreased pain and improved ROM, muscle strength, and shoulder function to levels comparable with those after a corticosteroid injection. All pain values, strength measurements, and functional scores significantly improved up to 6 months in the PRP group, but these measures improved up to 3 months and then were decreased at 6 months in the corticosteroid group. ROM was significantly improved in the 2 groups at 6 months compared with baseline. Allogenic PRP did not cause adverse events. For the in vitro findings, PRP induced inflammation but significantly improved the IL 1β-induced synovial inflammatory condition by decreasing proinflammatory cytokines such as IL-1β, tumor necrosis factor-α, IL-6, cyclooxygenase-2, and microsomal prostaglandin E synthase-1 and decreased matrix enzymes (matrix metalloproteinase-1, -3, and -13 as well as a disintegrin and metalloproteinase with thrombospondin motifs-4 and -5) and further increasing anti-inflammatory cytokines such as vasoactive intestinal peptide.

CONCLUSION

This study showed that PRP decreased pain and improved shoulder ROM and function to an extent comparable with that of a corticosteroid in patients with AC. Allogenic pure PRP acted in a pleiotropic manner and decreased proinflammatory cytokines only in the inflammatory condition.

CLINICAL RELEVANCE

Allogenic PRP could be a treatment option for the inflammatory stage of AC.

What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey

OBJECTIVE

Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome.

METHODS

A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks.

RESULTS

260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics.

CONCLUSION

Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.

Clinical Guidelines in the Management of Frozen Shoulder: An Update!

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.

A Comprehensive Update of Adhesive Capsulitis and Minimally Invasive Treatment Options

Background

Adhesive capsulitis of the shoulder (AC) is characterized by fibrosis and contracture of the glenohumeral joint capsule, resulting in progressive stiffness, pain, and restriction of motion of the shoulder. The prevalence of AC is estimated to be 2-5% of the general population. Patients with AC typically have an insidious onset of pain and can progress to severe limitation of the shoulder leading to significant disability and decreased quality of life.

Objectives

The objective of this manuscript is to provide a comprehensive review of AC with a focus on clinical presentation, natural history, pathophysiology, and various treatment modalities.

Study Design

A review article.

Setting

A review of literature.

Methods

A search was made on the Pubmed database using the keywords of adhesive capsulitis, frozen shoulder, shoulder capsulitis, arthrofibrosis, shoulder pain, shoulder stiffness.

Results

Our search identified numerous studies in order to provide a comprehensive review of the current understanding of the treatment and management of AC.

Limitations

There remains limited evidence in literature about the understanding of AC and optimal treatment.

Conclusion

AC is an important cause of chronic pain and disability. There is currently no consensus on treatment. Initial treatment modalities revolve around conservative measures as well as aggressive physical therapy. Further treatment options include intraarticular injections, hydro-dilation, nerve blocks, and for more refractory cases, surgical interventions such as arthroscopic capsulotomy.

Transcriptomic analysis of adhesive capsulitis of the shoulder

Adhesive capsulitis (AC) is a disabling condition of the shoulder joint affecting 2 to 5% of the general population. Our understanding of the molecular mechanisms is limited. The present study aimed to determine potential biomarkers of AC through transcriptomic analysis. This multi-centre study investigated patients undergoing arthroscopic capsulotomy surgery for resistant AC compared to those undergoing arthroscopic stabilization surgery for glenohumeral instability (control). Tissue samples were harvested from the anterior capsule during surgery. Total RNA was extracted and RNA-sequencing-based transcriptomics were performed. A number of genes deemed differentially expressed in RNA-sequencing analysis were validated using real-time reverse transcription polymerase chain reaction (RT-PCR). Baseline characteristics of the AC group (n = 22) were; mean age 52.7 years (SD: 10.2), 73% female, and Oxford Shoulder Score 19.6 (SD: 8.0), compared with the control group (n = 26), average age 23.9 years (SD: 5.2), 15% female, and Oxford Shoulder Score 39.0 (SD: 7.4). Transcriptomic analysis with false discovery rate correction and log₂ fold change cut-off of ±1.5 revealed 545 differentially expressed genes in AC relative to control. Bioinformatic analyses were carried out to identify biological processes and pathways enriched in this dataset. Real-time RT-PCR using two different normalization processes confirmed increased expression of matrix metallopeptidase 13 (MMP13) and platelet-derived growth factor subunit B (PDGFB), in patients with AC, while tumor necrosis factor α (TNFA) expression was reduced. These findings provide a comprehensive assessment of transcriptional changes associated with AC that give insights into the aetiology of the disease and provides a resource for molecular targets to better diagnose and treat this condition.

Arthroscopic release for frozen shoulder: Does the timing of intervention and diabetes affect outcome?

Purpose

To evaluate the effect of timing of arthroscopic release and manipulation under anesthesia for frozen shoulder in patients with diabetes and non-diabetes.

Methods

One hundred and twenty-seven patients with frozen shoulder were included in the study. Each patient was assigned to: 1) one of four groups according to the duration from symptom onset to surgery (group A: ≤3 months; group B: 3–6 months; group C: 6–12 months; group D: >12 months), 2) diabetic or nondiabetic group. The outcomes were measured by shoulder range of motion (ROM), Disabilities of the Arm, Shoulder, and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) Shoulder score, the period of pain relief, overall duration of disease, and satisfaction.

Results

All the patients got great improvement in shoulder ROM (P < .0001) after arthroscopic surgery, but there was no statistical difference in the pre-operative and post-operative shoulder ROM between the four groups and between diabetic and nondiabetic groups. The overall duration of disease was mean 55.4~68.7 weeks, which demonstrated much shorter disease course compared with nature course.

Improvement were also seen in shoulder ROM at one week to one month, and the period of total pain relief was at a mean time of 3.7 to 3.8 weeks. There were higher ASES Shoulder score in group B than in group C (P = 0.02) and higher DASH score in diabetic group in short term follow-up.

Conclusions

Arthroscopic release provides effective and rapid improvements to shoulder motion and function, unrelated to the timing of surgery, in patients with frozen shoulder. The diabetic patients do not have functional outcomes as good as the nondiabetic patient at short-term follow-up.

Outcomes of arthroscopic capsular release for the diabetic frozen shoulder in Asian patients

INTRODUCTION

Diabetic patients have been known to have a higher incidence of frozen shoulder. Arthroscopic capsular release has been described for diabetic frozen shoulder refractory to non-surgical treatment. We describe our single-surgeon experience of this procedure done in Asian patients presenting with diabetic frozen shoulder.

RESULTS

Data were prospectively collected from 25 patients from 2007 to 2008, who underwent arthroscopic capsular release for frozen shoulder with diabetes mellitus. This included the University of California-Los Angeles (UCLA) Shoulder Score by an independent observer. Mean follow-up duration was 44.3 ± 22 months with the age of 57.3 ± 10.9 years at the time of surgery. Mean duration of symptoms prior to surgery was 8.9 ± 7.5 months. Ten right shoulders and 15 left shoulders were operated on. Arthroscopic capsular release was performed in the beach chair position with the aid of a 90° electrocautery hook, from the rotator interval to posterior capsule. Significant improvement was observed in the UCLA scores post-operatively (preoperative total score 15.8 ± 3.6 vs. post-operative 33.3 ± 2.5, p < 0.00), including all domains of pain (3.9 ± 1.8 vs. 9.4 ± 0.9, p < 0.00), function (4.8 ± 1.7 vs. 9.4 ± 1.4, p < 0.00), active forward flexion (2.6 ± 0.7 vs. 4.6 ± 0.6, p < 0.00) and satisfaction (0.0 ± 0.0 vs. 5.0 ± 0.0, p < 0.00). No significant correlation between duration of symptoms and UCLA scores. Significant improvement was observed in forward flexion (preoperative 100.4 ± 18.8° vs. post-operative 157.6 ± 15.9°, p < 0.00) and external rotation (preoperative 14.4 ± 6.34° vs. post-operative 63.8 ± 8.3°, p < 0.00). Although the duration of symptoms correlated significantly with preoperative forward flexion ( r = 0.443 and p < 0.027), there was no significant correlation with post-operative forward flexion ( r = 0.023 and p < 0.91). No axillary nerve palsy observed.

CONCLUSION

The diabetic frozen shoulder can be treated favourably with arthroscopic capsular release and the duration of symptoms prior to surgery does not affect the outcomes.

The impact of pre-existing shoulder diseases and traumatic injuries of the shoulder on adhesive capsulitis in adult population: A population-based nested case-control study

Adhesive capsulitis (AC) is a common chronic disorder for adult patients; however, whether a history of pre-existing shoulder diseases may affect the development of AC is still not fully understood. We aimed to investigate the incidence and prevalence of AC and to assess the association of pre-existing shoulder diseases and traumatic injuries of the shoulder with the development of AC in adults.This retrospective population-based cohort and nested case-control study used data from the National Health Institute Research Database of Taiwan. A total of 24,414 patients aged 20 years or older and with a diagnosis of AC were identified between 2000 and 2013. We calculated the incidence of AC for each year during the study period. In addition, these AC patients were matched with controls (n = 97,656) in a ratio of 1:4 based on age, gender, and index date. Univariate and multivariate logistic regression models were performed to identify variables associated with AC.Females and patients aged 50 to 69 years had higher age-gender standardized incidence and prevalence of AC than their counterparts. Multivariate analyses showed that after adjusting for relevant covariates, pre-existing shoulder diseases of calcific tendinitis (odds ratio [OR] = 8.74, 95% confidence interval [CI] = 5.66-13.5), biceps tendinitis (OR = 7.93, 95% CI = 5.33-11.79), rotator cuff syndrome (OR = 6, 95% CI = 5.26-6.85), osteoarthritis (OR = 4.27, 95% CI = 3.44-5.3), and impingement syndrome (OR = 3.13, 95% CI = 2.64-3.71), as well as fracture (OR = 4.51, 95% CI = 3.82-5.34) and dislocation (OR = 3.57, 95% CI = 2.35-5.45) of the shoulder were significantly associated with AC risk.Higher odds of AC were observed among patients with pre-existing shoulder conditions. This study highlights the need to consider differences in AC risk among patients with various types of shoulder diseases and traumatic injuries of the shoulder.

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review

INTRODUCTION

Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.

HYPOTHESIS

Different aetiological groups yield variable outcomes following arthroscopic capsular release.

MATERIALS AND METHODS

A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.

RESULTS

Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.

LEVEL OF EVIDENCE

IV, systematic review.

Do diabetic patients have different outcomes after arthroscopic capsular release for frozen shoulder?

INTRODUCTION

While the exact mechanism of primary adhesive capsulitis is unknown, we know that it has strong associations with diabetes mellitus (DM). Although self-limiting, a significant percentage of patients still have persistent pain and stiffness beyond 3 years. Arthroscopic capsular release (ACR) has been described as a successful intervention for recalcitrant adhesive capsulitis that provides early and long-term recovery. The aim of this study is to investigate the relationship between DM and ACR.

METHODS

We reviewed prospectively collected data of 56 consecutive patients with idiopathic frozen shoulder who underwent ACR (360° arthroscopic capsulotomy) under a single surgeon. Range of motion, pain score and shoulder function (Constant Shoulder Score, Oxford Shoulder Score, University of California Los Angeles Shoulder Score) were documented preoperatively and one year postoperatively. Patients were dichotomized into diabetic (n = 32) and non-diabetic patients (n = 24) and compared using a mixed ANOVA design to investigate for differences in outcomes.

RESULTS

Both group of patients had significant improvement in range of motion, reduced pain scores and improved shoulder scores one year postoperatively (p = 0.000). Diabetic patients had poorer internal rotation (p = 0.000), forward flexion (p = 0.035) and poorer postoperative Constant Shoulder score (p < 0.05). Otherwise both groups improved equally in all other aspects.

CONCLUSION

ACR offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function. However diabetic patients had poorer improvement in internal rotation and forward flexion postoperatively. Preoperative counselling and postoperative rehabilitation can be better tailored to treat diabetic patients with idiopathic adhesive capsulitis.

Management of Concomitant Preoperative Rotator Cuff Pathology and Adhesive Capsulitis: A Systematic Review of Indications, Treatment Approaches, and Outcomes

PURPOSE

Concomitant preoperative adhesive capsulitis (AC) and rotator cuff (RC) pathology pose therapeutic challenges in light of contrasting interventional and rehabilitative goals. The purposes of this systematic review were to assess the literature regarding the management and rehabilitation of patients with concomitant RC tears and preoperative AC and to compare overall clinical outcomes between strategies for this common scenario.

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.

RESULTS

Of 952 studies, 17 involving 662 shoulders, with a mean age of 59.6 ± 3.5 years, 57.9% female patients, and a mean follow-up period of 18.6 months, were included. Capsular release (CR) (86.1%) and manipulation under anesthesia (MUA) (33.1%) were the most common co-interventions with RC repair. Across studies, mean preoperative American Shoulder and Elbow Surgeons scores ranged from 29.0 to 61.3, visual analog scale scores (pain) ranged from 5.3 to 8.0, and Constant scores ranged from 18.0 to 48.0. Mean postoperative American Shoulder and Elbow Surgeons scores ranged from 76.9 to 92.0, visual analog scale scores (pain) ranged from 0.3 to 2.5, and Constant scores ranged from 72.6 to 93.2. Postoperative rehabilitation comprised abduction braces and passive range of motion immediately postoperatively for mean durations of 5.0 weeks and 5.3 weeks, respectively, followed by active range of motion at a mean of 5.3 weeks and strengthening at 10.9 weeks. Postoperative complications included stiffness, RC retear, instability, glenoid fracture, and superficial infection.

CONCLUSIONS

The results of this systematic review support treatment of patients with degenerative RC tears and concomitant AC with a combination of RC repair and MUA, CR, or both MUA and CR. Regardless of the treatment modality, accelerated postoperative rehabilitative protocols are beneficial in preventing postoperative persistence of AC and can be safely used in this scenario without a substantial increase in complication rates compared with patients undergoing RC repair alone with conservative rehabilitation.

LEVEL OF EVIDENCE

Level V, systematic review of Level II, III, IV, and V studies.

Procedure-Specific Pain Intensity Four Days After Day Surgery and the Relationship with Preoperative Pain: A Prospective Cohort Study

Background

Identification of painful procedures is essential for the development of procedure-specific pain-treatment schedules. The aim of this study was firstly, to analyze the prevalence of acute postsurgical pain (APSP) after various types of day surgery on the fourth postoperative day, and secondly, to assess the predictive value of preoperative pain for the development of APSP after different types of surgical procedures.

Methods

From November 2008 to April 2010, patients scheduled for elective day surgery were enrolled in this prospective cohort study. Data were collected one week preoperatively and four days postoperatively. The 11-point Numeric Rating Scale (NRS) was used for pain measurement. Moderate pain was defined as an NRS 4 to 5, and severe pain as an NRS > 5. The predictive value of preoperative pain for development of APSP was analyzed using a univariate logistic regression, stratified for the surgical procedure.

Results

From a total of 1123 included patients, 182 patients experienced moderate pain (16.3%) and 136 patients experienced severe pain (12.1%) on the fourth postoperative day. A large procedure-specific variability in APSP was observed, with shoulder, anal and dental surgery associated with the highest pain levels. Overall, preoperative pain significantly predicted postoperative pain on the fourth day (OR 4.45). This predictive value showed a procedure-specific variation and was not noted after various well-defined procedures.

Conclusions

The prevalence of moderate to severe APSP was high four days after day surgery and showed a significant procedure-specific variation. Furthermore, there was a strong relationship between preoperative and postoperative pain, likewise characterized by a significant procedure-specific variation.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature

INTRODUCTION

Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness.

SOURCE OF DATA

A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed.

AREAS OF AGREEMENT

Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release.

AREAS OF CONTROVERSY

No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined.

GROWING POINTS

The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder

BACKGROUND

Arthroscopic capsular release (ACR) and hydrodilatation (HD) have been developed for the management of frozen shoulder refractory to conservative treatment. To date no randomized trial has directly compared the efficacy of both interventions. The aim of this trial was to determine whether the Oxford Shoulder Score (OSS) differs between patients with frozen shoulder randomized to treatment with ACR or HD.

METHODS

Patients presenting with severe idiopathic frozen shoulder deemed suitable for surgical intervention by a consultant shoulder surgeon were randomized to ACR or HD. The primary outcome measure was OSS at 6 months, with secondary outcomes measures of the EuroQol-5D visual analog scale, external rotation, complications, and crossover rate also recorded.

RESULTS

Between June 2013 and December 2016, 50 patients were randomized to HD or ACR. The average age of the HD and ACR cohorts was 55.2 and 52.6 years, respectively (P = .36). At 6 months after the intervention, 20 patients were available for follow-up in the HD cohort and 19 in the ACR cohort. Both groups demonstrated significant improvements in OSS from baseline, but the OSS was significantly higher in the ACR cohort than the HD cohort (43.8 vs. 38.5, P = .023). The OSS was noted to improve rapidly after the intervention, with 75% of improvement in OSS noted at 6 weeks after surgery in both groups.

CONCLUSIONS

Patients randomized to ACR reported a significantly higher OSS at 6 months than those randomized to HD. Both groups, however, showed a significant improvement.

Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population

BACKGROUND

Shoulder arthroscopy is well established as a highly effective and safe procedure for the treatment for several shoulder disorders and is associated with an exceedingly low risk of infectious complications. Few data exist regarding risk factors for infection after shoulder arthroscopy, as previous studies were not adequately powered to evaluate for infection.

PURPOSE

To determine patient-related risk factors for infection after shoulder arthroscopy by using a large insurance database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005 to 2014 for patients undergoing shoulder arthroscopy. Patients undergoing shoulder arthroscopy for a diagnosis of infection or with a history of prior infection were excluded. Postoperative infection within 90 days postoperatively was then assessed with International Classification of Diseases, Ninth Revision codes for a diagnosis of postoperative infection or septic shoulder arthritis or a procedure for these indications. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection, as well as numerous patient-related risk factors for postoperative infection. Adjusted odds ratios (ORs) and 95% CIs were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

A total of 530,754 patients met all inclusion and exclusion criteria. There were 1409 infections within 90 days postoperatively (0.26%). Revision shoulder arthroscopy was the most significant risk factor for infection (OR, 3.25; 95% CI, 2.7-4.0; P < .0001). Intraoperative steroid injection was also an independent risk factor for postoperative infection (OR, 1.46; 95% CI, 1.2-1.9; P = .002). There were also numerous independent patient-related risk factors for infection, the most significant of which were chronic anemia (OR, 1.58; 95% CI, 1.4-1.8; P < .0001), malnutrition (OR, 1.42; 95% CI, 1.2-1.7; P = .001), male sex (OR, 2.71; 95% CI, 2.4-3.1; P < .0001), morbid obesity (OR, 1.41; 95% CI, 1.2-1.6; P < .0001), and depression (OR, 1.36; 95% CI, 1.2-1.5; P < .0001).

CONCLUSION

Intraoperative steroid injection was a significant independent risk factor for postoperative infection after shoulder arthroscopy. There were also numerous significant patient-related risk factors for postoperative infection, including revision surgery, obesity, male sex, chronic anemia, malnutrition, depression, and alcohol use, among others.

Frozen shoulder - A prospective randomized clinical trial

AIM

To compare the results of arthroscopic capsular release with intra-articular steroid injections in patients of frozen shoulder.

METHODS

Fifty-six patients with frozen shoulder were randomised to one of two treatment groups: Group 1, complete 360 degree arthroscopic capsular release and group 2, intra-articular corticosteroid injection (40 mg methyl prednisolone acetate). Both groups were put on active and passive range of motion exercises following the intervention. The outcome parameters were visual analogue scale (VAS) score for pain, range of motion and Constant score which were measured at baseline, 4, 8, 12, 16 and 20 wk after intervention.

RESULTS

All the parameters improved in both the groups. The mean VAS score improved significantly more in the group 1 as compared to group 2 at 8 wk. This greater improvement was maintained at 20 wk with P value of 0.007 at 8 wk, 0.006 at 12 wk, 0.006 at 16 wk and 0.019 at 20 wk. The Constant score showed a more significant improvement in group 1 compared to group 2 at 4 wk, which was again maintained at 20 wk with P value of 0.01 at 4, 8, 12 and 16 wk. The gain in abduction movement was statistically significantly more in arthroscopy group with P value of 0.001 at 4, 8, 12, 16 wk and 0.005 at 20 wk. The gain in external rotation was statistically significantly more in arthroscopy group with P value of 0.007 at 4 wk, 0.001 at 8, 12, and 16 wk and 0.003 at 20 wk. There was no statistically significant difference in extension and internal rotation between the two groups at any time.

CONCLUSION

Arthroscopic capsular release provides subjective and objective improvement earlier than intra-articular steroid injection.

Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments

Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. It is a debilitating condition that can occur spontaneously (primary or idiopathic adhesive capsulitis) or following shoulder surgery or trauma (secondary adhesive capsulitis). Here, we review the pathophysiology of adhesive shoulder capsulitis, highlighting its clinical presentation, natural history, risk factors, pathoanatomy and pathogenesis. Both current non-operative and operative treatments for adhesive capsulitis are described, and evidence-based studies are presented in support for or against each corresponding treatment. Finally, the review also provides an update on the gene expression profile of adhesive capsulitis and how this new understanding can help facilitate development of novel pharmacological therapies.

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background:

Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it.

Methods:

A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided.

Results:

Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option.

Conclusion:

Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Serial Comparison of Clinical Outcomes After Arthroscopic Capsular Release for Refractory Frozen Shoulder With and Without Diabetes

PURPOSE

To compare serial clinical outcomes after arthroscopic treatment of refractory frozen shoulder with and without diabetes.

METHODS

Seventeen patients with diabetic frozen shoulder (diabetes group) and 20 patients with idiopathic frozen shoulder (idiopathic group) were included. The mean follow-up period was 48.4 ± 15.8 months. Visual analog scale pain score; University of California, Los Angeles score; American Shoulder and Elbow Surgeons score; and range of motion were evaluated preoperatively; at 3, 6, and 12 months after surgery; and at the final follow-up examination.

RESULTS

Both groups showed significant improvement in all clinical scores and range of motion during the serial follow-up periods (P < .001). There were no significant differences between the 2 groups in any of the assessed clinical scores, except the mean American Shoulder and Elbow Surgeons score in the diabetes group was significantly lower than that in the idiopathic group at 12 months after surgery (77.7 v 88.8, P = .025). In the diabetes group, mean forward flexion was significantly lower than that in the idiopathic group at 3 months (140.0° v 151.5°, P = .011) and 6 months (152.2° v 161.8°, P = .045) after surgery. Mean external rotation was significantly lower than that in the idiopathic group at 6 months after surgery (43.3° v 55.0°, P = .021). Mean internal rotation was significantly lower than that in the idiopathic group at 6 months (13.7 v 11.7, P = .006) and 12 months (12.2 v 9.9, P = .041) after surgery. There were no significant differences between the 2 groups in any assessed outcomes at the final follow-up examination.

CONCLUSIONS

These results provide supportive evidence suggesting that the diabetes group had slower postoperative functional recovery until 12 months postoperatively, although arthroscopic capsular release for refractory frozen shoulder with and without diabetes yielded satisfactory clinical outcomes at the final follow-up examination.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care

BACKGROUND

Optimal management for adhesive shoulder capsulitis (frozen shoulder) is currently unclear. We intended to explore whether treatment by intra-articular injections with corticosteroid and distension is more effective than treating with corticosteroids alone or treatment-as-usual in a primary care setting in Norway.

METHODS

In this prospective randomised intention to treat parallel study, 106 patients were block randomised to three groups; 36 (analysed 35) receiving steroid injection and Lidocaine (IS), 34 receiving steroid and additional saline as distension (ISD) and 36 had treatment-as-usual (TAU). Intervention groups received four injections within 8 weeks, assessed on 1st visit, at the 4th and 8th week. Outcomes were Shoulder Pain and Disability Index (SPADI), Numerical pain rating scale (NPRS) and passive range of motion (PROM). Postal assessment was repeated after 1 year for SPADI. Patients in the IS and ISD groups were "blinded" for intervention received and the assessor was "blinded" to group allocation.

RESULTS

At baseline there were no differences between groups in outcome measures. There were no statistical significant differences between the intervention groups in SPADI, NPRS and PROM at baseline, at short-term (4-and 8 weeks) or long-term (12 months). There were statistically significant differences (p < 0.01) in change scores at short-term for SPADI when comparing the IS and TAU groups (-20.8; CI-28.9 to -12.7), and the ISD and TAU groups (-21.7; CI-29.4 to -14.0), respectively for NPRS (-2.0; CI-2.8 to -1.1 and -2.2; CI-3.0 to -1.4), and for PROM, but not at long-term for SPADI (p > 0.05). Effect size (ES) at 8 weeks was large between both injection groups and TAU (ES 1.2). At 12 months ES was reduced to 0.3 and 0.4 respectively. Transitory side effects as flushing and after-pain were reported by 14 % in intervention groups.

CONCLUSION

This intention to treat RCT in primary care indicates that four injections with corticosteroid with or without distension, given with increasing intervals during 8 weeks, were better than treatment-as-usual in treatment of adhesive shoulder capsulitis. However, in the long run no difference was found between any of the groups, indicating that natural healing takes place independent of treatment or not.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov/ identifier: NCT01570985.

Rates of surgery for frozen shoulder: an experience in England

AIM

the aim of this study was to identify the incidence of surgical treatment for frozen shoulder in a western population.

METHODS

patients included in this study all resided within a well-defined area in the North West of England, all had surgery for frozen shoulder over a 3-year period and were identified from theatre logbooks of two local hospitals. Cases having surgery for shoulder stiffness other than frozen shoulder were excluded. Local and national population size estimates were based on data obtained from the UK Office for National Statistics.

RESULTS

117 patients underwent surgery for frozen shoulder during the period examined; of these 101 had arthroscopic arthrolysis and 16 had manipulation under anaesthesia. The overall incidence of frozen shoulder surgery was calculated at 2.67 procedures per 10,000 general population per year, and at 7.55 for those aged 40-60.

CONCLUSION

surgical intervention for frozen shoulder is common, estimated at over 14,180 cases per year in England. Given the variation in costs associated with arthroscopic arthrolysis and manipulation under anaesthesia, comparative studies of the cost effectiveness of the two procedures would be of great value.

LEVEL OF EVIDENCE

2C (outcome research).

Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder

BACKGROUND

In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates.

METHODS

This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention.

RESULTS

Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention.

CONCLUSIONS

A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.

Frozen shoulder after simple arthroscopic shoulder procedures

Frozen shoulder is a recognised complication following simple arthroscopic shoulder procedures, but its exact incidence has not been reported. Our aim was to analyse a single-surgeon series of patients undergoing arthroscopic subacromial decompression (ASD; group 1) or ASD in combination with arthroscopic acromioclavicular joint (ACJ) excision (group 2), to establish the incidence of frozen shoulder post-operatively. Our secondary aim was to identify associated risk factors and to compare this cohort with a group of patients with primary frozen shoulder.

We undertook a retrospective analysis of 200 consecutive procedures performed between August 2011 and November 2013. Group 1 included 96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed post-operatively using the British Elbow and Shoulder Society criteria. A comparative group from the same institution involved 136 patients undergoing arthroscopic capsular release for primary idiopathic frozen shoulder.

The incidence of frozen shoulder was 5.21% in group 1 and 5.71% in group 2. Age between 46 and 60 years (p = 0.002) and a previous idiopathic contralateral frozen shoulder (p < 0.001) were statistically significant risk factors for the development of secondary frozen shoulder. Comparison of baseline characteristics against the comparator groups showed no statistically significant differences for age, gender, diabetes and previous contralateral frozen shoulder.

These results suggest that the risk of frozen shoulder following simple arthroscopic procedures is just over 5%, with no increased risk if the ACJ is also excised. Patients aged between 46 and 60 years and a previous history of frozen shoulder increase the relative risk of secondary frozen shoulder by 7.8 (95% confidence interval (CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively.

Cite this article: Bone Joint J 2015; 97-B:963–6.

Arthroscopic capsular release and manipulation under anaesthesia for frozen shoulders: A hot topic

A frozen shoulder is a common cause of shoulder pain and stiffness. The etiology and pathology of frozen shoulders is not fully understood yet. Frozen shoulder is characterized by a decrease in intra-articular volume and capsular compliance. This can lead to significant limitations in daily life. The majority of the patients can be treated conservatively, with functional recovery to be expected in two to three years. However, if conservative treatment fails, manipulation under anaesthesia and arthroscopic capsular release can both be considered as appropriate treatments. Manipulation is a traditionally well-established technique but in recent years it seems that arthroscopic capsular release has gained popularity. Manipulation is a relative time efficient and technically low-demanding procedure in which the glenohumeral joint is forced into different directions under general anaesthesia to release the capsular contracture, thereby increasing the range of motion of the joint. In arthroscopic capsular release the glenohumeral capsule can be released in a more controlled manner under direct vision. There are no prospective comparative trials available to display superiority of one procedure over the other. In addition, the optimal timing of both these interventions still has to be determined. An overview of the literature concerning this topic and a description of both procedures with its own advantages and disadvantages is provided.

Frozen shoulder: A systematic review of therapeutic options

Frozen shoulder is a common disease which causes significant morbidity. Despite over a hundred years of treating this condition the definition, diagnosis, pathology and most efficacious treatments are still largely unclear. This systematic review of current treatments for frozen shoulder reviews the evidence base behind physiotherapy, both oral and intra articular steroid, hydrodilatation, manipulation under anaesthesia and arthroscopic capsular release. Key areas in which future research could be directed are identified, in particular with regard to the increasing role of arthroscopic capsular release as a treatment.

Frozen shoulder - A stiff problem that requires a flexible approach

Frozen shoulder is a specific, painful and debilitating condition effecting patients mainly in middle age. While it has been recognised for over 100 years, it is still mis-diagnosed, with a natural history that is poorly understood and with limited evidence for the efficacy for various treatments. This review considers what is known about this common painful condition and the treatments available.