Arthroscopic capsular release for adhesive capsulitis secondary to diabetes provides better functional outcome than conservative management

Objectives: Comparison of outcome of subacromial bursal resection with capsular release for adhesive capsulitis of shoulder secondary to diabetes, with conservative management. Materials and Methods: This study was conducted on 68 patients of adhesive capsulitis of shoulder secondary to diabetes. The patients were divided into two groups: Arthroscopic capsular release group (group I n 32) and Conservative management group (Group II n 36) after fulfilling inclusion/ exclusion criteria. Follow-up was done at 2, 6, 24 weeks, 6 months, 1 year, and 2 years. In addition to pre-operative measurement, at each follow-up pain was assessed by visual analog scale (VAS), range of motion (ROM) was assessed by goniometer and functional outcome was assessed by Constant-Murley score. Values obtained were filled in Excel sheet and analyzed by independent t-test, Wilcoxon Rankosin test, and Analysis of Variance test on Statistical Package for the Social Sciences software. Results: Two patients in Group I and six in Group II were lost to follow-up. There was statistically significant improvement in VAS of both groups at each follow-up, but the noticeable difference was that the patients in arthroscopic release group were pain free by 6 weeks and the pain relief was sustained till final follow-up. In contrast, though there was pain relief in conservative group but they were not completely pain free till final follow-up. There was statistically significant improvement in Constant Murley score in both groups at each follow-up but arthroscopic release group achieved near normal score by 6 months and the improvement was maintained till last follow-up. The comparison of mean and median values of ROM, between the arthroscopic capsular release group and conservative group were statistically significant (P value of 0.001) for each movement. Conclusion: The improvement in ROM, decrease in pain, and functional outcome are better in diabetic patients with adhesive capsulitis undergoing Arthroscopic capsular release than conservative management.

Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes

This retrospective study compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy. The patients who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy (Group I, n = 30) or received only corticosteroids injection and physiotherapy (Group II, n = 29) were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later. The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome. Group I had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.

Comparison of Gene Expression of Inflammation- and Fibrosis-Related Factors Between the Anterior and Posterior Capsule in Patients With Rotator Cuff Tear and Shoulder Stiffness

Background: Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness, yet there are no basic studies that can explain the extent of the release. Purpose: This study aimed to compare the genetic expression of inflammation- and fibrosis-related factors between the anterior and posterior capsules in patients with shoulder stiffness and rotator cuff tear. Study Design: Descriptive laboratory study. Methods: Enrolled in this study were 35 patients who underwent arthroscopic capsular release for shoulder stiffness along with the rotator cuff repair. Anterior and posterior glenohumeral joint capsular tissues were obtained during the capsular release. For the control tissue, anterior capsule was obtained from 40 patients without stiffness who underwent arthroscopic rotator cuff repair. The gene expression of collagen types I and III, fibronectin, extracellular matrix, basic fibroblast growth factor, transforming growth factor–β, connective tissue growth factor, matrix metalloproteinase (MMP)-1, MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, TIMP-2, intercellular adhesion molecule 1, interleukin 1, and tumor necrotizing factor–α were analyzed using real-time reverse transcription polymerase chain reaction. Differences in gene expression between the anterior capsule, the posterior capsule, and the control tissue were compared with the Kruskal-Wallis test. Results: The expression levels of collagen types I and III were significantly higher in the anterior capsule with stiffness com (pared with both the posterior capsule with stiffness ( P = .010 for both) and the control ( P = .038 and .010, respectively). The levels of fibronectin, MMP-2, and MMP-9 in the anterior capsule were significantly higher than in both the posterior capsule ( P = .013, .003, and .006, respectively) and the control ( P = .014, .003, and .005, respectively). Conclusion: Genetic analysis of the shoulder capsule revealed that more fibrogenic processes occur in the anterior capsule compared with the posterior capsule in patients with shoulder stiffness. Clinical Relevance: Capsular release for shoulder stiffness should be more focused on the anterior capsule than on the posterior capsule.

L-Shaped Arthroscopic Posterior Capsular Release in Frozen Shoulder

Background: The inadequate arthroscopic release of the tight posterior capsule in frozen shoulder may result in limited postoperative shoulder internal rotation. Indication: The purpose of this article is to describe an L-shaped arthroscopic posterior capsular release to overcome the limited internal rotation that may be encountered following the standard longitudinal technique. Operative intervention is indicated in patients with refractory shoulder stiffness with limitation of internal rotation of grade 0, +2, +4 (according to the Constant-Murley Score), after failure of conservative measures for 3 to 6 months. The technique is contraindicated if less than 3 months of physical therapy, shoulder stiffness due to osseous deformity, infection, or cuff tear arthropathy. Technique: After performing a standard anterior capsular release, the scope is shifted to the anterior portal to perform posterior capsular release by introducing the radiofrequency ablation device through the posterior portal. Posterior release begins from the glenoid level down to the 6 o’clock position until the back fibers of the infraspinatus muscle appear. Then the hook-tip part of the radiofrequency ablation device is used to perform a transverse release in the posterior capsule, starting from the beginning of the longitudinal limb. The transverse limb is performed in a stepwise manner going step-by-step laterally but ending before reaching the rotator cuff to avoid any damage of the cuff. After that, the shoulder was manipulated according to Codman technique. Results: A comparative study was performed on 43 patients with primary frozen shoulder to compare the standard longitudinal (22 patients) and L-shaped (21 patients) posterior capsular release. At the final follow-up, there was a statistically significant improvement in the internal rotation range of motion in the L-shaped group ( P < .001). There was no loss of function over time. Moreover, there were no infections, instability, or axillary nerve injury in either group. Discussion/Conclusion: Restriction of internal rotation in frozen shoulder has been attributed to posterior capsular tightness. The L-shaped arthroscopic posterior capsular release in patients with primary frozen shoulder significantly improves the postoperative internal rotation range of motion.

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.