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.

Short-term and long-term outcome of manipulation under anesthesia in primary frozen shoulder

Background: Painful restriction of active and passive shoulder range of motion which cannot be attributed to any internal shoulder pathology is termed as primary frozen shoulder. It has three stages – freezing stage, frozen stage, and thawing stage. Nonsteroidal anti-inflammatory drugs, physiotherapy, intra-articular corticosteroid injection, hydrodilatation, arthroscopic capsular release, and manipulation under anesthesia (MUA) are different modalities of treatment. Aims and Objectives: The main objective of our study was to assess the short-term and long-term outcome of MUA in frozen shoulder once it did not respond to 3 months course of physiotherapy. Materials and Methods: Fifty patients of primary frozen shoulder fulfilling inclusion criteria were manipulated under general anesthesia, and intra-articular Depo-Medrol and bupivacaine were administered. Functional status of the shoulder was assessed using the adjusted Constant-Murley (CM) score preoperatively and in subsequent follow-ups. Results: There was a significant improvement of mean adjusted CM score in short- and long-term follow-ups compared to pre-manipulation value. A significant negative correlation was found between the age of the patient and the final outcome. Conclusion: MUA is an effective modality of treatment in primary frozen shoulder with good short- and long-term outcomes.

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.

Effectiveness of interventions for the management of primary frozen shoulder

Aims This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. Methods MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. Results Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. Conclusion The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773–784.

Cost-effectiveness of surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder

Aims A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care. Methods A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods. Results ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses. Conclusion While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective. Cite this article: Bone Jt Open 2021;2(8):685–695.

Shoulder Disorders: The Challenging Issue Among Orthopedic Surgeons

Background: Choose a proper therapeutic approach for various shoulder joint involvements is still a significant challenge. Objectives: The study aimed to assess the knowledge and attitude of orthopedic surgeons in managing patients with shoulder problems. Methods: In a cross-sectional survey, a questionnaire consisted of 2 different parts was directly presented to orthopedic surgeons. Part 1 investigated the experience of shoulder surgeries, and part 2 evaluated their knowledge and attitude toward 4 patients with different scenarios. Results: The surgeons were divided into 2 groups: shoulder surgeons (n=17) and general orthopedic surgeons (n=192). The first scenario is about a 21-year-old male with first anterior shoulder dislocation. In this scenario, shoulder surgeons chose surgical intervention more than general surgeons (88.21% vs 33.54%, P<0.05). The second scenario presents a 55-year-old male with shoulder osteoarthritis and complete and repairable rupture of supraspinatus and rupture of the long head of the biceps tendon. Shoulder surgeons chose total shoulder arthroplasty (43.8%) and arthroscopic rotator cuff repair (37.5%). But, only 21.87% of general orthopedic surgeons choose these two items together. The third scenario is a 65-year-old male with supraspinatus and infraspinatus tendon rupture. Sixteen of 17 shoulder surgeons answered this case, and 100% chose surgical interventions (62.5% arthroscopic and 37.5% open repair). On the other hand, 180 general surgeons of 192 answered this case scenario, and only 41.11% chose surgical treatment. The fourth scenario presents a 52-year-old female with refractor adhesive capsulitis. Arthroscopic capsular release and manipulation was the most frequent answer among shoulder surgeons compared to general surgeons (64.71% vs 31.38%). Conclusion: It seems that an advanced course of shoulder surgeries is necessary to improve the knowledge of general orthopedic surgeons about shoulder diseases and treatment choices

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.