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© 1996 The Journal of Bone and Joint Surgery, Inc. Treatment of a Stiff Shoulder after Posterior Capsulorrhaphy. A Report of Three Cases* , PITTSBURGH , PHILADELPHIA, PENNSYLVANIAInvestigation performed at the University of Pittsburgh, Pittsburgh, and the University of Pennsylvania, Philadelphia
Loss of external rotation is a recognized complication after anterior capsular repair1,17; however, there is little information in the literature with regard to similar problems associated with posterior capsular shift reconstruction for posterior glenohumeral instability2,3,5,6,11-16. The purpose of this paper is to describe three patients who had a painful shoulder associated with loss of flexion, internal rotation, and horizontal adduction after a posterior capsular shift procedure for posterior instability of the shoulder. The pain and loss of motion were treated with a posterior soft-tissue-lengthening procedure.
CASE 1. A thirty-three-year-old male truck driver was first seen by us sixteen months after a posterior capsular shift procedure on the left, non-dominant shoulder. Before that procedure, he had had an unsuccessful open acromioplasty followed by a long program of physical therapy. According to the operative report, the capsule was lax. In addition, the capsular repair was performed with the shoulder in external rotation. During the sixteen months before he was first examined by us, the patient continued to have pain and stiffness in the involved shoulder; this led to three additional operative procedures, including a second open acromioplasty followed by a coracoidplasty and, later, by a biceps tenodesis. When he was first seen by us, the patient reported an inability to use the left arm above the level of the shoulder and he described ongoing discomfort in the shoulder. Physical examination revealed marked limitation of both active and passive motion of the shoulder, which was confirmed by an examination performed with the patient under general anesthesia. Passive flexion was 70 degrees, internal rotation in adduction was to the fifth lumbar level, internal rotation in abduction was 20 degrees, and horizontal (cross-chest) adduction was 10 degrees. After the examination under general anesthesia, the patient was placed in the lateral decubitus position. With use of the previous posterior incision, the deltoid was split in line with its fibers. The posterior aspect of the glenohumeral capsule and the infraspinatus tendon were observed to be thickened, scarred, and contracted. A coronal z-plasty lengthening of these structures was performed, starting laterally near the insertion of the infraspinatus and raising a five to ten-millimeter-thick flap of tissue extending in a medial direction (Figs. 1-A and 1-B). The deeper layer of tissue was then divided medially at the level of the posterior aspect of the glenoid rim. The shoulder was internally rotated, and the deeper and superficial layers of the capsule and the infraspinatus tendon were sewn together with number-0 non-absorbable braided sutures. Approximately three centimeters of lengthening was accomplished.
Postoperatively, passive range-of-motion exercises were begun. Four weeks after the operation, active range-of-motion exercises as well as exercises to strengthen the muscles of the shoulder girdle were started. Twenty-six months after the operation, the patient reported no pain with motion of the shoulder but he noted discomfort when lifting heavy objects. The range of motion of the shoulder had improved to 140 degrees of flexion, internal rotation in adduction to the seventh thoracic level, internal rotation in abduction to 60 degrees, and horizontal (cross-chest) adduction to 50 degrees. CASE 2. A twenty-nine-year-old female flight attendant was managed with a posterior capsular shift procedure six months after sustaining an injury of the shoulder in a motor-vehicle accident. According to the operative report, the shoulder subluxated posteriorly when it was examined with the patient under anesthesia. The posterior capsulorrhaphy was performed with the arm adducted and the shoulder held in external rotation. The postoperative course was complicated by a lack of return of mobility of the shoulder. Six months postoperatively, she had an unsuccessful manipulation of the shoulder. This was followed by additional operative procedures, including an acromioplasty, a coracoidplasty, and a biceps tenodesis. When she was first seen by us, the range of motion of the shoulder included 120 degrees of flexion, internal rotation in adduction to the fifth lumbar level, internal rotation in abduction to 10 degrees, and horizontal (cross-chest) adduction to 10 degrees. Operative exploration was performed and, as in Case 1, the posterior aspect of the capsule and the infraspinatus tendon were found to be thickened and contracted. A coronal z-plasty was done in a manner similar to that for Case 1, and three centimeters of lengthening was achieved. The postoperative management was also similar to that for Case 1. Twenty-eight months after the operation, there was 170 degrees of flexion, internal rotation in abduction to 50 degrees, and horizontal (cross-chest) adduction to 50 degrees. She had a major limitation only in active internal rotation; she was able to reach the twelfth thoracic level, which was ten spinous process levels caudad to the level that she could reach with the contralateral thumb. She reported no pain and had returned to her previous occupation. CASE 3. A nineteen-year-old female college student had symptomatic posterior subluxation of the right shoulder after a motor-vehicle accident. She subsequently had a posterior capsular shift procedure, at which time the humeral head was noted to dislocate posteriorly. The operative report described the posterior aspect of the capsule as redundant, and the posterior capsular shift was done with the arm in 45 degrees of abduction and 10 degrees of external rotation. The postoperative course was similar to that of the other two patients in that it was complicated by pain and loss of active and passive mobility. When the patient was first seen by us, the range of motion of the shoulder included 150 degrees of flexion, internal rotation in adduction to the fifth lumbar level, internal rotation in abduction to 0 degrees, and horizontal (cross-chest) adduction to 0 degrees. Six months after the posterior capsular shift procedure, operative exploration was performed. With the patient under anesthesia, the shoulder was noted to subluxate anteriorly but there was no posterior laxity. A coronal z-plasty of the posterior aspect of the capsule and the infraspinatus tendon was done in a manner similar to that for the other two patients, and two centimeters of lengthening was achieved. The postoperative course was complicated by repeated sensations of anterior subluxation of the shoulder despite a return of mobility, although there had been no actual episodes of anterior dislocation. Physical therapy failed to decrease the symptoms and, six months after the coronal z-plasty, an anterior capsular shift procedure was performed. Twenty-four months after the latter procedure, the patient noted discomfort only with exertion. The range of motion of the shoulder was 160 degrees of flexion, internal rotation in adduction to the eighth thoracic level, internal rotation in abduction to 30 degrees, and horizontal (cross-chest) adduction to 30 degrees.
Symptomatic loss of motion after a posterior capsular shift procedure is a rarely reported complication, as most authors have been concerned principally with recurrence of instability3,6,12-14,16. In fact, some reports of posterior capsulorrhaphy have not included the range of motion of the shoulder at the time of follow-up12-14,16. Fronek et al. reported on eleven patients who had had a so-called T-plasty posterior capsulorrhaphy, but they did not specifically document the range of motion at the latest follow-up examination. Hawkins et al.12, in a retrospective review of the results of fifty posterior shoulder repairs that had been performed with use of several different operative techniques, described two patients who had had a symptomatic external rotation contracture. In one of these patients, the contracture was attributed to immobilization in excessive external rotation postoperatively, and two attempts at a posterior release did not correct the problem. The other patient had decreased motion of the shoulder twelve months after the operation and did not have any additional treatment. Gerber et al.7 reported on seven shoulders that had pain and limitation of horizontal adduction and internal rotation after a posterior glenoid osteotomy combined with a capsulorrhaphy. We believe that it can be difficult to recognize loss of motion as a reason for pain after a posterior capsulorrhaphy. Two of our patients (Cases 1 and 2) had procedures presumably to treat impingement and biceps tendinitis after a posterior capsular repair. Neither had relief of pain after these procedures. Both patients also had a coracoidplasty to treat subcoracoid impingement. This diagnosis makes some sense, as subcoracoid impingement has been shown to occur after procedures for posterior stabilization of the shoulder4,7-9. The mechanism is believed to be a compensatory increase in anterior and superior translation of the humeral head on the glenoid when internal rotation or flexion is attempted after over-tightening of the posterior aspect of the capsule10 (Fig. 1-A). Nevertheless, as a coracoidplasty did not eliminate pain in either of these patients, subcoracoid impingement cannot be the explanation for the pain. Our third patient (Case 3) had symptoms of anterior subluxation after posterior capsular lengthening. It is possible that she had multidirectional instability that was not initially recognized. The posterior capsular shift procedure would have tightened the shoulder eccentrically, and after a posterior soft-tissue release she had anterior instability. Ultimately, the shoulder was stabilized with a repair of the anterior aspect of the capsule. Although it is difficult to come to any conclusions as to the etiology of the posterior contracture in these patients, we postulate that the position of the arm at the time of the soft-tissue repair may have contributed to the tightness of the repair. We believe that posterior capsular repair should probably be performed with the shoulder in neutral rotation. Our operative technique of posterior coronal z-plasty lengthening is similar to that described previously for lengthening of the subscapularis and the capsule for the treatment of loss of external rotation11,15. Because the posterior aspect of the capsule and the infraspinatus tendon were found to be indistinguishable from one another, they were divided as one unit in the coronal plane, with a superficial flap connected to the infraspinatus and a deep flap connected to the humeral neck. In all three patients, we were able to lengthen the posterior soft tissues at least two centimeters.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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