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The Journal of Bone and Joint Surgery 79:1151-8 (1997)
© 1997 The Journal of Bone and Joint Surgery, Inc.

Arthroscopic Release of Postoperative Capsular Contracture of the Shoulder*

JON J. P. WARNER, M.D.{dagger}, ANSWORTH A. ALLEN, M.D.{ddagger}, PAUL H. MARKS, M.D., F.R.C.S.(C)§ and PATRICK WONG, M.D.¶, PITTSBURGH, PENNSYLVANIA

Investigation performed at the Shoulder Service, Center for Sports Medicine, University of Pittsburgh, Pittsburgh


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
A loss of motion after an operation on the shoulder often cannot be treated successfully with physical therapy or closed manipulation. Although open release techniques generally improve motion, they involve extensive dissection. We developed a technique of arthroscopic capsular release and applied it in eighteen patients who had postoperative stiffness of the shoulder. The patients were selected for the arthroscopic release technique if a conservative program of physical therapy and an attempted closed manipulation had failed to restore motion and if they had no known extra-articular contractures. Five of the thirteen patients who had had a global loss of shoulder motion had motion restored with the anterior capsular release, and six needed an additional release of the posterior aspect of the capsule—that is, a combined (anterior and posterior) capsular release. The arthroscopic procedure could not be completed in the remaining two patients because of an extra-articular scar involving the subscapularis, but those patients were managed successfully with an open release. As five patients had lost only internal rotation and flexion, they had only a posterior capsular release. For the eleven patients who had had either an anterior or a combined (anterior and posterior) capsular release, the mean improvement in the score of Constant and Murley was 43 points (range, 31 to 62 points) and all improvements in motion were significant (p < 0.01). Flexion improved a mean of 51 degrees (range, 10 to 65 degrees); external rotation in adduction and abduction, 31 degrees (range, 10 to 50 degrees) and 40 degrees (range, 5 to 80 degrees), respectively; and internal rotation in adduction and abduction, six spinous-process levels (range, three to eleven levels) and 41 degrees (range, 20 to 70 degrees), respectively. For the five patients who had an isolated posterior capsular release, the score of Constant and Murley improved a mean of 20 points (range, 5 to 35 points) and the improvements in motion also were significant (p < 0.05 and 0.005). Internal rotation in adduction and abduction improved a mean of four spinous-process levels (range, one to ten levels) and 42 degrees (range, 30 to 60 degrees), respectively. Eight patients had an arthroscopic acromioplasty for concomitant impingement disease. One patient who had had a combined (anterior and posterior) release and one who had had a posterior capsular release continued to have pain because of injury of the articular cartilage from a previous operation. We concluded that arthroscopic capsular release is a reliable method for restoring motion with minimum morbidity in carefully selected patients who have postoperative stiffness of the shoulder. When necessary, it can be converted to an open release.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Treatment of loss of shoulder motion after an operation on the shoulder has been described in few studies11,14,16,17,23,24. Most of those studies have addressed treatment of loss of external rotation after a repair for anterior instability, and the general consensus has been that non-operative treatment, even with supervised physical therapy, is ineffective. Closed manipulation also may be unsuccessful11,14,16,17,21,23,31,35. If functional motion is not regained with these non-operative approaches, an open operative release has been the only alternative, often necessitating a z-plasty lengthening of the subscapularis and the anterior aspect of the capsule11,14,15,17,23,24,29. Although the open approach generally has improved motion, it is associated with short-term operative morbidity from extensive dissection. Also, if a z-plasty repair has been performed, it must be protected with controlled motion postoperatively.

Recently, arthroscopically guided sectioning of the contracted shoulder capsule has been applied in the treatment of adhesive capsulitis9,27. The advantages of this procedure are reduced postoperative morbidity because of the limited dissection involved and the ability to perform a precise, controlled sectioning of the contracted capsule. During a three-year period, we assessed the effectiveness of arthroscopic capsular release for patients who had postoperative stiffness of the shoulder. The purpose of the present study was to describe our experience with this approach.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 

Selection of Patients
From September 1990 through December 1993, twenty-six patients were seen at the Shoulder Service of the University of Pittsburgh because of painful stiffness of the shoulder after an operation. None of these patients had loss of motion associated with advanced arthritis, and none had a full-thickness tear of the rotator cuff. Eight of the patients had had a previous operation (fixation of a fracture in two, a Bristow procedure in three, a Putti-Platt repair in two, and a Magnuson-Stack procedure in one) that had resulted in a demonstrable extra-articular contracture of the shoulder joint. An open release of extra-articular soft-tissue, which we believe is necessary in such patients, was performed, and these patients were eliminated from the present study.

The remaining eighteen patients were thought to have a contracture that did not involve the extracapsular structures. Therefore, they were considered to be good candidates for an arthroscopic capsular release. We believed that the loss of motion in these patients was limited mainly to capsular contracture as they all had had a procedure that was not likely to have shortened or entrapped the subscapularis tendon. There were thirteen men and five women. The right shoulder was involved in eleven patients and the left, in seven patients. The mean age was thirty-seven years (range, twenty to sixty-five years). The previous operations included an open Bankart procedure and a capsular shift (two patients); an arthroscopic Bankart procedure with a Suretac device (Acufex Microsurgical, Mansfield, Massachusetts) (one); an arthroscopic Bankart procedure combined with an arthroscopic repair of a lesion of the superior portion of the labrum, anterior and posterior (a so-called SLAP lesion), with a Suretac device (three); an arthroscopic repair of a lesion of the superior portion of the labrum, anterior and posterior, with a metal staple (one); a repair of the rotator cuff (four); an open acromioplasty (two); an arthroscopic acromioplasty and resection of the acromioclavicular joint (one); a posterior capsular shift (three); and a resection of a juxta-articular osteochondroma of the anterior aspect of the scapula (one). A notable feature common to all of these patients was prolonged immobilization of the shoulder after the previous operation. Although not all patients could recall the exact duration of the immobilization, each believed that the arm had been in a sling at the side for more than six weeks after the operation. All of the patients had failed to regain an adequate range of functional motion after a mean of eight months (range, four to twelve months) of supervised physical therapy, and the mean duration of the symptoms before they were seen by us was nine months (range, seven to twenty-two months). Although loss of shoulder motion was not an absolute criterion for this operation, all of the patients had painful and substantial limitation of motion in at least two planes.

Clinical Assessment
All of the patients were evaluated preoperatively and postoperatively by the senior one of us (J. J. P. W.), and all completed a written questionnaire about their symptoms. The preoperative, intraoperative, and postoperative motion of the shoulder was documented and recorded on videotape, and a videotape and photographs were made intraoperatively to record the operative findings and the procedure.

Both the active and the passive ranges of motion were measured with a goniometer. Flexion and external rotation in adduction (0 degrees of abduction) and abduction (90 degrees) as well as internal rotation in abduction (90 degrees) were assessed with the patient supine. Active internal rotation was measured, with the patient seated, as the most cephalad spinous process to which the patient could apply the thumb.

Thirteen patients had global loss of motion affecting external and internal rotation and flexion. Four of them had had a previous repair of the rotator cuff; one, an open anterior capsular shift; one, an arthroscopic Bankart repair with the Suretac device; three, a combined arthroscopic repair of a Bankart lesion and a lesion of the superior portion of the labrum, anterior and posterior, with the Suretac device; three, an acromioplasty; and one, an excision of an osteochondroma of the anterior aspect of the scapula. The remaining five patients had loss of internal rotation and flexion but no loss of external rotation. One of these patients had had an open Bankart repair and capsular shift; one, an arthroscopic repair of a lesion of the superior portion of the labrum, anterior and posterior, with a metal staple; and three, an open posterior capsular shift.

The function of all shoulders was graded according to the 100-point scoring system of Constant and Murley5,6. With this system, assessments of subjective symptoms and objective findings are combined and the results are normalized to gender and age-matched controls. The maximum score for pain is 15 points, with 15 representing no pain and 0, severe, constant pain. The ability to carry out activities of daily living is assigned a maximum of 20 points, and flexion, abduction, external rotation, and internal rotation each is assigned a maximum of 10 points (total maximum score for motion, 40 points). Pain-free motion of the shoulder is given a score of 25 points, and marked weakness, 0 points.

Eight patients had painful flexion, which suggested concomitant subacromial impingement. Three of them had had a repair of the rotator cuff; three, an acromioplasty; and two, a posterior capsular shift. This diagnosis was confirmed in these eight patients by a positive impingement sign, as described by Neer20 or by Hawkins and Hobeika12, and a positive impingement test20. The Neer impingement sign is considered positive when the examiner causes pain by elevating the humerus with one hand while depressing the scapula with the other. The impingement sign of Hawkins and Hobeika is positive when flexion to 90 degrees combined with internal rotation and horizontal adduction produces pain. An impingement test is considered positive when pain with flexion of the shoulder is eliminated after injection of fifteen milliliters of 1 per cent lidocaine (Xylocaine) into the subacromial space through a posterior approach. No patient had tenderness of the acromioclavicular joint.

Plain radiographs made in the anteroposterior and axillary planes were evaluated. For the eight patients who had pain in the anterosuperior portion of the shoulder with active flexion, special radiographs of the acromion (a supraspinatus outlet radiograph1,22 and a caudal tilt radiograph28) were made in order to define the supraspinatus outlet1,22. Three patients were found to have a type-I (flat) acromion; three, a type-II (curved) acromion; and two, a type-III (hooked) acromion, according to the classification of Bigliani et al.1.

Operative Technique

Anesthesia and Postoperative Analgesia
Three patients had general anesthesia; seven, an interscalene block; and eight, an interscalene catheter2,15. As it has been our impression that regional anesthesia provides better postoperative control of pain and thus allows more intensive physical therapy in the immediate postoperative period, we counsel our patients to have this form of anesthesia. The interscalene block was performed with use of about thirty milliliters of 0.5 per cent bupivacaine with 1:200,000 epinephrine for anesthesia and postoperative analgesia. This provides adequate anesthesia for the procedure as well as for about five to six hours after it. As the patients were admitted to the hospital for forty-eight hours so that immediate range-of-motion exercises of the shoulder could be performed after the operation, good postoperative analgesia was important. Therefore, the patients who had an interscalene block for anesthesia also had repeat blocks with use of 0.5 per cent bupivacaine with 1:200,000 epinephrine on the mornings of the first and second postoperative days. This provided excellent analgesia well into the afternoon of each day and allowed the therapist to perform both a morning and an afternoon session of passive motion.

To achieve regional anesthesia and postoperative analgesia by means of an interscalene catheter, a continuous infusion of 0.25 per cent bupivacaine is administered at a rate of six milliliters an hour for forty-eight hours. All of the patients also had self-administered (patient-controlled) analgesia through an intravenous pump that was set to administer one milligram of morphine every eight minutes, as needed, to a maximum of thirty milligrams in four hours.

Anterior Capsular Release
An anterior capsular release was performed in thirteen patients. First, the passive range of motion was recorded after induction of adequate anesthesia. A gentle closed manipulation was attempted for each patient, but all of our patients had a hard block to motion and this was unsuccessful.

Although some investigators have recommended against the insertion of an arthroscope into a stiff shoulder because of concerns about articular injury25,26,35, our technique allows a standard-size arthroscope to be inserted without injuring the articular surfaces. This technique has been described previously23,32,33. However, several points need to be emphasized. In order to restore external rotation, the anterior aspect of the capsule is released beginning just inferior to the biceps tendon and continuing to the inferior edge of the glenoid10,23,24,29. The subscapularis tendon must be defined and preserved. Failure to do so may result in division of the tendon. If the tendon cannot be defined, the procedure is converted to an open approach.

We do not release the axillary pouch distal to the five o'clock level (for a right glenoid), as we are concerned about the risk of injury to the axillary nerve in this region. A previous operation may have distorted the anatomy and have caused the nerve to become attached, with scar tissue, to the inferior aspect of the capsule. Thus, the nerve may be injured if the capsular release is performed in this region. It has been our experience that the shoulder can be manipulated easily to regain motion after release of only the anterior aspect of the capsule.

In five of the thirteen patients, a gentle closed manipulation after the arthroscopic release restored motion. In the patient who had had a previous resection of a scapular osteochondroma, the arthroscopic release was unsuccessful, as the subscapularis tendon could not be clearly distinguished from the capsular scar. Therefore, an open release was performed after removal of the arthroscope. The patient subsequently regained external rotation and flexion to within 10 degrees of those on the contralateral side and had complete relief of pain. In one patient who had had stiffness after a repair of the rotator cuff, the procedure also had to be converted to a similar open release; again, the outcome was good.

When a release is necessary for treatment of refractory loss of shoulder motion in a patient who has had a previous operation, it usually involves an open release through the deltopectoral interval. The rotator interval usually is released first23,24,29 and then, if there is still substantial limitation of motion, the subscapularis and the anterior aspect of the capsule are lengthened in a coronal z-plasty fashion11,14,16,18. When there is still marked loss of internal rotation, the posterior aspect of the capsule may be released directly through the joint. These approaches require extensive operative dissection. When a z-plasty is necessary, it must be protected in the initial postoperative period by controlled motion. However, all of our patients were able to begin a program of active range-of-motion exercises immediately after arthroscopic release, and none of them used a sling. Moreover, it was our impression that they were pleased with the appearance of the shoulder after the arthroscopic approach as well.

In six patients, the anterior release restored external rotation in adduction and abduction, but there was still marked limitation of internal rotation and flexion that did not improve with closed manipulation. A posterior capsular release also was necessary for these patients.

Posterior Capsular Release
A posterior capsular release was performed in eleven patients, including the six who had persistent limitation of flexion and internal rotation after the anterior capsular release and the five in whom the primary symptom was a limitation of flexion and internal rotation without any loss of external rotation. In the former group, a posterior capsular release was performed in addition to the anterior capsular release. Thus, the entire capsule (except the axillary pouch) was released. In the latter group, only the posterior capsule was released as the anterior aspect appeared normal at arthroscopy.

The posterior capsular release is performed with the arthroscope placed through a cannula in the anterior-superior portal in order to visualize the posterior portion of the glenohumeral joint. An electrocautery device, placed through a cannula in the posterior portal, is used to divide the posterior aspect of the capsule adjacent to the glenoid rim, beginning just posterior to the biceps tendon (Fig. 1). The posterior aspect of the capsule is divided along the glenoid rim as the rotator cuff muscles at this level are superficial to the capsule and the depth of the capsular division is determined by when the surgeon sees the muscle fibers. If there is additional lateral division of the capsule, the tendons of the rotator cuff would be at risk for injury as they are conjoined with the capsule14. It usually is possible to divide the posterior aspect of the capsule from the eleven to the eight o'clock position (for a right glenoid) (Fig. 1). The posterior part of the capsule was observed to be thickened and shortened in all of these patients. After removal of the arthroscope, gentle manipulation restored internal rotation and flexion, although the improvement of motion usually was achieved through a gradual yielding of tissue, similar to stretching a rubber band, rather than by the discrete improvement of motion (sometimes with an audible snap) seen after anterior release.



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  		Fig. 1 Drawing showing division of the posterior aspect of the capsule along the glenoid rim with use of a hooked electrocautery device placed through the posterior portal. The arthroscope is in the anterior-superior portal.

 
Five of the six patients who had a combined (anterior and posterior) capsular release had marked improvement of motion. However, the procedure could not be completed in one patient who had had a repair of the rotator cuff, as the subscapularis tendon could not be clearly defined when the capsular release was attempted. An open approach was performed, and extensive scarring was found in all tissue planes. Release of these planes along with a z-plasty lengthening of the subscapularis improved motion and reduced pain.

All five of the patients who needed an isolated posterior capsular release for loss of internal rotation had completion of the procedure without difficulty.

Additional Concomitant Procedures
In the eight patients who had findings that suggested concomitant subacromial impingement, an arthroscopic subacromial bursoscopy revealed an inflamed, thickened bursa and an extensive bursectomy was performed. In one patient, who had had a previous arthroscopic acromioplasty, a large spur on the anteroinferior aspect of the acromion was removed by a revision arthroscopic acromioplasty. In three patients who had stiffness after a repair of the rotator cuff, the superior surface of the rotator cuff appeared to be attached to the undersurface of the acromion by dense scar tissue. This scar tissue was removed with arthroscopic instruments so that passive motion of the arm demonstrated free motion of the cuff underneath the acromion.

Two patients had full-thickness loss of cartilage from both the glenoid labrum and the humeral head. The injury occurred as a result of intra-articular placement of a staple during repair of a lesion of the superior portion of the labrum, anterior and posterior, in one patient and during a previous arthroscopic Bankart repair with a Suretac device in the other. The sites of the cartilaginous injuries were debrided.

Postoperative Treatment
On the morning of the first postoperative day, passive range-of-motion exercises were begun with a physical therapist. Therapy sessions were conducted in both the morning and the afternoon, and the patient also was instructed in self-assisted motion exercises. Analgesia was maintained with the methods described earlier. The patients were discharged in the afternoon of the second postoperative day, after the second physical therapy session of that day. For the first two weeks, the patients attended daily supervised physical therapy sessions in an outpatient facility five times each week and performed a home-exercise program. This was reduced to supervised physical therapy three times each week for the next two weeks. Thereafter, the program was individualized according to the progress of each patient. A sling was not used for support at any time, and the patients were encouraged to use the affected extremity for activities of daily living as soon as possible after the operation. Strengthening of the muscles of the shoulder was begun as soon as postoperative pain and active shoulder motion allowed. Patients were encouraged to try to swim in a pool between two to four weeks after the operation.

Statistical Analysis
Statistical analysis was performed with use of a t test for paired samples (SPSS [Statistical Package for the Social Sciences] release 5.0 for VAX/VMS; SPSS, Chicago, Illinois). The postoperative motion was compared with the preoperative motion and with that of the contralateral, asymptomatic shoulder. The preoperative and postoperative scores of Constant and Murley5,6 also were compared.

As there were two distinct patterns of loss of motion, we analyzed the results in these two separate groups. The cohort of five patients who had loss of only internal rotation and flexion were analyzed separately from the eleven patients who had loss of motion that involved all planes. In the latter group, an anterior capsular release was performed successfully—that is, gentle manipulation restored motion in all planes—in five patients and a combined (anterior and posterior) capsular release was necessary in six patients because they continued to have loss of internal rotation and flexion after the anterior release. Presumably, the difference between these two subgroups was the extent of the scarring of the posterior aspect of the capsule. We chose to analyze these eleven patients together as the loss of motion involved all planes of rotation. This distinguished them from the five patients who had loss of only internal rotation and flexion and had no evidence of contracture of the anterior aspect of the capsule.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 

Patients Who Had an Anterior or a Combined Capsular Release
The mean duration of follow-up for the eleven patients who had an anterior or a combined capsular release was twenty-seven months (range, twenty-four to thirty-four months), and there were no complications related to the arthroscopic procedure. The score of Constant and Murley5,6 improved a mean of 43 points (range, 31 to 62 points), from a mean (and standard deviation) of 42 ± 12 points preoperatively to a mean of 85 ± 7 points postoperatively. All improvements in the range of motion were significant (p < 0.01). Flexion improved a mean of 51 degrees (range, 10 to 65 degrees), and the mean postoperative flexion of the affected shoulder was within 7 ± 9 degrees of that of the contralateral, normal shoulder. External rotation improved a mean of 31 degrees (range, 10 to 50 degrees) and 40 degrees (range, 5 to 80 degrees) with the arm positioned in adduction and abduction, respectively. Postoperatively, external rotation with the arm in adduction was within a mean of 7 ± 14 degrees of that of the normal shoulder and external rotation with the arm in abduction was a mean of 8 ± 9 degrees less than that of the normal shoulder. Internal rotation in adduction improved a mean of six spinous-process levels (range, three to eleven levels) and internal rotation in abduction, a mean of 41 degrees (range, 20 to 70 degrees). Postoperative internal rotation in adduction was a mean of 1 ± 1 spinous-process level caudad to that of the normal side, and internal rotation in abduction was a mean of 2 ± 11 degrees less than that of the normal shoulder. With the numbers available, we could not detect a significant difference between the postoperative motion of the shoulder in flexion, external rotation in adduction, and internal rotation in abduction and that of the contralateral, normal shoulder, although the differences remained significant for internal rotation in adduction and external rotation in abduction (p < 0.01).

Patients Who Had a Posterior Release
The mean duration of follow-up for the five patients who had a posterior release was thirty-four months (range, twenty-four to forty-nine months). There were no complications related to the arthroscopic procedure. The mean improvement in the score of Constant and Murley5,6 was 20 points (range, 5 to 35 points). All but one patient, who had had damage to the cartilage from an intra-articular staple placed at a previous operation, had only slight or no pain.

The loss of motion in these patients was limited primarily to internal rotation. With the number of patients available, we could detect no significant difference between the preoperative and postoperative values for flexion or for external rotation in adduction or abduction. The mean improvement in internal rotation in abduction (p < 0.005) was 42 degrees (range, 30 to 60 degrees) (Fig. 2-A). With the arm in adduction (p < 0.05), the mean improvement in internal rotation was four spinous-process levels (range, one to ten levels) (Fig. 2-B). These improvements in internal rotation were significant.



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  		Figs. 2-A and 2-B Graphs showing the mean preoperative and postoperative ranges of internal rotation for the patients who had a posterior capsular release. The I-bars represent the standard deviation. Fig. 2-A Internal rotation in abduction. The difference between the preoperative and postoperative scores is significant (p <0.005).

 


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  		Fig. 2-B Internal rotation in adduction. The difference between the preoperative and postoperative scores is significant (p < 0.05). P.S.I.S. = posterior superior iliac spine.

 

Patients in Whom the Operation Failed
Postoperatively, two patients had moderate pain that was controlled only partially by oral use of non-narcotic medication. Although both of these individuals had objective and subjective improvement in shoulder motion, they said that the pain had decreased only slightly as a result of the procedure. The two patients had had full-thickness injuries of cartilage associated with a previous arthroscopic procedure for instability and repair of a lesion of the superior portion of the labrum, anterior and posterior. One of the patients, a fifty-two-year-old man, was considering a total shoulder replacement, and the other, a twenty-nine-year-old man, reduced the pain by modifying his activities. He did not want additional treatment.

Complications
There were no complications related to the arthroscopic procedures.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Most previous approaches to regaining motion lost after an operation on the shoulder have involved an open release11,14,16,17. We have had three years of experience with an arthroscopic technique and have found that it is also an effective form of treatment for this problem. However, careful selection of patients is critical. Patients who have had a previous operation that has shortened or entrapped extra-articular structures probably will not have a successful result from an arthroscopic capsular release alone11,14,16,17,31,35. During a three-year period, the arthroscopic procedure successfully restored motion in sixteen patients who met the selection criteria. The remaining two patients had extensive extra-articular scarring that necessitated an open release because the subscapularis tendon could not be clearly defined as an intra-articular structure when the arthroscopic release was attempted. We believe that it is critical to identify this tendon and to preserve it when dividing the thickened anterior aspect of the capsule. If the subscapularis tendon cannot be clearly identified, it is an indication that the soft-tissue contracture involves the extra-articular structures. The open exploration and release in these two patients confirmed this impression. Failure to curtail the arthroscopic release procedure might have resulted in division of the subscapularis tendon. We found that dissection and release through an open deltopectoral approach in these two patients was not hampered by the attempted arthroscopic release, and both patients had a satisfactory outcome.

Although the concept that loss of motion primarily involves internal rotation and flexion is not new18,30,34, we are not aware of any reports on release of the posterior aspect of the capsule to treat the condition. It has been shown experimentally that these losses of motion can occur from contracture of the posterior aspect of the capsule10. Loss of motion after a posterior capsular shift for instability is considered to be rare7,8,13,19; however, as the senior one of us (J. J. P. W.) previously had managed several such patients successfully with an open release, we were interested in determining whether an arthroscopic release technique would be effective as well. The posterior part of the capsule was found to be markedly thickened in all of the patients who had this release.

Postoperative control of pain has been shown to be critical for the maintenance of motion gained after closed manipulation for treatment of adhesive capsulitis9,26,31. It is our impression that regional anesthesia and analgesia is superior to general anesthesia with subsequent use of narcotics for the control of postoperative pain. Although we did not specifically study this issue, our patients repeatedly indicated that they were very pleased with the control of pain during the first forty-eight hours after the operation. We found, as have other investigators2,9,15,31, that this technique is safe, is well tolerated, and substantially reduces the need for narcotics while allowing an intensive program of passive range-of-motion exercises to be carried out in the immediate postoperative period. We now counsel all of our patients who are to be managed with this procedure to have this form of anesthesia and analgesia.

Pollock et al.31 suggested that arthroscopy was useful mainly in the treatment of concomitant pathological disorders after a closed manipulation of the shoulder had been performed and that arthroscopically guided sectioning of the coracohumeral ligament might be helpful in some patients who have refractory loss of external rotation. They were, however, concerned about the risk of injury of the axillary nerve if the capsular release was continued more inferiorly than the superior edge of the subscapularis tendon. In our patients, the anterior capsular release was carried out to the five o'clock position on the glenoid (for a right shoulder) and the axillary nerve was not injured in any of them. This makes sense because the subscapularis tendon forms an anatomical buffer between the capsule and the axillary nerve in the anterior aspect of the shoulder. Although an anatomical study3 of the axillary nerve demonstrated that the nerve remains medial to the inferior aspect of the capsule when the arm is in adduction, there still may be danger in releasing the inferior aspect of the capsule when the shoulder is stiff after an operation. In such patients, the normal anatomy may be distorted so that the nerve is attached to the inferior aspect of the capsule with scar tissue. Therefore, we never release the inferior portion of the capsule distal to the five o'clock position on the glenoid (for a right shoulder).

In our patients who needed a posterior capsular release, the arthroscopic division of the posterior portion of the capsule was performed at the level of the glenoid rim, thus avoiding injury of the more superficial tendons of the rotator cuff, as only muscle is superficial to the capsule at this level4. In all patients, the posterior part of the capsule was found to be thickened and contracted and its release resulted in a substantial improvement in both internal rotation and flexion.

In our two patients in whom the procedure was converted to an open release because the subscapularis tendon could not be clearly defined, the open release demonstrated extensive extra-articular scar tissue between all tissue planes. We performed a z-plasty lengthening of the subscapularis and the capsule16,17 and had no difficulty dissecting tissue after the arthroscopy.

The two procedures that failed were in patients who had injuries of cartilage that may have been secondary to previous operative treatment. Both individuals had objective and subjective improvement of motion. Nevertheless, we believe that the prognosis for patients who have injuries of cartilage is guarded, even though motion may be restored by an arthroscopic release procedure.

In conclusion, we believe that arthroscopic capsular release may be an effective form of treatment with minimum morbidity in selected patients who have postoperative stiffness of the shoulder. Contraindications are known extra-articular contractures, although the arthroscopic approach can be converted successfully to an open release in patients in whom the former procedure is unsuccessful.


   Footnotes
 
*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.

{dagger}Shoulder Service, Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 4601 Baum Boulevard, Pittsburgh, Pennsylvania 15213-1217. E-mail address for Dr. Warner: jwarner@uoi.upmc.edu.

{ddagger}Sports Medicine and Shoulder Service, The Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021.

§Orthopaedic and Arthritis Hospital, 43 Wellesley Street, East Toronto, Ontario MYY 1H1, Canada.

¶Department of Orthopaedics, Northwest Private Hospital, Brickport Road, Burnie, Tasmania 7320, Australia.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans., 10: 228, 1986.
  2. Brown, A. R.; Weiss, R.; Greenberg, C.; Flatow, E. L.; and Bigliani, L. U.: Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy, 9: 295-300, 1993.[Medline]
  3. Burkhead, W. Z.; Scheinberg, R. R.; and Box, G.: Surgical anatomy of the axillary nerve. J. Shoulder and Elbow Surg., 1: 31-36, 1992.
  4. Clarke, J.; Sidles, J. A.; and Matsen, F. A.: The relationship of the glenohumeral joint capsule to the rotator cuff. Clin. Orthop., 254: 29-34, 1990.
  5. Constant, C. R.: Age related recovery of shoulder function after injury. Thesis, University College, Cork, Ireland, 1986.
  6. Constant, C. R., and Murley, A. H.: A clinical method of functional assessment of the shoulder. Clin. Orthop., 214: 160-164, 1987.[Medline]
  7. Fronek, J.; Warren, R. F.; and Bowen, M.: Posterior subluxation of the glenohumeral joint. J. Bone and Joint Surg., 71-A: 205-215, Feb. 1989.[Abstract/Free Full Text]
  8. Gerber, C.; Ganz, R.; and Vinh, T. S.: Glenoplasty for recurrent posterior shoulder instability. An anatomic reappraisal. Clin. Orthop., 216: 70-79, 1987.
  9. Harryman, D. T., II: Shoulders: frozen and stiff. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 42, pp. 247-257. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1993.
  10. Harryman, D. T., II; Sidles, J. A.; Harris, S. L.; and Matsen, F. A., III: The role of the rotator interval capsule in passive motion and stability of the shoulder. J. Bone and Joint Surg., 74-A: 53-66, Jan. 1992.[Abstract/Free Full Text]
  11. Hawkins, R. J., and Angelo, R. L.: Glenohumeral osteoarthrosis. A late complication of the Putti-Platt repair. J. Bone and Joint Surg., 72-A: 1193-1197, Sept. 1990.[Abstract/Free Full Text]
  12. Hawkins, R. J., and Hobeika, P. E.: Impingement syndrome in the athletic shoulder. Clin. Sports Med., 2: 391-405, 1983.[Medline]
  13. Hawkins, R. J.; Koppert, G.; and Johnston, G.: Recurrent posterior instability (subluxation) of the shoulder. J. Bone and Joint Surg., 66-A: 169-174, Feb. 1984.[Abstract/Free Full Text]
  14. Kieras, D. M., and Matsen, F. A., III: Open release in the management of refractory frozen shoulder. Orthop. Trans., 15: 801-802, 1991.
  15. Kinnard, P.; Truchon, R.; St-Pierre, A.; and Montreuil, J.: Interscalene block for pain relief after shoulder surgery. A prospective randomized study. Clin. Orthop., 304: 22-24, 1994.
  16. Lusardi, D. A.; Wirth, M. A.; Wurtz, D.; and Rockwood, C. A., Jr.: Loss of external rotation following anterior capsulorrhaphy of the shoulder. J. Bone and Joint Surg., 75-A: 1185-1192, Aug. 1993.[Abstract/Free Full Text]
  17. MacDonald, P. B.; Hawkins, R. J.; Fowler, P. J.; and Miniaci, A.: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J. Bone and Joint Surg., 74-A: 734-737, June 1992.[Abstract/Free Full Text]
  18. Matsen, F. A., III, and Arntz, C. T.: Subacromial impingement. In The Shoulder, edited by C. A. Rockwood, Jr., and F. A. Matsen, III. Vol. 2, pp. 623-646. Philadelphia, W. B. Saunders, 1990.
  19. Mowery, C. A.; Garfin, S. R.; Booth, R. E.; and Rothman, R. H.: Recurrent posterior dislocation of the shoulder: treatment using a bone block. J. Bone and Joint Surg., 67-A: 777-781, June 1985.[Abstract/Free Full Text]
  20. Neer, C. S., II: Impingement lesions. Clin. Orthop., 173: 70-77, 1983.
  21. Neer, C. S., II: Frozen shoulder. In Shoulder Reconstruction, pp. 422-427. Edited by C. S. Neer, II. Philadelphia, W. B. Saunders, 1990.
  22. Neer, C. S., II, and Poppen, N. K.: Supraspinatus outlet. Orthop. Trans., 11: 234, 1987.
  23. Neer, C. S., II; Satterlee, C. C.; Dalsey, R. M.; and Flatow, E. L.: On the value of the coracohumeral ligament release. Orthop. Trans., 13: 235-236, 1989.
  24. Neer, C. S., II; Satterlee, C. C.; Dalsey, R. M.; and Flatow, E. L.: The anatomy and potential effects of contracture of the coracohumeral ligament. Clin. Orthop., 280: 182-185, 1992.
  25. Neviaser, R. J.: Painful conditions affecting the shoulder. Clin. Orthop., 173: 63-69, 1983.
  26. Neviaser, R. J., and Neviaser, T. J.: The frozen shoulder. Diagnosis and management. Clin. Orthop., 223: 59-64, 1987.
  27. Ogilvie-Harris, D. J., and Wiley, A. M.: Arthroscopic surgery of the shoulder. A general appraisal. J. Bone and Joint Surg., 68-B(2): 201-207, 1986.
  28. Ono, K.; Yamamuro, T.; and Rockwood, C. A.: Use of the thirty-degree caudal tilt radiograph in the shoulder impingement syndrome. J. Shoulder and Elbow Surg., 1: 246-252, 1992.
  29. Ozaki, J.; Nakagawa, Y.; Sakurai, G.; and Tamai, S.: Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J. Bone and Joint Surg., 71-A: 1511-1515, Dec. 1989.[Abstract/Free Full Text]
  30. Pappas, A. M.; Zawacki, R. M.; and McCarthy, C. F.: Rehabilitation of the pitching shoulder. Am. J. Sports Med., 13: 223-235, 1985.[Abstract/Free Full Text]
  31. Pollock, R. G.; Duralde, X. A.; Flatow, E. L.; and Bigliani, L. U.: The use of arthroscopy in the treatment of resistant frozen shoulder. Clin. Orthop., 304: 30-36, 1994.
  32. Warner, J. J. P.: Shoulder arthroscopy in the beach-chair position: basic set-up. Op. Tech. Orthop., 1: 147-154, 1991.
  33. Warner, J. J. P.; Allen, A.; Marks, P. H.; and Wong, P.: Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J. Bone and Joint Surg., 78-A: 1808-1816, Dec. 1996.[Abstract/Free Full Text]
  34. Warner, J. J.; Micheli, L. J.; Arslanian, L. E.; Kennedy, J.; and Kennedy, R.: Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. Am. J. Sports Med., 18: 366-375, 1990.[Abstract/Free Full Text]
  35. Wiley, A. M.: Arthroscopic appearance of frozen shoulder. Arthroscopy, 7: 138-143, 1991.[Medline]
  36. Young, D. C., and Rockwood, C. A., Jr.: Complications of a failed Bristow procedure and their management. J. Bone and Joint Surg., 73-A: 969-981, Aug. 1991.[Abstract/Free Full Text]

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