Arthroscopic capsular release for the treatment of stiff shoulder pathology

OVERVIEW

Chapter synopsis

The arthroscopic management of stiff shoulder pathology is detailed. The diagnosis, imaging, indications for operative treatment, and specific technique of arthroscopic capsular release, along with aftercare, are detailed.

Important points

Patients that have not responded to appropriate conservative treatment and have had symptoms for over 4 months are candidates for arthroscopic capsular release.
An existing shoulder arthroplasty implant may be more effectively treated by the open release technique.
Shoulder stiffness can be caused or maintained by the involvement of the glenohumeral capsule, the rotator interval, or the subacromial space. All areas can and should be evaluated and released if involved.
All causes of shoulder stiffness can be addressed by an arthroscopic technique.

Clinical and surgical pearls

Technically challenging procedure because of limited space. Be patient!
Know your chosen pump and fluid flow characteristics.
We prefer the 3.5-mm ArthroWand (ArthroCare, Sunnyvale, CA) bipolar cautery device to perform the release. It provides a bloodless release of the capsule and is stiff enough to access tight areas, and the right angle can cut through the thickened capsule.
The goal is a balanced release. Proceed from superior to inferior to access the contracted capsule. Anterior, posterior, and inferior areas should be addressed if involved.

Clinical and surgical pitfalls

Approximately 20% of post-release patients experience increasing stiffness 3 to 5 weeks postoperatively. This is an inflammatory flare-up and can be treated with anti-inflammatory medications, glenohumeral steroid injections, or oral steroid taper.
Manipulation before release should be avoided. It can cause soft tissue and bone injury. It also creates bleeding that makes visualization difficult during arthroscopy.

The diagnosis of shoulder stiffness, also termed frozen shoulder or adhesive capsulitis, is one of exclusion. It is a clinical syndrome characterized by painful restricted passive and active range of motion. It is associated with night pain and pain with activities. This clinical entity has been difficult to classify and follows an unpredictable clinical course, ^, ^, ^, although recent studies have largely shown this process to be self-limiting, but with variable durations. Etiologic factors in the pathophysiology of the disease include idiopathic causes, posttraumatic conditions, diabetes, and postsurgical factors; the condition can arise even as a consequence of prolonged impingement syndrome. ^, ^, It appears that susceptible shoulders respond to an insult in a common pathway of expression. This is glenohumeral synovitis. If this process continues unabated, the capsule will become thickened and disorganized in its collagen structure and actually become contracted. ^, The time course of the process and recovery is unpredictable. The true cause, diagnostic criteria, pathophysiology, treatment methods, and natural history of this condition are under debate and investigation. ^, ^, A randomized controlled trial comparing physical therapy, manipulation under anesthesia alone, and arthroscopic capsular release showed no superiority for any treatment arm. A recent meta-analysis showed that while nonoperative management and arthroscopic capsular release have no difference in clinical outcomes at 1 year, patients that undergo capsular release got better faster. With that taken into consideration, there are simply patients who do not respond to time, proper therapy, injections, or anti-inflammatory medications and who are profoundly affected by their shoulder stiffness. These patients can be offered an arthroscopic capsular release.

Preoperative considerations

History

The majority of adhesive capsulitis patients with an idiopathic cause are women between the ages of 35 and 60 years. A history should be taken for other contributing factors, especially endocrine abnormalities such as diabetes or hypothyroidism. A history of trauma or surgery is important to note. A neurologic history is important to note for the possible involvement of cervical disease. The type of prior surgical procedure on or around the shoulder is important to know, and a previous operative note can be helpful.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here