[Comparison of mid-term effectiveness between diabetic secondary stiff shoulder and primary frozen shoulder after arthroscopic shoulder capsular release combined with acromiohumeral distance restoration].

Objective: To compare the mid-term effectiveness of arthroscopic shoulder capsular release combined with acromiohumeral distance (AHD) restoration in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder. Methods: A retrospective analysis was conducted on clinical data of 22 patients with diabetic secondary stiff shoulder (group A) and 33 patients with primary frozen shoulder (group B), who underwent arthroscopic 270° capsular release combined with AHD restoration treatment. There was no significant difference between the two groups in gender, age, affected side, disease duration, and preoperative AHD, shoulder flexion range of motion, abduction range of motion, American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale (VAS) score, and Constant score ( P>0.05). Only the difference in the internal rotation cone rank and external rotation range of motion between the two groups showed significant differences ( P<0.05). The improvement in shoulder pain and function was evaluated by using VAS score, ASES score, and Constant score before operation and at last follow-up. Active flexion, abduction, external rotation range of motion, and internal rotation cone rank were recorded and compared. AHD was measured on X-ray films. Results: All patients were followed up 24-92 months (median, 57 months). There was no significant difference in follow-up time between group A and group B ( P>0.05). No fractures or glenoid labrum tears occurred during operation, all incisions healed by first intention, and no complication such as wound infection or nerve injury was observed during the follow-up. At last follow-up, there were significant improvements in active flexion, abduction, external rotation range of motion, internal rotation cone rank, AHD, VAS score, ASES score, and Constant score when compared with preoperative ones in both groups ( P<0.05). Except for the difference in change in external rotation range of motion, which had significant difference between the two groups ( P<0.05), there was no significant difference in other indicators between the two groups ( P>0.05). Conclusion: Arthroscopic capsular release combined with AHD restoration can achieve good mid-term effectiveness in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder. However, the improvement in external rotation range of motion is more significant in the patients with diabetic secondary stiff shoulder.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis.

OBJECTIVE: Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. METHODS: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. CONCLUSIONS: In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Current Evidence Based Recommendations on Rehabilitation following Arthroscopic Shoulder Surgery: Rotator Cuff, Instability, Superior Labral Pathology, and Adhesive Capsulitis.

PURPOSE OF REVIEW: Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis. RECENT FINDINGS: For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3 cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release. Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research.

Combination of Superior and Posterior Capsular Release Versus Superior Capsular Release Alone in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears.

Background: Superior capsular release has been used to reduce tendon tension, especially in arthroscopic repair of large-to-massive rotator cuff tears. Some clinicians have used a more extensive release of capsules in arthroscopic cuff repair for adequate reduction of torn tendons to footprints. Purpose: To explore the effects of additional posterior capsular release for superior capsular release in arthroscopic repair of large-to-massive rotator cuff tears. Study Design: Cohort study; Level of evidence, 3. Methods: We compared 26 shoulders that underwent superior and posterior capsular release (group S&P) with 26 shoulders that underwent superior capsular release alone (group S) in arthroscopic repair of large-to-massive rotator cuff tears between January 23, 2013 and December 2, 2015. The visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and range of motion (ROM) and muscle power were checked preoperatively and at 2 years postoperatively. Follow-up ultrasound was checked at 2 years postoperatively. Results: In both groups, the overall mean functional outcomes improved from preoperatively to postoperatively. Patients in group S&P showed more pre- to postoperative improvement than patients in group S with regard to internal rotation ROM (mean difference, 30.0° vs 20.6°; P < .001) and internal rotation power (3.4 vs 1.8 kgf; P = .001). Patients in group S had a higher retear rate on the follow-up ultrasound than patients in group S&P, but this difference did not reach statistical significance (23.1% vs 11.5%, respectively; P = .465). Conclusion: In the current study, patients who underwent superior and posterior capsular release in arthroscopic repair of large-to-massive rotator cuff tears had greater postoperative improvement in internal rotation ROM and power compared with patients who underwent superior capsular release alone.

Risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block.

Background: This study aimed to investigate risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC). Methods: We retrospectively reviewed 135 frozen shoulders in 121 patients who underwent MUC. We defined frozen shoulder as a limited shoulder range of motion (ROM) (passive forward flexion <120°, external rotation <30°, or internal rotation lower than L3). Patients fulfilling any one criteria were considered to have frozen shoulder. If patients continued to have severe pain and limited ROM at 3 months after MUC, we defined as recurrence of frozen shoulder and they were offered a further MUC or arthroscopic capsular release (ACR). We compared the ROM, Constant Shoulder (CS) score, and University of California, Los Angeles score before and 3 months after MUC between patients with the successful of MUC group (Success group) with those recurrence of frozen shoulder who required a further MUC or ACR group (Recurrence group). Multiple logistic regression analysis was used to identify risk factors for recurrence of frozen shoulder after MUC. Results: Patients who underwent MUC were retrospectively enrolled and divided into: the successful of MUC group (Success group, n = 112) and required a further MUC or ACR group (Recurrence group, n = 9). The Recurrence group had significantly lower external rotation and CS score before MUC than those in the Success group (P < .05). The Recurrence group showed significantly inferior all ROM and functional scores 3 months after MUC (P < .05). The levels of blood glucose and hemoglobin A1c both before and 3 months after MUC in the Recurrence group showed inferior compared with those of Success group. The difference, although not statistically significant, trended towards significance (before MUC/3 months after MUC; the glucose levels P = .06/.06, the hemoglobin A1c levels P = .07/.09, respectively). The visual analog scale pain score (at rest, during activity, at night) both before and 3 months after MUC in the Recurrence group showed significantly higher scores compared with those of Success group (P < .05). Multiple logistic regression analysis revealed that lower CS score before MUC was independent risk factor for recurrence of frozen shoulder after MUC. Conclusion: The overall incidence of recurrence of frozen shoulder after MUC was 7.4%. The lower CS score before MUC was an independent risk factor for recurrence of frozen shoulder after MUC. Moreover, patients in the Recurrence group tended to have poorly controlled diabetes and higher visual analog scale pain score both before and 3 months after MUC.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Incidence of Repeat Elbow Capsular Release After Arthroscopic Elbow Capsular Release.

Background: Elbow capsular release can be performed arthroscopically or through an open method to improve range of motion (ROM). However, it is unclear how frequently patients require an open capsular release after unsatisfactory results from an arthroscopic release. Purpose/Hypothesis: The purpose of this study was to determine the percentage of patients who underwent an arthroscopic elbow release for loss of motion who then required a repeat elbow capsular release or other subsequent surgery on the same elbow. It was hypothesized that patients who underwent arthroscopic elbow release would rarely (<5%) require a subsequent elbow release. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent arthroscopic elbow capsular release from January 1, 2010, to December 31, 2019, were identified by chart review and procedure code. Demographic parameters, pre- and postoperative ROM, and surgical history were collected by chart review. Follow-up data included patient satisfaction and the Timmerman-Andrews (TA) elbow score. Data were compared between patients who did and those who did not require subsequent elbow surgery. Results: Overall, of 140 study patients (116 male, 24 female; mean age, 49.6 years), 18 (12.9%) required subsequent surgery, including 6 capsular releases (4.3%; 1 open and 5 arthroscopic). The most common follow-up procedure was ulnar nerve releases/transpositions (n = 7). Total arc of elbow motion (flexion to extension) improved by a mean of 51.4°. The mean TA score was 76.5 ± 20.4 at a mean of 5.25 years postoperatively. Mean satisfaction score was 77.6 ± 26.3. In this study, 82.4% of patients stated that their symptoms either improved or resolved completely. Patients who required subsequent surgery had a significantly lower preoperative total arc of elbow motion versus those who did not require subsequent surgery (P = .046). There was no difference between the groups in symptom resolution, satisfaction, ROM, or TA score (P ≥ .279 for all). Conclusion: After arthroscopic elbow release, <5% of patients required a repeat elbow capsular release, 12.9% required some form of follow-up elbow surgery, and 4.3% had a new injury of the elbow. Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release.

Arthroscopic capsular release for frozen shoulder: when etiology matters.

PURPOSE: No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder. METHODS: A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS: After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, ß = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release. CONCLUSION: High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient. LEVEL OF EVIDENCE: III.

Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis.

Background: Adhesive capsulitis of the shoulder is a painful and debilitating condition. While the majority of patients improve with conservative treatment, those who do not improve require surgery such as arthroscopic capsular release (ACR) for symptom relief. However, there is limited literature regarding the optimal timeframe to proceed with surgery. Methods: This retrospective cohort evaluated 134 Hispanic patients who underwent ACR for the treatment of adhesive capsulitis. Patients were divided into an early and a delayed treatment group that included all patients. Patients were then divided into diabetic and idiopathic subgroups. Early vs. delayed treatment outcomes (forward flexion, external rotation, Visual Analog Scale pain scores, and recurrence requiring reoperation) were assessed in all patients and in each subgroup. Results: No statistically significant differences were found between the early and delayed release groups in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up in the all-patient group. In the idiopathic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up. In the diabetic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month and 6 months of follow-up visits. Conclusions: There was no difference in outcomes following ACR for adhesive capsulitis between patients who underwent early release vs. delayed release. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus.

Management of shoulder stiffness following rotator cuff repair: a systematic review and meta-analysis.

The purpose was to systematically review and synthesize the literature on treatment modalities for shoulder stiffness following rotator cuff repair (RCR) and investigate which modality provides the greatest postoperative range of motion (ROM). A search was performed on PubMed, Embase, and Cochrane. Clinical case series and comparative studies that report pre- and posttreatment ROM of shoulder stiffness following RCR were included. Studies that exclusively assess idiopathic frozen shoulder or primary shoulder stiffness were excluded. Five eligible studies that reported on a total of 177 patients who underwent treatment for shoulder stiffness following RCR were included. The ranges of postoperative ROM following arthroscopic capsular release were 158°-166° for active forward elevation (AFE) and 53°-59° for external rotation (ER). The ranges of postoperative ROM following infiltration were 146°-163° for AFE and 34°-35° for ER. The ranges of postoperative ROM following rehabilitation were 166° for AFE and 62° for ER. For AFE, 4 studies (5 data sets) were eligible for meta-analysis, which indicated better AFE when treated with a mean difference (MD) of 5.10° with no heterogeneity (I2 = 0%, CI, 0.83-9.38). For ER, 3 studies (4 data sets) were eligible for meta-analysis, which indicated better ER without treatment with an MD of 4.59° with no heterogeneity (I2 = 0%, CI, -7.04 to -2.13). For the treatment of shoulder stiffness following RCR, all included treatments improved the ROM, resulting in comparable AFE and ER compared to the comparative group. Among the treatment modalities, arthroscopic capsular release granted the greatest posttreatment AFE, while rehabilitation granted the greatest posttreatment ER.

Triamcinolone acetonide with arthroscopic capsular release for frozen shoulder promotes early recovery of shoulder abduction.

Background: Current treatment options for frozen shoulder are not established as the standard-of-care. The condition may resolve without intervention, but symptoms may persist despite treatment. Frozen shoulder is associated with inflammatory reactions that can reduce quality of life. Our aim was to determine whether triamcinolone acetonide, an immunosuppressive steroid, improved functional recovery when administered after arthroscopic capsular release (ACR) for frozen shoulder. Methods: We selected participants using inclusion and exclusion criteria designed to reduce the impact of potential confounding factors. Under general anesthesia, we performed ACR followed by manipulation to ensure adequate range of motion (ROM) and wound closure. In the steroid treatment group, we injected triamcinolone acetonide into the glenohumeral joint immediately prior to wound closure. The follow-up period was six months. To determine the efficacy of steroids in improving overall post procedure functional recovery we statistically analyzed data from various qualitative and quantitative variables. Results: Our study consisted of 22 patients with frozen shoulder, 11 in each of the surgery-only and surgery with steroid injection groups. There were no significant differences between groups in the demographic data of the study participants. We observed significantly greater improvements in abduction ROM in the steroid treatment group than in the surgery-only group, at three and six months post treatment. Improvements in other movement parameters were similar in both groups. The steroid-treated group had a significantly higher numerical rating scale score for night pain at three months post treatment than the surgery-only group. Conclusions: Postoperative steroid treatment led to early recovery of the abduction ROM in patients with frozen shoulder. Hence, the current standard-of-care protocol for frozen shoulder and other similar conditions requiring surgical intervention should include this type of treatment. Therapeutic reduction in the inflammatory response following ACR can significantly improve prognosis and quality of life.

Limited medial posterior capsular release increases the intraoperative medial component gap while maintaining the joint varus angle at extension in posterior-stabilized total knee arthroplasty.

PURPOSE: There is a lack of robust evidence for the magnitude of the effects of posterior capsular release (PCR) on intraoperative component gaps during total knee arthroplasty (TKA). The purpose of the present study was to quantify and compare the effects of partial versus full PCR on the intraoperative component gaps at various degrees of flexion during posterior-stabilized TKA. METHODS: Full PCR was performed on 39 consecutive cases (full PCR group), and partial PCR (the medial side up to and including the intercondylar notch) was performed on the subsequent 39 consecutive cases (partial PCR group) during posterior-stabilized TKA using the measured resection technique for varus knee osteoarthritis. Medial component gaps and varus angles at 0°, 10°, 45°, 90°, and a maximum of flexion were measured with a tensor device before and after the PCR. Differences between the two groups in post-release medial component gap increase and post-release joint varus angle increase were assessed using a t test. Pre- to post-release medial component gaps and joint varus angles in each group were compared using a paired samples t test. RESULTS: In both groups at 0° and 10° of flexion, post-release medial compartment gaps were significantly greater than pre-release gaps (all P < 0.001). At 45°, 90° and maximum flexion, the medial compartment gap increase did not exceed the minimal detectable change in either group. At 0° and 10° of flexion, there was no significant difference in post-release medial compartment gap change between the two groups. In the full PCR group, post-release joint varus angles at 0° of flexion were significantly greater than pre-release angles (P < 0.001), while there was no significant pre- and post-release difference in the partial PCR group. The change in post-release joint varus angles at 0° of flexion was significantly greater in the full PCR group than in the partial PCR group. CONCLUSION: Both full and partial PCR show similar clinical usefulness for increasing the medial component gap at extension and reducing component gap mismatch. A partial PCR can be used to avoid increasing joint varus angles at 0° of flexion. LEVEL OF EVIDENCE: Level 2 (prospective comparative study).

Adhesive Capsulitis.

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Effect of posterior capsular release on intraoperative joint gap mismatch in the mid-flexion range during posterior-stabilized total knee arthroplasty.

INTRODUCTION: Intraoperative mismatch between extension and mid-flexion joint gaps remains a critical issue in posterior-stabilized total knee arthroplasty (PS-TKA). Posterior capsular release has been found to increase the extension joint gap. However, there is still a lack of robust evidence for the effect of posterior capsular release on the mid-flexion joint gap. The purpose of the present study was to quantify the effect of posterior capsular release on the intraoperative joint gap from extension through 45° mid-flexion to flexion and to clarify how this procedure might affect the improvement of gap mismatch in the mid-flexion 45° range. MATERIALS AND METHODS: In total, 38 consecutive cases of primary PS-TKA were reviewed. The center, medial, and lateral component gaps from extension to flexion were measured with a tensor device before and after posterior capsular release. The minimal detectable change for joint gap measurement was calculated using two methods, error variance and intra-observer intraclass correlation coefficients. Pre- and post-release joint gap differences were assessed using the paired t-test. RESULTS: Minimal detectable change was found to be 0.59 mm. At 0° and 10° of flexion, the post-release center, medial, and lateral component gaps were significantly greater than at pre-release. At 45° and 90° and maximum flexion, there were no joint gap differences exceeding the minimal detectable change. The joint gap mismatches between 0° and 10°, and 45°, 90° and maximum flexion were significantly smaller at post-release than those at pre-release with the change values exceeding the minimal detectable change (P < 0.05). CONCLUSION: Posterior capsular release significantly decreased both joint gap mismatch between extension and 45° mid-flexion, and extension and flexion, showing clinical usefulness in PS-TKA.

Sex Is Associated with the Success or Failure of Manipulation Alone for Joint Stiffness Associated with Rotator Cuff Repair.

Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation.

Arthroscopic Pan-Capsular and Transverse Humeral Ligament Release with Biceps Tenodesis for Patients with Refractory Frozen Shoulder.

Arthroscopic capsular release allows direct visualization and release of inflamed tissues in refractory frozen shoulder. The reticular neural network in the long head of the biceps tendon (LHBT) and nerve endings of the transverse humeral ligament (THL) might be responsible for shoulder pain. We hypothesized that patients with painful refractory frozen shoulder benefited from pan-capsular release, THL release, and LHBT tenodesis. The LHBT tenodesis decreased the possibility of LHBT instability. The balance of the shoulder joint was maintained after such extensive release. From October 2013 to June 2019, patients with painful refractory frozen shoulder were enrolled consecutively at the same institute. All patients received arthroscopic pan-capsular, THL release, and suprapectoral LHBT tenodesis with a minimum of 2-year follow-up. Preoperative and postoperative shoulder range of motion (ROM), pain visual analog scale (PVAS), subjective shoulder value (SSV), constant score, LHBT score, acromio-humeral distance (AHD), and critical shoulder angle (CSA) were recorded. In total, 35 patients with an average age of 53.1 ± 9 years were enrolled. The average follow-up period was 24 ± 1.5 months. Forward elevation improved from 105.1° ± 17° to 147° ± 12° (p < 0.001), external rotation improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001), and internal rotation improved from L3 to T9 (p < 0.001), respectively, at final follow-up. PVAS improved from 7.3 ± 1.1 to 1.8 ± 0.6 (p < 0.001), constant score from 23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV from 27.7 ± 10.5 to 77.4 ± 3.8, respectively, at follow-up. No differences were found in AHD and CSA after surgery (p = 0.316, and p = 0.895, respectively). Patients with painful refractory frozen shoulder benefited from pan-capsular and THL release. A radiographically balanced shoulder joint was maintained even after such extensive release.

Are soft tissue releases sufficient to correct moderate to severe flexion contractures during total knee replacement? Role of hamstring tenotomy and horizontal capsular release.

BACKGROUND: Performing total knee arthroplasty (TKA) in arthritic knees with persistent flexion deformities is a challenging task because secondary tightening of surrounding soft tissues makes it difficult to achieve appropriate ligament balancing. In this study, we shared our algorithm for correction of flexion contractures of moderate to severe grade while performing TKA as well as their outcomes with 1 year of follow up. METHODS: Forty-three patients (61 knees) having knee arthritis with moderate to severe flexion contractures (Lombardi classification) were included in the study. We followed a stepwise algorithm of soft tissue releases for correction of flexion contracture, which included: removal of posterior osteophytes, release of posterior capsule, gastrocnemius release, horizontal capsular release, and hamstring tenotomy. Patients were followed up at 15 days, 6 weeks, 3 months and 1 year, and assessed clinically for residual flexion deformity (FFD), range of motion (ROM), New Knee Society (New KSS) score and Hospital for Special Surgery (HSS) score. RESULTS: Pre-operative mean FFD 29.07 ± 18.04 standard deviation (SD) was corrected to 0.77 ± 2.93 SD at 1 year follow up. Pre-operative mean ROM 71.37 ± 22.18 increased to 107.7 ± 10.38 at 1 year follow up. There was statistically significant improvement in mean New KSS score and reduction in number of cases with poor HSS score at 1 year follow up. CONCLUSIONS: Moderate flexion contractures can be corrected with soft tissue releases without distal femoral over-resection. In severe deformities, horizontal release of posterior capsule and hamstring tenotomy are crucial, and residual contractures of up to 20° can be well corrected by postoperative physiotherapy and extension bracing.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study.

PURPOSE: Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures. METHODS: From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis. RESULTS: Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD. CONCLUSION: Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis.

AIMS: Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release. METHODS: A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) - one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks. RESULTS: IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)). CONCLUSION: IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value. Cite this article: Bone Joint Res 2022;11(1):32-39.

Efficacy of posterior capsular release for flexion contracture in posterior-stabilized total knee arthroplasty.

PURPOSE: Posterior capsular contracture causes stiffness during knee extension in knee osteoarthritis. Furthermore, in posterior-stabilized total knee arthroplasty (PS-TKA), a unique design such as the cam mechanism could conflict with the posterior capsule (PC) causing flexion contracture (FC). However, few studies have focused on the anatomical aspects of the PC. This study aimed to investigate the anatomical site and forms of posterior capsular attachment to the femoral cortex, and to evaluate the efficacy of posterior capsular release for FC by assessing changes in knee extension angles using a navigation system. METHODS: Attachment sites of the PC were investigated in 10 cadaveric knees using computed tomography. PS-TKA was performed in six cadaveric knees using a navigation system to evaluate the efficacy of posterior capsular release for FC. Posterior capsular release was performed stepwise at each part of the femoral condyle. RESULTS: The gastrocnemius tendon and PC were integrally attached to the femoral cortex at the medial and lateral condyles, whereas the PC at the intercondylar fossa was independently attached directly to the femoral cortex. Moreover, the PC at the intercondylar fossa was attached most distally among each femoral condyle. Posterior capsular release at the intercondylar fossa allowed 11.4° ± 2.8° improvement in knee extension. This angle was further improved by 5.5° ± 1.3°, after subsequent capsular release at the medial and lateral condyles. CONCLUSION: The forms and sites of posterior capsular attachment differed based on the part of the femoral condyle. Stepwise posterior capsular release was effective for FC in PS-TKA. LEVEL OF EVIDENCE: III.