Periarthritis of ShoulderWhen To Intervene Surgically And

How

Dr.G.Ramesh M.S(Ortho.)Asst.Professor, Dept. of OrthopaedicsGandhi Medical College and Hospital

Introduction

• Common problem

• Difficult to treat

• Non-surgical management

• What to do with failure of non-surgical management

Alternate names

• Duplay -1872: “Periarthritis scapulo-humerale”

• Codman -1934: “Frozen shoulder”

• Neviaser -1945: “Adhesive capsulitis”

“A condition of uncertain etiology characterized by significant restriction of both active and passive motion that occurs in the absence of a known intrinsic shoulder disease”

-American Academy of Orthopaedic Surgeons-1992:

Etiology and pathogenesis

“Chronic inflammatory process involving the capsule of the

shoulder causing a thickening and contracture of the capsule

which secondarily becomes adherent to the humeral head”.

-Neviaser

Natural History

Phase I : Freezing or painful phase Pain around the shoulder, worst at night

Duration 2 to 9 months

Phase II : Frozen or adhesive phase Pain present only at extremes of movements

Gross restriction of movements

Duration 4 to 12 months

Phase III: Thawing or resolution phase Pain subsides, ROM slowly returns

Return of full movements can take months to years

Motion restriction often persists

Natural History

• Believed to be self resolving

• But not in all patients

• Adhesive capsulitis in DM

• Adhesive capsulitis with co-morbid conditions

Management of Frozen Shoulder

Non-surgical management

Freezing or painful phase

Aims at pain relief

Initial treatment of Choice

Surgical management

Frozen or thawing phase

Aims at regaining the ROM

Surgical management

• Manipulation Under Anaesthesia (MUA)

considered gold standard

carries risks like fracture, dislocation, nerve injuries,

uncontrolled rupture of capsule

injuries to soft tissues

does not alter the time course of disease

contraindicated in osteoporosis, in post-surgery, post-trauma stiffness

• Arthroscopic capsular release

Arthroscopic capsular release

Advantages

• Allows controlled and precise capsular release

• Synovectomy

• Allows evaluation and possible treatment of additional pathology

• Joint distention via arthroscopic inflow

Arthroscopic capsular release

Indications

Idiopathic Adhesive capsulitis Non-responders (refractory cases)

Surrenders

When MUA fails to restore movements

Where MUA is contraindicated

Recurrence of stiffness after MUA

Adhesive capsulitis secondary to intrinsic shoulder pathology

Adhesive capsulitis associated with diabetes

Post surgical

Post traumatic

Arthroscopic capsular release

The Principle:

• A tightened coraco humeral ligament and rotator interval with contracted capsule are the “essential lesions” in adhesive capsulitis.

• Resection of these structures combined with appropriate exercises will restore ROM and relieves pain

NORMAL SHOULDER

FROZEN SHOULDER

Rotator interval

• The principal site of pathology

• Anatomy of rotator interval

• Contents of rotator interval Superior Glenohumeral Ligament(SGHL)

Anterior Superior Capsule

Coracohumeral Ligament(CHL)

Rotator interval

Arthroscopic capsular release

Timing

when to be advised

minimum of 6months period of conservative management

Arthroscopic capsular release

Surgical technique

Anaesthesia

G.A. with interscalene brachial block

Position of patient

lateral decubitus position

Arthroscopic portals

posterior portal

anterior superior portal

Arthroscopic capsular release

Rotator interval release

E.R. in adduction

superior gleno humeral ligament

anterior superior capsule

coraco humeral ligament

Middle glen humeral ligament release

E.R.in 450 of abduction

Sub scapular delineation

HUMERAL HEAD

MIDDLE GLENO HUMERAL LIGAMENT

HUMERAL HEAD

SUB SCAPULAR TENDON

SUBSCAPULAR TENDON

Arthroscopic capsular release

Release of inferior capsule

Rotations in 90 0 of abduction

Release of posterior capsule

Forward flexion and I.R

Manipulation of shoulder

HUMERAL HEAD

GLENOID

INFERIOR CAPSULE

HUMERAL HEAD

GLENOID

AFTER CUTING INFERIOR CAPSULE

HUMERAL HEAD

GLENOID

POSTERIOR CAPSULE

GLENOID

AFTER CUTTING POSTERIOR CAPSULE

Arthroscopic capsular release

Post-operative management

• For maintenance of gains in ROM

• Shoulder kept in full abduction and external rotation

• Interscalene block for 48 hrs

• Aggressive physiotherapy

Arthroscopic capsular release

Case Details

Name: Yellamma Age/Sex: 50 / Female

Occupation: Manual Labourer

Duration of Symptoms : 9 Months

Diagnosis: idiopathic adhesive Capsulitis

Clinical Video Surgical Video

Post operative Pictures

Arthroscopic capsular release

Authors

`

No. of pts

Mean age yrs

M;F ratio

Mean time of preop symptoms

Surgical treatment

Mean follow up

results

SEGMULLER et al 24 50 14:10 Not stated Arthroscopic release

13.5 months 88%satisfied 76% normal function

Beufils et al 25 48 6:19 13 months Arthroscopic release

21 months 69% very satisfied or satisfied

Watson et al 73 52 42:31 19.7 mnths Arthroscopic release

12 months Pain reduced by 2.2wks ROM 10% that of other shoulder by 5.5 wks

jerosch 28 49 13:15 24 months Arthroscopic release

26 Mean constant score inrease by 41 points

Benett 31 60 12:19 Min 6wks Arthroscopic release

18months Mean constant score increase 37 to 78 points

Nicholson 68 50 27:41 Not stated Arthroscopic release

3yrs Increase in ASES 35.5 TO 93 points

Clinical Studies

Conclusion

Arthroscopic Capsular Release is a reliable treatment for improving ROM

in patients with Refractory idiopathic Capsulitis , Secondary adhesive

Capsulitis, Post traumatic and Post operative Shoulder Stiffness

So the Arthroscopic Capsular Release should be in the

Armamentarium of Orthopaedic Surgeon for the management of refractive

adhesive Capsulitis

Thank You