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Surgery done in the subacute stage of adhesive capsulitis relieves pain, stiffness
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Idiopathic adhesive capsulitis, or frozen shoulder, should be diagnosed early and correctly. It is a global loss of glenohumeral motion secondary to capsular stiffness of the shoulder, usually starting as inflammation and progressing to fibrosis.
Once frozen shoulder is diagnosed, depending on the stage, it is amenable to physical therapy that involves progressive capsular stretching, subacromial or glenohumeral steroid injections done under fluoroscopic guidance, or to treatment with anti-inflammatory medication. These conservative therapies can be helpful in most cases, and some investigators have reported up to 90% satisfactory outcomes in about 3 months to 4 months with such approaches, including when patients performed self-directed exercises.
There is however, a role — albeit a limited one — for surgery to treat idiopathic frozen shoulder.
Indications for surgery
Surgery to treat idiopathic adhesive capsulitis is typically resorted to when the patient’s pain is recalcitrant to steroid injections or when the patient has residual pain and substantial stiffness following 4 months to 6 months of conservative management.
The most common indication for surgery is residual pain or residual functional restrictions after conservative management. This is a consideration in patients who are working hard in therapy for months, but are still in a lot of pain and having continued stiffness of their shoulders.
Keep in mind that patients scheduled to undergo surgery for this condition should not be in the acute stage of frozen shoulder. This stage is characterized by severe pain and limited capsular stiffness. Often, the shoulder is so inflamed and painful that it is hard to assess the true extent of their stiffness.
Those in the subacute and chronic phases, however, may be eligible for surgery. In the subacute stage, scarring and thickening of the capsule start to set in along with more constant and intense pain and increased stiffness. The third stage, or chronic or thawing stage, is actually associated with reduced pain and stiffness that persists but is gradually lessened with time. In some cases with refractory stiffness in the chronic phase, arthroscopic release and manipulation can be helpful.
Arthroscopic technique
For surgery, the patient is placed in the beach chair position. We first perform a manipulation under anesthesia, but it is only done to elevation.
To keep the shoulder stabilized, we put pressure right behind the elbow and then do the release.
To avoid causing a humeral fracture, and because the interval capsule is thickest with a frozen shoulder, we avoid performing any external rotation manipulations.
Next, we release the rotator interval capsule (Figure 1). This is shown in a left shoulder. The patient is in the beach chair position, and the arthroscope is at the back of the image. The tendon in the front is the subscapularis, and above it is the biceps tendon. You can see the tightness and contraction of the interval capsule. The dimensions of the rotator interval are visibly diminished as well, since the capsule normally should be about 1 mm to 1.5 mm thick.
Figure 1. Inflamed appearance of the rotator interval region in the left shoulder.
Images: Keener JD
Start with capsular ablation
The first surgical step is to establish the anterior working portal. We then begin to ablate the interval capsule, working from deep to superficial areas. The goal at this point is to release the thickened capsule all the way to where the coracoacromial ligament is seen. By releasing to that depth, this ensures that the complete release of both the superficial and deep portion of the coracohumeral ligament occurs.
Next, the middle glenohumeral ligament is released. I prefer doing this step with a capsular biter, rather than a cautery wand, because the cartilage of the humeral head is quite close to where I am working and I do not want to damage it (Figure 2). We start the release with the cautery wand, but switch to a capsular biter to release the entire anterior capsule and the middle glenohumeral ligament inferiorly. This process is continued only until the point is reached where the capsule was ruptured during the manipulation done at the outset of the procedure.
As the capsule is gradually released, the humeral head falls away from the glenoid and the whole joint opens up (Figure 3). I find it rather amazing that the entire anterior capsule can be released without causing any instability issues.
Figure 2. Ablation of the thickened rotator interval capsule with electrocautery in the left shoulder is shown.
In cases with loss of internal rotation, the posterior capsule should be released. The arthroscope is switched to the anterior portal and a capsular biter is used to release the posterior capsule superiorly and inferiorly. Care is taken to protect the more superficially located rotator cuff muscles and tendons when releasing the posterior capsule.
Postoperative issues
In terms of postoperative range of motion, the only real restriction that remains is the subscapularis tendon. You have released the entire interval and the anterior capsule, which produces a good range of motion (Figure 4).
Figure 3. The anterior capsule and inferior gleno-humeral ligaments are released.
I start with physical therapy right away.
One technique pearl is that we now use interscalene catheters postoperatively. They are excellent for pain control and, more importantly, they allow you to have a family member or the therapist stretch the patient’s shoulder aggressively in the first 2 or 3 postoperative days, which is extremely beneficial. If patients can see that their shoulder can move fully and they are not having pain, this provides them with a huge psychological boost while completing their rehabilitation program.
Figure 4. Release of the inferior capsule is shown.
Also, we now routinely put a steroid injection into the shoulder. I introduce the needle into the joint under direct visualization and inject a little bit of the steroid after the case is completed, immediately after we close the portals. I think this practice has also proven helpful to the patients.
Arthroscopic surgical release followed by immediate postoperative rehabilitation and motion has been a successful treatment for frozen shoulder when done in the subacute and chronic phases of the condition, but only after appropriate conservative management has failed.
Reference:
Keener JD. Adhesive capsulitis-nonoperative strategies and operative technique. Presented at Orthopedics Today Hawaii 2012. Jan. 15-18. Wailea, Hawaii.
For more information:
Jay D. Keener, MD, can be reached at the Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington University, 660 South Euclid Ave., Campus Box 8233, St. Louis, MO 63110; email: keener@wustl.edu.