This article is more than 5 years old. Information may no longer be current.
L-shaped release leads to better internal rotation in primary frozen shoulder
Click Here to Manage Email Alerts
Mohamed Gamal Morsy
Frozen shoulder can often cause significant pain and limited shoulder motion. In cases that are resistant to nonoperative treatment including physiotherapy, a standard well-established arthroscopic release can effectively improve range of motion and comfort.
Figure 1. This schematic describes the idea of the new L-shaped release and compares it to the standard longitudinal technique.
Images: Morsy MG
However, after a standard arthroscopic capsular release, the patient’s shoulder internal rotation (IR) may remain limited. This is usually attributed to inadequate release of the tight posterior capsule. Therefore, the postoperative limitation of IR is considered a common complaint that diminishes the success of the procedure.
A new L-shaped arthroscopic posterior capsular release technique is described in refractory primary frozen shoulder cases in the hope of improving the postoperative IR range of motion. Unlike the standard longitudinal posterior capsular release, the new L-shaped technique aims at creating a large controlled posterior capsule opening which not only increases the length of the posterior capsule, but also may prevent the postoperative re-closure of the released capsule encountered with the longitudinal release (Figure 1).
In our practice, both techniques are done in a semi-sitting position with the arthroscope looking from the anterior shoulder portal whereas the radiofrequency (RF) ablation device is inserted from the posterior portal.
In the standard longitudinal technique, the posterior release begins from the glenoid level down to 6 o’clock position using the RF device. Then a shaver is inserted to remove any remaining debris and is used to complete the release of the posterior capsule until the fibers of the infraspinatus muscle appear (Figure 2).
Figure 2. The longitudinal release is seen with the appearance of the infraspinatus muscle.
Figure 3. The transverse release is done using the hook-tip of the radiofrequency ablation device.
In addition to the longitudinal release described before, the hook-tip part of the RF ablation device is used to do a transverse release in the posterior capsule, starting from the beginning of the longitudinal limb (Figure 3), superior to the level of the axillary nerve.
The transverse limb of the release is performed in a stepwise fashion going step by step laterally, but ends before reaching the rotator cuff in order to avoid any damage to the cuff (Figure 4).
After performing the L-shaped release of the posterior capsule, the area of the opening becomes larger. The posterior capsule will eventually heal in a wide position and this may improve the patient’s range of IR. The posterior capsule is also able to move more after the L-shaped arthroscopic release, and this in turn minimizes the risk of postoperative re-closure of the release (Figure 5).
Figure 4. Shown is how adherent the capsule is to the posterior structures.
Figure 5. Increased movement of the posterior capsule is evident at the end of the L-shaped release.
After the procedure a postoperative sling is applied for comfort. The rehabilitation program is the same in both techniques and consists of immediate postoperative passive and active assisted exercises followed by strengthening exercises.
The Constant and VAS scores were used to compare postoperative results in the 21 patients who underwent the L-shaped release and the 22 patients who had a standard release. At a mean follow-up of 21 months (range, 16 months to 24 months), the Constant scores, as well as the VAS scores were improved significantly in both groups with no differences in the two groups’ results.
In terms of the achieved range of motion, forward elevation and external rotation of the shoulder improved significantly in both groups. However, the range of IR was more improved in the group with the L-shaped capsule release than in the group with the standard release.
The addition of an L-shaped posterior capsule release in patients undergoing arthroscopic capsular release for primary frozen shoulder is a novel technique that is associated with significantly improved postoperative IR range of motion.
Reference:
Morsy MG. Paper #FP14-1470. Presented at: European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress; May 14-17, 2014; Amsterdam.
For more information:
Mohamed Gamal Morsy, MD, is a professor of Orthopedic Surgery at Alexandria University – Egypt. He can be reached at 8 Toson St., Gleem, El Ramel, 21411, Alexandria, Egypt; email: morsimoh@gmail.com.
Disclosure: Morsy has no relevant financial disclosures.