in Arthroscopic Release of the Stiff Shoulder

Fig. 3.1

Arthroscopic capsular release (left shoulder, visualisation from the antero-lateral portal). The capsule is released in a 360° fashion, incision of the anterior (a) and posterior (b) capsule with the radiofrequency probe

The most commonly reported complication in stiff shoulder release in the literature, however, is recurrence, with a described incidence as high as 11% [23, 24, 39]. The inferior and posterior capsule is often dramatically thickened and fibrotic, therefore, in cases of global shoulder stiffness we routinely perform a circumferential 360° release. The main restraint to shoulder mobility is usually the severely thickened rotator interval. In order to avoid recurrence of external rotational restrictions we usually not only release but also resect the rotator interval from the upper border of subscapularis to the anterior border of supraspinatus with a shaver to avoid further scarring (Fig. 3.2). Medially the lateral coracoid is skeletonized, laterally the interval is resected up to the medial pulley sling, which is spared so as not to jeopardise biceps stability. If the biceps tendon appears scarred to the articular layers of the supraspinatus or the rotator interval, however, long head of biceps tenotomy is often indispensable, and if in doubt should be performed anyway. Biceps tenodesis, by contrast, may carry the risk of further intraarticular scarring, and is in our experience unnecessary in any case, as the scarred biceps tendon tends to self-tenodese in the bicipital groove. A post-operative “popeye” deformity following simple tenotomy in stiff shoulder release is rare [4].

../images/437034_1_En_3_Chapter/437034_1_En_3_Fig2_HTML.png — Fig. 3.2

Release of a severely scarred rotator interval in post-operative shoulder stiffness following a proximal humerus fracture osteosynthesis (right shoulder, visualisation from the posterior portal). The interval is widely opened. Labrum (L), Conjoined tendon (CT), Subscapularis tendon (SSC)

Following interval resection, thorough haemostasis using electrocautery should be performed to avoid post-operative haemarthrosis and recurrence of intra-articular scarring.

Finally, in our practice, an intra-articular injection of corticosteroids is routinely performed at the end of the procedure to minimize the risk of further inflammation and recurrent adhesions.

Particularly in cases of secondary shoulder stiffness, following trauma or surgery, the subacromial space is often affected by severe scarring [10]. Thus, the subacromial space should also be addressed, in order not to compromise the patient’s outcome. This is usually performed after the capsular release to avoid early soft tissue swelling which would hamper intra-articular dissection. In post-surgical cases of stiffness, i.e. open reduction and internal fixation of proximal humerus or glenoid fractures, subacromial release is often accompanied by hardware removal via an mini-open or arthroscopic-assisted approach.

At the end of the procedure the shoulder should be assessed for range of motion to ensure, and document, an adequate surgical release. A brusque manipulation of the glenohumeral joint must not be performed as it bears the risk of iatrogenic fractures, glenohumeral dislocation, osteochondral lesions and soft tissue trauma [40].

3.4 Immediate Postoperative Complications

Besides typical complications in the immediate post-operative setting such as infection, haematoma and wound dehiscence, specific complications of an arthroscopic stiff shoulder release include insufficient post-operative rehabilitation, insufficient pain therapy, as well as post-operative shoulder instability.

Post-operative infections following an arthroscopic capsular release have been rarely described in the literature. While most studies report no post-operative infections, Jerosch et al. [23] reported of a single case of infection in their large population of 173 shoulders, which corresponds to an overall infection rate of 0.57% [4, 11, 19, 41].

To our knowledge, only a single case of post-release shoulder instability has been published. Gobezie et al. [42] reported a case of shoulder instability 6 weeks after arthroscopic revision stiff shoulder release. The patient was treated successfully with conservative measures.

Insufficient post-operative mobilisation of the shoulder, often due to insufficient pain control, is by far the most common issue during the immediate post-operative period. In order to maintain the achieved range of motion immediate and intensive physiotherapy is mandatory, starting immediately following surgery, at least twice per day during in-patient hospital stay, and on a daily basis after discharge for at least 2 weeks. Afterwards therapy is individualised and patients are encouraged to use hydro-therapy whenever possible.

All patients receive an interscalene brachial plexus catheter prior to surgery, which is left in situ for the duration of the in-patient stay in hospital. NSAIDs are recommended for at least 2 weeks post-operatively, both for pain relief and the prevention of secondary heterotrophic ossification.

No sling immobilisation is permitted and patients are encouraged to use their shoulder again for activities of daily living as soon as they are able.

3.5 Mid-Term Complications

The benefit of capsular release of the shoulder may be appreciated immediately following surgery. Especially if interscalene brachial plexus catheter is left in situ during in-hospital stay, patients are often impressed with the early post-operative results.

In order to avoid early dissatisfaction, however, patients should be informed that following removal of the regional block catheter, a certain range of motion is often lost and has to be regained in the following weeks and months of physiotherapy. Final range of motion, and pain reduction, is usually achieved between 3 and 6 months post-operatively, but may take up to a year in some cases [4, 10, 11, 18, 19, 35, 41, 43].

Recurrence of stiffness following shoulder release has been reported to be as high as 11% in early outcome studies [39]. More recent studies reporting the outcomes of large and representative patient populations, however, describe recurrence rates of between 3% and 6% [23, 24].

3.6 Long Term Complications

Other than recurrence, arthroscopic release of the stiff shoulder does not carry any specific long-term complications. As described previously, risk of recurrence is affected by many modifiable and non-modifiable factors. Long-term outcome studies have seen that the achieved range of motion and pain reduction can be maintained, and even further improved upon, on follow-up up to 7 years post-operatively [19, 20].