- Email: [email protected]
Frozen shoulder. Arthroscopy and manipulation under general anaesthesia and early passive motion
$24
35
J. ShoulderElbow Surg. March/April 1996
Abstracts
RESTRICTION OF GLENOHUMERAL MOTION IN PATIENTS WITH FROZEN SHOULDERS. M. L. Pearl, MD, C. C. Frank, MSPT, & K. A. Wang, MSPT, Department of Orthopedics, Southern California Permanente Medical Group, Los Angeles, CA. Frozen shoulders demonstrate a restricted passive range of motion at the gtenohumeral joint. Traditional measurements of shoulder motion assess the motion between the arm and thorax and, therefore, do not allow precise quantification of the restriction to motion where it occurs. This study introduces a clinical method for quantifying glenohumeral range of motion (GHROM) derived from a more comprehensive method published previously.* The G H R O M was measured in 20 consecutive patients with the clinical condition of a unilateral frozen shoulder. Frozen shoulders presented with 31% of the G H R O M observed on the uninvolved side. Motion was restricted in all directions. Maximal elevation occurred with the humerus in planes anterior to the plane of the scapula in contrast to the non-frozen shoulder in which maximal elevation occurred in the plane of the scapula. The G H R O M correlated well with conventional measures of humerothoracic elevation (p=.001), external rotation (p=.0001) and internal rotation (i>=.007). T h e clinical distinction between a frozen shoulder a n d a stiff shoulder can be difficult. In this study, frozen shoulders presented with a profound restriction in GHROM (95% confidence interval <50%). Humerothoracie measures of shoulder motion were also restricted but in ways that may obscure recognition of frozen shoulders that are less severe, or those in patients with greater than average scapulothoracic motion. For example, the mean humerothoraeic elevation was 63% of that observed on the normal side (95% confidence interval <83%). A frozen shoulder with 83% of the normal shoulder's humerothoracic elevation may be more readily recognized from a 50% or more reduction in GHROM.
37
ARTHROSCOPIC MANAGEMENT OF REFRACTORY SHOULDER STIFFNESS. D. T. Harryman II, MD, F. A. Matsen III, MD, J. A. Sidles, Ph.D., Dept of Orthopaedics, University of Washington, Seattle, WA. IntroduoUon: Glsnohumeral stiffness is a major cause of shoulder disability and pain. Conventional management strategies have not yielded consistant or prompt return of comfort and function. We have developed an effective approach to glenohumeral stiffness which employs arthroscopic retease of refractory capsular contracture. Methods: This report concerns twenty-six patients who failed at least six months (mean 27 • 30) of non-operative management for unilateral refractory shoulder stiffness. All patients were managed by arthroscepir capsular release and ten were diabetic. Each patients' range, motion and stability was documented according to the American Shoulder and Elbow Surgeons standard examination. Results: Before surgery, active range of motion for the affected extremity averaged 38% of the oppos=te asymptomatic side. Patient-assessed functional outcome was measured using the Simple Shoulder test before and after surgery. Only 8 • 28% were able to sleep comfortably on their side and 28 • 46% could place one pound on a shelf at shoulder height before surgery. Motion was improved dramatically immediately following surgery. An additional 15% of motion was gained after discharge from the hospital. The final motion averaged 91% of the opposite side. Functional improvement revealed 72 • 46% able to sleep comfortably on the affected side and 92 • 28% were able to place one pound on a shelf at shoulder height after surgery. There were no differences in the assessment of motion or function between those with short-term follow-up (18 months or less in 10 patients, mean 6 months) and those with long-term follow-up (greater than 18 months in 16 patients, mean 36 months). Also, there were no differences in all outcome measures between diabetic or non-diabetic patients. Three patients had persistent symptomatic stiffness. The only complication was a single axillary neuropraxia which resolved spontaneously. No patients developed instability. Conclusion: Arthroscopic capsular release can be a safe and effective tool in the management of refractory shoulder stiffness.
38
FROZEN SHOULDER. ARTHROSCOPY AND MANIPULATION UNDER GENERAL ANAESTHESIA AND EARLY PASSIVE MOTION. J,O.Sojbjerg,MD, N.H.Andersen,MD, H.V.Johanssen,MD, & O.Sneppen,MO. Shoulder and Elbow Clinic, University Hospital in Aarhus, Denmark. The aim of the study was to present the prefiminary ~'esults of manipulation, arthroscopic evaluation and eady passive motion in 24 consecutive patients suffering resistant frozen shoulders. Thirteen females and 11 males suffering resistant adhesive capsulitis of the shoulder, with a mean age of 46 years were treated over a 20 r~onths period. Twelve could be classified as primary cases and 12 patients were secondary, including 6 systemic (DM), one extrinsic and five intrinsic. Twenty-one patients had a reduction of active forward elevation > 50% compared to the unaffected shoulder and three a reduction between 25% and 50%. The mean pre-operative Constant score of the affected shoulder was 31 (range 15-55) compared to mean B4 points of the unaffected shoulder. Manipulation was carefully undertaken after arthroscopy, including forced elevation followed by abduction, internal rotation and finally external rotation. A catheter connected to an automatic bupivacaine pump system was introduced into the subacromial space for postoperative pain treatment. Early passive motion was started immediately after manipulation guided by a physiotherapist and often supplemented by CPM. At follow up mean 6 months postoperatively 12 patients had an active elevation > 135 degrees, ten between 90 and 135 degrees, and two < 90 degrees. The mean Constant score was 60 (range 32-91). No early or late complications were recorded. Conclusion: Arthroscopy and manipulation under GA followed by early passive motion seems to be successful in the treatment of patients with resistant adhesive capsulitis of the shoulder. The long term follow up will show if the improvements can be maintained.
*Pearl M.L., Jackins S., Lippitt S., et al. Humero-Scapular Positions in a Shoulder Range of Motion Examination. J Shoulder & Elbow Surg, 1:296-305, 1992.
36
ARTHROSCOPIC T R E A T M E N T OF ADHESIVE CAPSULITIS. Charlotte S Hogan, David E Taylor, Helen E Segmuller, Andrew D Saies and Michael G Hayes. From SPORTSMED-SA, ADELAIDE, SOUTH AUSTRALIA While conservative management with or w~lhout manipulation under anaesthesia is the generally accepted treatment strategy for adhesive capsulitis, considerable interest is being shown in arthroscopic surgical procedures for this disorder. This study reviews the outcome of patients who underwent an arthroscopic release of the inferior capsule reproducing in a controlled fashion, the traumatic disruption of the inferior capsule commonly caused by manipulation under anaesthesia. The outcome of 24 patients (26 shoulders) was assessed with an average follow-up of 13.5 months. 88% of patients were very satisfied with the procedure and no operative compJications OCGurred. A return to normal or near normal shoulder function in 76% or more of the study group for forward f~exion, abduction, and external rotation was demonstrated. 50% of patients still exhibited some restriction in internal rotation. The Constant Scoring system, also used to assess clinical shoulder function, revealed 87% of patients had achieved an excellent or good result, when compared to the contra-lateral normal shoulder score. Our results suggest that arthroscopic capsular release is a logical and effective treatment of adhesive capsulifis, with patterns of recovery that compare favourebly to other treatment modal•
35
J. ShoulderElbow Surg. March/April 1996
Abstracts
RESTRICTION OF GLENOHUMERAL MOTION IN PATIENTS WITH FROZEN SHOULDERS. M. L. Pearl, MD, C. C. Frank, MSPT, & K. A. Wang, MSPT, Department of Orthopedics, Southern California Permanente Medical Group, Los Angeles, CA. Frozen shoulders demonstrate a restricted passive range of motion at the gtenohumeral joint. Traditional measurements of shoulder motion assess the motion between the arm and thorax and, therefore, do not allow precise quantification of the restriction to motion where it occurs. This study introduces a clinical method for quantifying glenohumeral range of motion (GHROM) derived from a more comprehensive method published previously.* The G H R O M was measured in 20 consecutive patients with the clinical condition of a unilateral frozen shoulder. Frozen shoulders presented with 31% of the G H R O M observed on the uninvolved side. Motion was restricted in all directions. Maximal elevation occurred with the humerus in planes anterior to the plane of the scapula in contrast to the non-frozen shoulder in which maximal elevation occurred in the plane of the scapula. The G H R O M correlated well with conventional measures of humerothoracic elevation (p=.001), external rotation (p=.0001) and internal rotation (i>=.007). T h e clinical distinction between a frozen shoulder a n d a stiff shoulder can be difficult. In this study, frozen shoulders presented with a profound restriction in GHROM (95% confidence interval <50%). Humerothoracie measures of shoulder motion were also restricted but in ways that may obscure recognition of frozen shoulders that are less severe, or those in patients with greater than average scapulothoracic motion. For example, the mean humerothoraeic elevation was 63% of that observed on the normal side (95% confidence interval <83%). A frozen shoulder with 83% of the normal shoulder's humerothoracic elevation may be more readily recognized from a 50% or more reduction in GHROM.
37
ARTHROSCOPIC MANAGEMENT OF REFRACTORY SHOULDER STIFFNESS. D. T. Harryman II, MD, F. A. Matsen III, MD, J. A. Sidles, Ph.D., Dept of Orthopaedics, University of Washington, Seattle, WA. IntroduoUon: Glsnohumeral stiffness is a major cause of shoulder disability and pain. Conventional management strategies have not yielded consistant or prompt return of comfort and function. We have developed an effective approach to glenohumeral stiffness which employs arthroscopic retease of refractory capsular contracture. Methods: This report concerns twenty-six patients who failed at least six months (mean 27 • 30) of non-operative management for unilateral refractory shoulder stiffness. All patients were managed by arthroscepir capsular release and ten were diabetic. Each patients' range, motion and stability was documented according to the American Shoulder and Elbow Surgeons standard examination. Results: Before surgery, active range of motion for the affected extremity averaged 38% of the oppos=te asymptomatic side. Patient-assessed functional outcome was measured using the Simple Shoulder test before and after surgery. Only 8 • 28% were able to sleep comfortably on their side and 28 • 46% could place one pound on a shelf at shoulder height before surgery. Motion was improved dramatically immediately following surgery. An additional 15% of motion was gained after discharge from the hospital. The final motion averaged 91% of the opposite side. Functional improvement revealed 72 • 46% able to sleep comfortably on the affected side and 92 • 28% were able to place one pound on a shelf at shoulder height after surgery. There were no differences in the assessment of motion or function between those with short-term follow-up (18 months or less in 10 patients, mean 6 months) and those with long-term follow-up (greater than 18 months in 16 patients, mean 36 months). Also, there were no differences in all outcome measures between diabetic or non-diabetic patients. Three patients had persistent symptomatic stiffness. The only complication was a single axillary neuropraxia which resolved spontaneously. No patients developed instability. Conclusion: Arthroscopic capsular release can be a safe and effective tool in the management of refractory shoulder stiffness.
38
FROZEN SHOULDER. ARTHROSCOPY AND MANIPULATION UNDER GENERAL ANAESTHESIA AND EARLY PASSIVE MOTION. J,O.Sojbjerg,MD, N.H.Andersen,MD, H.V.Johanssen,MD, & O.Sneppen,MO. Shoulder and Elbow Clinic, University Hospital in Aarhus, Denmark. The aim of the study was to present the prefiminary ~'esults of manipulation, arthroscopic evaluation and eady passive motion in 24 consecutive patients suffering resistant frozen shoulders. Thirteen females and 11 males suffering resistant adhesive capsulitis of the shoulder, with a mean age of 46 years were treated over a 20 r~onths period. Twelve could be classified as primary cases and 12 patients were secondary, including 6 systemic (DM), one extrinsic and five intrinsic. Twenty-one patients had a reduction of active forward elevation > 50% compared to the unaffected shoulder and three a reduction between 25% and 50%. The mean pre-operative Constant score of the affected shoulder was 31 (range 15-55) compared to mean B4 points of the unaffected shoulder. Manipulation was carefully undertaken after arthroscopy, including forced elevation followed by abduction, internal rotation and finally external rotation. A catheter connected to an automatic bupivacaine pump system was introduced into the subacromial space for postoperative pain treatment. Early passive motion was started immediately after manipulation guided by a physiotherapist and often supplemented by CPM. At follow up mean 6 months postoperatively 12 patients had an active elevation > 135 degrees, ten between 90 and 135 degrees, and two < 90 degrees. The mean Constant score was 60 (range 32-91). No early or late complications were recorded. Conclusion: Arthroscopy and manipulation under GA followed by early passive motion seems to be successful in the treatment of patients with resistant adhesive capsulitis of the shoulder. The long term follow up will show if the improvements can be maintained.
*Pearl M.L., Jackins S., Lippitt S., et al. Humero-Scapular Positions in a Shoulder Range of Motion Examination. J Shoulder & Elbow Surg, 1:296-305, 1992.
36
ARTHROSCOPIC T R E A T M E N T OF ADHESIVE CAPSULITIS. Charlotte S Hogan, David E Taylor, Helen E Segmuller, Andrew D Saies and Michael G Hayes. From SPORTSMED-SA, ADELAIDE, SOUTH AUSTRALIA While conservative management with or w~lhout manipulation under anaesthesia is the generally accepted treatment strategy for adhesive capsulitis, considerable interest is being shown in arthroscopic surgical procedures for this disorder. This study reviews the outcome of patients who underwent an arthroscopic release of the inferior capsule reproducing in a controlled fashion, the traumatic disruption of the inferior capsule commonly caused by manipulation under anaesthesia. The outcome of 24 patients (26 shoulders) was assessed with an average follow-up of 13.5 months. 88% of patients were very satisfied with the procedure and no operative compJications OCGurred. A return to normal or near normal shoulder function in 76% or more of the study group for forward f~exion, abduction, and external rotation was demonstrated. 50% of patients still exhibited some restriction in internal rotation. The Constant Scoring system, also used to assess clinical shoulder function, revealed 87% of patients had achieved an excellent or good result, when compared to the contra-lateral normal shoulder score. Our results suggest that arthroscopic capsular release is a logical and effective treatment of adhesive capsulifis, with patterns of recovery that compare favourebly to other treatment modal•