Rev. bras. ortop. vol.52 número1

r e v b r a s o r t o p . 2017;52(1):61–68

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Clinical

evaluation

of

arthroscopic

treatment

of

shoulder

adhesive

capsulitis

夽

Alberto

Naoki

Miyazaki,

Pedro

Doneux

Santos,

Luciana

Andrade

Silva

_,

Guilherme

do

Val

Sella,

Leonardo

Carrenho,

Sergio

Luiz

Checchia

FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCMSCSP),DepartamentodeOrtopediaeTraumatologia,GrupodeCirurgia doOmbroeCotovelo,SãoPaulo,SP,Brazil

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Articlehistory:

Received29October2015 Accepted11April2016

Availableonline20December2016

Keywords:

Shoulderpain Arthroscopy Bursitis

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Objective:Toevaluatetheresultsofarthroscopicreleasesperformedinpatientswith adhe-sivecapsulitisrefractorytoconservativetreatment.

Methods:Thiswasaretrospectivestudy,conductedbetween1996and2012,whichincluded 56shoulders(52patients)thatunderwentsurgery;38werefemale,and28hadthe domi-nantsideaffected.Themeanagewas51(29–73)years.Themeanfollow-upwas65(12–168) monthsandthemeanpreoperativetimewas8.9(2–24)months.AccordingtoZukermann’s classification,23caseswereconsideredprimaryand33secondary.Withthepatientinthe lateraldecubitusposition,circumferentialreleaseofthejointcapsulewasperformed:joint debridement;rotatorintervalopening;coracohumeralligamentrelease;anterior,posterior, inferior,andfinallyantero-inferiorcapsulotomy.Asubscapularistenotomywasperformed whennecessary.Allpatientsunderwentintensephysicaltherapyintheimmediate post-operativeperiod.In33shoulders,aninterscalenecatheterwasimplantedforanesthetic infusion.FunctionalresultswereevaluatedbytheUCLAcriteria.

Results:Improvedrangeofmotionwasobserved:meanincreaseof45◦_{ofelevation,41}◦_of externalrotationandeightvertebrallevelsofmedialrotation.AccordingtotheUCLAscore excellentresultswereobtainedin25(45%)patients;good,in24(45%);fair,intwo(3%);and poor,intwo(7%).Patientswhohadundergoneinferiorcapsulotomyachievedbetterresults. Only8.8%ofpatientswhousedtheanestheticinfusioncatheterunderwentpostoperative manipulation.Sevenpatientshadcomplications.

Conclusion: Therewasimprovementinpainandrangeofmotion.Inferiorcapsulotomyleads tobetterresults.Theuseoftheinterscaleneinfusioncatheterreducesthenumberof re-approaches.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheFaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCMSCSP),DepartamentodeOrtopediae Trau-matologia,GrupodeCirurgiadoOmbroeCotovelo,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:lucalu@terra.com.br(L.A.Silva). http://dx.doi.org/10.1016/j.rboe.2016.12.004

62

Avaliac¸ão

dos

resultados

do

tratamento

artroscópico

da

capsulite

adesiva

do

ombro

Palavras-chave:

Dordeombro Artroscopia Bursite

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e

s

u

m

o

Objetivo: Avaliarosresultadosdasliberac¸õesartroscópicasfeitasempacientescom cap-suliteadesivarefratáriaaotratamentoconservador.

Métodos: Trabalhoretrospectivofeitoentre1996e2012,com56ombros(52pacientes) sub-metidosacirurgia;38eramdosexofemininoe28tinhamoladodominanteacometido. Amédiadeidadefoide51(29-73)anos.Oseguimentomédio,de65(12-168)meseseo tempomédiodepré-operatório,de8,9(2-24)meses.Pelaclassificac¸ãodeZukermann,23 casosforamconsideradosprimáriose33secundários.Comopacienteemdecúbitolateral, fizemosaliberac¸ãocircunferencialdacápsulaarticular:desbridamentoarticular,abertura dointervalorotador,liberac¸ãodoligamentocoracoumeral,capsulotomiaanterior, poste-rior,inferiorefinalmente,anteroinferior.Atenotomiadosubescapularfoifeitaquando necessária.Todosforamsubmetidosafisioterapiaintensanopós-operatórioimediato.Em 33ombrosfoiimplantadoocatéterinterescalênicoparainfusãodeanestésico.Os result-adosfuncionaisforamavaliadospeloscritériosdoescoredaUniversityofCaliforniaatLos Angeles(UCLA).

Resultados: Obtivemosmelhoriadoarcodemovimento:aumentomédiode45◦_{deelevac¸ão,} 41◦_{derotac¸ãolateraleoitoníveisvertebraisderotac¸ãomedial.PeloescoredaUCLA,tivemos} 25resultadosexcelentes(45%),25bons(45%),doisrazoáveis(3%)equatroruins(7%).Os pacientesquefizeramcapsulotomiainferiorevoluírammelhordoqueosquenãofizeram. Apenas8,8%dospacientesqueusaramcateterdeinfusãoanestésicoforamsubmetidosa manipulac¸ãonopós-operatório.Setepacientesapresentaramcomplicac¸ões.

Conclusão: Houvemelhoriadadoredoarcodemovimento.Acapsulotomiainferiorleva amelhoresresultados.Ousodocatéterinterescalênicodeinfusãoanestésicadiminuio númerodereabordagens.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Theterm“adhesivecapsulitis”wasfirstdescribedbyNeviaser in1945,asaninflammatorydiseaseoftheshoulderjoint cap-sulethatdevelopswithcontractureandresultsinstiffness andpain.1

Treatment aims to control pain and recover range of motion. Initially, treatment is conservative, especially in the acute phase2,3_{; there are several therapeutic options,}

suchasphysicaltherapy,corticosteroidsand/ornon-steroidal anti-inflammatorydrugs(NSAIDs),andsuprascapularnerve blocks.4–7 _{Inreview articles,Checchia etal.}7 _{and Robinson}

etal.5_{demonstratedgoodresultswhentreatingpatientswith}

physical therapy associated with anti-inflammatory drugs (hormonalandnon-hormonal)andserialsuprascapularnerve blocks.

Invasivetreatmentisindicatedincaseoffailureof con-servativetreatmentconductedforaminimumperiodofsix months;however, accordingtotheliteraturereviewed,this intervalmayrangefromsixweeksto12months.8–13

Proce-duresdescribedasinvasiveincludehydraulicdistentionofthe capsule(theliteraturedifferonitseffectivenessduetohigh recurrencerates),jointmanipulationunderanesthesia,and capsularrelease,whichcanbedonethroughopenor arthro-scopicsurgery.4–6,14

Joint manipulation under anesthesia, which was once widelyused,iscurrentlybeingdiscontinuedduetoits com-plications: fractures, glenoid labrum injuries, neurapraxis, rotatorcufftear,andpersistentpain.14–17

One of the first descriptions of the surgical technique for shoulder release through the open access route was made by Ozaki et al.,18 _{who advocated resection of the}

coracohumeral ligament and opening of the rotator inter-val. Literature shows that open surgery presents good results, but adds a greater morbidity than arthroscopy: it is difficult to release the posterior capsule and the intraoperative bleeding is greater, as well as postoperative pain, whichextendshospitalstay;furthermore, itis neces-sary to restrictmovements untilthe subscapularistendon heals.4,5,8,14,19

Recentstudieshaveshownexcellentresults,bothinterms of pain relief and range ofmotion gain,with arthroscopic releaseofadhesivecapsulitis.Itiscurrentlyconsideredtobe a reproduciblemethod, whichenables betteraccessto the entirejointcapsuleoftheshoulderwithlowratesof com-plications, sincethe release isdone graduallyunderdirect visionthroughaminimallyinvasivemethod,which nonethe-lessrequirespropertraining.8–11,19–21_{Literaturementionsas}

complicationsofthisproceduretheriskofiatrogenicinjury to the axillary nerve,22 _{chondral lesion due to the}

rev bras ortop.2017;52(1):61–68

63

chondrolysisduetothermalinjurycausedbytheuseof intra-articularradiofrequency.23

Thisstudy aimedtoevaluatethe resultsofarthroscopic releasesperformedinthisdepartmentinpatientswith adhe-sivecapsulitisrefractorytoconservativetreatment.

Material

and

methods

Thisstudyretrospectivelyanalyzed56shouldersof52patients who underwent arthroscopic release due to adhesive cap-sulitisrefractoryto conservative treatment. Surgerieswere performedbetweenFebruary1996andMay2012bythe Shoul-derandElbowGroupoftheSantaCasadeSãoPauloSchoolof MedicalSciences–FernandinhoSimonsenPavilion.

Patientswithadhesivecapsulitisrefractorytoconservative treatment,withaminimumfollow-upperiodofoneyear,with nootherabnormalitiesthatcouldjustifythelossofrangeof motion(osteoarthritis, malunion,andnecrosis,among oth-ers)wereincluded.Theclinicalandepidemiologicaldataare showninTable1.

Patients underwent conservative treatment for a mean periodof8.9months(2–24).Mostofthem(66%)weretreated withserialsuprascapularnerveblocksassociatedwith physio-therapy,withameanof12.2blocks.2–23_{Surgerywasindicated}

whentherewasnoresponsetoconservativetreatment,i.e., therewasimprovementinpain but patientremained with limitedjointmobility,whichhinderedtheirday-to-day activ-ities or even work activities. It was also indicated when patientcouldnotattendtheofficewiththeregularityneeded forundergoingblocks,thatis,every15daysuntilcomplete improvementofthecondition,whichtakessevenmonths,on average.7

Meanpostoperativefollow-upwas65months(12–168)and patients’ age ranged from 29 to 73 years (mean 51.2); 38 patientswere female (73%) and 14 male(27%). In 28 (54%) patients,thedominantlimbunderwentarthroscopicrelease; infourpatients(threefemaleandonemale),involvementwas bilateralandbothshouldersweresubjectedtothisprocedure (8%).

Regardingtheetiology,23shoulderswereclassified accord-ing toZuckermanand Rokito24 _{asprimary capsulitis (41%)}

and33assecondary(59%),20ofsystemicorigin.Ofthese,15 patientswerediabetic(29%oftotal),12hadintrinsiccauses (92.3%),andonehadextrinsiccauses(3.7%).

Patients underwent several arthroscopic procedures, whichvariedaccordingtotheneedandimprovementofthe surgicaltechnique,asshowninTable2.Withthepatient pos-itionedinlateraldecubitus,thefollowingstepsweretaken: through the anterior portal, joint debridement was made, therotatorintervalwasopened,thecoracohumeralligament wasreleased, and aninterior capsulotomywasperformed. Then,portalwaschanged.Throughtheposteriorportal, pos-teriorand inferiorcapsulotomies weremade. Finally,again through the anteriorportal, an anteroinferior capsulotomy was made with the aid of a basket-type forceps to avoid axillarynerveinjury.Attheendoftheseprocedures, circum-ferentialrelease of the joint capsulewas achieved. Lateral rotationwasclinicallyassessed;ifthegain wasconsidered

tobeinsufficient,apartialtenotomyofthesubscapulariswas made(Fig.1).

Fromthefirstdaypost-operativeonwards,patientswere subjectedtoanintensivephysicaltherapyworkwithpotent analgesia. An interscalene catheter was used in 33 shoul-ders(59%)foranesthesiainfusion(bupivacaine).Atdischarge, thecatheterwasremovedandpatientwasreferredfor out-patient physiotherapy sessions and received guidelines for performing capsular stretching exercisesathome. Patients werehospitalizedanaverageoffourdays.Inthefirstweeks, patientswereinstructed toattend4–5therapysessions per week; this schedule was modified according to patient’s improvement. On average, patients attended 53.4 sessions (12–139).

Theshoulder functional analysis criteriaby the Univer-sityofCaliforniaatLosAngeles(UCLA)25_{wasusedtoassess}

thepresentresults;shoulderrangeofmotionwasmeasured accordingtothecriteriasetforthbytheAmericanAcademy ofOrthopedicSurgeons.26

For thestatistical analysis,the followingprogramswere used:SPSS(StatisticalPackageforSocialSciences)version17, Minitab16,andExcelOffice2010,andthefollowingtestswere applied:ANOVA,Student’st-testforpairedsamples,equality oftwoproportions,andPearson’scorrelation.Toobtain the results,the95%confidenceintervalwasconsidered statisti-callysignificant(p<0.05).

Thisstudywasapprovedbythehospital’sethicscommittee underCAAENo.14412713.2.0000.5479.

Results

Patientspresentedanimprovedrangeofmotion.Mean pre-operativerangeofmotionwas96◦_{ofelevation,16}◦_oflateral rotation, andL5 medialrotation; afterarthroscopicrelease, meansbecame141◦ _{ofelevation,57}◦ _{oflateralrotation,and} T9medialrotation(p<0.001).

Whenpostoperativeresultswerecomparedwiththe con-tralaterallimb,excluding patientswho underwent bilateral arthroscopic release, a mean deficit of3◦ _{ofelevation was} observed(p=0.03).

Regarding the procedures, patients undergoing inferior capsulotomyhad ameanof8◦ _{ofelevation(p=0.057,close} tosignificancemargin),13◦_{oflateralrotation(p=0.003),four} vertebrallevels(p=0.002),and3.2pointsintheUCLAscore (p=0.021)morethanthosepatientswhodidnotundergo infe-riorcapsulotomy.

Patientsundergoingpartialtenotomyofthesubscapularis (25%)had lower preoperativelateral rotation(p=0.010)and elevation(p=0.062).Themeanelevationforthisgroupwas86◦_, andmeanlateralrotationwas5◦_{,whichwaslowerthanthe} 99◦_{ofelevationand20}◦_{oflateralrotationobservedinpatients} whodidnotundergothisprocedure.

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Table1–Patientclinicaldata.

Sex Age Dominant

side

Comorbidities Associated

lesions

Symptoms Pre-op

treatment

Rangeofmotion Post-opUCLA Follow-up Complications

T/years T/months T/months Pre-op. Post-op. Score Result T/months

Elev. LR MR Elev. LR MR

1 F 56 − DMII,SAH – 36 11 90◦ 35◦ L5 140◦ 45◦ T6 31 Good 23 Radialneurap.

2 F 43 + SAH,DMII _{– 36 18 95}◦ ₁₀◦ _{L4 130}◦ ₄₀◦ _{T10 27 Fair 50 –}

3 F 55 + DMI _{– 26 11 90}◦ ₂₀◦ _{Glut 150}◦ ₆₀◦ _{T11 33 Good 26 –}

4 F 44 + – – 7 5 70◦ ₂₀◦ _{Glut 150}◦ ₆₀◦ _{T8 33 Good 14 –}

5 F 56 − SAH – 17 11 90◦ 0◦ L5 125◦ 30◦ T8 30 Good 36 –

6 F 61 − SAH,DMII – 12 10 100◦ 15◦ L3 150◦ 45◦ T7 31 Good 72 –

7 F 47 + Epilep. – 24 18 70◦ ₃₀◦ _{S1 120}◦ ₄₀◦ _{T12 15 Bad 128 Pre-op+RCI}

8 F 45 + – – 22 13 90◦ ₀◦ _{S1 130}◦ ₅₀◦ _{S1 25 Fair 138 RSD}

− – – 15 15 100◦ ₁₀◦ _{T12 150}◦ ₆₀◦ _{T10 31 Good 72 –}

9 F 45 − SAH,DMII _{– 18 15 90}◦ ₀◦ _{Glut 150}◦ ₆₀◦ _{T7 35 Excellent 124 –}

+ – – 13 11 90◦ ₁₀◦ _{Glut 150}◦ ₆₀◦ _{L5 31 Good 124 PainAC}

10 F 47 + Asthma – 18 14 30◦ ₋₁₀◦ _{GT 90}◦ ₂₀◦ _{GT 15 Bad 51 Pre-op+RSD}

11 M 64 − DMII,SAH – 22 14 70◦ ₂₅◦ _{GT 130}◦ ₄₀◦ _{L1 30 Good 76 –}

12 F 49 + DMI – 42 7 90◦ ₀◦ _{Glut 120}◦ ₃₀◦ _{T10 30 Good 75 –}

13 F 52 + – Post-opRCI 13 13 100◦ ₃₀◦ _{L2 140}◦ ₆₀◦ _{T9 32 Good 64 –}

14 M 36 + Tab. Post-opft

GT+glenoid

34 23 125◦ ₀◦ _{L4 140}◦ ₄₀◦ _{T10 28 Good 67 –}

15 F 42 + SAH,Tab. Ft.humeralneck

surg.cons.treat.

49 10 90◦ ₄₀◦ _{Glut 120}◦ ₆₀◦ _{L3 30 Good 42 –}

16 F 56 + – – 24 22 90◦ ₂₀◦ _{S1 100}◦ ₂₀◦ _{L3 18 Bad 16 –}

17 F 55 + DMII_,SAH,

breastCA

– 24 24 80◦ ₄₅◦ _{Glut 130}◦ ₄₅◦ _{Glut 15 Bad 27 –}

18 M 55 − – Post-opcal.tend. 60 9 85◦ 10◦ L5 130◦ 70◦ T12 30 Good 22 –

19 F 67 + – – 8 8 70◦ ₀◦ _{GT 150}◦ ₄₅◦ _{T10 34 Good 115 –}

20 F 60 + Hypot. – 2.5 2.5 110◦ ₆₀◦ _{L5 140}◦ ₆₀◦ _{T8 32 Good 84 –}

21 M 60 + SAH,Dep. – 3.5 3 60◦ ₋₁₀◦ _{S1 150}◦ ₆₀◦ _{L4 35 Excellent 84 –}

22 F 55 + – – 5 5 110◦ ₁₀◦ _{L4 160}◦ ₆₀◦ _{T2 35 Excellent 39 –}

23 F 57 + DM,Coron. – 24 8 80◦ ₁₀◦ _{S1 140}◦ ₆₀◦ _{L5 35 Excellent 79 –}

24 F 57 − SAH – 13 6 90◦ ₂₀◦ _{L4 150}◦ ₈₀◦ _{T5 35 Excellent 27 –}

25 M 57 − DMII _{– 3 3 90}◦ ₁₀◦ _{S1 150}◦ ₈₀◦ _{T6 35 Excellent 70 –}

26 F 53 − – – 9.5 7 80◦ ₀◦ _{L5 150}◦ ₆₀◦ _{T7 35 Excellent 83 –}

27 M 51 + DMI _{Tend.calc. 36 12 100}◦ ₀◦ _{L5 150}◦ ₆₀◦ _{T10 35 Excellent 69 –}

28 F 45 + – – 12 8 80◦ ₁₀◦ _{L3 150}◦ ₆₀◦ _{T7 30 Good 74 –}

29 M 50 − – – 10 10 90◦ ₀◦ _{L5 140}◦ ₆₀◦ _{T10 34 Excellent 92 –}

30 F 49 + – – 24 24 100◦ ₂₀◦ _{L5 140}◦ ₆₀◦ _{T8 35 Excellent 118 –}

31 F 44 − – – 6 6 100◦ ₂₀◦ _{L5 160}◦ ₇₀◦ _{T5 35 Excellent 86 –}

32 M 43 + – Sd.impact 16 4 130◦ ₄₅◦ _{L1 140}◦ ₆₀◦ _{L1 35 Excellent 122 –}

33 M 43 + DMI _{– 13 5 120}◦ ₀◦ _{L3 150}◦ ₆₀◦ _{T10 35 Excellent 128 –}

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Table1–(Continued₎

Sex Age Dominant

side

Comorbidities Associated

lesions

Symptoms Pre-op

treatment

Rangeofmotion Post-opUCLA Follow-up Complications

T/years T/months T/months Pre-op. Post-op. Score Result T/months

Elev. LR MR Elev. LR MR

35 F 42 − – – 30 6 140◦ ₄₅◦ _{T10 150}◦ ₆₀◦ _{T6 35 Excellent 70 –}

36 M 29 − Tab. Ft.GT(cons.

treat.)

3 3 100◦ ₁₀◦ _{L2 140}◦ ₃₀◦ _{T12 28 Good 168 –}

37 F 35 − Hypot. – 5 3 80◦ ₀◦ _{S1 160}◦ ₄₅◦ _{T5 35 Excellent 16 –}

38 F 73 − SAH,DMII _{OsteoarthritisAC 4 3 130}◦ ₆₀◦ _{S1 140}◦ ₆₀◦ _{L4 34 Excellent 12 –}

39 F 65 − – – 3 3 70◦ ₀◦ _{S1 150}◦ ₇₀◦ _{T7 34 Excellent 25 Axillaryneurap.}

40 M 58 + – – 5 5 120◦ ₃₀◦ _{L4 140}◦ ₃₀◦ _{L1 32 Good 69 –}

41 F 52 − Dep. – 4 4 40◦−20◦ Glut 160◦ 80◦ T5 34 Excellent 107 Radialneurap.

42 F 55 − Hypot. – 8 6 100◦−10◦ L4 150◦ 60◦ T6 33 Good 44 –

43 F 57 − DLP Tend.calc. 12 6 120◦ 45◦ L5 150◦ 70◦ T7 33 Good 14 –

44 F 56 + DLP – 12 8 120◦ ₆₀◦ _{T12 160}◦ ₈₀◦ _{T3 35 Excellent 19 –}

45 M 52 + SAH,Hypot. – 7 2 100◦ ₂₀◦ _{L4 150}◦ ₈₀◦ _{T7 34 Excellent 85 –}

M − SAH,Hypot. – 3 3 120◦ 30◦ L5 150◦ 80◦ T6 35 Excellent 54 –

46 F 51 − – Wristft.+imob. 8 6 90◦ 10◦ L2 150◦ 70◦ T5 35 Excellent 96 –

F + – – 6 2 130◦ ₄₅◦ _{L3 140}◦ ₇₀◦ _{T6 34 Excellent 49 –}

47 F 49 + – Sd.impact 6 2 150◦ ₂₀◦ _{L4 140}◦ ₇₀◦ _{T5 32 Good 52 –}

48 F 53 + Sd.Panic Cal.tend.ofthe

sub.

5 2 100◦ ₁₀◦ _{L4 150}◦ ₇₀◦ _{T5 33 Good 72 –}

49 F 48 − Tob. – 5 7 90◦ ₀◦ _{L3 130}◦ ₇₀◦ _{T5 28 Good 14 –}

50 M 46 + – Post-opSLAP 8 12 140◦ ₄₅◦ _{T8 145}◦ ₇₀◦ _{T5 35 Excellent 19 –}

51 F 51 + BreastCA Post-op

epiphysealft

12 12 90◦₋₁₀◦ _{Glut 130}◦ ₃₀◦ _{T9 29 Good 21 –}

52 F 50 + DMI _{– 6 8 80}◦ ₀◦ _{Glut 110}◦ ₆₀◦ _{T10 30 Good 13 –}

Means 51.2 15.3 8.9 96◦ ₁₆◦ _{L5 141}◦ ₅₇◦ _{T9 31.4 64.8}

Source:SantaCasadeSãoPauloArchives.

AC,acromioclavicularjoint;CA,cancer;dep.,depression;RSD,reflexsympatheticdystrophy;DLP,dyslipidemia;DM,diabetesmellitus;elev.,elevation;epilep.,epilepsy;F,female;ft.,fracture;glut,

gluteus;GT,greatertrochanterofthefemur;SAH,systemichypertension;hypot.,hypothyroidism;imob.,immobilization;RCI,rotatorcuffinjury;neurap.,neurapraxia;post-op.,post-operativeperiod;

pre-op.,pre-operativeperiod;LR,lateralrotation;MR,medialrotation;sd,syndrome;sub,subscapularistendon;tob,tobaccosmoker;cal.tend.,calcareoustendinitis.;GT,greatertuberosity;cons.

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Fig.1–Surgicalstepsofthearthroscopicreleasefortreatingadhesivecapsulitis.Sagittalsectionoftheleftshoulder showing(a)releaseofcoracohumeralligament(arrow),(b)anteriorcapsulotomyperformedthroughtheanteriorportal,(c) posterosuperiorcapsulotomy,and(d)anteroinferiorcapsulotomy,alongtheaxillarynerve,withbothcapsulotomies performedusingtheposteriorportal,and(e)tenotomyofthesuperiorquarterofthesubscapularismuscletendon,again throughtheanteriorportal.

Table2–Proceduresperformedduringarthroscopy.

Procedures Numberofshoulders %

Openingoftherotatorinterval 56 100

Coracohumeralligamentrelease 55 98

Anteriorcapsulotomy 52 93

Posteriorcapsulotomy 44 78

Inferiorcapsulotomy 20 36

Subscapularistenotomy 14 25

Acromioplasty 24 43

Mumford 11 19

Calcareoustendinitisdrainage 2 3.5

Source:SantaCasadeSãoPauloArchives.

Nostatisticalsignificancewasobservedinrelationshipto theresultsandvariablesage,sex,andcomorbiditiesamong thediabeticandnon-diabeticpopulationsandbetween pri-maryandsecondarycapsulitis.

BasedontheresultsoftheUCLAcriteria,25 _25shoulders

wereclassified asexcellent (45%),25asgood (45%),two as fair(3%),andfouraspoor(7%).Sevenpatientshad compli-cations(12.5%),including two withradialneurapraxia, one withaxillaryneurapraxia,tworeoperations,twocasesofreflex sympatheticdystrophy,onerotatorcuffinjury,andonecase ofacromioclavicularpain.

Discussion

Theprimarygoaloftreatmentofadhesivecapsulitisispain reliefandrestorationofrangeofmotionintheshortesttime possible.

Initialtreatmentshouldbeconservative,becausethe lit-eratureshowsthatphysicaltherapyassociatedwithadjuvant methodsyieldsgoodresults.Theminimumduration recom-mendedbymostauthorsissixmonths,butitcanvaryfromsix weeksto12months.5,8,9,12,13,27_{Inthepresentstudy,themean}

timeofevolutiontosurgicalindicationwas8.9(2–24)months. Inthisservice,casesofadhesivecapsulitisaretreatedwith physicaltherapyassociatedwithserialsuprascapularnerve blocks,andarateof84%goodresultswasobservedinastudy bythepresentauthorspublishedin20067_{;37(66%)patientsin}

thecurrentstudyunderwentthistreatmentwithameanof12 (range:2–23)nerveblocksuntilsurgicalindication.Itis note-worthythatthenerveblockisdoneonanoutpatientbasis,in aminimallyinvasivemanner;however,itmustbedone regu-larlyevery15daysanditsinitialanalgesiceffect,onaverage, startsafterthefourthblock.7_{Forthesereasons,manypatients}

refusedtofollowthetreatmentandchosesurgery,despitethe initialguidanceforconservativetreatment.

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Gerberetal.19_{reportedagainof38}◦_{ofelevationand18}◦ oflateralrotation;Warneretal.,9_{anincreaseof49}◦ _of flex-ion,42◦_{oflateralrotation,andeightlevelsofspinalprocesses} inmedialrotation;Cohenetal.,21_{anincreaseof64}◦_of flex-ion,43.5◦_{oflateralrotation,andeightlevelsinspinalmedial} rotation;otherauthorshavealsoreportedgoodresults.8,12,13,20

Thepresentresultsshowedanimprovementintheelevation of45◦_,38◦ _{oflateral rotation,and eightlevelsinthe spinal} medialrotation, withafinalmeanrangeofmotionof141◦ ofelevation,57◦ _{ofmedialrotation,and9Tmedialrotation,} resultsthatareinagreementwiththeliterature.

Mean elevation and lateral and medial rotation of the contralateral limb of these patients, excluding those who underwentbilateralrelease,were143◦_{, 56}◦_{,and T9,} respec-tively. Comparing mean postoperative elevation, excluding patientswho had bilateral release,adeficit ofonly3◦ _was observed (p=0.030). This demonstrates that, albeit with a smalldeficit ofelevation, generallyit ispossibletorestore rangeofmotioninthesepatients.

Regardingtheproceduresperformedduringarthroscopic release,initialcaseswere limitedtoopeningofthe rotator interval,resection ofthe coracohumeral ligament,anterior andposteriorcapsularreleases,andafinaljointmanipulation forruptureoftheinferiorcapsule.Intheirstudy,Pollocketal.20

performedarthroscopyimmediatelyaftermanipulationofthe shoulderjointandfoundarateof30%ofinferiorcapsule rup-turefailurewiththisprocedure.Studiesofthearthroscopic anatomyoftheaxillarynerve10,28,29_{providedabetter}

under-standing,allowing the development ofsafe techniques for inferiorcapsularrelease;therefore, circumferentialreleases havebecomestandardintheservice.The20(36%)patients whounderwentinferiorcapsulotomyhadbetterresults com-paredwithother patientsinthefinalmean elevation(146◦

vs.138◦_{,p=0.057),meanlateralrotation(65}◦_vs.52◦_,p=0.003), meanmedialrotation(T7vs.T11,p=0.002),andmean post-operativeUCLAscore25_{(33.4vs.30.2,p=0.021).Theauthors}

believethatcircumferentialcapsulotomyreducestherisksof complicationsassociatedwithjointmanipulation,aswellas therecurrencerate,restoringmorefunctionalrangeofmotion inashortertime.Asforthetenotomyofthesubscapularis,the procedurewasperformedintheintra-articularportionofthe tendonthatisvisualizedduringarthroscopy;itwasindicated duringsurgery,aftercompletecapsularrelease,whenitwas notpossibletoachievethesamelateralrotation(indegrees) asthecontralateralside.

Pollock et al.20 _{and Cinar et al.}30 _{observed worse}

out-comesindiabeticpatientswhencomparedwithnon-diabetic patients after arthroscopic release. In the present study, resultsofarthroscopictreatmentwere similarinthesetwo populations, with no statistical significance, both in rela-tionship to the range of motion and final UCLA,2 _which

was inagreement withresults observed withconservative treatment.7_{Regardingfinalmeanrangeofmotion,diabetics}

showedaslightlimitationinrelationtonon-diabeticpatients, withmeanpost-operativeelevation(p=0.551),lateralrotation (p=0.357),andmedialrotation(p=0.154)of140◦_,54◦_,andT11. Inturn,theseresultsinnon-diabeticswere142◦_,58◦_,andT9, respectively.RegardingthemeanUCLA,25_{itwas31.4forboth}

groups(p=0.995),althoughnoneofthesedatawere statisti-callysignificant.

Another very important point inthe surgical treatment ofadhesivecapsulitisispostoperativerehabilitation.Physical therapyprotocol shouldbeinitiatedonthefirst postopera-tive day, in an intensive regimen associated with potent analgesia,inordertomaintainmovementgainachieved intra-operatively. Theuse ofinterscalenecatheter foranesthetic infusionintheearlypostoperativeperiodisrecommendedby someauthors.2,9,13_Marianoetal.31_{concludedthatcontinuous}

interscaleneblockissuperiortothesingleapplicationblock, providinggreaterpainrelief,minimizingtheuseofadditional opioids,improvingsleepquality,andincreasingpatient sat-isfactionaftershouldersurgery.Thisanalgesiafacilitatesthe physicaltherapyrehabilitationwork,thusleading toa bet-terresult.Inthepresentstudy,ofthe33shoulders(59%)in whichthiscatheterwasused,only8.8%patientsrequiredjoint manipulationduring thepostoperativefollow-up period:in onepatient,thecathetermovedoutoftheinterscalenespace andlostitsanalgesiceffectonthesecondpostoperativeday. Conversely,31.8%ofthoseinwhomthiscatheterwasnotused requiredjointmanipulationduetolossofmotioninthe post-operative follow-up, which provesthe effectivenessof this analgesiainpreventingrelapse(p=0.028).Thismanipulation isperformedwithinamaximumof30dayspostoperatively.

Complications were observed in seven patients: two patientsdevelopedradialneurapraxia,withreversalof symp-tomsafter2–3months.Thiscomplicationprobablyoriginated duringtheinterscaleneanestheticblock.Thispatientdidnot useinterscalenecatheterforanestheticinfusion.Onepatient developedaxillaryneurapraxiapostoperatively.Hepresented acompleterecoveryoffunctioninfourmonths.Thispatient didnotundergoinferiorcapsulotomy,butratherthe manipu-lationforinferiorcapsulerupture.Theauthorsbelievethat there was a probable traction of the axillary nerve during manipulation,causingsymptoms.Althoughmentionedasa possiblecomplicationofinferiorcapsulotomy,1 _nocasesof

injuryorneurapraxiaofthisnervewereobservedinpatients whounderwentthisprocedure. Therefore,wecanconclude thatinferiorcapsulotomyisasafeprocedure,aslongasthe correctsurgicaltechniqueisperformed.

Regardingtheothercomplications,onepatienthad resid-ualpainintheacromioclavicularjoint(case9),two(cases8 and10)developedreflexsympatheticdystrophyinthe oper-ated limb, and one had a rotator cuff injury. This patient (case7)underwenttwoarthroscopicproceduresfortreatment of adhesive capsulitis with joint release; during follow-up aftersecondsurgery,asthepatientstillpresentedrangeof motionlimitation andpain, amagneticresonanceimaging examwasperformed,whichdisclosedrotatorcuffinjury.In thetwoprevioussurgicalprocedures,patienthadundergone joint manipulation tocomplement capsularrelease, which mayhavecontributedtothecauseofinjury.

Anotherpatient(case10)requiredreoperation,andawider capsularreleasewasperformed;nonetheless,patientstill pre-sented range of motion limitation and pain. In the initial surgery, joint access was difficultdue to the small articu-larspace,whicheventuallycompromisedtheprocedure:the releaseofthejointcapsulewasincomplete.Anotherpatient (case 16) had poor UCLAscore25 _{results; anosteochondral}

68

Onepatient(case17),althoughtherangeofmotionwas satis-factorilyrestored,persistedinpainandwasdissatisfiedwith the results. The two patients (cases 2and 8) with regular resultsobtainedrangeofmotionimprovement;however,they stillhadrestrictionsandpainduringdailyactivities,andone ofthempresentedreflexsympatheticdystrophy(case8).

Conclusion

Arthroscopic release of patients with adhesive capsulitis refractorytoconservativetreatmentiseffectiveforimproving painandrangeofmotion.

Thebestresultswereobtainedinpatientswhounderwent inferiorcapsulotomy.

Lowerreoperationrateswereobservedinpatientsinwhom theinterscalene catheterforanesthetic infusionwasused, demonstratingitsimportanceinpostoperativerehabilitation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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