Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Open Capsular Release for Adhesive Capsulitis

Open surgical release of the glenohumeral capsule was more commonly utilized to treat patients with severe and refractory adhesive capsulitis prior to the advancement of arthroscopic techniques to treat this difficult patient population. Although the peri-operative morbidity of this open approach to treatment is now accepted to be somewhat greater than its arthroscopic counterpart, use of this technique has resulted in acceptable rates of clinical success. Open release of the contracted rotator interval tissues associated with adhesive capsulitis facilitated reduction of pain and return of motion in all patients treated by Ozaki and provided high rates of success for Nobuhara . Kieras and Matsen reported reduction or elimination of pain and uniform return to work after open capsular release in patients with chronic, refractory frozen shoulder. Restoration of range of motion was significantly improved, although incomplete in many cases. Omari and Bunker reported good or excellent results in 80% of their most severely affected patients who were treated with open release after having failed treatment with prior MUA. Because of the good results obtained with open capsular release, but the lower degree of peri-operative morbidity and very good outcomes associated with arthroscopic capsular release, open release currently seems best reserved for patients suffering from shoulder stiffness with extracapsular abnormalities requiring treatment in addition to their contracted glenohumeral capsule. Open release also continues to have potential application to those patients who intra-operatively do not obtain adequate return of range of motion after arthroscopic release; however, in practical application, we have yet to experience this occurrence in any patients being treated for adhesive capsulitis.

Complications

The complications associated with arthroscopic capsular release surgery have included postoperative instability of the glenohumeral joint, injury to the axillary nerve, and recurrence of shoulder stiffness. Although release of the glenohumeral capsule and ligaments to treat shoulder stiffness raises the theoretical concern that postoperative instability may result, experimental cadaveric studies by Moskal have shown no increase in glenohumeral instability after this procedure. Postoperative instability has not been observed clinically by the authors, and very few anecdotal reports of glenohumeral instability immediately after arthroscopic release have been noted in the course of personal conversations with fellow shoulder surgeons. When this phenomenon has occurred, it has corrected shortly after surgery with the return of rotator cuff tension, and was not present after healing at clinical follow-up. Although 3% of Pearsall patients reported the presence of a subjective sense of instability, no clinical instability after capsular release was observed in their series. The risk of possible injury to the axillary nerve during this procedure must be taken into account during pre-operative consultation and preparation, and careful attention to surgical technique must be observed to ensure that the capsular incision made during this procedure remains close to the labral margin and does not extend more than 5 to10 mm lateral to the glenoid rim. It is important to note, however, that the occurrence of neural injury during this procedure has been rare, and the clinical reports reviewed have only described patients with transient nerve dysfunction, which recovered over time. Finally, the recurrence of stiffness after arthroscopic capsular release has not been common in patients with adhesive capsulitis. For some patients with more severe or more chronic pre-operative stiffness, postoperative recovery of motion may be prolonged and more difficult to maintain, but recurrence has been reported to occur in only 10% to 11% of patients

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