Commentary & Perspective on
"Arthroscopic Capsular Release for the Treatment of Refractory Postoperative or Post-Fracture Shoulder Stiffness"
By G. Brian Holloway, MD, et al.

Commentary & Perspective by Robin R. Richards, MD, FRCSC*,
Department of Surgery, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada

In this issue of The Journal, Holloway and colleagues report their results of arthroscopic capsular release for the management of frozen shoulder. Their article differentiates those patients who developed frozen shoulder following surgery or fracture and compares them with patients who underwent the same operation for the treatment of idiopathic frozen shoulder. At the outset I would comment that this differentiation is important, and "lumping" all patients with frozen shoulder into a waste basket-type diagnosis is inappropriate since the natural history of shoulder stiffness is highly dependent on its etiology.

Holloway's study constitutes a genuine contribution to the literature since it divides the patients into three groups (idiopathic, postoperative, and post-fracture) according to etiology and includes functional outcomes data. During the time-period of the study, 1720 new patients were seen at the Shoulder and Elbow Service of the University of Pennsylvania for loss of shoulder motion secondary to soft-tissue contracture. Only eighty-one (<5%) of these patients had surgical treatment! This is a highly select group, and the treatment was only recommended after an intensive conservative management program that included a home-exercise program of at least one year's duration. The authors excluded patients with insulin-dependent diabetes, degenerative osteoarthritis of the glenohumeral joint, and a full-thickness rotator-cuff tear.

The authors' operative technique was very safe. In fact, no complications were related to the arthroscopic procedure. Four patients required subsequent surgery. The mean improvement in forward flexion varied between 26° and 45°; that in external rotation in adduction, between 29° and 40°; the mean improvement in external rotation in abduction ranged from 31° to 50°; and that in internal rotation, between 23° and 41°. The greatest improvements were seen in the idiopathic and post-fracture groups, and less improvement was seen in the postoperative group. There was a decrease in pain and an improvement of the functional score in each of the groups, although the improvement in the postoperative group was significantly (p < 0.003 for pain; p < 0.002 for function) lower than that in the idiopathic and post-fracture groups.

Holloway's study demonstrates a definite role for arthroscopic capsular release in the treatment of selected patients with chronic shoulder stiffness. The greatest degree of improvement can be anticipated in patients with idiopathic frozen shoulder and those with stiffness following fracture of the proximal part of the humerus. Conversely, since patients in the postoperative group had less improvement, the importance of preventing stiffness following elective shoulder surgery is once again indicated. Patients in the postoperative group had undergone a variety of previous shoulder procedures: arthroscopic acromioplasty; open rotator-cuff repair; open Bankart repair; arthroscopic capsular shift; prosthetic shoulder replacement; repair of a SLAP lesion; and open calcium-deposit excision.

Holloway and co-authors are to be commended for the clarity of their study. At the same time it must be noted that surgical treatment is rarely required for stiff shoulder since the vast majority of patients presenting with shoulder stiffness improved without the need for surgical treatment. Furthermore, the effectiveness of the treatment protocol that the authors have developed is the product of their highly specialized practice. The application of this specialized surgical technique should probably be restricted to surgeons performing a high volume of arthroscopic shoulder surgeries for other, more common diagnoses.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.