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Abstract

Introduction:

Diabetic patients have been known to have a higher incidence of frozen shoulder. Arthroscopic capsular release has been described for diabetic frozen shoulder refractory to non-surgical treatment. We describe our single-surgeon experience of this procedure done in Asian patients presenting with diabetic frozen shoulder.

Results:

Data were prospectively collected from 25 patients from 2007 to 2008, who underwent arthroscopic capsular release for frozen shoulder with diabetes mellitus. This included the University of California–Los Angeles (UCLA) Shoulder Score by an independent observer. Mean follow-up duration was 44.3 ± 22 months with the age of 57.3 ± 10.9 years at the time of surgery. Mean duration of symptoms prior to surgery was 8.9 ± 7.5 months. Ten right shoulders and 15 left shoulders were operated on. Arthroscopic capsular release was performed in the beach chair position with the aid of a 90° electrocautery hook, from the rotator interval to posterior capsule. Significant improvement was observed in the UCLA scores post-operatively (preoperative total score 15.8 ± 3.6 vs. post-operative 33.3 ± 2.5, p < 0.00), including all domains of pain (3.9 ± 1.8 vs. 9.4 ± 0.9, p < 0.00), function (4.8 ± 1.7 vs. 9.4 ± 1.4, p < 0.00), active forward flexion (2.6 ± 0.7 vs. 4.6 ± 0.6, p < 0.00) and satisfaction (0.0 ± 0.0 vs. 5.0 ± 0.0, p < 0.00). No significant correlation between duration of symptoms and UCLA scores. Significant improvement was observed in forward flexion (preoperative 100.4 ± 18.8° vs. post-operative 157.6 ± 15.9°, p < 0.00) and external rotation (preoperative 14.4 ± 6.34° vs. post-operative 63.8 ± 8.3°, p < 0.00). Although the duration of symptoms correlated significantly with preoperative forward flexion (r = 0.443 and p < 0.027), there was no significant correlation with post-operative forward flexion (r = 0.023 and p < 0.91). No axillary nerve palsy observed.

Conclusion:

The diabetic frozen shoulder can be treated favourably with arthroscopic capsular release and the duration of symptoms prior to surgery does not affect the outcomes.

Keywords

adhesive capsulitis arthroscopy diabetes mellitus shoulder

Introduction

The incidence of frozen shoulder is higher in diabetics compared to the general population, and these patients tend to be less responsive to treatment and suffer from a greater restriction of range of motion.^1,2 The underlying pathology is thought to be related to the increased expression of vascular endothelial growth factor.³

Arthroscopic capsular release has been described previously for patients with frozen shoulder who are recalcitrant to non-surgical management.^{4

–13} Compared to manipulation under anaesthesia which carries a risk of iatrogenic fracture, arthroscopic capsular release allows for a controlled release of a tight glenohumeral joint capsule and can be combined with a selective manipulation.¹⁴

Ogilvie-Harris and Myerthall in 1997 reported good outcomes in their series of 17 patients who underwent arthroscopic capsular release for the diabetic frozen shoulder.⁸ Mehta et al. reported that the outcome for arthroscopic capsular release was worse in diabetics, with 71% recovering to full range of motion compared to 90% in non-diabetics.⁷ Smith et al. reported that the post-operative range of motion was less in diabetics compared to non-diabetics undergoing arthroscopic capsular release.¹⁵ Çınar et al. reported that the range of motion and Constant score were worse in patients with diabetes undergoing arthroscopic capsular release.¹³

In Asian patients, similar to their Caucasian counterparts, diabetes is a risk factor for frozen shoulder.¹⁶ Cho et al. from Korea reported that the functional recovery of patients with diabetes undergoing arthroscopic capsular release was slower than those without diabetes, though there was no difference in outcome at final follow-up.¹⁷ Ide and Takagi from Japan reported a poor outcome in one of his three patients with diabetes undergoing arthroscopic capsular release.¹⁸ There, however, remains a paucity of literature on the outcomes of arthroscopic capsular release for the diabetic frozen shoulder in Asian patients.

Aim

The aim of our study is to assess the clinical outcomes of arthroscopic capsular release for the diabetic frozen shoulder in Asian patients.

Materials and methods

We collected data of diabetic patients with frozen shoulder who underwent arthroscopic capsular release performed by a single surgeon, from 2007 to 2008. All patients had failed non-surgical management prior to surgery, including physiotherapy and oral and topical analgesics. Patients with associated rotator cuff tears and patients with post-surgical shoulder stiffness were excluded. Preoperative and 2-year post-operative range of motion and University of California–Los Angeles (UCLA) shoulder scores were collected by a single observer.

Surgical technique

The procedure is performed under general anaesthesia with the patient on a beach chair. Glenohumeral arthroscopy is performed using the posterior portal as a viewing portal and an antero-superior portal through the rotator interval as the working portal.

An anterior capsular release is performed using a radiofrequency wand starting at the rotator interval. The portals are then switched with the rotator interval as the viewing portal and a posterior capsular release is then performed. The release spares the inferior portion of the capsule, so as to avoid injury to the axillary nerve. No additional procedures such as synovial ablation, adhesiolysis, superior capsular release (including posterior portion of biceps tendon), coracohumeral ligament release, tenotomy of subscapularis tendon, subacromial decompression or intra-articular injection of corticosteroids were performed. After arthroscopy, an examination is then done under anaesthesia and any residual stiffness is dealt with a selective manipulation. Range-of-motion exercises are started as soon as the patient awakes and the patient is discharged from the ward on the first post-operative day with outpatient physiotherapy.

Statistical analysis was performed using the χ ² test for categorical variables and the t-test and Pearson’s correlation coefficient for continuous variables.

Results

We had 25 shoulders in our series, and although most were right-handed patients 23/25 (92.0%), most of the shoulders operated on were left, 15/25 (60.0%). The mean age of our patients was 57.3 ± 10.9 (36.0–78.0) years and were symptomatic for 8.9 ± 7.5 (2–36) months. We had a mean follow-up duration of 4.8 ± 1.9 (2.4–7.8) years with at least 2 years of follow-up.

The mean operative duration was 40.8 ± 16.9 (20.0–95.0) min. There was significant improvement in forward flexion at 2 years after surgery from a preoperative forward flexion of 110.4° ± 18.8° to a post-operative forward flexion of 157.6° ± 15.9°(p < 0.00) without any fracture or axillary nerve palsy. Likewise, there was a significant improvement in external rotation of the shoulder with the arm by the side from 14.4° ± 6.34° to 63.8° ± 8.3° (p < 0.00) at 2 years after surgery. There were no infections or other wound complications despite performing surgery on patients with diabetes mellitus. Although the duration of symptoms correlated significantly with preoperative forward flexion (r = 0.443 and p < 0.027), there was no significant correlation with post-operative forward flexion (r = 0.023 and p < 0.91). There was no significant correlation between the duration of symptoms and preoperative external rotation (r = −0.080 and p < 0.71) and post-operative external rotation (r = −0.030 and p < 0.88).

We report an improvement in internal rotation as well from the coccyx preoperatively to the level of T12 post-operatively (Table 1). There was a significant improvement in total UCLA scores post-operatively (preoperative total score 15.8 ± 3.6 vs. post-operative 33.3 ± 2.5, p < 0.00; Figure 1). There was a significant improvement in all domains of the UCLA score which includes pain (3.9 ± 1.8 vs. 9.4 ± 0.9, p < 0.00), function (4.8±1.7 vs. 9.4 ± 1.4, p < 0.00), active forward flexion (2.6 ± 0.7 vs. 4.6 ± 0.6, p < 0.00) and patient satisfaction (0.0 ± 0.0 vs. 5.0 ± 0.0, p < 0.00; Figure 2).

Table 1.

Preoperative and 2-year post-operative shoulder internal rotation.

Level	Preoperative (n = 25)	Two-year post-operative (n = 25)
T8	0	1 (4%)
T10	1 (4%)	2 (8%)
T11	0	1 (4%)
T12	0	16 (64%)
L2	2 (8%)	3 (12%)
L3	0	2 (8%)
L5	7 (28%)	0
Coccyx	14 (56%)	0
Greater trochanter	1 (4%)	0

Figure 1.

Preoperative and 2-year post-operative total UCLA scores. UCLA: University of California–Los Angeles.

Figure 2.

Preoperative and 2-year post-operative UCLA component scores. UCLA: University of California–Los Angeles.

Discussion

Our study showed a significant improvement in UCLA scores in our patients with diabetic frozen shoulder treated with arthroscopic capsular release, and this did not correlate with the duration of symptoms. Our findings of improvement in quality of life and symptoms regardless of duration of symptoms is supported by a series by Dattani et al.¹⁹ Hence, we can consider utilizing and exhausting non-surgical measures first and reserving surgery for patients who are not improving with non-surgical management, without worrying that delayed surgical intervention will lead to poorer outcomes. This is in contrast to patients with rotator cuff tears and frozen shoulder managed arthroscopically where a longer duration of symptoms is associated with a poorer outcome.²⁰

The benefits of arthroscopic capsular release for our patients are the avoidance of fractures and other intra-articular injuries that can occur with manipulation under anaesthesia.²¹ We did not have any recurrence of frozen shoulder in our series of patients. Regarding manipulation under anaesthesia for the diabetic frozen shoulder, Woods and Loganathan reported a 40% recurrence requiring repeat manipulation.²² Comparing diabetic versus non-diabetic patients with frozen shoulder, Jenkins et al. reported that the gain in range of motion after manipulation under anaesthesia was significantly less in patients with the diabetic frozen shoulder compared to non-diabetics.²³

Axillary nerve palsy is a known complication following arthroscopic capsular release, and this is in view of its close proximity to the axillary pouch.²⁴ Ogilvie-Harris et al. described their technique which included a rotator interval release, an inferior capsular release and a release of the tendinous portion of the subscapularis tendon.^8,25 In our series, we did not encounter any patients with axillary nerve palsy, as we avoid releasing the inferior-most portion of the capsule, as advised in most surgical techniques on arthroscopic capsular release. We did not release the subscapularis tendon nor the coracohumeral ligament in our series of patients as we performed a selective manipulation under anaesthesia after capsular release as needed for residual stiffness.

In our study, there was an improvement in strength of forward flexion as documented by the UCLA scores. This is consistent with Waszczykowski et al. who reported that there was no significant decrease in strength after arthroscopic capsular release compared to the unoperated shoulder.⁵

In Asian patients, as mentioned previously, Cho et al. reported a slower functional recovery, while Ide and Takagi reported that one of three patients with diabetes had a poor outcome with arthroscopic capsular release compared to the patients without diabetes.^17,18 Mehta et al. similarly reported a worse outcome in diabetics compared to non-diabetics undergoing arthroscopic capsular release.⁷ This is similar to Western data from other patient populations.^7,13,15,25 Our study, however, shows that arthroscopic capsular release in Asian patients with diabetic frozen shoulder leads to good clinical outcomes.

The weakness of our study is the lack of a comparative arm with a different treatment modality. We did not look at arthroscopic grading of the severity of adhesive capsulitis either.

Conclusion

In summary, arthroscopic capsular release provides good outcomes in Asian patients with diabetic frozen shoulder, and the duration of symptoms prior to surgery does not affect the outcomes.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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