Lateral Decubitus 360° Capsular Release for Treatment of Recalcitrant End-Stage Adhesive Capsulitis

Abstract

Background:

Recalcitrant adhesive capsulitis, manifesting as persistent pain and continued range of motion deficits after a trial of conservative care, can be managed via lysis of adhesions with associated capsular release. While traditionally performed in the beach-chair position, capsular release performed via a lateral decubitus approach may provide enhanced visualization and the ability to perform a 360° release without iatrogenic injury to the cartilage surfaces.

Indications:

Arthroscopic capsular release in the setting of adhesive capsulitis is utilized when conservative strategies, such as physical therapy and/or corticosteroid injections, do not provide pain and range of motion improvement.

Technique Description:

Upon induction of general anesthesia, the patient is placed on the operating table in a lateral decubitus position utilizing the arm positioner of choice. The shoulder’s bony landmarks are identified for proper placement of the arthroscopic portals. A standard posterior portal is first established followed by an anterior portal in the rotator interval. Two-portal diagnostic arthroscopy then ensues. The rotator interval is then released, as is the superior capsule, to the 12-o’clock position using electrocautery. Next, a basket scissor is utilized to release the anterior capsule to the 6-o’clock position followed by posterior-superior and posterior-inferior capsular release while viewing anteriorly. Scope instrumentation is withdrawn and the shoulder manipulated, achieving full range of motion.

Results:

It is the senior author’s belief that by performing a capsular release via the lateral decubitus approach, better visualization, and access to the anterior, inferior, and posterior glenoid can be achieved for a complete 360° release. Additionally, risk of cerebral hypoperfusion and iatrogenic injury to the cartilage surfaces while instrumenting the joint is diminished. Upon procedure completion, the patient was observed to have gained full forward flexion, external rotation, and internal rotation.

Discussion/Conclusion:

Although traditionally approached via a beach-chair approach, capsular release of end-stage adhesive capsulitis via a lateral decubitus approach has shown to facilitate a circumferential view while providing ease of access to the inferior, anterior, and posterior glenoid, thereby substantially and immediately increasing patient range of motion.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video will demonstrate the senior author’s preferred surgical approach to address recalcitrant end-stage adhesive capsulitis via lateral decubitus patient positioning.

Author disclosures are as listed.

Background

Although traditionally approached via a beach-chair approach, capsular release of end-stage adhesive capsulitis via a lateral decubitus approach has shown to facilitate a circumferential view while providing ease of access to the inferior, anterior, and posterior glenoid. In addition to providing enhanced access to the glenohumeral joint, which translates into more efficient and comfortable maneuvering of the instruments with the arms at the side rather than in an abducted position, the lateral decubitus approach also possesses the advantage of eliminating the risk of cerebral hypoperfusion associated with the beach-chair approach. While the authors believe these benefits outweigh the risks, some drawbacks include the requirement for arm suspension devices, a more technically demanding and time-consuming conversion to open surgery, the potential for traction neuropraxia, and a steeper learning curve for accurate identification of intra- and extra-articular anatomic landmarks.^1,5

The patient is a 59-year-old woman, with no history of diabetes mellitus or thyroid disease, who presented with insidious onset of left shoulder pain and restricted range of motion after failure of conservative management for 1 year. On examination, she had forward flexion and abduction to 95°, external rotation to 30°, and internal rotation to the back pocket with pain on terminal range of motion. The patient also presented with negative impingement and Jobe, O’Brien, and speed tests. Absent tenderness to palpation on the acromioclavicular (AC) joint or biceps tendon was noted. Standard 3-view radiographs showed no evidence of arthritis, fracture, or dislocation. Magnetic resonance imaging revealed capsular thickening with mild AC joint arthritis along with an intact rotator cuff on the coronal, sagittal, and axial views.

Technique Description

After induction of anesthesia, the patient underwent an interscalene nerve block and was placed into a modified lateral decubitus position, as previously described by Batra et al., ¹ with care to pad bony prominences and appropriately position the neck and contralateral extremity. Examination under anesthesia revealed limited shoulder internal rotation, forward flexion, and external rotation. The left side was then prepped and draped sterilely. The surgical arm was then placed in a sterile stockinette, wrapped around with a Coban wrap, and secured in an arm holder via Velcro straps and an additional outer loop of Coban wrap. Next, the arm was loaded into the pneumatic traction arm and a 10-pound axial traction force exerted to place the arm in 15° of forward flexion and 30° to 40° of abduction for the entirety of the procedure. An arm jack, attached to the anterior side of the surgical table and positioned beneath the surgical arm at the midshaft of the humerus, can be employed to facilitate glenohumeral abduction.

Anatomic landmarks were marked in addition to standard posterior and anterior portal locations. A posterior portal was first established, followed by usage of a spinal needle for establishment of an anterior rotator interval portal. The spinal needle was placed in the center of the rotator interval on top of the superior border of the subscapularis and anterior to the long head of the biceps. A cannula was then placed at the location of the anterior portal for ease of instrument manipulation. Upon cannula placement, a 2-portal diagnostic arthroscopy was then performed, revealing preserved articular cartilage and rotator cuff tendons, mild biceps tenosynovitis, and significant capsulitis.

A radiofrequency probe was then utilized to release anterior interval soft tissue as well as the superior capsule to the 12-o’clock position. Additionally, release of the anterior-inferior capsule was performed via radiofrequency probe, followed by basket scissor release down to the 6-o’clock position. It is the senior author’s preference to use a radiofrequency probe for tissue release above the 3-o’clock position and a basket scissor for tissue release below it. The basket scissor is particularly effective for dissection and capsule release from the muscle, as utilizing it with 1 beak positioned between the muscle and capsule and the other on top ensures clear visualization while preserving the integrity of the axillary nerve. Following this, an arthroscopic shaver, with its blade consistently oriented toward the glenoid, is employed to debride the released tissue. This technique provides optimal visualization of the fat layer over the axillary nerve, which is crucial for minimizing the risk of nerve injury.

The arthroscope was then switched to the anterior portal location for completion of the posterior capsule release. Completion of the posterior-superior capsular release was achieved via an arthroscopic shaver, whereas an arthroscopic shaver and a basket scissor were both utilized for extension of the posterior-inferior capsular release. After completion of the release, the remainder of the articular surface was visualized and found to be normal.

Scope instrumentation was withdrawn and the shoulder manipulated for identification of full passive range of motion. Portal sites were closed, and sterile dressing was applied prior to completion of the procedure.

Postoperatively, patients are discharged with a sling for 24 hours, and pain is managed with hydrocodone 5 mg/acetaminophen 325 mg every 4 to 6 hours, and formal physical therapy begins on postoperative day 2. Patients are advised to attend 5 physical therapy sessions per week during the first 2 weeks before their initial follow-up for an active range of motion assessment. Based on this 2-week evaluation, patients will either transition to therapy 3 times a week for an additional 4 weeks or receive a course of oral or injectable corticosteroids, continuing therapy to achieve terminal range of motion. Isometric shoulder exercises typically begin around the 6-week mark, with full return to activities anticipated between 8 and 12 weeks postoperatively.

Discussion

Investigations comparing surgical versus nonsurgical management of adhesive capsulitis show conflicting results as the list of surgical procedures performed in these studies included lysis of adhesions, manipulation under anesthesia, and capsular release, thereby lacking homogeneity between them.^3,6 When specifically investigating the outcomes of the described technique, 2 studies revealed significant early and lasting improvements in range of motion up until 2 years after surgery.^2,4

Cvetanovich et al. ² reported 2-year outcomes for 27 patients undergoing lateral decubitus release to treat idiopathic adhesive capsulitis. Significant improvements in active forward flexion (115° to 156.2°, mean Δ41.2, P < .001) and external rotation (28.1° to 56.8°, mean Δ27.7, P < .001) were observed as early as 2 weeks postoperatively. Furthermore, all patients returned to their desired activities without any associated complications. In a recent series by Gómez-Muñoz et al. ⁴ , the authors evaluated 26 patients that underwent circumferential release in the lateral decubitus position. Their results align with those of Cvetanovich et al., ² showing significant improvements in forward flexion (Δ38.6°, P < .01) and external rotation (Δ21.9°, P < .01) from baseline. The authors additionally measured a significant improvement in shoulder abduction at final follow-up (88.8° to 124°, mean Δ35.2°, P < .01). Notably, no complications were reported in this series, thus underscoring the usefulness of the described approach in patients with recalcitrant adhesive capsulitis.

Thank you.