Arthroscopic management of recalcitrant stiffness following rotator cuff repair: A retrospective analysis

Abstract

Background: Rotator cuff repair surgery is one of the most commonly performed procedures in the world but limited literature exists for guidance of optimal management of post-operative arthrofibrosis following cuff repair. The purpose of this study is to report the results of arthroscopic capsular release, lysis of adhesions, manipulation under anesthesia, and aggressive physical therapy in patients with recalcitrant postoperative stiffness after rotator cuff repair.

Materials and methods: Twenty-nine patients who had recalcitrant arthrofibrosis following either an arthroscopic (62%), open (28%), or mini-open (10%) rotator cuff repair were included in study. The average age at the time of index cuff repair surgery was 49.8 years (range 24-70 years). Sixteen patients (55%) were involved in worker's compensation claims. The mean time from the date of index operation to lysis of adhesions was 9.7 months (range 4.2-36.2 months), and the mean time from lysis of adhesion to most recent follow-up 18.2 months (range 4.1-43.7 months). Post-operative evaluation was performed using American Shoulder and Elbow Surgeons Score (ASES), Visual Analog Score (VAS), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) on 18 (62%), while range of motion (ROM), dynamometer strength testing, and Constant-Murley Scoring were performed on 13 (45%). Statistical analysis was performed using a Student's t-test.

Results: Prior to arthroscopic lysis of adhesions, mean forward active elevation (FE) was 103.8°, (range 60-145° (SD 26.3) and external rotation at the side (ERS) was 25.3°, (range 5-70° SD 15.1°). Post-operatively, at the most recent follow-up, FE was significantly improved to 158.3°, (range 110-180° SD 22.3°), and ERS improved to 58.9°, (range 15-90° SD 18.6°) in both cases. Involvement in a worker's compensation claim resulted in a lower ASES, VAS, and SANE score, but there was no statistically significant difference in motion.

Conclusion: Arthroscopic capsular release, lysis of adhesions, and manipulation under anesthesia is a safe, reliable method of treating persistent stiffness following rotator cuff repair.

Keywords: Arthroscopic lysis; rotator cuff repair; stiffness.

Figure 1

Arthroscopic view of left shoulder in beach chair position. Following diagnostic arthroscopy (a), an arthroscopic shaver (b) and RF tool (c) was used to take down the anterior capsule. Capsular release was continued with the aid of an arthroscopic biter (d) from the 12 o'clock to 6 o'clock position (e). Following anterior capsular release, the camera was placed in the anterior portal and a posterior capsular release was performed in similar fashion from the posterosuperior recess down to the 6 o'clock position. The scope was then removed and a manipulation under anesthesia was performed intraoperatively after all arthroscopic releases were completed

Figure 2

Bar diagram showing (a) Outcomes after arthroscopic capsular release in all patients (n = 29). Mean follow-up in this cohort: 18.2 ± 13.1 months. (b) Outcomes after arthroscopic lysis of adhesions in patients available for final followup (n = 13). Mean follow-up in this cohort: 24.6 ± 10.0 months

Figure 3

Bar diagram of postoperative outcomes following lysis of adhesions procedure in Workers' Compensation and Non-workers' Compensation patients. Statistically significant differences are indicated with an asterisk. (a) Postoperative range of motion in forward elevation (FE) and external rotation at the side (ERS) (b) Postoperative shoulder scores