Introduction
In 3 percent-5 percent of the general population annually adhesive capsulitis (AC) occurs. The most common type of adhesive capsulitis of shoulder is Idiopathic. Diabetes mellitus, Disorders of thyroid gland, Dupuytren's contractures, autoimmune disorders, treatment of breast malignancies, trauma and surgery are the other common conditions to which this has been attributed.1, 2
The regular care and control of the condition includes the usage of NSAIDS, local corticosteroid injections, physiotherapy, hydro dilation, arthroscopic release, and manipulation under anesthesia. Our aim is therefore to study and compare the clinical efficacy of the capsule's manipulation under General Anesthesia and Combination of Arthroscopic Release with Sub acromial decompression, Rotator interval release, and Manipulation under General Anesthesia in the treatment of Shoulder Primary Adhesive Capsulitis.
Materials and Methods
A prospective interventional study was conducted from June 2018 to June 2020 with a sample size of 40 patients who were diagnosed with primary adhesive capsulitis of shoulder.
Age group of participants was 30 to 60 years. All patients with comorbidities were excluded from study. Patients were initially treated conservatively with analgesics and physiotherapy with Dr. Brian Dierckman protocol for a good period of 6 months. Patients who have not improved with conservative treatment were randomly allocated with simple random sampling into 2 groups.
Group 1: Who were treated with only manipulation under general anesthesia.
Group 2: Who were treated with a combination of arthroscopic release of capsule with sub acromial decompression, rotator interval release plus manipulation under general anesthesia.
20 cases were included in each group. Pre-procedural and post-procedural limitation of activities of daily living of the patients due to frozen shoulder is evaluated with Visual Analogue Scale[VAS] and Oxford Shoulder Scores[OSS]. Data was collected and analyzed by SPSS software. Anova tests were applied to compare the scores obtained from 2 groups.
Procedure of an arthroscopic adhesiolysis of frozen shoulder.
Arthroscopic picture showing long head of biceps[LHB] with synovium over coracohumeral ligament.
Rasp is used outside the labrum along the neck of glenoid bone.
Sub acromial decompression performed with the help of an abrader arthroscopically.
After releasing the capsule arthroscopically coracohumeral ligament attached to long head of biceps is removed and widening of joint space is done.
Results
Most of the study population were female (24) while males were 16 in number. No significant association was found between gender among both the groups.
Right side (19) and left side (21) were comparably affected in study population. Right was dominant side in most of the patients undergoing ACR with SAD, RIR plus MUGA and only MUGA.
Mean age of patients was 47.95 years with standard deviation of 6.7.
Pre-procedural and post-procedural mean [Including both only MUGA and combination of ACR with SAD, RIR plus MUGA] of VAS and OSS at 1 week, 1 month, 3 months and 6 months follow up is given below.
Pre-procedural mean OSS was 49.9, mean OSS at 1 week, 1 month, 3 months and 6 months follow up was 42.4, 35.4, 29.7, 23.7 respectively. gradual decline in OSS was observed with respect to time.
Decreasing trend of mean VAS was observed with respect to time interval, mean pre-procedural VAS was 7.13 while post procedural VAS was 4.8
Table 1
Comparison of mean OSS and VAS among both procedures for treatment of shoulder primary adhesive capsulitis. (Pre-procedural)
Month follow-up
Mean OSS in MUGA was 39.2 while in ACR with SAD, RIR plus MUGA was 31.6.
Mean VAS in MUGA was 2.6 while in ACR with SAD with MUGA was 1.
Significant association was found in 1 month follow up VAS score and OSS among both methods.
Table 2
Comparison of mean OSS and VAS among both procedures in the treatment of shoulder primary adhesive capsulitis. (3 month follow up)
Table 3
Comparison of mean OSS and VAS among both procedures in the treatment of shoulder primary adhesive capsulitis. (6 month follow up)
Discussion
A comparative Study comparing the efficacy of arthroscopic capsular release with sub acromial decompression, rotator interval release along with manipulation under general anesthesia and only manipulation under general anesthesia in the treatment of shoulder primary adhesive capsulitis. In the treatment of a frozen shoulder, there are many popular strategies: ranging from supervised neglect [Dierecks RL et al.,]3 physiotherapy [Donner et al.,] 4 [Russel et al.,]5 corticosteroid infiltration, [ Carrette S]6, Ryabs I,7 Manipulation Under Anaesthesia (MUA) [ Kivimäki J et al.,] 8 Arthroscopic Capsular Release (ACR) [Beimers L et al.,] 9 arthrographic capsular distension [Buchbinder R et al.,] 10 and stretching devices [Ibrahim M et al.,].11 The best regimen for treatment has not been developed yet.
Conservative care appears to be appropriate for most cases, taking into account all this, and nearly complete recovery happens in two or three years.12 Most scholars note that failure of at least 6 to 12 months of effective non-operational therapy is a sign for more invasive treatments. 13 However, as more invasive procedures are performed early in the disease, it is debated whether the duration of the disease will be reduced. 14
A Dennis L et al., 14 research survey among health care specialists (orthopaedic surgeons, general physicians, physiotherapists) revealed that in the painful phase, most professionals suggested non-operative treatment, including oral analgesia and physiotherapy. Most of them focused on professional experience and training rather than published research to choose treatment. MUGA is comparatively straightforward to implement and time-saving. ACR is visually regulated, but physically more challenging, time-consuming, and has its own unique dangers (e.g. chondrolysis due to coagulation thermal heat, damage to the axillary nerve). In comparison, a combination of partial ACR accompanied by gentle shoulder joint manipulation seems to be a secure alternative. This significantly lowers dangers associated with MUGA alone, since the manipulation requires less force. For such a mixed treatment, a specific indication is not obvious, but is recommended for most patients. Hence, our study helps in providing a statistical significance in comparing the efficacy of combination of arthroscopic capsular release with SAD, RIR plus MUGA and only MUGA in the management of primary adhesive capsulitis of shoulder.
Conclusion
At the end of this study, it is concluded that a combination of arthroscopic capsular release with sub acromial decompression, rotator interval release along with MUGA has a better outcome in comparison to only MUGA in the treatment of shoulder primary adhesive capsulitis which has not responded to 6 months of conservative treatment with analgesics and physiotherapy.