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Year |
2001 |
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Question Number |
52 |
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Category |
Select |
Question
A 52 year old woman has pain and limited shoulder motion after undergoing an open repair of a medium sized rotator cuff tear involving the supraspinatus and infraspinatus tendons1 year ago. Examination reveals mild atrophy, active and passive total elevation of 100 °, active and passive external rotation of 0 °, and passive internal rotation to the gluteal level. Physical therapy has failed to provide relief. Management should now consist of
1- A subacromial corticosteroid injection
2- Arthroscopic acromioplasty
3- Distal clavicle resection
4- Manipulation under anesthesia
5- Arthroscopy and soft tissue releases
Figures
Answer (click for answer)
Preferred Response : 5
The paper in reference opens its introduction with : « A loss of motion after an operation on the shoulder often cannot be treated successfully with physical therapy or closed manipulation. » The clinical study describes a successful series of patients status post shoulder surgery who, after failing to recover range of motion, are managed successfully with arthoscopic releases involving the anterior capsule. A few patients, with history of decreased internal rotation and flexion also had arthoscopic posterior capsular releases as well. The study mentions that patient selection is crucial to success of this surgery. Pts with known contractures, scarring of the infraspinatus(especially after RCR), and extraarticular scars involving the subscapularis do not do well with arthoscopic release surgery….necessitating conversion to an open approach. The paper concluded that arthroscopic capsular release is a reliable method for restoring motion with the minimum morbidity . When necessary, this procedure can be converted to an open appoach and more formal soft tissue surgery (z-plasty).
A subacromial steroid injection would not help ROM if there is a soft tissue block to motion. Arthroscopic acromioplasty is usally performed in addition to a RCR or if pt has a symptomatic impingement syndrome. Distal clavicle resection is for C-C arthritis.
Reference: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997; 79: 1151-1158.
Warner JJ, Greis PE: The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect 1998; 47:67-75 (In case any of you have remembered to keep your hand out from that lecture.)