[Comparison of mid-term effectiveness between diabetic secondary stiff shoulder and primary frozen shoulder after arthroscopic shoulder capsular release combined with acromiohumeral distance restoration].

Objective: To compare the mid-term effectiveness of arthroscopic shoulder capsular release combined with acromiohumeral distance (AHD) restoration in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder. Methods: A retrospective analysis was conducted on clinical data of 22 patients with diabetic secondary stiff shoulder (group A) and 33 patients with primary frozen shoulder (group B), who underwent arthroscopic 270° capsular release combined with AHD restoration treatment. There was no significant difference between the two groups in gender, age, affected side, disease duration, and preoperative AHD, shoulder flexion range of motion, abduction range of motion, American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale (VAS) score, and Constant score ( P>0.05). Only the difference in the internal rotation cone rank and external rotation range of motion between the two groups showed significant differences ( P<0.05). The improvement in shoulder pain and function was evaluated by using VAS score, ASES score, and Constant score before operation and at last follow-up. Active flexion, abduction, external rotation range of motion, and internal rotation cone rank were recorded and compared. AHD was measured on X-ray films. Results: All patients were followed up 24-92 months (median, 57 months). There was no significant difference in follow-up time between group A and group B ( P>0.05). No fractures or glenoid labrum tears occurred during operation, all incisions healed by first intention, and no complication such as wound infection or nerve injury was observed during the follow-up. At last follow-up, there were significant improvements in active flexion, abduction, external rotation range of motion, internal rotation cone rank, AHD, VAS score, ASES score, and Constant score when compared with preoperative ones in both groups ( P<0.05). Except for the difference in change in external rotation range of motion, which had significant difference between the two groups ( P<0.05), there was no significant difference in other indicators between the two groups ( P>0.05). Conclusion: Arthroscopic capsular release combined with AHD restoration can achieve good mid-term effectiveness in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder. However, the improvement in external rotation range of motion is more significant in the patients with diabetic secondary stiff shoulder.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis.

OBJECTIVE: Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. METHODS: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. CONCLUSIONS: In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach.

Aims: Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA. Methods: Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators. Results: Following initial exposure, the ischiofemoral ligament (7 to 8 o'clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o'clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%). Conclusion: Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.

Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder.

BACKGROUND: Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease. METHODS: Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated. RESULTS: The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases. CONCLUSIONS: Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis.

PURPOSE: To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis. METHODS: A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated. RESULTS: Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES. CONCLUSIONS: In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tear with limited shoulder movement.

BACKGROUND: To determine the clinical efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tendinopathy to improve the Constant-Murley and Visual Analogue Scale (VAS) scores, and shoulder flexion. METHODS: Fifty-one patients with full-thickness rotator cuff tears and limited shoulder movement who were admitted to our hospital from October 2017 to October 2020 were selected; all patients were treated with arthroscopic rotator cuff suture and 360° capsular release. The Constant-Murley score, VAS score, and shoulder flexion angle were used to evaluate shoulder joint function before and during follow-up. Rotator cuff healing was assessed by MRI with the Sugaya classification. RESULTS: After treatment, the Constant-Murley score (58.98 ± 9.84) was significantly improved compared with pre-treatment (29.33 ± 9.71), the VAS score (1.23 ± 0.87) was significantly lower than pre-treatment (7.54 ± 1.22), and the shoulder flexion angle (142.67 ± 8.59°) was significantly improved compared with pre-treatment (51.50 ± 2.10°); the difference was statistically significant (P < 0.05). CONCLUSIONS: Arthroscopic rotator cuff suture and simultaneous 360° capsular release have a significant effect on the treatment of rotator cuff tear with limited shoulder movement.

Arthroscopic capsular release for frozen shoulder: when etiology matters.

PURPOSE: No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder. METHODS: A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS: After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, ß = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release. CONCLUSION: High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient. LEVEL OF EVIDENCE: III.

Limited medial posterior capsular release increases the intraoperative medial component gap while maintaining the joint varus angle at extension in posterior-stabilized total knee arthroplasty.

PURPOSE: There is a lack of robust evidence for the magnitude of the effects of posterior capsular release (PCR) on intraoperative component gaps during total knee arthroplasty (TKA). The purpose of the present study was to quantify and compare the effects of partial versus full PCR on the intraoperative component gaps at various degrees of flexion during posterior-stabilized TKA. METHODS: Full PCR was performed on 39 consecutive cases (full PCR group), and partial PCR (the medial side up to and including the intercondylar notch) was performed on the subsequent 39 consecutive cases (partial PCR group) during posterior-stabilized TKA using the measured resection technique for varus knee osteoarthritis. Medial component gaps and varus angles at 0°, 10°, 45°, 90°, and a maximum of flexion were measured with a tensor device before and after the PCR. Differences between the two groups in post-release medial component gap increase and post-release joint varus angle increase were assessed using a t test. Pre- to post-release medial component gaps and joint varus angles in each group were compared using a paired samples t test. RESULTS: In both groups at 0° and 10° of flexion, post-release medial compartment gaps were significantly greater than pre-release gaps (all P < 0.001). At 45°, 90° and maximum flexion, the medial compartment gap increase did not exceed the minimal detectable change in either group. At 0° and 10° of flexion, there was no significant difference in post-release medial compartment gap change between the two groups. In the full PCR group, post-release joint varus angles at 0° of flexion were significantly greater than pre-release angles (P < 0.001), while there was no significant pre- and post-release difference in the partial PCR group. The change in post-release joint varus angles at 0° of flexion was significantly greater in the full PCR group than in the partial PCR group. CONCLUSION: Both full and partial PCR show similar clinical usefulness for increasing the medial component gap at extension and reducing component gap mismatch. A partial PCR can be used to avoid increasing joint varus angles at 0° of flexion. LEVEL OF EVIDENCE: Level 2 (prospective comparative study).

A Modified Arthroscopic Outside-in Shoulder Release Approach for Severe Shoulder Stiffness.

OBJECTIVE: Arthroscopic release is effective for patients with shoulder stiffness, but the traditional inside-out procedure cannot effectively alleviate the mobility of some severe stiff shoulder and even cause itrogenic injuries sometimes. The aim of this study is to evaluate the clinical efficacy and advantages of a modified outside-in shoulder release approach for severe shoulder stiffness. METHODS: Included in this retrospective study were 15 patients (five male and 10 female) with severe shoulder stiffness who underwent modified outside-in shoulder release surgery at our hospital between June 2019 and March 2021. Of them, 10 patients had a primary frozen shoulder and five had secondary shoulder stiffness, involving the right shoulder in six cases and the left shoulder in nine cases. The mean age of the 15 patients was 56.7 (34-69) years. The patients were instructed to exercise passively from second-day post-operation and enhance the rehabilitation exercise gradually. All patients received a range of motion (ROM) examination before and after surgery. The American Shoulder and Elbow Surgeon's Score (ASES), Constant Score (CS), and Visual Analog Scale (VAS) score for pain were recorded. All data were tested by normal distribution first and then by paired T test, otherwise by Wilcoxon rank sum test. RESULTS: The mean follow-up period was 18.2 (12-33) months. Compared with the preoperative value, the mean ASES score at the final follow-up improved from 38.4 ± 7.37 to 88.13 ± 6.33 points; the mean CS score from 43.27 ± 6.71 to 78.74 ± 6.93 points; the mean VAS score from 5.07 ± 1.03 to 0.81 ± 0.83 points; forward flexion from 81.93° ± 11.45° to 156.73° ± 9.12°; abduction from 65.93° ± 16.82° to 144.80° ± 8.83°; neutral external rotation from 13.53° ± 10.38° to 51.20° ± 4.77°; internal rotation from the buttock to waist (L3), all showing a significant difference (P < 0.0001). No serious complication was observed in any patient during the postoperative follow-up periods. CONCLUSION: The present study has demonstrated that the modified arthroscopic outside-in shoulder release approach can improve ROM of patients and alleviate pain effectively, proving it to be an appropriate surgical option for the treatment of severe shoulder stiffness.

Are soft tissue releases sufficient to correct moderate to severe flexion contractures during total knee replacement? Role of hamstring tenotomy and horizontal capsular release.

BACKGROUND: Performing total knee arthroplasty (TKA) in arthritic knees with persistent flexion deformities is a challenging task because secondary tightening of surrounding soft tissues makes it difficult to achieve appropriate ligament balancing. In this study, we shared our algorithm for correction of flexion contractures of moderate to severe grade while performing TKA as well as their outcomes with 1 year of follow up. METHODS: Forty-three patients (61 knees) having knee arthritis with moderate to severe flexion contractures (Lombardi classification) were included in the study. We followed a stepwise algorithm of soft tissue releases for correction of flexion contracture, which included: removal of posterior osteophytes, release of posterior capsule, gastrocnemius release, horizontal capsular release, and hamstring tenotomy. Patients were followed up at 15 days, 6 weeks, 3 months and 1 year, and assessed clinically for residual flexion deformity (FFD), range of motion (ROM), New Knee Society (New KSS) score and Hospital for Special Surgery (HSS) score. RESULTS: Pre-operative mean FFD 29.07 ± 18.04 standard deviation (SD) was corrected to 0.77 ± 2.93 SD at 1 year follow up. Pre-operative mean ROM 71.37 ± 22.18 increased to 107.7 ± 10.38 at 1 year follow up. There was statistically significant improvement in mean New KSS score and reduction in number of cases with poor HSS score at 1 year follow up. CONCLUSIONS: Moderate flexion contractures can be corrected with soft tissue releases without distal femoral over-resection. In severe deformities, horizontal release of posterior capsule and hamstring tenotomy are crucial, and residual contractures of up to 20° can be well corrected by postoperative physiotherapy and extension bracing.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study.

PURPOSE: Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures. METHODS: From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis. RESULTS: Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD. CONCLUSION: Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.

Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty.

Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up. Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.

Ultrasound-guided aponeurotomy and interphalangeal joint capsular release for treatment of Dupuytren's disease.

This study describes a new ultrasound-guided surgical technique for aponeurotomy and interphalangeal joint capsular release in patients with Dupuytren's disease and analyses the clinical outcomes. We carried out a retrospective review of 70 digits in 35 patients who underwent ultrasound-guided aponeurotomy and interphalangeal joint capsular release, with a minimum follow-up of 2 years. The primary outcome was the correction of the deformity and the QuickDASH questionnaire score after surgery and at 1 and 2 years. The secondary outcome was the presence of residual contracture immediately after surgery. The mean QuickDASH score fell from 28 before surgery to 14 after surgery. A significant decrease of -63° was observed for the global contracture, -35° the metacarpophalangeal joint contracture and -28° for the proximal interphalangeal joint contracture. Ultrasound-guided aponeurotomy and interphalangeal joint capsular and palmar plate releases are highly accurate and safe.Level of evidence: IV.

Posteromedial Accessory Incision for Posterior Capsular Release and Retractor Placement in a Total Ankle Replacement.

The standard approach for performing a total ankle replacement (TAR) is the anterior approach as this offers good direct visualization of the tibiotalar joint. Irrespective of implant system used, most commonly, bone cuts are made in the anterior to posterior direction and may potentially injure the posterior neurovascular structures and tendons running close to the ankle joint. Careful consideration must be taken to ensure these structures are protected. We introduce a new intraoperative technique of protection for the posteromedial soft tissues and neurovascular structures and include the early results of 60 consecutive patients where the described technique was employed. There were no technique-related complications, or evidence of injury to the PTT, FHL, flexor digitorum longus (FDL), or neurovascular bundles.

Both arthroscopic and open posterior knee capsulotomy are effective in terms of extension recovery and functional improvement-systematic review.

PURPOSE: To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit. METHODS: A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach. RESULTS: Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15-63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4-4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE. CONCLUSIONS: Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes. LEVEL OF EVIDENCE: IV.

[Effectiveness of arthroscopic 360° capsular release for frozen shoulder].

OBJECTIVE: To investigate the effectiveness of arthroscopic 360° capsular release for frozen shoulder. METHODS: Between April 2018 and April 2019, 42 patients with frozen shoulders were treated with arthroscopic 360° capsular release. There were 13 males and 29 females, with an average age of 52.3 years (range, 45-56 years). There were 14 left shoulders and 28 right shoulders. The disease duration ranged from 5 to 18 months (mean, 11.1 months). The main clinical symptoms were limited active and passive movement of the shoulder joint with severe pain. All patients excluded impingement syndrome and shoulder osteoarthritis. Preoperative range of motion was as follows: forward flexion (93.2±15.4)°, external rotation at side (15.9±6.0)°, external rotation at 90° abduction (18.4±9.9)°, and internal rotation reaching the greater trochanter in 5 cases, buttocks in 20 cases, S 1 level in 17 cases. The visual analogue scale (VAS) score was 6.7±1.7 and the American Society of Shoulder and Elbow Surgery (ASES) score was 41.6±9.3. The active range of motion of shoulder joint, VAS score, and ASES score were recorded during follow-up. RESULTS: All incisions healed by first intention, and no early complications occurred. Patients were followed up 12-24 months (mean, 15.6 months). After operation, forward flexion, external rotation at side, and external rotation at 90° abduction significantly improved when compared with preoperatively ( P<0.05). The range of internal rotation restored to the level of T 6-12 at 3 weeks, which was equivalent to that of the normal side at 12 months after operation ( Z=-0.943, P=0.346). VAS scores decreased and ASES scores increased after operation, and the differences between pre- and post-operation were significant ( P<0.05); and with time, the VAS scores and ASES scores improved further ( P<0.05). CONCLUSION: Arthroscopic 360° capsular release can significantly increase the range of motion of the shoulder joint, release pain, and improve function. It is an effective method for the treatment of frozen shoulders.

Capsular Healing in Interportal and Periportal Capsulotomy Methods of Hip Arthroscopy.

OBJECTIVE: To evaluate the midterm outcomes and the capsular healing in patients who had interportal capsulotomy versus periportal capsulotomy of hip arthroscopy. METHODS: Retrospectively reviewed 33 patients with labral tear received hip arthroscopy, with an average age of 41 (27-67) years, including 13 cases of Cam deformity and three cases of Pincer deformity. All patients had positive sign of flexion adduction internal rotation or flexion abduction external rotation. With MRI and radiographic (CT, X plain) imageological examination. MRI showed that all patients had labral tear. Radiographic finding (CT, X plain) showed the pathological changes of acetabular and femoral neck osteophyte. One group with 23 patients were treated with periportal capsulotomy. Another group with 10 patients were treated with interportal capsulotomy. All patients did not close the capsule. Clinical outcomes were measured with the Hip Outcome Score Activities of Daily Living (HOS-ADL) and the modified Harris Hip Score (mHHS), patient satisfaction measured with visual analogue scale (VAS). The healing of the capsule was evaluated by MRI. MRI showed continuous capsular indicated healing, discontinuous capsular indicated unhealing. Postoperatively 6 months, mHHS and HOS-ADL were obtained. Randomized controlled trials were used in this study for analysis. RESULTS: All patients were followed up with average time of 9.3 months(3-29 months). The postoperative symptoms were obviously relieved, the VAS decreased from (4.9 ± 0.6) to (1.2 ± 0.2) after 3 months postoperative. Follow up 6 months post-operation, patients in the interportal group, the mHHS and HOS-ADL scores improvement were respectively 69.4 ± 9.3 & 70 ± 8.8 pre-operation, and 92.5 ± 5.0 & 86.6 ± 5.4 post-operation (P < 0.05); Patients in the periportal group, the mHHS and HOS-ADL scores improvement were respectively 69.9 ± 15.8, 68.1 ± 15.0 pre-operation, and 90.1 ± 9.3 & 86.7 ± 7.9 post-operation (P < 0.05).The differences were statistically significant. Six months after operation, MRI showed that 23 patients with periportal capsulotomy, the capsule have healed, without other complications. Three of the ten patients with interportal capsulotomy were healed and seven were not. CONCLUSION: Interportal and periportal capsulotomy had good outcomes. The technique of periportal capsulotomy had little damage to the joint capsule. Although the capsule did not close, the capsule healed well in postoperative follow-up. The nonunion rate of the joint capsule was high in the interportal capsulotomy without close the capsule.

Longitudinal Capsulotomy in Hip Arthroscopy: A Safe and Feasible Procedure for Cam-Type Femoracetabular Impingement.

OBJECTIVE: To evaluate the surgical security, feasibility, and clinical efficacy of the longitudinal outside-in capsulotomy in hip arthroscopic treatment for cam-type femoracetabular impingement (FAI). METHODS: We retrospectively reviewed patients with cam-type FAI who underwent hip arthroscopy in our institute from January 2018 to June 2019. All hip arthroscopic procedures were performed by one experienced surgeon in the same manner, except the fashions of capsulotomy. Fifty six patients with mean age of 39.1 and mean body mass index (BMI) of 24.5 were categorized into two groups according to the fashions of capsulotomy. Twenty six cases with longitudinal outside-in capsulotomy were categorized into Group L, and 30 cases with transversal interportal capsulotomy were categorized into Group T as the control group. The demographic parameters were retrieved from medical documents and compared between the two groups. Surgical outcome including overall surgical time, traction time, complications, visual analogue score (VAS), and intraoperative radiation exposure were compared to investigate the security and feasibility. Radiographic assessment, and functional outcome were compared between the two groups to determine the clinical efficacy of the longitudinal capsulotomy. RESULTS: There was no significant difference in the demography and duration of follow-up between the two groups. The overall surgical time demonstrated no significant difference between Group L and Group T (130.8 ± 16.6 min and 134.0 ± 14.7 min, P = 0.490). Significantly decreased traction time was found in Group L (43.2 ± 8.4 min and 62.2 ± 8.6 min, P < 0.001) compared to Group T. The Median of the fluoroscopic shot was 1 and 3 (P < 0.001). No major complications and reoperation were reported in both groups. The case of intraoperative iatrogenic injure was 0 (0%) and 6 (20%) in Group L and Group T respectively (P = 0.035), and the case of postoperative neurapraxia was 0 (0%) and 8 (26.6%) in Group L and Group T respectively (P = 0.017). The Median of postoperative VAS was 2 and 3 in Group L Group T (P = 0.002). The postoperative α angle was 42.3° ± 3.4° and 44.4° ± 3.5° in group L and group T respectively (P = 0.001). The postoperative iHOT-12 score at final follow-up was 79.3 ± 6.7 and 77.0 ± 7.9 respectively (P = 0.141). CONCLUSION: Longitudinal outside-in capsulotomy with less radiation exposure, reduced traction time, and reduced complications could be a safe and feasible procedure in arthroscopic treatment for cam FAI. Its clinical efficacy was not worse compared with traditional interportal capsulotomy in short-term follow-up.