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.

Aims. Animal models have been developed that allow simulation of post-traumatic joint contracture. One such model involves contracture-forming surgery followed by surgical capsular release. This model allows testing of antifibrotic agents, such as rosiglitazone. Methods. A total of 20 rabbits underwent contracture-forming surgery. Eight weeks later, the animals underwent a surgical capsular release. Ten animals received rosiglitazone (intramuscular initially, then orally). The animals were sacrificed following 16 weeks of free cage mobilisation. The joints were tested biomechanically, and the posterior capsule was assessed histologically and via genetic microarray analysis. Results. There was no significant difference in post-traumatic contracture between the rosiglitazone and control groups (33° (standard deviation (. sd. ) 11) vs 37° (. sd. 14), respectively; p = 0.4). There was no difference in number or percentage of myofibroblasts. Importantly, there were ten genes and 17 pathways that were significantly modulated by rosiglitazone in the posterior capsule. Discussion. Rosiglitazone significantly altered the genetic expression of the posterior capsular tissue in a rabbit model, with ten genes and 17 pathways demonstrating significant modulation. However, there was no significant effect on biomechanical or histological properties. Cite this article: M. P. Abdel. Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis. Bone Joint Res 2016;5:11–17. doi: 10.1302/2046-3758.51.2000593

A cadaver study was performed to determine the effect of arm position and capsular release on rotator cuff repair. Artificial defects were made in the rotator cuff to include only the supraspinatus (small) or both supraspinatus and infraspinatus (large). The defects were repaired in a standard manner with the shoulder abducted 30 degrees at the glenohumeral joint. Strain gauges were placed on the lateral cortex of the greater tuberosity and measurements were recorded in 36 different combinations of abduction, flexion/extension, and medial/lateral rotation. Readings were obtained before and after capsular release. With small tears, tension in the repair increased significantly with movement from 30 degrees to 15 degrees of abduction (p < 0.01) but was minimally affected by changes in flexion or rotation. Capsular release significantly reduced the force (p < 0.01) at 0 degree and 15 degrees abduction. For large tears, abduction of 30 degrees or more with lateral rotation and extension consistently produced the lowest values. Capsular release resulted in 30% less force at 0 degree abduction (p < 0.05)

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively. . ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms. Cite this article: Bone Joint J 2013;95-B:942–6

Aims. Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release. Methods. A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks. Results. IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)). Conclusion. IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value. Cite this article: Bone Joint Res 2022;11(1):32–39

The February 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty

Aims. A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care. Methods. A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods. Results. ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses. Conclusion. While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective. Cite this article: Bone Jt Open 2021;2(8):685–695

Aims. This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. Methods. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. Results. Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. Conclusion. The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773–784

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus

Aims. Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR). Methods. In this prospective trial, 219 hips in 190 patients were randomized to either the CS (n = 104) or CR (n = 115) cohort. In the CS cohort, a medial based anterior flap was created and sutured back in place at the end of the procedure. The anterior capsule was resected in the CR cohort. Primary outcome was defined as the difference in patient-reported outcome measures (PROMs) after one year. PROMs (Harris Hip Score (HHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and Short Form 36 Item Health Survey (SF-36)) were collected preoperatively and one year postoperatively. Radiological parameters were analyzed to assess implant positioning and implant ingrowth. Adverse events were monitored. Results. At one year, there was no difference in HSS (p = 0.728), HOOS (Activity Daily Life, p = 0.347; Pain, p = 0.982; Quality of Life, p = 0.653; Sport, p = 0.994; Symptom, p = 0.459), or SF-36 (p = 0.338). Acetabular component inclination (p = 0.276) and anteversion (p = 0.392) as well as femoral component alignment (p = 0.351) were similar in both groups. There were no dislocations, readmissions, or reoperations in either group. The incidence of psoas tendinitis was six cases in the CS cohort (6%) and six cases in the CR cohort (5%) (p = 0.631). Conclusion. No clinical differences were found between resection or preservation of the anterior capsule when performing a primary THA through the DAA on a regular theatre table. In case of limited visibility during the learning curve, it might be advisable to resect a part of the anterior capsule. Cite this article: Bone Joint J 2021;103-B(2):321–328

Aims. The primary aim of this study was to evaluate the efficacy of distension arthrography in the treatment of adhesive capsulitis of the shoulder. The secondary aim was to assess which patient and procedural factors predicted the recurrence of symptoms after the procedure. Methods. All patients referred to our shoulder clinic over a ten-year period, between 2008 and 2018, with a clinical diagnosis of capsulitis and symptoms persisting for more than six months, were offered treatment with a distension arthrogram. All procedures were performed by one of five musculoskeletal radiologists, with a combination of steroid, local anaesthetic, and a distention volume of 10 ml, 30 ml, or 50 ml. Patient demographics, procedural details, recurrence of symptoms, and the need for further intervention were evaluated. Results. A total of 2,432 distension arthrograms were performed during the study period. The mean time between arthrography and analysis was 5.4 years (SD 4.4; 1 to 11). Recurrent symptoms occurred in 184 cases (7.6%), all of whom had a repeat distension arthrogram at a median of nine months (interquartile range (IQR) 6.0 to 15.3). The requirement for further intervention for persistent symptoms following arthrography was significantly associated with diabetes (p < 0.001) and bilateral capsulitis (p < 0.001). The volume of distension, either with air or saline, showed a dose-dependent advantage. Distension of 50 ml versus 30 ml showed a significantly decreased odds ratio for recurrence of 2.2 (95% confidence interval (CI) 1.6 to 3.0; p < 0.001). Capsule rupture (p = 0.615) or steroid dose (p = 0.275) did not significantly affect the rate of recurrence. There were no infections or neurovascular injuries. Following the second distension arthrogram, the symptoms resolved in 137 cases (74.5%) with no further intervention being required. An arthroscopic capsular release was ultimately required in 41 cases, comprising 1.7% of the entire cohort. Conclusion. We found a low rate of repeat intervention following distension arthrography in patients with adhesive capsulitis of the shoulder, at long term follow-up. Greater volumes of distension are associated with lower rates of recurrence independent of capsule rupture. Cite this article: Bone Joint J 2020;102-B(5):606–610

Aims. The aims of this study were to determine the effect of osteophyte excision on deformity correction and soft tissue gap balance in varus knees undergoing computer-assisted total knee arthroplasty (TKA). Methods. A total of 492 consecutive, cemented, cruciate-substituting TKAs performed for varus osteoarthritis were studied. After exposure and excision of both cruciates and menisci, it was noted from operative records the corrective interventions performed in each case. Knees in which no releases after the initial exposure, those which had only osteophyte excision, and those in which further interventions were performed were identified. From recorded navigation data, coronal and sagittal limb alignment, knee flexion range, and medial and lateral gap distances in maximum knee extension and 90° knee flexion with maximal varus and valgus stresses, were established, initially after exposure and excision of both cruciate ligaments, and then also at trialling. Knees were defined as ‘aligned’ if the hip-knee-ankle axis was between 177° and 180°, (0° to 3° varus) and ‘balanced’ if medial and lateral gaps in extension and at 90° flexion were within 2 mm of each other. Results. Of 50 knees (10%) with no soft tissue releases (other than cruciate ligaments), 90% were aligned, 81% were balanced, and 73% were aligned and balanced. In 288 knees (59%) only osteophyte excision was performed by subperiosteally releasing the deep medial collateral ligament. Of these, 98% were aligned, 80% were balanced, and 79% were aligned and balanced. In 154 knees (31%), additional procedures were performed (reduction osteotomy, posterior capsular release, and semimembranosus release). Of these, 89% were aligned, 68% were balanced, and 66% were aligned and balanced. The superficial medial collateral ligament was not released in any case. Conclusion. Two-thirds of all knees could be aligned and balanced with release of the cruciate ligaments alone and excision of osteophytes. Excision of osteophytes can be a useful step towards achieving deformity correction and gap balance without having to resort to soft tissue release in varus knees while maintaining classical coronal and sagittal alignment of components. Cite this article: Bone Joint J 2020;102-B(6 Supple A):49–58

The April 2014 Shoulder & Elbow Roundup. 360 . looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. . This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Fixed flexion deformities are common in osteoarthritic knees that are indicated for total knee arthroplasty. The lack of full extension at the knee results in a greater force of quadriceps contracture and energy expenditure. It also results in slower walking velocity and abnormal gait mechanics, overloading the contralateral limb. Residual flexion contractures after TKA have been associated with poorer functional scores and outcomes. Although some flexion contractures may resolve with time after surgery, a substantial percentage will become permanent. Therefore, it is essential to correct fixed flexion deformities at the time of TKA, and be vigilant in the post-operative course to maintain the correction. Surgical techniques to address pre-operative flexion contractures include: adequate bone resection, ligament releases, removal of posterior osteophytes, and posterior capsular releases. Post-operatively, extension can be maintained with focused physiotherapy, a specially modified continuous passive motion machine, a contralateral heel lift, and splinting

Frozen shoulder is a recognised complication following simple arthroscopic shoulder procedures, but its exact incidence has not been reported. Our aim was to analyse a single-surgeon series of patients undergoing arthroscopic subacromial decompression (ASD; group 1) or ASD in combination with arthroscopic acromioclavicular joint (ACJ) excision (group 2), to establish the incidence of frozen shoulder post-operatively. Our secondary aim was to identify associated risk factors and to compare this cohort with a group of patients with primary frozen shoulder. We undertook a retrospective analysis of 200 consecutive procedures performed between August 2011 and November 2013. Group 1 included 96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed post-operatively using the British Elbow and Shoulder Society criteria. A comparative group from the same institution involved 136 patients undergoing arthroscopic capsular release for primary idiopathic frozen shoulder. . The incidence of frozen shoulder was 5.21% in group 1 and 5.71% in group 2. Age between 46 and 60 years (p = 0.002) and a previous idiopathic contralateral frozen shoulder (p < 0.001) were statistically significant risk factors for the development of secondary frozen shoulder. Comparison of baseline characteristics against the comparator groups showed no statistically significant differences for age, gender, diabetes and previous contralateral frozen shoulder. . These results suggest that the risk of frozen shoulder following simple arthroscopic procedures is just over 5%, with no increased risk if the ACJ is also excised. Patients aged between 46 and 60 years and a previous history of frozen shoulder increase the relative risk of secondary frozen shoulder by 7.8 (95% confidence interval (CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively. Cite this article: Bone Joint J 2015; 97-B:963–6

We retrospectively assessed the value of identifying impinging osteophytes using dynamic computer simulation of CT scans of the elbow in assisting their arthroscopic removal in patients with osteoarthritis of the elbow. A total of 20 patients were treated (19 men and one woman, mean age 38 years (19 to 55)) and followed for a mean of 25 months (24 to 29). We located the impinging osteophytes dynamically using computerised three-dimensional models of the elbow based on CT data in three positions of flexion of the elbow. These were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively to 9° (0° to 25°) post-operatively, and the mean flexion improved from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively. The mean Mayo Elbow Performance Score improved from 62 (30 to 85) to 95 (70 to 100) post-operatively. All patients had pain in the elbow pre-operatively which disappeared or decreased post-operatively. According to their Mayo scores, 14 patients had an excellent clinical outcome and six a good outcome; 15 were very satisfied and five were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients with osteoarthritis of the elbow. Cite this article: Bone Joint J 2014;96-B:237–41

Aims. The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. . Patients and Methods. A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. . The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. Results. The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. Conclusion. Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. Take home message: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion. Cite this article: Bone Joint J 2016;98-B:365–73

Aims

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

Aims

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.