Impact of open bursectomy and biceps tendon release with closed manipulation in frozen shoulder

Abstract

This retrospective observational study evaluated the efficacy of 2 different surgical approaches for the treatment of frozen shoulder (adhesive capsulitis). This study aimed to compare the efficacy, safety, and recovery times of the 2 treatment modalities. Fifty patients diagnosed with frozen shoulder and treated at Seyhan State Hospital were included in the study. The patients were retrospectively divided into 2 groups based on the treatment received. Group 1 consisted of 25 patients who underwent standard closed manipulation under anesthesia, a technique involving passive movements of the shoulder joint to tear the tight capsule and expand the range of motion (ROM). Group 2, which included 25 patients, underwent closed manipulation in addition to open bursectomy and biceps tendon capsule release. Open bursectomy involves surgical removal of the bursa to alleviate inflammation, while biceps tendon capsule release addresses chronic biceps tendonitis by partially removing the capsule of the tendon. Data on demographic information, operative details, preoperative and postoperative conditions, and patient-reported outcomes were collected and analyzed. Data analysis revealed that the combination of closed manipulation with open bursectomy and biceps tendon capsule release was more effective in reducing pain, increasing ROM, and improving quality of life than closed manipulation alone. The discussion would typically elaborate on how the results compare with existing literature, the clinical implications, and any potential limitations of the study. The results showed that the method that combined closed manipulation with open bursectomy and biceps tendon capsule release was better than closed manipulation alone in terms of reducing pain, increasing ROM, and improving quality of life.

1. Introduction

Frozen shoulder (FS), also known as adhesive capsulitis (AC), is a debilitating condition characterized by pain and restricted movement of the shoulder joint. The pathophysiology of AC remains incompletely understood, but it is believed to involve inflammation and fibrosis of the joint capsule.^[1] This condition significantly affects patients’ quality of life, limits their range of motion (ROM), and causes persistent pain.^[2] The complexity of its pathogenesis, involving both inflammatory and fibrotic processes, poses a challenge in the development of effective treatment strategies.^[3]

Traditional treatment modalities for AC include physical therapy, corticosteroid injections, and various surgical techniques. Closed manipulation under anesthesia (MUA) is a standard treatment that involves passive movement of the shoulder joint to break adhesions and improve mobility.^[4] However, the effectiveness of MUA alone has been questioned, with some studies suggesting the need for additional interventions.^[5] This gap in treatment efficacy highlights the need to explore combined therapeutic approaches that address the multifaceted nature of the disease.^[6]

Recent advances in surgical techniques have introduced a combination of closed manipulation with open bursectomy and biceps tendon capsular release. Open bursectomy involves surgical removal of the inflamed bursa, a fluid-filled sac that facilitates joint movement, while biceps tendon capsular release involves partial removal of the capsule of the tendon.^[1] This combination aims to address both primary and secondary pathological changes in the shoulder, potentially offering a more comprehensive treatment approach.^[7] The rationale behind combining these procedures is to target both intrinsic capsular pathology and secondary changes in the surrounding soft tissues, which are often overlooked in traditional treatments.^[8]

Despite these advancements, there is a lack of consensus regarding the most effective treatment strategy for AC. A systematic review by Salomon et al suggested that limited and inconsistent evidence currently exists on the efficacy of MUA compared to other non-surgical strategies in the management of patients with FS contracture syndrome.^[9] The present study aimed to compare the outcomes of standard closed manipulation with those of the combined approach of closed manipulation, open bursectomy, and biceps tendon capsular release. By analyzing patient outcomes in terms of pain, ROM, and quality of life, this study seeks to contribute valuable insights into the optimal management of AC.^[10] The objective was to fill the existing research gap by providing empirical evidence on the efficacy of these combined surgical interventions, thereby guiding clinical decision-making and improving patient outcomes.^[11]

In summary, this study is set against the backdrop of an evolving understanding of the pathophysiology and treatment of AC. It aims to bridge the knowledge gap regarding the comparative effectiveness of traditional and combined surgical approaches, with a focus on enhancing patient quality of life and functional recovery. The findings of this research could potentially lead to a paradigm shift in the management of AC, offering new hope to patients suffering from this challenging condition.^[12]

2. Methods

This study was approved by the ethics committee of Adana City Hospital (August 3, 2023; approval number: 2729). All the patients included in the study provided informed consent before participation. This study was conducted in accordance with the ethical standards of our institution and the 1964 Declaration of Helsinki and its subsequent amendments.

This retrospective observational study analyzed the treatment of 50 patients with FS who were treated at Seyhan State Hospital and were subsequently followed up. Patients will be divided into 2 groups according to their treatment strategy. Group 1 included 25 patients who underwent standard closed manipulation. Closed manipulation involves passive movements of the shoulder joint under anesthesia, resulting in the tearing of the tight capsule and expansion of the ROM. Group 2 consisted of 25 patients who underwent closed manipulation, open bursectomy, and biceps tendon capsule release procedures. Open bursectomy involves surgical removal of the bursa, a fluid-filled sac that surrounds the joint and facilitates its movement. Biceps tendon capsule release involves partial removal of the capsule of the tendon to treat the chronic biceps tendonitis that develops in these patients. The patient outcomes in both treatment groups were analyzed retrospectively and compared in terms of efficacy, safety, and recovery times.

The study included patients diagnosed with FS between January 2020 and January 2023, as stated in the medical records of the orthopedic clinic of Seyhan State Hospital. Patients were divided into 2 groups according to the treatment methods they received: Group 1 (n = 25) consisted of patients who underwent closed manipulation only, and Group 2 (n = 25), consisted of patients who underwent both closed manipulation and open bursectomy and biceps tendon capsule release procedures (Fig. 1).

Figure 1.

Shoulder anatomy.

The diagnosis of FS was based on clinical assessment, which included a detailed history taking and physical examination, consistent with standard diagnostic criteria for FS. This involved evaluating shoulder pain and stiffness, and confirming the diagnosis through imaging techniques such as X-ray or MRI where necessary.^[13]

A differential assessment was performed to exclude serious pathologies that could mimic FS symptoms. This was critical to ensure accurate diagnosis and appropriate treatment planning. The assessment included a review of patient medical history, physical examination, and when indicated, additional tests such as blood tests or imaging studies, to rule out conditions like rotator cuff tears, arthritis, or neoplasms.^[13]

Surgical technique:

Before the intervention, closed manipulation of the shoulder joint was performed to increase the ROM. This is achieved by passive movements of the shoulder joint under anesthesia, targeting the tearing of the tight capsule.

Following closed manipulation, for patients assigned to Group 2, a surgical approach began with a 3 cm skin incision made laterally. It is important to note that the deltoid muscles were not cut during the procedure. Instead, a split-style approach is used to navigate between the muscles, ensuring minimal tissue damage and preserving muscle integrity.

The joint bursa was reached after passing through the deltoid muscles. This fluid-filled sac, which facilitates movement of the joint, is excised to relieve any inflammation and restriction it may cause. After excision of the bursa, a partial excision of the bicep tendon sheath was performed. This procedure aims to further release any constrictions around the joint and improve joint mobility (Fig. 1).

It is important to note that acromioplasty, a surgical procedure to reshape the acromion in the shoulder, was not performed in the surgical protocol of this study.

Routine data collection included demographic information (age, sex, dominant hand), operative details (operative time, tear location, tear size), preoperative (Preop) conditions (pain level, functional capacity, and quality of life), and postoperative (Postop) outcomes (recovery time, pain level, functional capacity, quality of life, and complication rates). Variables assessed pre- and postoperatively included patient-reported outcomes such as ROM, pain (visual analog scale [VAS]), and quality of life (Shoulder Pain and Disability Index, Shoulder Pain and Disability Index [SPADI]). Data were obtained from the hospital medical records and physiotherapy notes. The VAS and SPADI rating scales were used. Data were collected and analyzed by an independent observer to minimize bias. The study size was limited to the number of patients diagnosed with FS, as reported in the hospital records. All statistical analyses were performed using the SPSS software, and the significance level was set at P < .05. Missing data were managed using appropriate data analysis methods.

Pain, ROM, and quality of life were evaluated preoperatively and postoperatively in both groups. We also investigated whether there was a significant difference between the 2 groups in terms of these values. This study was designed to better understand the Postop recovery process of patients’ dull shoulder discomfort and the factors affecting.

3. Results

The demographic breakdown of the patients included in the study was balanced between treatment groups 1 and 2, with mean ages of 53.5 years and 54.2 years, respectively. Both groups had a nearly equal distribution of male and female participants, with Group 1 comprising 12 males and 13 females and Group 2 consisting of 13 males and 12 females. Analysis of the dominant hand revealed that the majority of patients in both groups had right hand dominance: 20 in Group 1 and 21 in Group 2. Left-hand dominance was less common, observed in 5 patients in Group 1 and 4 patients in Group 2 (Fig. 2).

Figure 2.

Demographic information.

Prior to being assigned to the respective treatment groups, patients underwent a thorough clinical evaluation to determine the severity of their condition and to ascertain their suitability for the respective treatments. This preassignment evaluation included a detailed assessment of their pain duration, intensity, and the presence of other symptoms related to dull shoulder conditions. The average duration of symptoms before the initiation of the treatments was 6 months for Group 1 and 7 months for Group 2.

This study evaluated the efficacy of the 2 treatment modalities in 50 patients with dull shoulder conditions based on parameters such as pain (VAS), ROM, and quality of life (SPADI) in both the Preop and Postop periods. Average VAS, ROM, and SPADI values were found and evaluated separately for each patient in Groups 1 and 2 (Tables 1 and 2) (Fig. 3). The average VAS ROM and SPADI values for groups 1 and 2 were compared (Table 3).

Table 1.

Group 1 preoperative and postoperative evaluations.

Treatment Group 1	VAS average	ROM average	SPADI average
Preop	73	47º	68
Postop	40	92º	32
P value	<.005	<.005	<.005

Statistically significant differences are marked with P < .05.

ROM = shoulder range of motion, SPADI = shoulder pain and ability assessment scale, VAS = visual pain scale.

Table 2.

Group 2 preoperative and postoperative evaluations.

Treatment Group 2	VAS average	ROM average	SPADI average
Preop	72	45º	68
Postop	35	100º	25
P value	<.005	<.005	<.005

Statistically significant differences are marked with P < .05.

ROM = shoulder range of motion, SPADI = shoulder pain and ability assessment scale, VAS = visual pain scale.

Figure 3.

Comparison preop and postop clinical outcomes of Group 2.

Table 3.

Comparison of postop clinical results of Group 1 and Group 2.

	VAS average	ROM average	SPADI average
Group 1	40	92º	32
Group 2	35	100º	25
P value	<.005	<.005	<.005

Pain (VAS): Initially, no significant difference was observed in the VAS scores between treatment groups 1 and 2 in the Preop phase. Postoperatively, however, Group 2 exhibited a noteworthy reduction in VAS scores (Preop: 72, Postop: 35, P value: <.005) compared to Group 1 (preop: 73, Postop: 40, P value: <.005), indicating superior pain management in Group 2.

Shoulder ROM: Similar to the pain scores, Preop ROM assessments revealed no significant differences between the groups. Post-treatment, Group 2 showed a significant enhancement in ROM (Preop: 45º, Postop: 100º, P value: <.005) compared to Group 1 (Preop: 47º, Postop: 92º, P value: <.005).

Quality of Life (SPADI): Quality of life metrics followed a parallel trend. While Preop SPADI scores were comparable, Group 2 showed a more pronounced improvement postoperatively (Preop: 68, Postop: 25, P value: <.005) than Group 1 (Preop: 68, Postop: 32, P value: <.005).

Moreover, it was observed that patients in both groups had previously undergone various non-surgical therapeutic strategies, such as physical therapy, NSAIDs, and corticosteroid injections, before being considered for the procedures in our study. This prior treatment history was important in understanding the baseline condition of the patients and their response to previous interventions.

A direct comparison of Postop clinical outcomes between Group 1 and Group 2 further affirmed these findings, with Group 2 showing superior results in all evaluated parameters (VAS, ROM, and SPADI), all with P values < .005. Our results showed that closed manipulation therapy for patients with dull shoulder conditions, as well as bursectomy and capsule loosening of the biceps tendon, were more effective in terms of reducing pain, increasing ROM, and improving quality of life (Fig. 3).

4. Discussion

The findings of our study offer valuable insights into the treatment of FS, particularly highlighting the efficacy of a combined surgical approach over closed manipulation alone. Our analysis revealed that integrating closed manipulation with open bursectomy and biceps tendon capsular release resulted in superior outcomes in pain reduction, ROM enhancement, and quality of life improvement. This underscores the effectiveness of addressing both intra-capsular adhesions and secondary inflammatory changes in surrounding soft tissues for a more comprehensive treatment of FS.^[14–17]

The combined approach success in significantly reducing pain is consistent with prior research emphasizing the role of inflammation in FS pathophysiology. The surgical intervention in our study effectively reduced the inflammatory burden, thus expediting pain relief.^[18,19] This finding aligns with existing literature and highlights the necessity of targeting both the joint capsule and adjacent structures for optimal pain management.

Moreover, the study results regarding the improved ROM in patients undergoing the combined approach are notable. This improvement is attributed to the extensive release of the joint capsule and surrounding tissues, facilitating enhanced mobility.^[12,20] This aspect is particularly crucial given the restrictive nature of FS and its impact on patients’ functionality and daily activities.

In terms of quality of life, measured by the SPADI, the combined approach demonstrated significant improvements. Given the debilitating effects of FS, this improvement in quality of life is both clinically and personally significant for patients.^[21]

However, it is crucial to acknowledge the limitations of our study. The retrospective design and the relatively small sample size may limit the extrapolation of these results to a broader population. Furthermore, the absence of long-term follow-up data restricts our understanding of the sustained efficacy of these treatment modalities.^[22,23]

The clinical implications of our study are significant. The results suggest that a more aggressive yet comprehensive surgical approach may be beneficial for patients with FS. This could potentially lead to faster recovery and improved long-term outcomes, indicating a possible shift in the standard treatment protocol for this condition.^[24]

In summary, our study provides substantial evidence in favor of a combined surgical approach in treating FS, offering a new perspective in the management of AC. This approach not only addresses the immediate symptoms but also contributes to the overall enhancement of patient well-being, marking a progressive step in the treatment of this challenging condition.^[24] The findings advocate for a reevaluation of current treatment strategies, emphasizing the need for a more holistic approach to patient care in FS management.

5. Conclusion

This study contributes to the growing body of evidence supporting the use of a combined surgical approach for the treatment of FS. This underscores the need for a comprehensive treatment strategy that addresses both primary capsular pathology and secondary soft-tissue changes. Future research should focus on larger prospective studies with longer follow-up periods to validate these findings and further refine treatment strategies for this challenging condition.

Author contributions

Conceptualization: Serdar Menekse.

Data curation: Serdar Menekse.

Formal analysis: Serdar Menekse.

Funding acquisition: Serdar Menekse.

Investigation: Serdar Menekse.

Methodology: Serdar Menekse.

Project administration: Serdar Menekse.

Resources: Serdar Menekse.

Software: Özlem Karataş.

Supervision: Serdar Menekse.

Validation: Özlem Karataş, Hakan Zora.

Visualization: Özlem Karataş, Hakan Zora.

Writing – original draft: Serdar Menekse.

Writing – review & editing: Serdar Menekse.