Table 2.

Key Intraoperative Steps

1.Closed manipulation: Examine the patient's passive shoulder range of motion after induction of general anesthesia. If passive motion remains limited despite anesthesia, perform gentle closed manipulation.

2.Diagnostic arthroscopy: After shoulder manipulation, perform glenohumeral arthroscopy and evaluate for capsular inflammation and thickening. Identify capsular rents created by closed manipulation.

3.Anterior capsular release: Place the arthroscope posteriorly and use an arthroscopic biter or hooked cautery within an anterior cannula. Withdraw the cannula until it is just superficial to the capsule but deep to the rotator cuff musculature, allowing instrument access to the thickened capsule.

4.Use the biter and/or cautery to incise the thickened capsule, remaining deep to the rotator cuff musculature. Create a vertical, linear full-thickness defect in the capsule that parallels the glenoid margin.

5.Then use a shaver or blunt dissection with the biter to widen the capsular defect, creating space between the capsular limbs so they heal in an elongated position.

6.Inferior capsular release: If instrumented inferior capsular release is necessary, use a hooked cautery device via the anterior portal while the arthroscope views from a posterior portal. Release the inferior capsule under direct arthroscopic visualization. Stay directly adjacent to the glenoid and release the capsule in a controlled fashion to avoid axillary nerve injury.

7.Posterior capsular release: Use the above-described anterior capsular release technique, except that instead the arthroscope is placed anteriorly and the cannula is placed posteriorly.