S ORIGINAL ARTICLE Stiffness after arthroscopic shoulder surgery: incidence, management and classification

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1 Shoulder & Elbow. ISSN S ORIGINAL ARTICLE Stiffness after arthroscopic shoulder surgery: incidence, management and classification Puneet Monga, Holly N. Raghallaigh & Lennard Funk Upper Limb Unit, Wrightington Hospital, Wigan, UK Medical Student, University of Manchester, Manchester, UK Received Received 21 April 2011; accepted 30 January 2012 Keywords Shoulder arthroscopy, stiffness, complications, postoperative stiffness. Conflicts of Interest None declared Correspondence Puneet Monga, Upper Limb Unit, Wrightington Hospital, Appley Bridge, Wigan WN6 9EP, UK. Tel.: +44 (0) Fax: +44 (0) puneet.monga@wwl.nhs.uk DOI: /j x ABSTRACT Background Stiffness after arthroscopic shoulder surgery is of significant concern to the patient, surgeon and therapist. The present study aimed to investigate the natural history of stiffness after shoulder arthroscopic procedures. Methods Postoperative recovery of range of motion (ROM) in patients who underwent 234 consecutive arthroscopic procedures over a 1-year period was reviewed. The time needed to regain full ROM was recorded for every patient. Stiffness was graded from 0 to 3 depending on the loss of movements as compared to the opposite side. Results Postoperative ROM returned to normal in 63% of patients within 3 months, 94% of patients within 6 months, 96% of patients within 9 months and 97% of patients within 1 year after surgery. Stiffness was graded as a loss of ROM compared to the contralateral shoulder, with less than a third loss as grade 1, one third to two-thirds loss as grade 2 and more than two thirds loss as grade 3. Some 85% patients with Grade 1 stiffness recovered complete ROM at 6 months, whereas only 43% of grade 2/3 stiffness returned to normal at 6 months. Only four patients required further active intervention for recovery from stiffness. Risk of developing stiffness was related to the pre-operative diagnosis. Conclusions Although, minor (grade 1) stiffness after shoulder surgery occurs commonly despite early mobilization rehabilitation protocols; it resolves rapidly without further surgical intervention in a majority of the patients. INTRODUCTION Over the past two decades, there has been an exponential growth in shoulder surgery [1], which has primarily been driven by development of safer and efficient arthroscopic instruments and a better understanding of shoulder pathologies. The risk of major complications such as infection, neurovascular injury and ligament damage after arthroscopic procedures in general has been reported to be very low, between 0.56% [2] and 1.68% [3]. Although the rate of complications, especially with newer procedures, remains unknown, most recent review studies suggest that the rate is low, at 5.8% to 9.5% [4]. At the same time, the expectations of patients from surgical input have been progressively increasing. Not only are patients rightly expecting a safer treatment with low complication rate, but also they are more inquisitive about the risk of a particular complication and the likely final outcome if they develop it. Many patients will experience some temporary stiffness after surgery, which will resolve once the shoulder is mobilized. Huberty et al. reported that 4.9% of patients undergoing arthroscopic rotator cuff repair developed postoperative stiffness severe enough to warrant further surgery [5]. They identified risk factors predisposing patient to postoperative stiffness, including workers compensation insurance, age <50 years, a pre-operative diagnosis of calcific tendonitis or adhesive capsulitis, concomitant coracoplasty, Bankart repair or any labral repair and small cuff tears. This is comparable with the results of Tauro, who reported a postoperative stiffness (requiring surgery) rate of 4.3% (three from 72 patients) [6]. Flurin et al. also reported that 3.1% of their patients developed stiffness after arthroscopic repair of massive rotator cuff tears [7]. There had been no reported difference between postoperative stiffness between arthroscopic versus open acromioplasty, although arthroscopic surgery offers other advantages, including a quicker return to normal range of motion (ROM) [8 10]. Warner et al. suggested that a loss of motion after surgery on the shoulder often cannot be treated successfully with physical therapy or closed manipulation and recommended capsular release in carefully selected patients as the preferred management [11]. In a similar study by Vezeridis et al., it was suggested that true arthrofibrosis after shoulder arthroscopy is uncommon and surgical release should be used as the preferred option only if initial physical therapy fails [12]. Studies have often only reported the incidence of stiffness, which needed further surgical input. It is recognized anecdotally that postoperative stiffness after shoulder surgery is common. The incidence of lesser degrees of stiffness, which is still a source of morbidity to the patients, although not suffieciently severe enough to warrant surgical release, remains unknown. There is no Shoulder and Elbow. Shoulder and Elbow , pp

2 information available detailing the time taken to recover ranges of motion after shoulder surgery. Although success of surgical release inseveredegreesofstiffnesshasbeenclearlydemonstrated [11,12], there is a lack of knowledge regarding the overall prognosis for postoperative stiffness. This information would be immensely useful for obtaining appropriate and informed pre-operative consent and guiding appropriate postoperative management. The present study was designed to assess the time taken to recover ROM after arthroscopic shoulder surgery, as well as the incidence of postoperative stiffness, its natural history and outcome. MATERIALS AND METHODS The present study was designed as a retrospective review of all patients who underwent arthroscopic shoulder surgery over a 1-year period by the senior author (L.F). Using an electronic patient record database, a search was performed for all operations performed during the period 1 December 2008 to 1 December These surgeries were performed across three hospitals. Standardized postoperative rehabilitation protocols were used across all sites for similar procedures. Procedures performed on joints other than the shoulder or injections were excluded. Patients undergoing open procedures and arthroscopic arthrolysis for frozenshoulderwereexcluded. Patientswithanincompletedataset were excluded. Each operation was treated as an independent event and, in the case of patients who underwent more than one surgery on the same shoulder during the timeframe, only their first operation was included. Revision surgery introduces a significant bias and the aim of the study was to extract the incidence of stiffness after primary surgery. For the purposes of this study, even if the patient had two procedures at the same sitting, the bigger procedure was listed as the key procedure. For example, in the event that subacromial decompression was performed along with a rotator cuff repair, this was considered as a rotator cuff repair for the purpose of the present study. Two hundred and thirty four arthroscopic procedures were identified using the above inclusion and exclusion criteria (Table 1). The primary outcome was the time to return to full ROM. It was from this variable that the frequency of postoperative stiffness and its outcome was derived. The grade of stiffness was recorded at each follow-up. A shoulder therapist identified and graded the severity of postoperative stiffness by recording the ROM at 3 months. Postoperative stiffness was graded 0 to 3 based on the percentage loss of passive glenohumeral motion compared to the opposite side. Passive movements were used in the assessment because they would be less prone to bias from pain and fatigue compared to active movements. ROM in abduction, external rotation or internal rotation (both rotations tested with the arm in adduction) was measured using a goniometer and the most restricted movement of the three was used for grading. These measurements rather than activities of daily living/functional movements were chosen to improve consistency in measurement: grade 0 = normal ROM; grade 1 = less than one-third loss; grade 2 = one to two-thirds loss; and grade 3 = more than two-thirds loss. Microsoft Excel (Microsoft Corp., Redmond, WA, USA) was used for data collection, as well as for statistical and descriptive analysis. RESULTS Three hundred and nineteen patients underwent shoulder surgery during the study period. After exclusions for incomplete records, arthroscopic capsular release for frozen shoulder and open surgeries such as arthroplasty and open reconstructions, 234 procedures formed the basis of the study group. The mean age at operation was 41 years (range 14 years to 79 years). Of these, 75.2% were male (n = 176) and 24.8% were female (n = 58). The right shoulder was involved in 53.4% of patients (n = 125), the left shoulder in 45.3% (n = 106) and both shoulders in 1.3% (n = 3). Only arthroscopic operations were included. The median follow-up time was 4 months (mean = 4.1 months; minimum of 1 month; maximum of 15 months). Patients were discharged when they had achieved a full range of pain-free motion of their shoulder. Mean pre-operative and postoperative Oxford shoulder scores were 30.4 (range 5 to 47) and 40.6 (range 18 to 48) at a mean of 3.11 months postoperatively (Oxford shoulder score: range 0 to 48, with 0 being the worst possible score and 48 being the best possible score). We plotted the percentage of patients who regained full ROM after surgery against time (Fig. 1). Postoperative ROM returned to normal in 63% of patients within 3 months, 92% patients within 6 months, 96% patients within 9 months and 97% within 1 year after surgery. The patients who had not recovered ROM at 1 year included three patients who had arthroscopic Table 1 Case mix and recovery Procedure n Residual stiffness at 3 months (n) Percentage stiff at 3 months Grade 2/3 (n) Percentage Grade 2/3 Needing aggressive intervention (n) Arthroscopic stabilization ASD Arthroscopic cuff repair ASD and ACJ Arthroscopic SLAP repair Arthroscopic debridement ACJ, acromioclavicular joint; ASD, arthroscopic subacromial decompression; SLAP, superior labral tear from anterior to posterior. 170 Shoulder and Elbow. Shoulder and Elbow , pp

3 Fig. 1 Overall pattern of regaining rangeof motion over time(all patients). Fig. 3 Recovery pattern for grade 2/3 stiffness over time. Fig. 2 Recovery pattern for grade 1 stiffness over time. debridement for osteoarthritis, two patients with arthroscopic rotator cuff repairs and one patient who underwent arthroscopic subacromial decompression and debridement of a partial cuff tear. Patients were assessed for the severity of stiffness at 3 months after surgery and classified using the simple grading system. Eightyfive percent of patients with grade 1 stiffness recovered complete ROM at 6 months (Fig. 2), whereas only 53% of grade 2/3 stiffness returned to normal at 6 months (Fig. 3). All the patients with postoperative stiffness resolved satisfactorily by non-operative measures(physiotherapy, injection, analgesia or anti-inflammatory medication), except for four patients (1.7%) who required active intervention in the form of either hydrodilatation or arthroscopic capsular release. The most common procedure associated with delayed recovery of ROM was arthroscopic debridement of the joint. Along with arthroscopic cuff repair, this was also the most common procedure associated with the development of grade 2/3 or a severe degree of stiffness. Two patients who underwent cuff repair needed active intervention in the form of hydrodilatation or arthrolysis to aid in the recovery of their ROM. Comparative values for various procedures and relative risk of delayed recovery of ROM are shown in Table 1. Four patients required a more aggressive input in the form of arthrographic hyrodilatation or further surgery. All four procedures were offered to patients experiencing significant symptoms related to the restriction of ROM. A 56-year right-handed male who had undergone arthroscopic repair of a large rotator cuff tear needed arthroscopic capsular release for grade 2 stiffness at 4 months as a result of symptomatic restriction of movement. He regained pain-free functional ROM at 1 year. A 46-year-old righthanded male who underwent arthroscopic acromioplasty and acromioclavicular joint resection, developed grade 2 stiffness and underwent arthrographic hydrodilation at 3 months after surgery, again for symptomatic restriction of ROM. One of the patients who required surgical release postoperatively was a 62-year-old right-handed lady with a right-sided massive rotator cuff tear treated with arthroscopic cuff repair. She developed grade 3 stiffness and was treated with capsular release for at 3 months after initial surgery. She was followed for up to 7 months after initial surgery when she had regained complete painless ROM. A 44-year-old right-handed man who underwent arthroscopic repair of a superior labral anterior posterior lesion developed grade 3 stiffness and at 5 months after initial surgery needed hydrodilatation. His symptoms of pain had resolved at 7 months after initial surgery. DISCUSSION The incidence of major complications (such as deep infection or neurovascular injury) is reassuringly quite low. The incidence of complications such as postoperative stiffness is important with respect to monitoring practice, benchmarking, directing further research and developing decision-making pathways. There has been no previous work carried out aiming to identify the overall incidence of postoperative stiffness or to monitor trends for the recovery of ROM after shoulder surgery. It is clear from the present study that the majority of patients recover ROM rapidly within the first 6 months of surgery, even though 37% of the patients had not achieved full ROM at 3 months after surgery. These values are clearly much higher than previous reports of 4.9% [5], 4.3% [6] or 3.1% [7] for arthroscopic repair of rotator cuff Shoulder and Elbow. Shoulder and Elbow , pp

4 tears because most of the previous reports either focussed on stiffness, which needed intervention in the form of surgery, or severe forms of stiffness [13]. The need for aggressive intervention (surgical/hydrodilatation) remains very low, even in the present study (1.7% overall), as does the incidence of severe (grade 2/3) stiffness (5.9%). Previous reports of postoperative stiffness have underestimated the true extent of the incidence by excluding lesser degrees of stiffness. It is therefore useful to classify the degree of stiffness and to monitor it during the recovery phase after surgery. All cases in the present study underwent arthroscopic shoulder surgery, with arthroscopic stabilization, arthroscopic subacromial decompression and cuff repair being by far the most common procedures employed. The present study was performed in a tertiary level centre with a mixture of primary and referred cases. The most common surgery performed for patients who remained stiff at 3 months (all grades) was arthroscopic rotator cuff repair (Table 1). It is difficult to determine why a large proportion of rotator cuff repairs experiences took a long time to regain ROM despite early mobilization protocols. This may simply be related to the fact that, in the present study, all degrees of restricted movements at 3 months were classified as postoperative stiffness. At this stage, people are still in active stages of their rehabilitation and this trend represents an expected recovery. Parsons et al. found that the rate of severe stiffness (i.e. grade 2/3 stiffness) was 23% after a continuous immobilization without active rehabilitation in a sling for 6 weeks after arthroscopic cuff repair [13]. They found no difference in their stiff group versus the not stiff group at 1 year. Their work is again suggestive of an overall trend towards recovery with time. Even though early rehabilitation protocols may shorten the morbidity period, the present study did not attempt to answer this question. It is reassuring, however, that postoperative stiffness recovers in the majority of patients without aggressive measures. The vast majority of the patients who were noted to be stiff at 3 months recovered satisfactory painless ROM with non-operative measures. Physiotherapy modalities were used as a first line in all patients. Anti-inflammatories were prescribed over 2 weeks along with physiotherapy if the patient had diffuse tenderness along with painful restriction of movements, suggestive of an inflammatory component to the restricted ROM. The chances of developing stiffness appear to be linked to the pre-operative diagnosis as well. Some 57% of the patients undergoing arthroscopic debridement were stiff at the 3-month assessment. All these procedures were performed in patients with degenerative/arthritic pathologies. The high incidence of postoperative stiffness observed in patients with arthroscopic cuff repair (52.6%) also reflects that degenerative pathologies have a higher chance of developing postoperative stiffness. This is more likely a reflection of failure to regain normal movements from a pre-existing restriction of ROM rather than a secondary restriction of the surgical input. There is presently no classification system for grading the severity of shoulder stiffness. Clearly, the impact of shoulder stiffness on a particular subject would be determined by its severity. Reliance on recording the exact degrees for measuring ROM is associated with significant problems because the individual variation of normal movements between different subjects is significant. There is also significant inter-observer variability along with an absence of a simple accurate way of assessing shoulder ROM in the clinical setting. A grading system for shoulder stiffness as used in the present study is thus proposed because it is simple, uses the contralateral side for comparison and is not affected by minor variations in measuring ROM clinically. No single grading system for measuring ROM would be entirely accurate, reliable, easy to use and practical in a clinical setting, although the proposed system allows communication, is intuitive and easy to administer. It should be accepted that a pathology affecting the opposite shoulder would have an impact on assessing ROM using this method, and hence it is proposed that further work on interand intra-observer reliability of this grading system would further enhance it validity and usefulness. The retrospective nature of the present study admittedly means that there may be confounding factors that influenced the results. The presence of co-morbid conditions or whether the patients smoked were not recorded and such factors may have influenced the risk of postoperative stiffness. Although the follow-up rate of 90.3% was reasonable, it is possible that the missing 9.7% dataset could have influenced the outcomes. The influence of a relative period of inactivity in a sling could have been a source of bias in terms of symptom relief. Clearly, a prospective study on a multicentre multisurgeon practices would eliminate a majority of confounding factors related to case mix, surgeon practices and the varying success of physiotherapy input. Conclusions Mild restriction of ROM after shoulder surgery does not require aggressiveinput. Severegradesofstiffnessarelesscommonandthe incidence of postoperative stiffness is affected by the pre-operative condition. A simple classification for postoperative stiffness has been suggested to aid in the early identification of severe cases. An initial non-operative approach towards management for postoperative stiffness is recommended. References 1. Vitale MA, Arons RR, Hurwitz S, Ahmad CS, Levine WN. The rising incidence of acromioplasty. J Bone Joint Surg Am 2010; 92: [No authors listed]. Complications in arthroscopy: the knee and other joints. Committee on Complications of the Arthroscopy Association of North America. Arthroscopy 1986; 2: Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988; 4: Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy 2002; 18(Suppl 1): Huberty DP, Schoolfield JD, Brady PC, et al. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy 2009; 25: Tauro JC. Stiffness and rotator cuff tears: incidence, arthroscopic findings,and treatment results.arthroscopy 2006; 22: Flurin PH, Landreau P, Gregory T, et al. Arthroscopic repair of fullthickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment. Rev Chir Orthop Reparatrice Appar Mot 2005; 91: Spangehl MJ, Hawkins RH, McCormack RG, Loomer RL. Arthroscopic versus open acromioplasty: a prospective, randomized, blinded study. J Shoulder Elbow Surg 2002; 11: Shoulder and Elbow. Shoulder and Elbow , pp

5 9. Norlin R. Arthroscopic subacromial decompression versus open acromioplasty. Arthroscopy 1989; 5: Sachs RA, Stone ML, Devine S. Open vs. arthroscopic acromioplasty: a prospective, randomized study. Arthroscopy 1994; 10: Warner JJ, Allen AA, Marks PH, Wong P. Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997; 79: Vezeridis PS, Goel DP, Shah AA, Sung SY, Warner JJ. Postarthroscopic arthrofibrosis of the shoulder. Sports Med Arthrosc 2010; 18: Parsons BO, Gruson KI, Chen DD, et al. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: Shoulder and Elbow. Shoulder and Elbow , pp

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