Journal of Orthopaedics 21 (2020) 459–464

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Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Arthroscopic capsular release and continuous upper arm brachial block in

frozen shoulder – A midterm outcome analysis
Sibin Surendran a, Gopinathan Patinharayil b, Raju Karuppal a, *, Anwar Marthya b,
Muhammed Fazil b, Shibi Mohammed Ali b
a
Department of Orthopaedics, Government Medical College, Kozhikode, Kerala, India
b
IQRAA International Hospital and Research Centre, Kozhikode, Kerala, India

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: This prospective study aims to evaluate the efficacy of Continuous upper arm brachial block (modified
Capsular release interscalene block) with an arthroscopic capsular release in the outcome of resistant frozen shoulder cases.
Frozen shoulder Methods: We studied 123 patients who underwent arthroscopic capsular release and subacromial decompression
Modified interscalene block
for resistant frozen shoulder cases between June 2016 and July 2019. Postoperative analgesia was provided with
Continuous upper arm brachial block and ambulatory patient-controlled analgesia pump for 2–3 weeks. The
patients were started on regular physiotherapy on the first postoperative day. All the patients were followed up at
3rd week, 6th week, 3rdmonth, 6th month, 1st year, and 2nd year with VAS and Constant-Murley scores.
Results: At a mean follow-up period of 18 months, there was a statistically significant improvement in the range
of motion, VAS scores, and Constant-Murley scores postoperatively (p < .01). None of the cases required post­
operative opioid administration for pain control. Minor neurological complications like recurrent laryngeal nerve
palsy and Horner’s syndrome were seen in few cases that resolved with titration of the drug dose.
Conclusion: Our study verifies the use of continuous upper arm brachial block (CUABB) with a portable infusion
pump for 2–3 weeks in arthroscopic capsular release for resistant frozen shoulder cases. It significantly reduced
postoperative pain in the initial two weeks that aided with early recovery of the shoulder movements and
functions without an increased incidence of acute or chronic neurologic complications.

1. Introduction physiotherapy, manipulation under anesthesia (MUA) or cervical nerve

Shoulder pathologies are notorious for producing pain. Though
newer strategies and methods have evolved, the treatment of frozen
shoulder remains a mystery for orthopedic surgeons. Frozen shoulder is
a benign, self-limiting condition that resolves spontaneously in 2–3
years in the majority, but some patients remain symptomatic and
disabled for many years after the onset of disease.1 Resistant frozen
shoulder is refers to the group of cases who fails to show any significant
clinical improvement after undergoing at least 3 months of nonsurgical
therapy. Only a few patients can afford or will accept months of sig­
nificant disability affecting their routine life. A treatment that acceler­
ates recovery is indicated in the majority who fail to respond to the
initial nonsurgical therapy.There are no definite management guidelines
for the frozen shoulder that yield consistent outcomes. A good number of
patients respond well to non-surgical measures with analgesics, steroids,
root block, hydrodistension, and steroid infiltration.2,3 General
consensus is to try non-operative measures for at least six months.4 In
patients with significant pain and functional disability, early arthro­
scopic intervention is recommended with the established safety of the
procedure and predictable outcomes in the current literature.5 Arthro­
scopic glenohumeral capsular release has been widely accepted as a
proven treatment for refractive frozen shoulder.6 Maintenance of the
gained shoulder range of motion (ROM) with early aggressive physical
therapy is the key to the success of the arthroscopic capsular release.
However, the major hindrance to achieving an early shoulder range of
movement in these cases is the postoperative pain. Lack of persistent
pain relief following arthroscopic procedures resulted in recurrence or
incomplete resolution of symptoms in the majority.
Interscalene brachial plexus block has been used for pain relief in a
variety of shoulder surgery procedures such as operative treatment of

* Corresponding author.
E-mail addresses: drsibinortho@gmail.com (S. Surendran), gopinathan.p@gmail.com (G. Patinharayil), drrajuortho@rediffmail.com (R. Karuppal), anwarmh@
gmail.com (A. Marthya), drfazilvv@gmail.com (M. Fazil), shibimuhammadali@gmail.com (S. Mohammed Ali).

https://doi.org/10.1016/j.jor.2020.08.033
Received 29 July 2020; Received in revised form 28 August 2020; Accepted 30 August 2020
Available online 8 September 2020
0972-978X/© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.
S. Surendran et al.
proximal humeral fractures, arthroplasties, instability, and rotator cuff
repairs. Continuous interscalene nerve block (CISB) gives predictable
and prolonged analgesia following shoulder surgeries, thus allowing
early post-surgical rehabilitation with good functional outcome.7
Despite having increasing evidence, continuous ISB is not universally
accepted by the orthopedic surgeons. A 2013 survey showed that only
15% of surgeons elected for continuous ISB whereas 59% elected for
single-injection ISB and 26% opted for no peripheral nerve block.8
Concerns regarding the safety of CISB has limited its use for a short
duration. In the majority of centers, interscalene block is maintained
only for a day or two after the shoulder surgery.
We hypothesized that arthroscopic capsular release and subacromial
decompression (SAD) combined with continuous local anesthetic infu­
sion using a modified interscalene block technique, termed continuous
upper arm brachial block (CUABB) method, with an indwelling catheter
placed for a longer duration (2–3 weeks) in the postoperative period
would provide sustained pain relief and improved outcomes in re­
fractory frozen shoulder cases.
2. Material and methods
After getting the institutional research board (IRB) approval and
written informed consent, 134 patients were enrolled in this prospective
outcome analysis study conducted at a tertiary care hospital, between
June 2016 and July 2019. Eleven patients were lost to follow up and 123
patients were included in the study (Table 1). We included all the pa­
tients having frozen shoulder with ASA physical status I to II patients,
≥30 years of age, body mass index (BMI) ≤35 kg/m2. We followed the
criteria laid by Zuckerman et al. to diagnose frozen shoulder that
included (1) insidious onset of true shoulder pain (2) night pain (3)
painful restriction of both active and passive elevation to less than 100◦
and/or external rotation to less than one half of normal and (4) normal
radiologic appearance.9 Clinically all the patients had global restriction
of movements interfering with their activities of daily living (ADL). MRI
showed intact rotator cuff or tendinosis or partial cuff tears less than
50% thickness. All the patients were taken up for surgery after failure of
nonoperative measures of at least three months. We also included pa­
tients with diabetes mellitus in our study group as they were commonly
affected with frozen shoulder. Those patients with sensitivity to local
anesthetics, coagulopathy, local site infections, age <30 yrs or >70 yrs,
ipsilateral upper limb neurological deficits, renal, pulmonary, hepatic or
cardiac contraindications, obstructive sleep apnoea patients, hypothy­
roid patients, psychiatric or cognitive disorders having difficulty in
understanding the instructions for using the infusion pump or pain
scales, rotator cuff full thickness or partial thickness tears >50% that
needed repair, calcific tendinitis, traumatic bony or labral pathology
were excluded from the study.
2.1. Continuous upper arm brachial block (CUABB) technique- a
modified interscalene block technique
All patients were given intramuscular 0.05%mg/kg of Midazolam 30
min before the induction of anesthesia. Once the vitals are stable, the
patient was positioned in the lateral decubitus position with the head in
slight lateral flexion to expose the supraclavicular fossa and neck. An
Table 1
Patient demographics at baseline.
Male 39
Female 84
Age 58 (33–74)
Right side 74
Left side 49
Diabetes 33 (M-11; F-22)
Mean duration of symptoms 4 months (2–9 months)
460
Journal of Orthopaedics 21 (2020) 459–464
assistant gives slight traction in the arm with the elbow flexed to stretch
the skin over the lateral side of the neck to make the anatomical land­
marks prominent. The posterior edge of the clavicular head of the
sternocleidomastoid is palpated by asking the patient to lift the head off
the table and marked with a marker pen. Another transverse line is
drawn laterally from the thyroid notch intersecting the previous line.
The external jugular vein is seen on the way which is an additional
landmark. The needle entry point is at the intersection of these two lines
posterosuperior to the external jugular vein (Fig. 1). The entry site is
infiltrated subcutaneously with a local anesthetic agent (1% Ligno­
caine). The localized point was punctured using a 55 mm 22G needle
(Stimuplex, B.Braun, Germany) directed anteriorly, caudally, and
medially (Fig. 2). The needle with the sheath is connected to the nerve
stimulator (Stimuplex, B. Braun, Germany) and the circuit is completed
by an ECG electrode placed in the ipsilateral arm of the patient. The
needle is slowly advanced in the same direction till we noticed the
contractions of Supraspinatus muscle followed by contractions of Bi­
ceps/Brachialis. The stimulating voltage of nerve stimulator is initially
set at 1 mA (2 Hz, 100 μsec) and then gradually the stimulating current is
reduced. The block is attempted to get the effect of both suprascapular
nerve and axillary nerve block which are the major sensory suppliers to
the shoulder joint. The needle tip is advanced beyond the Erb’s point
down to the posterior cord and positioned in between the two to get the
stimulation of C5, C6 area. Contractions of the deltoid muscle are
noticed next. The stimulating current is further reduced up to 0.3 mA. At
0.3 mA the muscle contractions should be noticed. The stimulation of
the nerve with the minimum current of 0.3 mA indicates that the needle
tip is perfectly near to the nerve. The upper trunk block completely in­
volves the suprascapular nerve but axillary nerve escapes. Advancing
the needle beyond this point will also block the axillary nerve, so
shoulder analgesia could be obtained without separately blocking the
suprascapular nerve. With the catheter in place, apart from intra­
operative analgesia, postoperative analgesia is also accomplished.
Consistent twitching of the supraspinatus, biceps/brachialis, and deltoid
with electric stimulation of 1 Hz and 0.3 mA was taken as the correct
blocking location. At this point, contractions of the ipsilateral hemi­
diaphragm are looked for and if noticed, needle direction is adjusted till
diaphragmatic contraction disappears. This largely avoids hemi­
diaphramatic palsy due to the block. Aspirate the needle to rule out
intravascular location. Now the stimulating needle is removed by
retaining the sheath in situ. The catheter is passed into the catheter
sheath and advanced up to 5–10 mm beyond the tip of the sheath.
Thereafter, the sheath is removed by paying meticulous attention to
retain the catheter in situ. After repeat aspiration to reconfirm the
catheter position, we slowly injected 1 ml of 0.2% Ropivacaine. There­
after, the remaining 10 ml of 0.2% Ropivacaine was injected. Complete
loss of pinprick sensation to a blunted needle tip on the skin over the
deltoid and loss of active shoulder abduction was defined as a successful
upper brachial plexus block.The main deterrent to Continuous nerve
Fig. 1. Point of needle insertion at intersection of line drawn along the pos­
terior border of the clavicular head of the sternocleidomastoid and horizontal
line along the thyroid notch.
S. Surendran et al.
Fig. 2. Stimuplex needle directed anteriorly, caudally and medially in
lateral decubitus.
block catheters placement at many centers is the frequent dislodgement
of the catheter in the postoperative period. To prevent such catastrophe,
stable fixation of the catheter is of paramount importance. After the
introduction of the catheter, it is first fixed at the entry point with 1-
0 black silk. A no. 18 cannula is used to double tunnel the catheter
subcutaneously at the entry point (Fig. 3). Both tunnels are fixed with
the 1-0 black silk and affixed using an adhesive, clear occlusive dressing
at the base of the neck to avoid the surgical field. If the catheter could
not be advanced past the end of the needle, the needle hub was moved
medially, in small increments, until the catheter could be advanced.
Thereafter, the patient was positioned for general anesthesia and
arthroscopy procedure.
A portable infusion pump Dosi-Fuser, (Leventon SAU, Spain) filled
with 250 ml of 0.2% Ropivacaine was attached to the perineural cath­
eter, and infusion started at 4 ml/h in the recovery room. With this
pump, drug delivery can be adjusted from 1 ml/h up to 7 ml/h by the
patient using the control knob.The option of 0 is there for no drug de­
livery. If the recurrent laryngeal nerve is blocked, hoarseness of voice
may be present which could also be due to endotracheal intubation. But
still, all hoarseness of voice in this study was taken as recurrent laryn­
geal nerve block and the dose and rate of flow of Ropivacaine is adjusted
till recurrent laryngeal nerve recovers. Ipsilateral Horner’s syndrome
suggested blockade of the stellate ganglion. This also warranted drug
delivery titration. The continuous upper arm brachial block (CUABB)
was given by the experienced senior surgical faculty in all cases.
2.2. Surgical technique arthroscopic capsular release
All the patients were operated in a lateral decubitus position. Gentle
manipulation of the shoulder in the flexion-extension axis was done
Fig. 3. Subcutaneous tunneling of the catheter.
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Journal of Orthopaedics 21 (2020) 459–464
before positioning the patient. No attempt was made to manipulate the
shoulder in internal or external rotation. The degree of restricted ROM
was noted after the manipulation. This guided the capsular release
needed peroperatively. The shoulder joint was entered through the
posterior portal. The anterior portal was created under vision. After
preliminary evaluation to confirm the diagnosis, the capsular release
was started from the anterior portal region using the radiofrequency
device (Arthrocare, Sunnyvale, CA). Initially, the rotator interval was
released thoroughly along with the release of the coracohumeral (CHL)
ligament from the base of the coracoid process. Thereafter, the ante­
roinferior capsule was released up to 5 o’clock position. All three gle­
nohumeral ligaments were released. The subscapularis tendon was not
released. The posterior capsule was released only in cases with gross
restriction of the internal rotation after manipulation following the in­
duction of anesthesia. The inferior capsule was released from 5 to 7
o’clock position with utmost care using a hooked RF probe/basket for­
ceps under the vision and maintaining close contact with the glenoid
margin to avoid damaging the axillary nerve. Biceps was assessed
intraoperatively for any pathology. It was treated with tenotomy/
tenodesis based on the degree of damage and age of the patient. The
location of tenodesis was decided peroperatively based on the biceps
pathology. Following glenohumeral work, subacromial space was
inspected and arthroscopic release of the bursal adhesions done. Acro­
mioplasty was not done. The shoulder was again manipulated to assess
the improvement in the motion achieved by arthroscopic release after
surgery.
2.3. Postoperative treatment
The patients were started on passive mobilization of the shoulder the
next day of surgery. They were taught passive assisted mobilization
using their non-operated arm. Therapy sessions were conducted twice a
day during the inpatient stay by the trained physiotherapist. The arm
was supported in a sling throughout the infusion period. Motor and
sensory recovery were reviewed in the post-operative period. If the
ipsilateral hand or the elbow was completely insensate and paralyzed in
the next morning of the surgery, the infusion rate was reduced until
sensations and motor recovery were seen. Patients were also enquired
regarding any symptoms of local anesthetic toxicity. If there was a motor
blockade seen on the next day of the surgery, the rate of the infusion was
adjusted. The patients were followed up at 6hr, 12 h, 24 h, 48 h,7thday,
14th, and 21st day. Patients were discharged on the third postoperative
day and then seen on 7th, 14th and 21stday. Three doses of intravenous
antibiotics were given for all cases. At the time of discharge, patients
gained nearly 90deg of passive assisted forward flexion/abduction and
around 20–30 deg of external rotation. All the patients were provided
with a home exercise regimen to follow. The infusion pump was filled
every 4–6 days or earlier if got emptied. Sutures were removed on the
14th postoperative day. Thereafter they were continued on physio­
therapy protocol and seen at 3rd week, 6th week, 3rdmonth, 6th month,
1st year, and 2nd year. The patient and caretaker were given standard
postoperative instructions. Verbal and written instructions on the use of
an infusion pump and catheter were provided. Specific directions were
given to recognize the early signs and symptoms of local anesthetic
toxicity and catheter site infection. Contact phone numbers of the
treating surgeons were provided for any queries. Patients were pre­
scribed a nonsteroidal anti-inflammatory drug (Diclofenac 50 mg, taken
2–3times/d, depending on patient age) be taken in case of pain and four
additional occlusive dressings to be applied over the catheter site in case
of slackening of the applied patch. In the case of “break-through” pain,
patients were advised to first increase the flow rate of the infusion pump.
If the pain had not resolved after 30 min, patients were instructed to use
oral NSAIDs and to record it in their medication log. The catheter was
removed between 10 and 21 days. The pain was assessed on a 10 cm
Visual analog scale (VAS) (0 = no pain, 10 maximal pain). Passive
movements of both affected and non-affected shoulders were measured
S. Surendran et al.
using a goniometer. Clinical evaluation was done using Constant-Murley
scoreat regular intervals (at three months, six months, one year, and two
years/final follow-up).10 Patients were also assessed for oral analgesic
consumption, sleep quality, and catheter site discomfort on every
follow-up. The average duration of follow-up was 18 months (range:
12–24 months).
3. Results
The mean follow-up period was 18 months (range, 8–24 months).
Statistically, there was a significant improvement in the range of motion
postoperatively (p < .001).A similar finding was a significant reduction
in postoperative pain scores. The average VAS pain score before surgery
was 8.2 which reduced to an average of 3.4 by three weeks. (p < .001)
(Table 2). At the latest follow up, the average forward elevation
improved from a preoperative level of 38.6–172.8 deg and average
abduction improved from 44.4 deg to 165.6 deg. External rotation
improved from an average of 10.6–55.8 deg. Internal rotation improved
from the lateral thigh region to T10 spine levels (p < .05) (Table 3). The
average duration of the surgery was 66 mts (54–118 mts). The infusion
pump with the catheter was kept for a mean duration of 12 days
(10–21days). The constant score increased from an average of 32–84 at
the final follow-up (p < .001) (Table 4).The outcome assessment at the
final follow up is shown in Table 5.
We found a delay in the achievement of ROM in diabetic cases in the
initial months but all of them regained similar ROM as nondiabetic cases
by the end of 6 months. 24 patients (19.5%) complained of paresthesia
in the C5, 6 distribution areas, which got relieved after the removal of
the catheter. Of the 33 diabetic patients, 3 cases (2.4%) developed an
infection at the catheter site which required early removal of the cath­
eter in 2 cases. Around 8 cases (6.5%) developed recurrent laryngeal
nerve palsy and 19 cases (15.4%) developed Horner’s syndrome in the
postoperative period which got relieved in the first week with dose
titration (Table 6). We found a good number of patients (19.5%) com­
plaining of paresthesia in the C5,6 distribution area. None of the cases
required postoperative opioid administration for pain control. There
was no significant discomfort at the catheter site apart from those cases
with catheter site infection. All the patients reported a significant
improvement in the sleep quality post-surgery with an infusion of the
local anesthetic. The sleep quality was assessed using sleep question­
naires and sleep diary.
3.1. Statistical analysis
The difference in ROM (forward flexion, external rotation, and in­
ternal rotation) and VAS pain score were computed for each patient,
summarized, and tested using student’s paired T-test from before
CUABB placement to final follow up. The nonparametric data were
analyzed with the use of Wilcoxon signed-rank tests. Results were
considered significant if P ≤ .05. Data were analyzed using SPSS soft­
ware (ver.18, SPSS, Chicago, IL).
4. Discussion
Arthroscopic release and mobilization have become one of the
widely accepted treatment modalities for the management of resistant
frozen shoulder cases. Early and efficient postoperative rehabilitation
therapy is necessary for the successful outcome. Loss of the regained
shoulder range of movements in the early postoperative period is at
significant risk without aggressive stretching exercises early on in the
Table 2
Postoperative VAS pain scores.
Preop 1week 2week 3week 6weeks
8.2 ± 0.96 3.6 ± 1.24 3.4 ± 1.46 3.4 ± 1.36 2.6 ± 1.08
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Journal of Orthopaedics 21 (2020) 459–464
postoperative period.6,11 Pain, which is severe to very severe in this
condition, has become the main factor limiting efficient rehabilitation
after the arthroscopic capsular release of the shoulder joint. Adequate
control of postoperative shoulder pain following capsular release plays a
vital role in patient compliance to an efficient rehabilitation program.
We studied the outcome of continuous upper brachial plexus block kept
for a prolonged duration of 2–3 weeks in the management of frozen
shoulder using a patient-controlled pump and catheter system.
Interscalene blocks (ISB) and catheters have emerged as a safe and
effective modality for postoperative pain relief in shoulder surgery.12,13
In addition to postoperative analgesia, ISB has advantages of
intra-operative bleeding reduction, good muscle relaxation, and reduced
general anesthetic complications.13 We utilized the nerve stimulation
technique as the method of controlling the insertion of the needle and
catheter as described in previous studies although the use of ultrasound
is on the rise.14-16The main issues sited with the use of the ISB are the
complete motor and sensory blockade that interferes with active
participation in physiotherapy protocols by the patient. Also, the
insertion and maintenance of the ISB catheters are difficult.17 In our
technique, the patient was placed in a lateral decubitus position for
placement of the catheter which made the insertion technically easier.
The catheter was held in position by tunneling through the skin multiple
times and retaining the position by water-resistant adhesive plaster. By
adjusting the rate of drug flow through the catheter, the motor blockade
could be avoided with retention of the sensory blockade for pain relief.
Our approach of upper arm brachial plexus blocks differs from the
classical anterior approach by Winnie, posterior approach by Pippa, and
modified lateral approach by Borgeat et al. in a few points.18–20 Firstly,
the patient is positioned in the lateral position that gives a good tra­
jectory and a three-dimensional image of the interscalene space for
needle insertion and catheter placement. The needle puncture point is at
the level of thyroid notch, below the insertion point of Winnie’s and
Meiers’ tech which reduces the chances of piercing the scalene muscles.
The entry point of our technique is similar to the point described by
Borgeat et al.20,21 None of our patients developed major complications
such as total spinal anesthesia, epidural anesthesia, or injection in the
spinal cord as reported with Winnie’s techniques.22–24 Similarly, diffi­
culties to insert the catheter were reported by Singelyn et al.in 66% and
Tuominenet al. in up to 25% cases where Winnie’s approach was
used.25,26 These complications were reduced in our approach as it is
easier to direct the needle trajectory away from the cervical spine to­
ward the interscalene space in the lateral position.
Minor side effects such as recurrent laryngeal nerve blockade or
Horner syndrome were encountered in 4% and 19% of cases in our
study. Jochum et al. noticed an incidence of recurrent laryngeal nerve
blockade of 3% and an incidence of Horner syndrome of 71% similar to
the incidences reported by Vester-Andersen et al. using Winnie’s tech­
nique.27,28 Borgeat et al. reported an incidence of 0.9% of recurrent
laryngeal nerve blockade and 6% incidence of Horner’s syndrome which
is lower than our findings.29 The more distal administration of the local
anesthetic through the catheter placed within the interscalene space
makes the preganglionic sympathetic fibers going to the stellate gan­
glion less exposed to it, thus reducing the incidence of Horner’s syn­
drome and recurrent laryngeal nerve palsy in our group of patients.
Maintenance of strict aseptic precautions reduced the incidence of
infection around the catheter site to 2.4% in our cases. All these were
superficial infections in diabetic patients that resolved with oral anti­
biotics but necessitated the removal of the catheter in 2 cases.We have
used Ropivacaine instead of Bupivacaine as we found better preserva­
tion of hand strength and reduced incidence of paresthesias with the
3 mths 6mths 1 year Last Fu
1.8 ± 1.04 1.4 ± 0.46 1.4 ± 0.28 1.2 ± 0.26
S. Surendran et al. Journal of Orthopaedics 21 (2020) 459–464

Table 3
Data are presented as mean ± SD.
Preop 1wk 2week 3week 6weeks 3mths 6mths 1year Last fu

Abductionrowhead 44.4 ± 16 125.2 ± 12a 148.6 ± 14a 153.8 ± 16a 124.8 ± 12a 152.2 ± 11a 165.2 ± 08a 160.4 ± 09a 165.6 ± 12a
Forward Flexionrowhead 38.6 ± 12 153.2 ± 16a 169.8 ± 08a 165.2 ± 06a 125.6 ± 10a 149.2 ± 06a 166.4 ± 08a 168.4 ± 04a 172.8 ± 04a
External Rotationrowhead 10.6 ± 04 34.2 ± 12a 34.4 ± 10a 54.2 ± 08a 33.4 ± 06a 54.8 ± 06a 55.4 ± 07a 55.4 ± 08a 55.8 ± 06a
Internal Rotationrowhead Lateral thigh Buttocks LS junction L3 L3 L1b T12b T10b T10b
a
P < .05 preoperative vs postoperative (student’s paired T-test).
b
P < .05 preoperative vs postoperative (Wilcoxon signed-rank tests).

postsurgical inflammatory phase after adequate arthroscopic capsular

Table 4
releases. Retention of analgesia for 2–3 weeks permits patients to follow
Summary of Constant scores as a function of time.
the aggressive physiotherapy even at their home. This helps to regain the
Preop 3mths 6mths 1 year Final follow-up/2 year ROM early as compared to other regimens with limited period contin­
32 67 74 78 84 uous ISB. We found no significant difference in the final ROM between
diabetics and nondiabetics though there was a delay in achieving the
comparable ROM between both groups as reported in previous studies.33
Table 5 This delay was not found to be statistically significant in our study.
Outcome assessment at final follow up. Though the long term outcomes may be comparable to other studies, our
regimen allows early recovery of ROM in resistant frozen shoulder
Preoperative Postoperative P value
cases.34
Abduction 44.4 ± 16 165.6 ± 12 P < 0.001a Although continuous upper arm brachial plexus block (CUABB) with
Forward flexion 38.6 ± 12 172.8 ± 04 P 0.001a
local anesthetic infusion offers significant improvements in post­
<
ER 10.6 ± 04 55.8 ± 06 P < 0.05a
IR Lateral Thigh T10 P < 0.05b operative pain control and shoulder function, there are several potential
CS 32 84 P < 0.05a inherent risks involved in the use of these catheters like catheter site
VAS 8.2 ± 0.96 1.2 ± 0.26 P < 0.05a infection, nerve injury, catheter migration, local anesthetic toxicity and
a
P < .05 student’s paired T-test. even epidural/intrathecal anesthesia.35–38 Previous studies have
b
P < .05 Wilcoxon signed-rank tests. demonstrated the safety and efficacy of home administration of peri­
neural blocks in shoulder surgery.39,40 To our knowledge, this is the first
study supporting the use of continuous upper brachial plexus block
Table 6 procedure in lateral decubitus position and maintaining it for a pro­
Complications. longed duration of 2–3 weeks to optimize pain control and mobilization
Complications Number of cases of frozen shoulder. Metanalysis has demonstrated good results of
1. Catheter site infection 3
continuous ISB in shoulder surgery than single-shot ISB but none of the
1. Transient recurrent laryngeal palsy 8 studies retained the catheter for more than 72 h.7 The data in this study
1. Transient Horner’s syndrome 19 demonstrate that it is possible to achieve adequate pain relief by
1. Paresthesia C5,6 distribution 24 retaining the catheter and single-use of an infusion pump for a longer
duration of 2–3 weeks to aid the rapid rehabilitation in frozen shoulder.
former in our routine practice as has been reported by Borgeat et al.20 In this study, we observed no episodes of iatrogenic instability in the
The use of Ropivacaine as compared to Bupivacaine seems to advantages follow-up, although case reports of iatrogenic instability have been
in terms of better sensorimotor dissociation with the former.30 The recorded.41 Besides, none of our patients required any form of revision
concentration of 0.2% Ropivacaine was found to be adequate for most surgery. In our study, we found no major complications related to the
patients. regional block catheter placement or prolonged local anesthetic infu­
We performed a limited arthroscopic release as compared to the 360◦ sion. There could be many reasons for the limited use of continuous
release for all cases as suggested by some authors.31 The inferior capsule nerve blocks in shoulder surgery. Lack of a simple, reproducible method
was released with adequate caution from the glenoid side to prevent of insertion and retention of the perineural catheter, fear of local anes­
damage to the axillary nerve. The cadaveric dissection studies by Bowen thetic toxicity, catheter site infection and nerve injury-related issues.
et al has guided us to determine the regional capsule that needs to be Singelyn et al. noted the difficulty in the insertion of 84% (21 of 25) of
released to regain the lost glenohumeral motion.32 Loss of external catheters.25 This is in contrast with the ease and success of catheter
rotation mandated a release of the rotator interval, the coracohumeral insertion in this study. Klein et al. reported successful interscalene
ligament, the superior and middle glenohumeral ligaments, and/or the catheterization for the continuous block for all of their patients similar
intra-articular portion of the subscapularis. Loss of abduction or forward to our study.42 Our success could be attributed to the increasing expo­
elevation required the release of the anteroinferior capsule, including sure and experience of the treating faculties to peripheral nerve
the anterior band of the inferior glenohumeral ligament. Loss of internal blockade in routine arthroscopic surgery as well as the availability of
rotation warranted posterosuperior capsular release. We have never less toxic local anesthetic drugs. However, given the success of
released the subscapularis tendon. In our series, the majority of the cases long-duration ambulatory perineural blocks in this series of patients,
demanded the release of the rotator interval, coracohumeral ligament, further larger prospective trials to establish the learning curves and
all three glenohumeral ligaments including the inferior capsule. The safety of the procedure is needed.
posterior capsule was released only in a few cases of our series (12 A potential limitation is the lack of an analytic determination of the
cases). As we were able to maintain adequate pain relief for the initial Ropivacaine levels in the plasma. A further limitation is the lack of a
2–3 weeks with the use of the infusion pump, we could maintain the control group. One of the strengths of this study lies in its large sample
patients on aggressive physiotherapy without loss of compliance due to size and follow up. As all the patients are not willing to accept the added
pain from their side. We believe that the crux of getting back the responsibility that comes with the catheter and infusion pump system
movements in frozen shoulder lies in maintaining adequate analgesia in for a long duration, appropriate patient selection is crucial for the suc­
the postoperative period for a sufficient period to tide over the cess and safety of ambulatory local anesthetic infusion following

463
S. Surendran et al.
arthroscopic shoulder surgery.
5. Conclusion
This prospective study validates the use of continuous upper arm
brachial plexus (CUABB) block with a portable infusion pump and
catheter in resistant frozen shoulder cases. It significantly reduced
postoperative pain and opioid use with early recovery of the shoulder
movements and functions. Our technique of modified interscalene block
in lateral decubitus position and catheter placement in trained hands
does not seem to increase the incidence of acute or chronic neurologic
complications. The efficacy of continuous upper arm brachial plexus
block (CUABB) with ambulatory patient-controlled analgesia pump and
patient satisfaction with pain control in the frozen shoulder is high in
our study.
CRediT authorship contribution statement
Sibin Surendran: Investigation, Methodology, Writing - original
draft. Gopinathan Patinharayil: Conceptualization, Methodology,
Resources, Supervision. Raju Karuppal: Investigation, Resources.
Anwar Marthya: Supervision, Project administration. Muhammed
Fazil: Investigation, Formal analysis. Shibi Mohammed Ali: Concep­
tualization, Formal analysis, Data curation, Methodology.
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