Skip to main content
Download PDF

Preemptive middle glenohumeral ligament release in arthroscopic rotator cuff repair does not reduce the postoperative stiffness: a retrospective comparative study

BMC Musculoskeletal Disorders volume 24, Article number: 490 (2023) Cite this article

Abstract

Background

This study aimed to evaluate the efficacy of preemptive middle glenohumeral ligament (MGHL) release in arthroscopic rotator cuff repair (ARCR) to reduce postoperative stiffness.

Methods

Patients who underwent ARCR were enrolled and allocated into two groups retrospectively: the preemptive MGHL release group (n = 44) and the preemptive MGHL non-release group (n = 42). Clinical outcomes were assessed and compared between the two groups, including the range of motion, Japanese Orthopedic Association Shoulder Score, Constant Shoulder Score, and the University of California, Los Angeles Score preoperatively and 3 months, 6 months, and 12 months postoperatively and complications. The integrity of the repaired tendon was assessed at the 12-month follow-up using magnetic resonance imaging.

Results

There were no significant differences between the groups in all range of motion and all functional scores at any of the assessed time points. There was also no significant difference in the healing failure rate 2.3% in the preemptive MGHL group and 2.4% in the preemptive MGHL non-release group (p = .97), and postoperative stiffness was 2.3% in the preemptive MGHL group and 7.1% in the preemptive MGHL non-release group (p = .28). There was no postoperative instability in both group.

Conclusion

ARCR effectively facilitates the recovery of range of motion and function in patients with a rotator cuff tear. However, preemptive MGHL release could not be an effective method to reduce postoperative stiffness.

Peer Review reports

Introduction

Although arthroscopic rotator cuff repair (ARCR) is a minimally invasive procedure, postoperative stiffness may still develop and lead to less functional outcomes [1,2,3]. Surgeons have made several efforts to prevent postoperative stiffness, for instance, encouraging early passive shoulder exercise [4], injecting an anti-adhesive agent into the subacromial space or glenohumeral joint postoperatively [5], or the combination of ARCR with either manipulation under anesthesia or arthroscopic capsular release [6, 7], however, the efforts remain controversial and lack of consensus [6, 8,9,10,11,12].

The main causes of shoulder stiffness have been reported to be the thickening of the coracohumeral ligament (CHL) and joint capsule in the rotator interval (RI) or obliteration of the fat triangle between the coracoid process and the CHL [11,12,13]. Postoperative stiffness has a greater component of intra-articular causes, predominantly capsular fibrosis and adhesions arising from the bodily reactions to the damaged glenohumeral ligaments [3, 14, 15]. Nevertheless, there have been few studies on intraoperative surgical procedures to reduce postoperative stiffness after ARCR in patients with no preoperative stiffness [11, 12].

Although the RI capsule containing the CHL is considered the predominant area of the stiffed shoulder [11,12,13], it is difficult to gain a full range of motion (ROM) after the release of only the RI capsule [16]. Holloway et al. reported that wide arthroscopic capsule release is necessary for regaining the full ROM in a stiffed shoulder, which indicates that the capsule, including the glenohumeral ligaments, is one of the main causes of the restricted ROM [17].

The middle glenohumeral ligament (MGHL) is one of the three ligaments that reinforce the anterior glenohumeral capsule along with the superior (SGHL) and the inferior (IGHL) glenohumeral ligaments [18, 19], which respectively connect the anterosuperior labrum to the top of the bicipital groove, and the inferior part of the glenoid to the inferomedial aspect of the surgical neck of the humerus. Many biomechanical studies emphasized the effect of MGHL on the anterosuperior stability of the shoulder [19,20,21]. Although thickening of the CHL that covers the RI is recognized as a causative factor limiting external rotation (ER) of the shoulder joint [12], and previous studies have reported the effect of the CHL release [22,23,24,25], it has been reported that the capsule, including the glenohumeral ligaments, is one of the main causes of a restricted ROM [17]. However, to our knowledge, there has been only one study on whether preemptive MGHL release as an intraoperative procedure would reduce postoperative stiffness [11]. Therefore, this study aimed to evaluate the efficacy and safety of MGHL release in ARCR to reduce postoperative stiffness. We hypothesized that patients who underwent ARCR with preemptive MGHL release would experience reduced postoperative stiffness than patients who underwent ARCR without MGHL release.

Materials and methods

Inclusion and exclusion criteria

Between January 2018 and May 2021, 280 consecutive patients underwent ARCR at our hospital. Informed consent was obtained from all participants, and institutional review board approved this study (2,023,008). We enrolled patients who met the following inclusion criteria: presence of complete rotator cuff tears, including the supraspinatus tendon as verified by preoperative magnetic resonance imaging (MRI); patients who underwent complete rotator cuff repair; and follow-up for at least one year after ARCR with an evaluation of successful repair using MRI. The exclusion criteria were as follows: irreparable rotator cuff tears, patients who underwent partial repair, preoperative shoulder stiffness, revision surgery and traumatic rotator cuff tears. Patients were divided into two groups: ARCR without MGHL release from January 2018 to December 2019 (MGHL- group) and ARCR with MGHL release from January 2020 to May 2021 (MGHL + group). The tear size of the rotator cuff was evaluated using MRI. We measured the longitudinal and transverse dimensions of the tear on preoperative MRI along the oblique coronal and sagittal planes, respectively [26]. The tear size was categorized as small (< 1 cm), medium (1–3 cm), large (3–5 cm), or massive (> 5 cm), according to Cofield [27]. We defined shoulder stiffness as limited shoulder ROM (passive forward flexion less than or equal to 120°and/or ER less than or equal to 30°), as previously described [28]. Patients who met these criteria were considered to have preoperative stiffness. A total of 280 ARCRs were performed during the study period. After the exclusion of 194 patients, the remaining 86 patients were included in this study (Fig. 1).

Fig. 1
figure 1

Study design flow diagram

Full size image

Surgical technique

All operations were performed uniformly under general anesthesia and in a beach chair position by a single skilled surgeon. The arthroscope was inserted through the posterior portal, and a standard anterior portal was made a working portal in the RI capsule. After visualization, all hypertrophic synovial tissues were cleared as needed. In the MGHL + group, MGHL was released from the undersurface of the glenoid using a radiofrequency device through the anterior portal (Fig. 2). Then, the CHL release was performed until the base of the coracoid process into the glenohumeral joint using a radiofrequency device and the coracoacromial ligament was exposed into the subacromial space using a radiofrequency device in both groups (Fig. 3). Following the removal of the subacromial bursal tissue and bone spur, a standard ARCR was performed using suture anchors. The number of anchors was decided according to the size of the tear and repair configuration in the suture-bridge repair. In patients who also required the subscapularis tendon repair, the subscapularis tendon was repaired using the suture anchor by a single row technique. Tenotomy or tenodesis was performed in case of a biceps long head lesion.

All patients received the same postoperative rehabilitation [29]. The shoulder was immobilized for four weeks for small-to-medium tears and six weeks for large-to-massive tears using an abduction brace (Global Sling; COSMOS, Sapporo, Japan). The elbow, wrist, and fingers exercises were started immediately after surgery. Passive forward flexion exercises were initiated from the day after surgery. An active-assisted motion exercise was initiated at four weeks for small-to-medium tears and six weeks for large-to-massive tears postoperatively. An active motion was allowed at six weeks for small-to-medium tears and eight weeks for large-to-massive tears postoperatively. A strengthening exercise program was allowed at eight weeks for small-to-medium tears and 12 weeks for large-to-massive tears postoperatively. Rehabilitation was performed at least three months after surgery with the assistance of a physical therapist. Full return to sports or heavy labor was allowed after six months.

Fig. 2
figure 2

The MGHL release in the glenohumeral joint of the right shoulder (A) The radiofrequency device was inserted through the anterior portal into the glenohumeral joint (B) MGHL was released along the margin of the glenoid with the radiofrequency device. G; glenoid, HH; humeral head, MGHL; middle glenohumeral ligament

Full size image
Fig. 3
figure 3

The CHL release and coracoacromial ligament release of the right shoulder. (A) The radiofrequency device was inserted through the anterior portal into the glenohumeral joint. The CHL was released until the base of the CP using a radiofrequency device. (B) The coracoacromial ligament was released into the subacromial space using a radiofrequency device. HH; humeral head, CHL; coracohumeral ligament, LHB; long head of biceps, SSC; subscapularis, CP; coracoid process

Full size image

Clinical outcomes

Clinical outcomes were evaluated between the two groups, including the ROM, Japanese Orthopedic Association (JOA) Shoulder Score, Constant Shoulder Score, and the University of California, Los Angeles (UCLA) Score preoperatively and 3 months, 6 months, and 12 months postoperatively and complications. Active ROM (forward flexion, ER, and internal rotation [IR]) were measured with the scapular in a fixed position. IR was defined as the highest vertebral body the patient could reach with the thumb of the affected arm. IR was scored in accordance with the JOA shoulder score as follows: above Th12, 6 points; above L5, 4 points; at the buttocks, 2 points; and below the buttocks, 0 points. The integrity of the repaired tendon was assessed at the 12-month follow-up using MRI. Repair integrity after ARCR was classified into five categories according to the Sugaya classification using oblique coronal, oblique sagittal, and transverse views of T2-weighted images [30]. Types 4 and 5 were considered retears using this classification system.

Statistical analysis

All statistical analyses were performed using the SPSS software (ver.18.0, SPSS Inc, Chicago, IL, USA). The sample size for this study was set as the maximum number of cases that could be obtained during the study period. Therefore, post-hoc power analysis was performed on the actual sample size to calculate the power at moderate effect size (d = 0.5 [unpaired t-test], w = 0.3 [chi-square test]) and at large effect size (d = 0.8 [unpaired t-test], w = 0.5 [chi-square test]). The chi-squared test was used to analyze categorical variables to compare patients’ gender ratio, affected side, tear size, the number of rotator cuff tears, the procedure of biceps long head, the presence of diabetes mellitus, and complications between two groups. Student’s t-test was used to compare age, ROM, and functional scores between the two groups, and the paired t-test was used to compare these variables between two consecutive periods in each group. Statistical significance was set at p < .05.

Results

A total of 280 ARCRs were performed during the study period. After excluding 194 patients, the remaining 86 were included in this study. The mean age of all patients was 62.2 ± 9.4 years and the mean follow-up period was 15.6 ± 3.5 months. Forty-four patients underwent ARCR with MGHL release (MGHL + group; 32 males and 12 females, mean age was 62.8 ± 8.9 years), and 42 underwent ARCR without MGHL release (MGHL- group; 23 males and 19 females, mean age was 61.7 ± 9.9 years).

The demographic characteristics of the patients are presented in Table 1. There were no significant differences in gender, mean age, affected side, tear size, the number of rotator cuff tears, the procedure of biceps long head, the presence of diabetes mellitus, ROM, and functional scores between the two groups. There were no significant differences between the groups in all ROM and all functional scores at any of the assessed time points (Tables 2 and 3). There was also no significant difference in the healing failure rate 2.3% in the MGHL + group and 2.4% in the MGHL- group (one patient in the large-sized tear in each group) (p = .97), and postoperative stiffness was one patient in the large-sized tear (2.3%) in the MGHL + group and 3 patients (two patients in the large-sized and one in the medium-sized tear) (7.1%) in the MGHL- group (p = .28) There was no postoperative instability in both group. (Table 4).

Table 1 Patient’s demographics at baseline
Full size table
Table 2 Comparison of preoperative and postoperative ROM
Full size table
Table 3 Comparison of preoperative and postoperative functional scores
Full size table
Table 4 Complications
Full size table

When post-hoc power analysis was performed on the actual sample size obtained, the power of unpaired t-test was 0.630 and chi-square test was 0.794 for a moderate effect size, while the power of unpaired t-test was 0.956 and chi-square test was 0.996 for a large effect size.

Discussion

The main finding of this study was that the MGHL + group did not experience more reduced postoperative stiffness than the MGHL- group. Postoperative shoulder stiffness is a prevalent adverse event after ARCR that is associated with major limitations in daily activities and prolonged rehabilitaion [9, 31, 32].

The incidence of postoperative stiffness after ARCR has been reported to range from 4.91 to 32.7% and, if left untreated, may lead to substantial morbidity [31, 33, 34]. The exact etiology of postoperative stiffness has not been established yet; capsular contractures and postsurgical adhesion to the surrounding soft tissues are considered responsible for causing postoperative stiffness [32]. Preoperative risk factors for developing postoperative shoulder stiffness after ARCR have been reported to be preoperative shoulder stiffness, age less than 50 years, workers compensation, diabetes, hypothyroidism, and coexisting diagnosis of calcific tendonitis or adhesive capsulitis [9, 31, 35]. Intraoperative risk factors reported include single-tendon tears, partial articular-sided tears, and concomitant labral repair [31]. Several studies have reported that associated procedures, including long head of biceps tenotomy or tenodesis, acromioplasty, capsulotomy, and glenohumeral/acromioclavicular osteoarthritis, could also increase the rate of postoperative shoulder stiffness [36,37,38].

The CHL has been reported to originate from the base and horizontal limb of the coracoid process, enclosing the subscapularis, supraspinatus, and infraspinatus tendons [39]. In this study, it enveloped vaster areas of the subscapularis than previously reported [22]. A thickened CHL at the RI has been well known to be one of the most specific manifestations of a stiff shoulder and the primary restraint against ER [23]. Neer et al. reported that ER could be increased up to an average of 32° when sectioning CHL [24]. Harryman et al. reported that the sectioning of the RI increased the ROM of the shoulder [25]. Tsai et al. reported that arthroscopic extended RI release for patients with refractory adhesive capsulitis improved the shoulder ROM [40]. Furthermore, Jazrawi et al. examined the effects of arthroscopic RI closure and found that imbrication of the RI resulted in a loss of approximately 11° of ER [41]. Mologne et al. also reported that arthroscopic RI closure significantly reduced ER in both neutral and abducted arm positions [42]. These studies suggested that the RI is closely associated with the ROM of the shoulder.

If postoperative stiffness is not resolved, additional procedures such as manipulation under anesthesia or arthroscopic capsular release could be considered [6, 7, 10]. Although many trials have been conducted on these clinical factors, only a few studies have investigated intraoperative procedures to prevent postoperative stiffness [11, 12]. Kim et al. reported that preemptive RI release in ARCR presented significantly better ROM and functional scores at postoperative 3 months than in the RI non-release group [11]. However, the functional scores and ROM were not significantly different between the two groups at postoperative 6 or 12 months or the final follow-up. Park et al. reported that concomitant CHL release in ARCR presented significantly better ER in the early postoperative period than in the CHL non-release group, which was effective in patients with a small-to-medium-sized rotator cuff tear [12]. They concluded that CHL release in ARCR can be used as a selective procedure to prevent postoperative stiffness in patients that may benefit from this procedure with decreased preoperative ER compared to the normal side.

The MGHL is one of the three ligaments that reinforce the anterior glenohumeral capsule along with the SGHL and IGHL [18, 19]. It originates from the anterior margin of the glenoid and crosses the subscapularis tendon during its course and attaches inferior of the SGHL attachment side [43]. Many biomechanical studies emphasized the effect of MGHL on the anterosuperior stability of the shoulder [19,20,21].The MGHL is one of the first anatomical elements observed during arthroscopic explorations of the glenohumeral joint from a posterior approach. As previously mentioned, although thickened CHL at the RI has been well known to be one of the most specific manifestations of a stiff shoulder [23], it has been reported that the capsule, including the glenohumeral ligaments, is one of the main causes of a restricted ROM [17]. Therefore, we considered that the MGHL, which is adjacent to CHL and RI, is also one of the causes of stiff shoulder and we hypothesized that preemptive MGHL release could prevent postoperative stiffness after ARCR, similar to Kim et al. [11]. However, IGHL was not released, which can be an invasive procedure in patients who underwent ARCR with no preoperative stiffness. There were no significant differences between the groups in all ROM and all functional scores at any of the assessed time points.

Although capsulectomy is considered to be an effective procedure for patients with preoperative stiffness [40, 44, 45], there is no consensus in the literature regarding the optimal extent of a glenohumeral ligament release. Bowen et al., in their cadaveric study, showed that releasing the SGHL, the MGHL, the RI, and the CHL resulted in increased ER of the shoulder joint. Releasing the anteroinferior glenohumeral ligament and the anteroinferior capsule increased elevation, and releasing the posterior-superior capsule increased IR [46]. Further comparative studies are needed according to the optimal extent of a glenohumeral ligament release, including with or without the CHL release.

In this study, all patients underwent ARCR using the suture-bridge technique. This technique revealed a superior contact area and contact pressure for the footprint of the rotator cuff stump [29, 47]. Because the technique also demonstrated excellent fixation, it has been widely used for ARCR. The main cause of retear in the suture-bridge technique has been suggested to be a medial cuff failure caused by over-tensioning the medial row [29]. The use of the knotless technique in the medial row is still controversial. It has been reported that the knotless suture-bridge technique in medial row anchors reduced retears at the musculotendinous junction and that this technique could be used to avoid necrosis of tissue caused by knot tying at the medial row anchors [48]. In this study, all patients underwent the use of the knotless suture-bridge technique in the medial row. Moreover, the major factors for retears after ARCR are said to be tissue quality and tear size. Tear size is especially associated with retears, and the retear rate of large-to-massive postoperative retears is high [29]. In this study, tear size of 80 patients (93%) were small-to-medium tears. It is difficult to know the precise reason, these might be the reasons why our study had lower retear rate compared past studies.

Our study has several limitations. First, the study design was retrospective. Second, the number of enrolled patients was relatively small. Third, the mean follow-up period of 15.6 months was relatively short. Finally, the MGHL has the greatest variation in its shape and size among all the ligaments of the shoulder joint [18, 49, 50]. The common variations of MGHL include a sublabral foramen, cord-like MGHL, and the Buford complex [49, 50]. The incidence rate is reported to range from 8 to 12% for the sublabral foramen, 1.5–5% for the Buford complex, and 19–23% for the cord-like MGHL. We could not evaluate the variation of the MGHL in this study.

Conclusions

The preemptive MGHL release in ARCR does not significantly change the overall clinical outcomes because there were no significant differences in all ROM and all functional scores at any of the assessed time points between the groups. Moreover, there were also no significant difference in the healing failure rate and postoperative stiffness between the groups. ARCR with preemptive MGHL release could not be an effective method to reduce postoperative stiffness.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

MGHL:

middle glenohumeral ligament release

ARCR:

arthroscopic rotator cuff repair

ROM:

range of motion

CHL:

coracohumeral ligament

RI:

rotator interval

ER:

external rotation

IR:

internal rotation

MRI:

magnetic resonance imaging

JOA score:

Japanese Orthopedic Association Shoulder Score

UCLA score:

the University of California, Los Angeles Score

References

  1. Tauro JC. Stiffness and rotator cuff tears: incidence, arthroscopic findings, and treatment results. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2006 Jun;22(6):581–6.

  2. Brislin KJ, Field LD, Savoie FH 3. rd. Complications after arthroscopic rotator cuff repair. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 Feb;23(2):124–8.

  3. Chang KV, Hung CY, Han DS, Chen WS, Wang TG, Chien KL. Early Versus delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: a Meta-analysis of Randomized controlled trials. Am J sports medicine 2015 May;43(5):1265–73.

  4. De Roo PJ, Muermans S, Maroy M, Linden P, Van den Daelen L. Passive mobilization after arthroscopic rotator cuff repair is not detrimental in the early postoperative period. Acta Orthop Belgica 2015 Sep;81(3):485–92.

  5. Oh CH, Oh JH, Kim SH, Cho JH, Yoon JP, Kim JY. Effectiveness of subacromial anti-adhesive agent injection after arthroscopic rotator cuff repair: prospective randomized comparison study. Clin Orthop surgery 2011 Mar;3(1):55–61.

  6. Cho NS, Rhee YG. Functional outcome of arthroscopic repair with concomitant manipulation in rotator cuff tears with stiff shoulder. Am J sports medicine 2008 Jul;36(7):1323–9.

  7. Oh JH, Kim SH, Lee HK, Jo KH, Bin SW, Gong HS. Moderate preoperative shoulder stiffness does not alter the clinical outcome of rotator cuff repair with arthroscopic release and manipulation. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2008 Sep;24(9):983–91.

  8. Chan K, MacDermid JC, Hoppe DJ, Ayeni OR, Bhandari M, Foote CJ, Athwal GS. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. J shoulder Elb surgery 2014 Nov;23(11):1631–9.

  9. Denard PJ, Ladermann A, Burkhart SS. Prevention and management of stiffness after arthroscopic rotator cuff repair: systematic review and implications for rotator cuff healing. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2011 Jun;27(6):842–8.

  10. Hsu SL, Ko JY, Chen SH, Wu RW, Chou WY, Wang CJ. Surgical results in rotator cuff tears with shoulder stiffness. J Formos Med Association = Taiwan yi zhi 2007 Jun;106(6):452–61.

  11. Kim JH, Ha DH, Kim SM, Kim KW, Han SY, Kim YS. Does arthroscopic preemptive extensive rotator interval release reduce postoperative stiffness after arthroscopic rotator cuff repair?: a prospective randomized clinical trial. J shoulder Elb surgery 2019 Sep;28(9):1639–46.

  12. Park JH, Yang SH, Rhee SM, Oh JH. The effect of concomitant coracohumeral ligament release in arthroscopic rotator cuff repair to prevent postoperative stiffness: a retrospective comparative study. Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA 2019 Dec;27(12):3881–9.

  13. Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M. Frozen shoulder: MR arthrographic findings. Radiology 2004 Nov;233(2):486–92.

  14. Neviaser RJ, Neviaser TJ. The frozen shoulder. Diagnosis and management. Clin Orthop Relat research 1987 Oct(223):59–64.

  15. Parker RD, Froimson AI, Winsberg DD, Arsham NZ. Frozen shoulder. Part II: treatment by manipulation under anesthesia. Orthopedics 1989 Jul;12(7):989–90.

  16. Hagiwara Y, Ando A, Onoda Y, Takemura T, Minowa T, Hanagata N, Tsuchiya M, Watanabe T, Chimoto E, Suda H, Takahashi N, Sugaya H, Saijo Y, Itoi E. Coexistence of fibrotic and chondrogenic process in the capsule of idiopathic frozen shoulders. Osteoarthr cartilage 2012 Mar;20(3):241–9.

  17. Holloway GB, Schenk T, Williams GR, Ramsey ML, Iannotti JP. Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness. J bone joint Surg Am volume 2001 Nov;83(11):1682–7.

  18. Collotte P, Nove-Josserand L. Arthroscopic anatomy of the middle glenohumeral ligament. Surg radiologic anatomy: SRA 2018 Dec;40(12):1363–70.

  19. Kaptan AY, Ozer M, Alim E, Percin A, Ayanoglu T, Ozturk BY, Kanatli U. The middle glenohumeral ligament: a classification based on arthroscopic evaluation. J shoulder Elb surgery 2022 Mar;31(3):e85–e91.

  20. Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop Relat research 2002 Jul(400):32–9.

  21. Ferrari DA. Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J sports medicine 1990 Jan-Feb;18(1):20–4.

  22. Arai R, Nimura A, Yamaguchi K, Yoshimura H, Sugaya H, Saji T, Matsuda S, Akita K. The anatomy of the coracohumeral ligament and its relation to the subscapularis muscle. J shoulder Elb surgery 2014 Oct;23(10):1575–81.

  23. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J bone joint Surg Am volume 1989 Dec;71(10):1511–5.

  24. Neer CS 2nd, Satterlee CC, Dalsey RM, Flatow EL. The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop Relat research 1992 Jul(280):182–5.

  25. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3. rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J bone joint Surg Am volume 1992 Jan;74(1):53–66.

  26. Manaka T, Ito Y, Matsumoto I, Takaoka K, Nakamura H. Functional recovery period after arthroscopic rotator cuff repair: is it predictable before surgery? Clin Orthop Relat research 2011 Jun;469(6):1660–6.

  27. Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM. Surgical repair of chronic rotator cuff tears. A prospective long-term study. J bone joint Surg Am volume 2001 Jan;83(1):71–7.

  28. Giuseffi S, Field LD, Giel TV 3rd, Brislin BT, Savoie FH. 3rd. Arthroscopic rotator cuff repair with concomitant capsular release. Arthrosc techniques 2016 Aug;5(4):e833–e7.

  29. Kajita Y, Iwahori Y, Harada Y, Takahashi R, Sagami R, Deie M. Clinical outcome and repair integrity after arthroscopic full-thickness rotator cuff repair: triple-row versus suture-bridge techniques. J Orthop science: official J Japanese Orthop Association 2022 Jun 7.

  30. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J bone joint Surg Am volume 2007 May;89(5):953–60.

  31. Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2009 Aug;25(8):880–90.

  32. Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, Mazzocca AD, Sugaya H, Yoo YS. Shoulder stiffness: current concepts and concerns. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2016 Jul;32(7):1402–14.

  33. Seo SS, Choi JS, An KC, Kim JH, Kim SB. The factors affecting stiffness occurring with rotator cuff tear. J shoulder Elb surgery 2012 Mar;21(3):304–9.

  34. Warner JJ, Greis PE. The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect. 1998;47:67–75.

    CAS  PubMed  Google Scholar 

  35. Cucchi D, Marmotti A, De Giorgi S, Costa A, D’Apolito R, Conca M, Russo A, Saccomanno MF, de Girolamo L, Committee SR. Risk factors for shoulder stiffness: current concepts. Joints 2017 Dec;5(4):217–23.

  36. Ansok CB, Muh SJ. Optimal management of glenohumeral osteoarthritis. Orthop Res reviews. 2018;10:9–18.

    Google Scholar 

  37. Eraghi AS. Acromioplasty in the surgical operations of partial-thickness rotator cuff tears: a comprehensive review. J family Med Prim care 2020 Feb;9(2):520–5.

  38. Guity MR, Eraghi AS. Open Rotator Cuff tear repair using Deltopectoral Approach. Med archives 2015 Oct;69(5):298–301.

  39. Clark JM, Harryman DT 2. nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J bone joint Surg Am volume 1992 Jun;74(5):713–25.

  40. Tsai MJ, Ho WP, Chen CH, Leu TH, Chuang TY. Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis. J Orthop surgery 2017 Jan;25(1):2309499017692717.

  41. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J sports medicine 2006 Oct;34(10):1656–61.

  42. Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT. The addition of rotator interval closure after arthroscopic repair of either anterior or posterior shoulder instability: effect on glenohumeral translation and range of motion. Am J sports medicine 2008 Jun;36(6):1123–31.

  43. Kask K, Poldoja E, Lont T, Norit R, Merila M, Busch LC, Kolts I. Anatomy of the superior glenohumeral ligament. J shoulder Elb surgery 2010 Sep;19(6):908–16.

  44. Cvetanovich GL, Leroux TS, Bernardoni ED, Hamamoto JT, Saltzman BM, Verma NN, Romeo AA. Clinical outcomes of arthroscopic 360 degrees capsular release for idiopathic Adhesive Capsulitis in the lateral decubitus position. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2018 Mar;34(3):764–70.

  45. Hagiwara Y, Kanazawa K, Ando A, Sekiguchi T, Yabe Y, Takahashi M, Koide M, Takahashi N, Sugaya H. Clinical outcomes of arthroscopic pan-capsular release with or without entire coracohumeral ligament release for patients with frozen shoulder. JSES international 2020 Dec;4(4):826–32.

  46. Bowen MK, Warren RF. Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin sports medicine 1991 Oct;10(4):757–82.

  47. Tanaka M, Hanai H, Kotani Y, Kuratani K, Koizumi K, Hayashida K. Triple-row technique confers a lower Retear Rate Than Standard Suture Bridge technique in arthroscopic rotator cuff repairs. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2021 Oct;37(10):3053–61.

  48. Rhee YG, Cho NS, Parke CS. Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: knotless versus knot-tying suture bridge technique. Am J sports medicine 2012 Nov;40(11):2440–7.

  49. Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid labrum and associated pathology. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2002 Oct;18(8):882–6.

  50. Lee BI, Kim YB, Won SH, Hwang SC, Choi SW, Nho JH, Chun DI. Isolated tear of the cord-like middle glenohumeral ligament in Buford complex: a case report. Medicine 2017 Nov;96(45):e8604.

Download references

Acknowledgements

Not applicable.

Funding

The authors did not receive any funding or grants in support of this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, 1Jihira, Ichinomiya City, 494-0001, Kaimei, Aichi, Japan

    Ryosuke Takahashi & Yukihiro Kajita

  2. Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, 734-8551, Hiroshima, Japan

    Yohei Harada

  3. Sports Medicine and Joint Center, Asahi Hospital, 2090 Shimoharacho Azamurahigashi, Kasugai, 486-0819, Aichi, Japan

    Yusuke Iwahori

Authors
  1. Ryosuke Takahashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yukihiro Kajita
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yohei Harada
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yusuke Iwahori
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study’s conception and design. YK, YH, and YI designed the study, drafted the manuscript, and designed the figures. YK and YH collected the clinical data and performed the analysis. YK and YI aided in interpreting the results, supervised the work, and performed corrections of the first draft. All authors have read and approved the final submitted manuscript.

Corresponding author

Correspondence to Ryosuke Takahashi.

Ethics declarations

Ethics approval and consent to participate

The Institutional Review Board of the Ichinomiya Nishi Hospital approved this study. All methods in this study were performed in accordance with the ethical standards of the Institutional Review Board of the Ichinomiya Nishi Hospital, the 1964 Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all particilants and their parents.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Takahashi, R., Kajita, Y., Harada, Y. et al. Preemptive middle glenohumeral ligament release in arthroscopic rotator cuff repair does not reduce the postoperative stiffness: a retrospective comparative study. BMC Musculoskelet Disord 24, 490 (2023). https://doi.org/10.1186/s12891-023-06611-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12891-023-06611-7

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

Contact us