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Arthrographic Distension injection results - Tim McBride 2012
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Outcome of Hydrodilatation for Frozen Shoulder
Does Capsular Rupture Matter?
Tim McBride
Upper Limb Fellow
Hydrodilatation
Andren and Lundberg in 1965
“…fluid was injected and then allowed to run back out into the syringe ….re-injected….. repeated several times and usually until capsular rupture”
Hydrodilatation
Local Anaesthetic Outpatient procedure Radiologist / Surgeon Image Guided GHJ injection
Contrast Local Anaesthetic Saline Corticosteroid Volume: 20 – 30ml fluid
Hydrodilatation video
Mechanism of Action
Rupture effectStretching Rupture
Stretching = No Rupture
Andren and Lundberg 1965
Capsular stretching Early rupture = no stretching therefore failure
to restore motion BUT..Early rupture in very stiff patients with
less pliable capsule
Rupture = less stretching
Gavant 1994
Reduced capsular tension Interruption of pain receptors As per MUA / RI release
No adhesions to stretch in frozen shoulder, no abolition of synovial serrations or filling of recesses….BUT…all pts ruptured.
Background Evidence
• Andren and Lundberg 1965 Moderate stiffness 2/3 improve at 2 months, Severe
stiffness: 1/5 recovered. Gavant et al 1994
13/16 pain free at 6 months, 69 – 90 % of normal ROM Cochrane review 2009
5 RCT Minimal harm May shorten duration of symptoms and disability
Ng et al 2012 Better AB for MUA, but equal pain relief and ER
Aim
Outcome of hydrodilatation
Does capsular rupture matter?
Method
Retrospective review Consecutive patients August 2009 and August 2010
Inclusion
All frozen shoulder patients who had undergone Hydrodilatation
Diagnosis Clinical Normal XR
Exclusion
Surgery within the follow-up period Trauma within the follow-up period
Procedure
Standard Radiologist lead Standard post operative physio regime
Outcome Measures
Primary Pain and ROM
Secondary Constant-Murley score Oxford Shoulder score
Subgroup Analysis
Cohort of patients within the group Procedure done by single radiologist Capsular rupture or not documented
Subgroup analysis performed
Statistics
Dr Nuttall T-test
Paired Independent
Results 58 patients
42 (72%) primary 16 (28%) secondary
(12 trauma, 3 surgery, 1 radiotherapy)
27 Male, 31 Female
Average duration of symptoms: 5.4 months (1-18)
Previous treatment: Physio 42 (72%), Steroid 14 (24%), none 14 (24%).
Baseline Demographics n=57
Primary Pain 9 Flex 56 AB 39 ER 3
Secondary Constant 26 Oxford 26
Post Intervention Data
Follow up 8.4 months mean (2-16) 4 excluded due to surgery / trauma within
intervention Complete data on 35 patients, near complete data
on 40 (60 – 69%)
Post Intervention Data
n Pre Post
Pain 35 9 2
Flex 39 56 158
Abd 40 39 148
ER 40 3 42
CS 39 26 77
OS 35 26 43
All cases: Pre and Post
0
20
40
60
80
100
120
140
160
180
Pre Post
Pain
Flex
Abd
ER
CS
OS
Overall Improvement
Diff. 95% CI
Sig. (2-tailed) in Mean Lower Upper
Prepain – Postpain (n35)
-6.9 -5.1 -8.6 P<0.05
PreFL – postFL (n39) 95.6 108.9 82.3 P<0.05
PreAB – postAB (n40) 106.0 121.0 91.1 P<0.05
PreER – postER (n40) 37.5 43.9 31.1 P<0.05
PreCS – postCS (n39) 49.0 55.7 42.3 P<0.05
PreOS – postOS (n35) 15.5 18.4 12.6 P<0.05
Subgroup
19 patients 12 f, 7 m Mean Age 50 (33-66)
Rupture n = 7 (4m, 3f) No Rupture n = 12 (3m, 9f)
Length of symptoms 6 months (2 – 18) Follow up 7.4 months (2-15)
Subgroup: pre intervention: paired analysis
No Rupture Rupture Difference
Pre pain score 7.08 5.57 1.512
Pre Flex 51.43 62.92 11.488
Pre Abd 39.58 38.57 1.012
Pre ER 7.08 2.14 4.940
Pre CS 30.08 27.14 2.940
Pre OS 26.67 28.57 -1.905
Subgroup: Post: No Rupture
Pre Post
pain score 8 3
Flex 63 151
Abd 40 139
ER 7 44
CS 30 71
OS 28 39
Subgroup: Post: Rupture
Pre Post
pain score 6 1
Flex 51 161
Abd 39 154
ER 2 35
CS 27 80
OS 29 43
Subgroup: pre and postRupture
0
20
40
60
80
100
120
140
160
180
Pre Post
pain
Flex
Abd
ER
CS
OS
No Rupture
0
20
40
60
80
100
120
140
160
Pre Post
pain
Flex
Abd
ER
CS
OS
Rupture vs. Intact (constant)Intact pre_constant post_constant
08
22 25
55
12
31
84
19
43
21
33
08
56 60
89 85
51
91 93
22
61
85
79 80
0
20
40
60
80
100
Rupture pre_constant post_constant
19
46
19
26
33
25 22
85 85
95
100
91
28
78
0
20
40
60
80
100
Outliers
Rupture group NIDDM
No Rupture Group On going pain, required further injection at follow
up.
Both at lower end of Constant scoring. No specific complications in these patients.
Subgroup: post intervention: paired analysis
No Rupture Rupture Difference
Post pain score 2.78 1.33 1.444
Post Flex 150.83 161.43 -10.595
Post Abd 139.17 154.29 -15.119
Post ER 44.17 35.00 9.167
postCS 71.00 80.29 -9.286
postOS 39.00 43.29 -4.286
Conclusion Mean significant improvement in Pain, ROM, CS,
and OS
No significant difference in baseline data between subgroups
All subgroup patients improved in all areas
No Significant difference in magnitude of improvement between rupture and no-rupture groups
Discussion
Outpatient procedure Local Anaesthetic No Adverse events Generally well tolerated Few Outliers Further research
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