hydrodilation for frozen shoulder does capsular rupture matter

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

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 PostPain 35 9 2 Flex 39 56 158Abd 40 39 148ER 40 3 42 CS 39 26 77OS 35 26 43

All cases: Pre and Post

0

40

80

120

160

Pre Post

PainFlexAbdERCSOS

Overall Improvement Diff. 95% CI Sig. (2-

tailed) in Mean Lower UpperPrepain – Postpain (n35) -6.9 -5.1 -8.6 P<0.05

PreFL – postFL (n39) 95.6 108.9 82.3 P<0.05PreAB – postAB (n40) 106.0 121.0 91.1 P<0.05PreER – postER (n40) 37.5 43.9 31.1 P<0.05

PreCS – postCS (n39) 49.0 55.7 42.3 P<0.05PreOS – 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 DifferencePre pain score 7.08 5.57 1.512Pre Flex 51.43 62.92 11.488Pre Abd 39.58 38.57 1.012Pre ER 7.08 2.14 4.940 Pre CS 30.08 27.14 2.940Pre OS 26.67 28.57 -1.905

Subgroup: Post: No Rupture Pre Postpain score 8 3 Flex 63 151Abd 40 139ER 7 44

CS 30 71OS 28 39

Subgroup: Post: Rupture Pre Postpain score 6 1 Flex 51 161Abd 39 154ER 2 35

CS 27 80OS 29 43

Subgroup: pre and postRupture

0

45

90

135

180

Pre Post

painFlexAbdERCSOS

No Rupture

0

40

80

120

160

Pre Post

painFlexAbdERCSOS

Rupture vs. Intact (constant)Intact pre_constant post_constant

0

20

40

60

80

100

Rupture pre_constant post_constant

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 DifferencePost pain score 2.78 1.33 1.444Post Flex 150.83 161.43 -10.595Post Abd 139.17 154.29 -15.119Post ER 44.17 35.00 9.167

postCS 71.00 80.29 -9.286postOS 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