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