Hydrodilatation for frozen shoulder

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Arthrographic Distension injection results - Tim McBride 2012

Arthrographic Distension injection results - Tim McBride 2012

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  • 1. Outcome ofHydrodilatation forFrozen Shoulder Does Capsular Rupture Matter? Tim McBride Upper Limb Fellow
  • 2. 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”
  • 3. Hydrodilatation LocalAnaesthetic Outpatient procedure Radiologist / Surgeon Image Guided GHJ injection  Contrast  Local Anaesthetic  Saline  Corticosteroid  Volume: 20 – 30ml fluid
  • 4. Hydrodilatation video
  • 5. Mechanism of Action  Rupture effect Stretching Rupture
  • 6. 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
  • 7. 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.
  • 8. 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
  • 9. Aim Outcome of hydrodilatation Does capsular rupture matter?
  • 10. Method Retrospectivereview Consecutive patients August 2009 and August 2010
  • 11. Inclusion Allfrozen shoulder patients who had undergone Hydrodilatation Diagnosis  Clinical  Normal XR
  • 12. Exclusion Surgerywithin the follow-up period Trauma within the follow-up period
  • 13. Procedure Standard Radiologistlead Standard post operative physio regime
  • 14. Outcome Measures Primary  Pain and ROM Secondary  Constant-Murley score  Oxford Shoulder score
  • 15. Subgroup Analysis Cohort of patients within the group  Procedure done by single radiologist  Capsular rupture or not documented Subgroup analysis performed
  • 16. Statistics Dr Nuttall T-test  Paired  Independent
  • 17. 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%).
  • 18. Baseline Demographics n=57 Primary  Pain 9  Flex 56  AB 39  ER 3 Secondary  Constant 26  Oxford 26
  • 19. 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%)
  • 20. Post Intervention Data n Pre PostPain 35 9 2Flex 39 56 158Abd 40 39 148ER 40 3 42CS 39 26 77OS 35 26 43
  • 21. All cases: Pre and Post180160140120 Pain Flex100 Abd 80 ER CS 60 OS 40 20 0 Pre Post
  • 22. Overall Improvement Diff. 95% CI Sig. (2- in Mean Lower Upper tailed)Prepain – Postpain(n35) -6.9 -5.1 -8.6 P<0.05PreFL – 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<0.05PreCS – postCS (n39) 49.0 55.7 42.3 P<0.05PreOS – postOS (n35) 15.5 18.4 12.6 P<0.05
  • 23. Subgroup 19 patients  12 f, 7 m  Mean Age 50 (33-66) Rupturen = 7 (4m, 3f) No Rupture n = 12 (3m, 9f) Length of symptoms 6 months (2 – 18) Follow up 7.4 months (2-15)
  • 24. 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 4.940Pre CS 30.08 27.14 2.940Pre OS 26.67 28.57 -1.905
  • 25. Subgroup: Post: No Rupture Pre Postpain score 8 3Flex 63 151Abd 40 139ER 7 44CS 30 71OS 28 39
  • 26. Subgroup: Post: Rupture Pre Postpain score 6 1Flex 51 161Abd 39 154ER 2 35CS 27 80OS 29 43
  • 27. Subgroup: pre and post Rupture No Rupture180 160160 140140 120120 pain pain 100 Flex100 Flex Abd Abd ER 8080 CS ER OS 60 CS60 OS 4040 2020 0 0 Pre Post Pre Post
  • 28. Rupture vs. Intact (constant) Intact pre_constant post_constant 100 Rupture pre_constant 100 post_constant 95 91100 85 93 91 80 89 78 84 85 80 80 79 60 60 61 60 55 56 46 51 40 43 40 33 33 28 31 26 25 25 22 22 22 20 19 20 21 19 12 08 0 0
  • 29. Outliers Rupture group  NIDDM No Rupture Group  On going pain, required further injection at follow up. Bothat lower end of Constant scoring. No specific complications in these patients.
  • 30. 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 9.167postCS 71.00 80.29 -9.286postOS 39.00 43.29 -4.286
  • 31. 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
  • 32. Discussion Outpatient procedure Local Anaesthetic No Adverse events Generally well tolerated Few Outliers Further research