Hydrodilation distension injection for forzen shoulder - results from Wrightington Upper Limb Unit 2011

1. Sheila Augustine and David Temperley
Lennard Funk, John Haines, Ian Trail, Mike Walton, Puneet Monga

2. Filling spot films
Subcoracoid
Axillary recess

3. Biceps sheath

4. Rupture of subcoracoid bursa

5. Introduction
!We have used hydrodilatation as a treatment
for frozen shoulder for several years. We
have been monitoring our results informally;
this is the first formal audit of the procedure
in WWL.

6. Presentation
! We will present
! - information on frozen shoulder
! - how we undertake hydrodilatation
! - information on hydrodilatation from the literature
! - how the study was undertaken
! - results
! - summary and recommendations.

7. Patient selection and indications for HD WWL
! Most patients with stiff shoulder are offered HD
! Almost all with FS
! Occasional patient with stiff shoulder + other Dx
! Most would go on to capsular release if HD not
available
! However threshold for HD lower than surgery
! Occasionally surgery first; e.g. DM with very stiff
shoulder or patient with good experience of surgery
for other side or needle phobic

8. ! Contra-indications- infection
! Special precautions- anticoagulation.
! Consent
! Patient supine, turned towards affected
shoulder
! Arm externally rotated

9. ! identify GH joint
! (upper/ medial humerus)
! Inject local anaesthetic.
! Needle directed vertically into joint.
! Injection of Omnipaque 120mg/ml- confirm position
! Inject Depomedrone 2ml/80mg. Local 8ml.
! Return to contrast injection

10. ! Continue injection until
! …capsular rupture
! …injection limited by pain
! …50-55ml injected (is this frozen shoulder!)
! Procedure takes 15 minutes
! Patient waits in department for 10-15mins
! Not to drive home, but do not restrict activities
for too long
! Physiotherapy within 1 week.

11. Complications
! Pain- immediate due to distension. Ceases with
capsular rupture or subsides in 5-15 minutes
! Pain ongoing as with any joint injection- 1-2 days,
can take pain killers or anti inflammatories prn
! Infection- rate unknown- estimate vary from
1:1000 to 1:50,000
! Allergy especially to contrast.
! Corticosteroid effect. 80mg Depomedrone/
methylprednisolone= 400mg hydrocortisone or
100 mg prednisolone. Warn Diabetics!

12. ! Fluid should be injected to achieve capsular
rupture if possible
!
! Steroid and local anaesthetic injection should
be used.
!
! Diabetic patients respond less well.

13. ! Improvement can occur immediately or take 1-2
weeks. Full improvement often requires time and
physiotherapy
!
! Improvement is as likely to occur in any phase of
the disease, and with any severity.
!
! Multiple injections can be used, but not
necessary routinely

14. ! Lots of relatively small observational studies,
few controlled trials
!
! Non- controlled studies indicate ‘good’
outcome of 67-94%.
! Typically 70% show significant improvement in
movement and up to 90% improvement in
pain.

15. ! Controlled studies: -
!
! The most quoted study shows no benefit
over steroid injection only
! Other studies show HD better than steroid
only and MUA
! Small studies with flawed technique.

16. Aims of Audit
! To assess whether Hydrodilatation is
effective in the treatment of Frozen Shoulder
! Is it equally effective in all groups of patients?
! Can we predict whether it will work at the time of the
procedure?
! To assess how quickly patients respond- can response
be predicted at one week?
! To review side effects.

17. Study technique- data
! 116 patients who had HD during 2010 and
2011 (118 shoulders, 119 procedures)
! Information from EPR, CRIS and PACS.
! Either day lists assessed, and hydrodilatation
identified or patients followed prospectively.
! INFORMATION GATHERED
! PAS No, age, sex, date of H,

18. Study Technique- data
! Co- morbidity (diabetes and others)
! Length of Symptoms
! Technique- Volume injected, rupture?,
complications.
! 25 patients were contacted at 1 week
! Physiotherapy?
! Length of follow up
! Outcome: Response (pain, movement)
! Outcome: Usually discharge or surgery.

19. Outcome/ Response
! Primary outcome- surgery or discharge
! Special attention if patient unfit for surgery.
! Secondary outcome- pain and movement
response ‘semi-quantitative’
! Standard scores for pain relief or function not
used
! e.g. SPADI, Shoulder Disability Questionnaire (SDQ-UK) and
Oxford Shoulder Score (OSS) (Generally not available)

20. Comparison made for different groups-
! 1. Male/ Female
! 2. Age groups.
! 3. Healthy/DM/other co-morbidity
! 4. Idiopathic vs Traumatic
! 5. Early rupture/ standard/ no rupture.
! 6. Consultant/ Registrar
! 7. Response at 1 week vs. final response.
! 8. Length of symptoms vs. response

21. Scoring of Response
Excellent- no or minimal pain, can do all activities
without pain. Full or nearly full movement= 4
Good- Some pain and reduced movement, but can do
activities of normal daily living without restriction= 3
Fair/ Partial- Significant relief, but still some pain and
reduced movement on normal activities= 2
!
Little/ Poor- Some improvement, but still significant
pain and reduced movement= 1
None= 0
Worse= -2

22. Patient Details
! 118 Shoulders, 116 Patients, 119 procedures
!
! Indication: All frozen shoulder except 1 (OA)
!
! All cases: 56 Male 62 Female (47%M:53%F)
! Spontaneous FS 11 Male 15 Female (42%M:58%F)
!
! Age 26-77, Mean 53

23. Patient age groupings
Age groups

24. TECHNIQUE
! 35ml injected (mean)
!
! All received 80mg Depomedrone, IA LA,
contrast, saline and post op physio except:
!
! 1 patient- no record of LA,
! 2-patients- no record of physiotherapy

25. Analysis of Data
! Time from procedure to audit-
10-21 months.
! Referrers
Orthopaedic 96% Rheumatology 4%
! Co-morbidity (medical)
! DM 20
! Others 10
! Asthma, cardiac, warfarin, CRF, depression, CVD, PVD,
CML, breast ca, MS, RA
! ‘DNA’
10- no record of FU,
108 Followed up

26. Duration of symptoms (Months)- 32 patients
Mean 11 months- Median 7.5 months
Months

27. RESPONSE out of 108 shoulders
! Discharged without surgery, fair response or
better =
‘SUCCESS’ (Special
attention if not fit for surgery)
!
! Needed surgery, offered surgery or awaiting
surgery for frozen shoulder, or poor response
in those not fit for surgery = ‘FAILURE’

28. RESPONSE, 108 shoulders
!
!Success 81 = 75%
!
!Failure 27 = 25%

29. Response Scores
Score

30. Response- Sex and Age
Criterion Number
+ve/-ve
Success %
Male 36/12 75
Female 45/15 75
Age <40 4/3 57
Age 40’s 24/8 75
Age 50’s 33/11 75
Age 60+ 20/5 80

31. Response- co-morbidity
Criterion Number
+ve/ -ve
Success %
1. Spontaneous 21/4 84
2. Diabetes 12/7 63
3. Other morbidity 6/4 60
4. Post trauma or surgery 12/7 63
5. TOTAL all cases 81/27 75

32. Response- Pain vs. Movement
! 58 cases
!
! 44 Equal improvement (or equal lack of improvement)
in pain and movement
! 11 Pain response greater
! 3 Movement response greater

33. Response- Injected volume/ rupture.
Grade of operator.
Criterion Number
+ve/-ve
Success %
All rupture 65/23 74%
No rupture 16/4 80%
Low volume rupture
(<30ml)
6/3 67%
Consultant 66/22 75%
Registrar 15/5 75%
TOTAL 81/27 75%

34. Duration of symptoms vs response
30 patients
Success/
Failure %
Success
< 7.5 months
symptoms 11/4 73
> 7.5 months
symptoms 11/4 73

35. Length of Follow Up
!Length of follow up-
!(to discharge)
!
! Mean 16 weeks
! Half<3/12

36. Response at 1 week vs final response
N=25 Final
Ex/ Good
Final
Fair/ Partial
Final
Poor/ None
1 week
Excellent/good 12 0 1
1 week
Fair/ Partial 3 3 2
1 week
Poor/None 1 0 3
Few cases did well initially then badly

37. Complications
! Painful procedure- 2 cases recorded- recovered
quickly
!
! Distension of shoulder is painful, but pain goes
away when capsule ruptures
!
! No record of any other complications
!
! Two patients died- 1 lung cancer, 1 unknown cause

38. Analysis of surgery
! HD> failed > surgery (N=15)
! Excellent 6
! Good 2
! Fair 5
! Poor/ Nil 2 > HD- 2nd attempt in 1>success
!
! Surgery first 2 > HD- both unsuccessful

39. Problems with Audit
! Pain and movement measurement not objective –
(however surgery or discharge is good outcome measure)
!
! No control group
!
! Inadequate research base
!
! No accepted standard.

40. Summary
! Hydrodilatation is a treatment for Frozen Shoulder
! It is well tolerated, with no side effects apart from pain
at and soon after the time of the study. It takes about
15 minutes, and the patient goes home within 30’.
! It is associated with a ‘good’ outcome, with significant
pain relief and increase in movement, precluding the
need for surgery, in 75% of cases.
! It works in all groups of patients that were referred, but
there is some evidence that those with secondary FS,
diabetes and other co-morbidity do a little less well.
! Of those patients who do well, some recover almost
immediately, while some improve slowly with physio.
In most cases outcome can be predicted in 1 week.

41. Recommendations
!
! Hydrodilatation is a treatment for frozen
shoulder. It is simple to perform, with few
side effects, and is effective in ¾ of cases. It
is recommended that we continue to
undertake this procedure in appropriate
patients.
! Present this audit to orthopaedic surgeons.
Discuss referral criteria.