Arthrographic Distension injection results - Tim McBride 2012

1. Outcome of
Hydrodilatation for
Frozen 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 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

21. All cases: Pre and Post
180
160
140
120 Pain
Flex
100
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<0.05
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

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 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

25. 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

26. Subgroup: Post: Rupture
Pre Post
pain score 6 1
Flex 51 161
Abd 39 154
ER 2 35
CS 27 80
OS 29 43

27. Subgroup: pre and post
Rupture
No Rupture
180
160
160
140
140
120
120
pain
pain 100 Flex
100 Flex
Abd Abd
ER 80
80 CS
ER
OS
60 CS
60 OS
40
40
20
20
0
0 Pre Post
Pre Post

28. Rupture vs. Intact (constant)
Intact pre_constant post_constant 100 Rupture pre_constant 100 post_constant
95
91
100
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 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

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