Does hydrodilatation help avoid the need for surgical intervention in adhesive capsulitis?

Transcription

1 Does hydrodilatation help avoid the need for surgical intervention in adhesive capsulitis? Poster No.: P-0122 Congress: ESSR 2013 Type: Scientific Exhibit Authors: K. Rajesparan, S. Molathoti, T. Sikdar, N. Saw, S. Redla; Harlow/ UK Keywords: Outcomes, Dilatation, Treatment effects, Outcomes analysis, Dilation, Fluoroscopy, Musculoskeletal soft tissue, Musculoskeletal joint, Interventional non-vascular DOI: /essr2013/P-0122 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Purpose Adhesive capsulitis is a common debilitating condition of the shoulder, affecting 3-5% of the general population with an increased incidence in diabetics [1,2]. The hallmarks of this condition are severe pain, and shoulder stiffness, characterised by near total loss of passive and active external rotation. As a result individuals find their activities of daily living are severely impaired. Adhesive capsulitis has been described by some authors as a self-limiting condition, resolving in 1 to 3 years [1,3,5,8]. Others have reported that symptoms can persist for up to 10 years without complete resolution [4,8]. What is clear is that left untreated, the natural course of this disease entity is a long and protracted debilitating process which can severely affect an individuals psychological well-being. Physiotherapy is usually advocated as the first line of treatment, but effectiveness in the early stages of the condition is variable [6,7,9,10,11]. A significant proportion of patients do not achieve resolution of symptoms with physiotherapy alone within a reasonable time-frame. Further treatment options for those who have not responded to conservative management include manipulation under anaesthesia, and arthroscopic or surgical capsular release. These options require the use of general anaesthesia, are invasive and have associated potential complications. Hydrodilatation of the shoulder has emerged as an alternative treatment option for adhesive capsulitis which may help patients avoid more invasive surgical treatments. There is sparse evidence within the literature documenting its efficacy and in particular whether its role in avoiding surgical intervention. This study assesses the frequency at which surgical intervention is required for persistent symptoms of adhesive capsulitis following hydrodilatation. Methods and Materials A retrospective study of 34 consecutive hydrodilatations performed for adhesive capsulitis of the shoulder at Princess Alexandra Hospital (Harlow, United Kingodom). Page 2 of 14

3 The diagnosis of adhesive capsulitis in all cases was made clinically by the referring orthopaedic team. All cases of adhesive capsulitis referred for hydrodilatation to the radiology department over the study period were included. Hydrodilatation technique: The hydrodilatation procedure was performed by a consultant radiologist or radiology specialist registrar. A standard format was followed for all procedures. Informed consent was obtained from the patient. All procedures were performed under strict asepsis with the patient positioned supine. Using an anterior approach a 20G spinal needle was introduced into the glenohumeral joint under fluoroscopic guidance [Figure 1]. Position was checked using iodinated contrast medium [Figure 2]. The joint was then injected with 80mg Depomedrone (depot preparation of methylprednisolone acetate), 10mls 0.5% Bupivacaine, 10mls of Omnipaque 300 (Iohexol), and a variable amount of additional normal saline (0-20mls) to achieve adequate capsular distension [Figures 3 & 4]. Data Collection: The imaging, radiology reports, and patient notes were analyzed for each patient. Data was collected on patient demographics, laterality, hand dominance, co-morbidities, pre-operative therapy, post-procedure patient satisfaction, residual pain, and range of movement. The primary outcome measure assessed was the need for subsequent surgical intervention post-hydrodilatation. For those patients who did not attend clinical follow-up, a telephone interview was conducted to ascertain the outcome of the hydrodilatation procedure, and whether or not further surgical intervention was required. Images for this section: Page 3 of 14

4 Fig. 1: Advancing needle via anterior approach into the glenohumeral joint Page 4 of 14

5 Fig. 2: Confirmation of intraarticular position with Omnipaque contrast Page 5 of 14

6 Fig. 3: Distension of capsule Page 6 of 14

7 Fig. 4: Capsule rupture with flow of contrast medially into subscapularis bursa Page 7 of 14

8 Results 34 patients attended for hydrodilatation. There were 14 males and 20 females, with a mean age of 52.3 years (±8.4) [see Figure 5]. The affected side was the right in 19 and the left in 15 cases [see Figure 6]. 1 patient underwent the procedure on both sides within a 15-month period. No patients underwent bilateral hydrodilatation at the same sitting. From available patient records in 23 patients the mean and median duration of symptoms prior to referral for hydrodilatation was 12 months. Figure 7 demonstates the majority of patients had symptoms between 8 and 12 months. All 34 cases were without intra-operative or immediate post-operative complication. 19 of these patients attended follow-up, and 15 did not. Of the 19, in 18 follow-up ranged from 1 to 16 months, with a mean and median followup of 6 months. 1 patient attended for 37 months, primarily due to ongoing problems with the contralateral shoulder. Of the 15 that did not attend follow-up, 13 were contacted for telephone interview and indicated resolution of symptoms or significant improvement. None of these patients required any further treatment for their adhesive capsulitis other than physiotherapy. The remaining 2 were lost to follow-up. Following hydrodilatatoin, only 1 patient in our cohort required surgical intervention (arthrolysis) for unresolved symptoms [see Figure 8], which was also the patient with 16 months' follow-up. This patient had had 3 unsuccessful shoulder injections and a suprascapular nerve block prior to hydrodilatation. The remaining 31 patients achieved sufficient resolution of symptoms from hydrodilatation to allow them to return to normal daily activities, and required no further invasive intervention. Images for this section: Page 8 of 14

9 Fig. 5: Age and sex distribution Page 9 of 14

10 Fig. 6: Laterality Page 10 of 14

11 Fig. 7: Box and Whiskers plot demonstrating duration of symptoms. (Box represents 75th and 25th centiles; whiskers represent maximum and minimum values). Page 11 of 14

12 Fig. 8: Outcome following hydrodilatation Page 12 of 14

13 Conclusion In our study adhesive capsulitis was more common in females (F:M 3:2), with a mean age of 52 years, in keeping with peviously reported findings [8, 12]. Only 1 patient in our cohort required further more invasive treatment (viz., arthrolysis) following hydrodilatation. Satisfactory outcome after hydrodilatation obviated the need for further surgical intervention in the remaining patients. There are shortcomings of using retrospective methodology. This includes limited information available from historic notes. Follow-up was carried out by a range of clinicians, and a shoulder disability score was not routinely used. This lack of standardisation does not allow for objective patient assessment. Despite these shortcomings, the primary outcome factor being assessed in this study, namely the need for further intervention post-hydrodilatation, is not affected and remains valid. This outcome factor is measurable and well-defined. Hydrodilatation is an effective treatment option for adhesive capsulitis that can provide suitable functional outcome and avoid the need for surgical intervention for the majority. This may be the preferred option in selected patients. References 1. Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl 1969; 119: Lesquesne M, Dang N, Benasson M, Mery C. Increased association of diabetes mellitus with capsulitis of the shoulder and shoulder-hand syndrome. Scand J Rheumatol 1977; 6: Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975; 4: Page 13 of 14

14 4. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg 1992; 74: Rowe CR, Leffert RD. Idiopathic chronic adhesive capsulitis ("frozen shoulder"). In: Rowe CR, ed. The Shoulder. New York: Churchill Livingstone; pp Manske RC, Prohaska D. Clinical commentary and literature review: diagnosis, conservative and surgical management of adhesive capsulitis. Shoulder & Elbow 2010; 2: Dierks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg 2004; 13: Vastamaki H, Kettunen J, Vastamaki M. The natural history of idiopathic frozen shoulder: A 2- to 27-year follow-up Study. Clin Orthop Relat Res 2012; 470: Owens-Burkhart H. Management of frozen shoulder. In: Donatelli R (ed) Physical therapy of the shoulder (1991). Churchill Livingstone, New York, pp Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S, Pagett BT. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop Relat Res 1998;356: Levine WN, Kashyap CP, Bak SF, Ahmad CS, Blaine TA, Bigliani LU. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg 2007;16(5): Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005;331: Personal Information No conflicts of interest declared. Page 14 of 14