Comparative outcome of ultrasound guided vs. fluoroscopy guided hydrodilatation in adhesive capsulitis: a prospective study.

BACKGROUND: The incidence of adhesive capsulitis varies from 2-5% in the general population to 20% in people with diabetes. One of the most effective treatment methods is hydrodilatation, which can be done under US-guidance or Fluoroscopic guidance. However, the clinical effectiveness of US-guided injections in comparison to fluoroscopy-guided injections is still debatable. The possibility of severe side effects, the expense, and the time required to carry out this minimally invasive procedure highlight how crucial it is for patients to have a precise intra-articular injection. This study aims to compare the effectiveness of Ultrasound-guided vs. Fluoroscopic guided hydrodilatation for patients with adhesive capsulitis. METHODS: Sixty-four patients were randomly selected for hydrodilatation using any one of the techniques. The patients were evaluated for clinical improvements using the visual analog scale (VAS), oxford shoulder score (OSS), and range of motion (ROM). RESULTS: The US-guided group experienced more pain reduction than the fluoroscopy group within the first four weeks (P < 0.001). The increase in ROM was much more significant in the US-guided group for the first 8 weeks. Improvement in Abduction and External rotation was much more significant (P < 0.001) in the first 4 weeks after hydrodilatation in the US-guided group. The improvement in ROM was maintained on long-term follow-up (mean 24 months), with 45 out of 64 (70.3%) reporting a normal or near normal ROM. On assessing the Oxford shoulder score improvements, the US-guided group's score significantly increased after the first week (P = 0.003), but the fluoroscopy-guided group's score increased after the second week. On comparison between the two groups, the amount of score improvement was more significant in the US-guided group than in the fluoroscopy-guided group in the first 4 weeks (P < 0.001). CONCLUSION: US-guided technique for intra-articular injection for patients with adhesive capsulitis provided a quicker pain reduction and a larger improvement in range of motion and overall shoulder functions.

A preliminary study of contrast-enhanced ultrasound guided capsule-preserving hydrodilatation in shoulder adhesive capsulitis.

Background: Capsule-preserving hydrodilatation is a common treatment for adhesive capsulitis (AC), and ultrasound (US) has recently become the most popular adjuvant tool for image-guided glenohumeral joint injection. However, traditional US is hardly adequate to assess extracapsular fluid leakage, which may decide the treatment outcomes. In this study, we explored the value of contrast-enhanced ultrasound (CEUS) guided capsule-preserving hydrodilatation with steroids and ultrasonic contrast agents for treatment of AC. Methods: A total of 40 consecutive patients with AC were prospectively enrolled and received CEUS-guided capsule-preserving hydrodilatation. The number of injection attempts, injection volume, and fluid leakage were recorded, and the correlations with clinical features were analyzed by Pearson or Spearman correlation coefficients. Outcome measures including visual analog scale (VAS) score, passive range of motion (ROM), and shoulder pain and disability index (SPADI) score were evaluated at baseline and 4 weeks after treatment. Comparisons between patients with good and poor clinical outcomes were performed with independent t-test, Mann-Whitney U test, and chi-square test. Logistic regression was used to identify predictors of good clinical outcomes. A P value <0.05 defined significance. Results: Access to the glenohumeral joint was successful in 87.5% patients on the first attempt. The infused fluid volume was 21.0±3.40 mL. Longer symptom duration (r=-0.676, P<0.001), greater SPADI (r=-0.148, P=0.007), and decreased ROM in abduction (r=0.38, P=0.016) were associated with a decreased volume of infused fluid. CEUS detected massive fluid leakage in 5 (12.5%) patients, with 4 capsule ruptures confirmed by magnetic resonance imaging (MRI). Longer symptom duration (r=0.485, P=0.001), decreased ROM in the direction of abduction (r=-0.33, P=0.037), and external rotation (r=-0.34, P=0.032) were correlated with an increased incidence of massive fluid leakage. Moreover, patients with good outcomes had significantly shorter symptom duration (5.7±2.09 vs. 11.2±3.89 months, P=0.002) and greater initial VAS score (6.9±1.04 vs. 6.3±0.50, P=0.022) than those with poor outcomes. Absence of massive fluid leakage was an independent predictor of clinical good outcomes at 4 weeks after treatment [odd ratio (OR) =0.05, 95% confidential interval (CI): 0.003-0.882, P=0.041]. Conclusions: CEUS-guided capsule-preserving hydrodilatation allows real-time visualization of capsule dilatation, accurate detection of extracapsular fluid leakage, and identification of risks for capsule rupture. It provides an effective treatment for AC, and is useful to predict patients' clinical outcomes.

The comparative effectiveness of combined hydrodilatation/corticosteroid procedure with two different quantities for adhesive capsulitis.

OBJECTIVE: To assess the efficacy of injecting various amounts of fluid into the shoulder joints for capsule distension in patients with adhesive capsulitis. DESIGN: A randomized controlled trial. SETTING: Outpatient clinic of a tertiary care centre. PARTICIPANTS: Eighty-four patients with adhesive capsulitis underwent a baseline (time0), 6 weeks (time1), and 12 weeks (time2) follow-up after hydrodilitation. INTERVENTION: Group 1 (n = 42) received 20 ml of lidocaine, steroid, and saline hydrodilatation via posterior glenohumeral recess, while Group 2 (n = 42) received 10 ml of lidocaine, steroid, and saline hydrodilitation. MAIN MEASURES: The primary outcome was the visual analogue scale for pain. The secondary outcomes were shoulder pain and disability index (SPADI) and ROM of the shoulder. RESULTS: There was a significant reduce in VAS scores for pain, SPADI scores, and increased shoulder ROM in both groups over time; however, the group-by-time interactions for any of the outcomes between groups were not significant except VAS pain in motion. Post-hoc pairwise analysis of the marginal effect of time and group showed that the significant difference of VAS in motion is due to time effect: time1 vs time0 (95% CI -4.09 to -2.68), time2 vs time0 (-4.21 to -2.77), and time2 vs time1 (-0.83 to 0.63), without between-group difference: group 1 vs group 2 (-0.38 to 0.59). CONCLUSION: Our study suggests hydrodilatation achieved an optimal effect at time1 for patients with adhesive capsulitis in both groups, and adding more saline offers additional benefits in flexion and external roatation until time2.

Ultrasound-guided hydrodilatation for adhesive capsulitis: capsule-preserving versus capsule-rupturing technique.

OBJECTIVE: To compare the clinical efficacy of capsule-rupturing versus capsule-preserving ultrasound-guided hydrodilatation in patients with shoulder adhesive capsulitis (AC). To determine potential factors affecting the outcome over a 6-month follow-up. MATERIALS AND METHODS: Within a 2-year period, 149 consecutive patients with AC were prospectively enrolled and allocated into (i) group-CR, including 39 patients receiving hydrodilatation of the glenohumeral joint (GHJ) with capsular rupture and (ii) group-CP, including 110 patients treated with GHJ hydrodilatation with capsular preservation. Demographics, affected shoulder, and AC grade were recorded. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and visual analog scale (VAS) were used for clinical assessment at baseline/1/3/6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value < 0.05 defined significance. RESULTS: DASH and VAS scores in both groups improved significantly compared to baseline (P < 0.001) and were significantly lower in the CP compared to CR group at all time-points following intervention (P < 0.001). Capsule rupture was a significant predictor of DASH score at all time-points (P < 0.001). DASH scores correlated to initial DASH score at all time-points (P < 0.001). DASH/VAS scores at 1 month were correlated to the AC grade (P = 0.025/0.02). CONCLUSION: GHJ hydrodilatation results in pain elimination and functional improvement till the mid-term in patients with AC, with improved outcome when adopting the capsule-preserving compared to the capsule-rupturing technique. Higher initial DASH score is predictive of impaired functionality in the mid-term.

Efficacy of combined ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy in patients with adhesive capsulitis: A randomised controlled trial.

OBJECTIVE: To evaluate the therapeutic effect of combining ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy compared with physical therapy alone in patients with adhesive capsulitis. DESIGN: A prospective, single-blinded, randomised controlled trial. SETTING: Single medical centre. PARTICIPANTS: Patients with adhesive capsulitis (N = 62) were divided into group A: ultrasound-guided hydrodilatation with hyaluronic acid + physical therapy (N = 31) and group B: physical therapy alone (N = 31). INTERVENTIONS: Group A received three doses of ultrasound-guided hydrodilatation with hyaluronic acid-based injectates (20 mL in total). Both groups underwent structured physical therapy. OUTCOME MEASURES: The primary outcome measure was Constant score, while secondary outcomes included Shoulder Pain and Disability Index score, numerical rating scale (at rest, night, and during motion), 36-item Short Form Health Survey, and range of motion of the shoulder. All measurements were collected at baseline, 6 weeks, and 12 weeks post-injection. RESULTS: At week 12, the Constant scores were 68.29 ± 14.55 and 62.77 ± 14.44 for groups A and B, respectively. There was a greater reduction in the Constant score, Shoulder Pain and Disability Index, and numerical rating scale between the baseline and 6 weeks and between the baseline and 12 weeks in group A (Constant score: p < 0.05, Shoulder Pain and Disability Index: p < 0.01, and numerical rating scale: p < 0.05). CONCLUSION: The combination of ultrasound-guided hydrodilatation with hyaluronic acid in conjunction with physical therapy provides additional benefits compared to physical therapy alone for the treatment of adhesive capsulitis at up to 12 weeks. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02708706.

Recurrence of the frozen shoulder after hydrodilatation, what is the true incidence?

Purpose of the study: To assess the outcome and recurrence rates of frozen shoulder treated by hydrodilatation in an independent hospital setting. Method: Patients presenting to a shoulder clinic from August 2019 to July 2021 with a diagnosis of frozen shoulder were offered hydrodilatation. Data included primary or secondary frozen shoulder, length of symptoms, and diabetic status. An Oxford Shoulder Score was completed prior to hydrodilatation. Using ultrasound guidance, 40 mg Triamcinolone and local anaesthetic (10-25 mL depending on patient tolerance) were injected into the rotator interval. At a mean of 9 months, patients recorded their tolerance of the procedure, subsequent progress, the need for further treatment, and their current Oxford Shoulder Score. Results: From 55 shoulders, six patients had a failure to improve and 10 patients had a transient improvement followed by recurrence (29%). 2/21 (9.5%) patients had 25 mL injected compared to 14/34 (41%) who had < = 20 mL (p = 0.012). 14/43 (33%) of primary frozen shoulder patients had a recurrence, compared with 2/12 (16%) secondary frozen shoulder patients, p = 0.019. Conclusion: Further treatment was indicated in 14/34 (41%) of patients who underwent hydrodilatation in the frozen stage of frozen shoulder and could not tolerate more than 20 mL of injection, and was more commonly required in primary (33%) versus secondary (16%) frozen shoulder.

Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis.

INTRODUCTION: It is unclear whether hydrodilatation is beneficial in the management of frozen shoulder compared with other common conservative management modalities. This systematic review evaluates the efficacy of hydrodilatation for the management of frozen shoulder. SOURCES OF DATA: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An extensive search of PubMed, Embase, Scopus, Cochrane Central, Web of Science and CINAHL databases using multiple keyword combinations of 'shoulder', 'rotator', 'adhesive capsulitis', 'hydrodilatat*', 'distension' since inception of the databases to June 2023 was implemented. AREAS OF AGREEMENT: Hydrodilatation leads to at least transient more marked improvements in shoulder disability and passive external rotation compared with intra-articular corticosteroid injections. AREAS OF CONTROVERSY: Hydrodilatation improves passive external rotation in the longer term. Moreover, hydrodilatation may be a preferable option over manipulation under anaesthesia, given its lower cost and better patient convenience. GROWING POINTS: Intensive mobilization after hydrodilatation is a promising adjuvant treatment option for patients suffering from a frozen shoulder. AREAS TIMELY FOR DEVELOPING RESEARCH: Although current evidence suggests that hydrodilatation provides a transient improvement in disability in patients with frozen shoulder, its clinical relevance remains unclear. Further research is necessary to establish its role in the management of the condition.

The role of MRI and Ultrasonography in Diagnosis and Treatment of Glenohumeral Joint Adhesive Capsulitis.

Adhesive capsulitis is a common disorder of the glenohumeral joint. Delayed diagnosis is the result of overlapping signs and symptoms with other disorders affecting the shoulder. Typically, the disease shows gradual progression of pain and loss of the range of motion. The hallmark of the physical examination is limitation of both passive and active motion without any associated degenerative changes on plain radiographs. Conservative and/or surgical treatments have shown conflicting results. Poor outcome may be related to co-morbid factors mainly including prolonged immobilization, rotator cuff pathology and diabetes mellitus among others. This review will present the current literature data on the natural history and pathophysiology of the disease, and will highlight the role of imaging in the prompt and accurate diagnosis as well as in the imaged-guided treatment with emphasis on ultrasonography.

Intra-articular Steroid alone vs Hydrodilatation with intra-articular Steroid in Frozen Shoulder - A Randomised Control Trial.

Introduction: Various non-operative treatment modalities have been advocated for a frozen shoulder. In the present study we compared the efficacy of single intra-articular steroid injection vs hydrodilatation with intra-articular steroids for frozen shoulder (FS) in the frozen phase. Materials and methods: This was a prospective, randomised control trial (RCT) done at a tertiary care centre. A total of 108 participants were randomised into two groups-one group received intra-articular steroid with hydrodilatation (HDS) and other group received intra-articular steroid injection only (S). Shoulder Pain and Disability Index (SPADI) scores were taken, and statistical analysis was done to measure the outcome at two weeks, six weeks and three-month intervals after the injection. Result: There was significant improvement in symptoms at each interval for both the groups (p=0.0). There was no statistically significant difference in the SPADI score between the two groups at two weeks post injection, however at six weeks (p=0.04) and 3 months (p=0.001) significant difference in the SPADI score was demonstrated with better scores in group S. The mean duration of analgesia required in group HDS was 5.17 days (S.D.=1.73) and for group S was 4.28 days (S.D.=1.01), with a statistical significance (p=0.002). Conclusion: Better clinical results were obtained at six weeks and three months with the group receiving corticosteroid only and also had a lesser requirement of analgesia post-intervention. Thus, intra-articular steroid injection only seems to be a more desirable method of management during the frozen phase of FS than that of hydrodilatation with intra-articular steroid injection.

Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: Is There Any Adjunct Effect of Immediate Post-Procedural Manipulation Over Instructed Physical Therapy?

OBJECTIVES: To compare the additive value of immediate post-procedural manipulation versus physiotherapy, following ultrasound (US)-guided hydrodistention of the glenohumeral joint (GHJ) in patients with adhesive capsulitis (AC) and define predictors of outcome. METHODS: Within a 19-month period, 161 consecutive patients with AC were prospectively enrolled and allocated to two groups according to treatment, based on patients' individual preferences: 1) group-I, US-guided hydrodistension plus immediate post-procedural manipulations and 2) group-II, US-guided hydrodistension plus supervised physiotherapy program. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and a visual analog scale (VAS) were used for clinical assessment at baseline (immediately after treatment), 1, 3, and 6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value <.05 defined significance. RESULTS: GHJ hydrodistension with manipulation or physiotherapy was linked to clinical improvement at all follow-up time-points. DASH scores of group-I remained constantly lower than DASH scores of group-II at all time-points (P < .001). VAS scores were lower in group-I than group-II at 1 and 3 months (P < .001 and P = .0019, respectively). Both groups had improved to a similar degree with respect to pain at 6 months (P = .29). The performance of post-interventional manipulations was predictive of improved shoulder functionality (as assessed with DASH scores) at all time-points, while low-grade disease and milder symptoms at presentation were associated with improved short-term pain. CONCLUSIONS: Immediate post-procedural manipulations appeared to be superior to physiotherapy following GHJ hydrodistension for AC in terms of shoulder functionality during a 6-month follow-up period. Post-interventional manipulations, the stage of AC and lower DASH and VAS scores at presentations were predictive of improved outcome.