Ultrasound-guided hydrodilatation for adhesive capsulitis - a step-by-step guide Poster No.: C-1817 Congress: ECR 2015 Type: Educational Exhibit Authors: P. Heire, R. Braham, M. Mubashar, W. Bhatti ; Manchester/ 1 1 1 2 1 2 UK, Stockport, Cheshire/UK Keywords: Musculoskeletal joint, Ultrasound, Dilation, Treatment effects, Inflammation, Dilatation DOI: 10.1594/ecr2015/C-1817 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. www.myesr.org Page 1 of 13
Learning objectives The aim of this e-poster is to describe, with the aid of images, the techniques employed in ultrasound-guided hydrodilatation of the shoulder for adhesive capsulitis at University Hospital of South Manchester. Background Adhesive capsulitis ("frozen shoulder") is a common but poorly understood disorder which causes severe pain and stiffness of the glenohumeral joint [1]. There is an incidence of 3-5% in the general population which increases to approximately 20% in diabetic patients and is one of the most common musculoskeletal disorders presenting to orthopaedic th th surgeons. Females in their 5-7 decades are most commonly affected [2]. Adhesive capsulitis is often self-limiting but can take a prolonged course lasting up to 3 years, thereby causing significant disability in affected patients [3]. Treatment options for adhesive capsulitis include analgesia, steroid injections, physiotherapy, manipulation under anaesthesia and surgical release [2]. Hydrodilatation is treatment method which involves distending the shoulder capsule using a mixture of corticosteroid, long-acting local anaesthetic and saline solution. This procedure has been shown to provide improved relief from symptoms with long term effects up to 2 years [4] without risks of anaesthesia or surgery. Hydrodilatation may be performed under fluoroscopic or ultrasound guidance and both methods have comparable outcomes. However, ultrasound-guided hydrodilatation avoids the use of ionizing radiation, is quicker, cheaper and allows assessment of the rotator cuff muscles [5]. At our institution hydrodilatation of the shoulder is routinely performed under ultrasound rather than fluoroscopy for these reasons. Findings and procedure details A standard ultrasound assessment of the shoulder and rotator cuff is performed first to eliminate the presence of a rotator cuff tear. If no other cause for shoulder pain is identified then hydrodilatation is undertaken. Informed consent is obtained and the risk of complications including pain, infection and bleeding are explained and documented in the final report. It is explained that the relief of symptoms could be variable from complete Page 2 of 13
resolution to no relief and this could be temporary or permanent. The equipment required is listed below (figure 1). Fig. 1: Equipment required to perform ultrasound-guided hydrodilatation. References: University Hospital South Manchester - Manchester/UK 1. Orange needle 2. Pink drawing needle 3. Long green needle 4. 5ml syringe 5. 10ml syringe 6. 3x10ml prepacked normal saline syringes 7. Extension set and 3 way stopcock Page 3 of 13
8. Sterile drape 9. Probe cover 10. Sterile gel 11. Sterile pack with sterile gloves 12. Antiseptic cleaning stick 13. 10ml 1% lignocaine 14. 10ml of 0.5% marcaine 15. 40mg/1ml Kenalog 16. Adhesive dressing 17. Ultrasound machine with 9 and 14MHz probes Anterior and posterior approaches are possible in hydrodilatation but a posterior approach is preferred at our institution. For the posterior approach, patient lies in lateral position, with the symptomatic shoulder superior and the couch inclination adjusted to ensure patient and operator comfort (figures 2 and 3). Page 4 of 13
Fig. 2: The lateral position required for hydrodilatation of the right shoulder. References: University Hospital South Manchester - Manchester/UK Page 5 of 13
Fig. 3: Images showing the position of the needle and ultrasound probe required for hydrodilatation of the right shoulder. References: University Hospital South Manchester - Manchester/UK The skin, subcutaneous tissues and deeper tissues are infiltrated with lignocaine along the line of the needle tract. The ultrasound guidance is used to enter the glenohumeral joint and confirm intraarticular position by visualisation the "flow artefact" (figures 4 and 5). Fig. 4: The left hand image shows the position of the needle which should be visualised during the procedure. Annotations have been added on the right hand image. The red dashed line shows the path of the needle which should not be advanced too far once the capsule is entered in order to avoid damage to the glenoid labrum. The green dashed line shows the region along the humeral head which should be targeted with the needle in order to administer safe intra-articular injection. References: University Hospital South Manchester - Manchester/UK Page 6 of 13
Fig. 5: This video shows the appearance of the "flow artefact" which confirms the intraarticular position of the needle during injection. References: University Hospital South Manchester - Manchester/UK The needle should be mildly oblique or perpendicular to the ultrasound waves (if possible) in order to be able to visualise the needle under ultrasound. The needle should not be advanced too far into the glenohumeral joint to reduce the risk of injury to the glenoid labrum. The 3-way stopcock with extensor set is flushed with saline, attached to the needle and injection of the steroid and marcaine is given, followed by gentle insufflation of normal saline solution until a pop is felt or 30ml-40ml has been introduced. Typically, the joint capsule is seen to distend as showin in figure 6. Page 7 of 13
Fig. 6: Distention of the glenohumeral joint with saline solution. References: University Hospital South Manchester - Manchester/UK The 3-way stopcock enables high pressures to be maintained within the joint capsule during the procedure. The injection is monitored under ultrasound as the joint becomes progressively distended, at which point there may or may not be capsular rupture, demonstrated by sudden collapse of the distended joint. The procedure may be stopped before this if the patient is experiencing severe pain. At this point the needle is removed and an adhesive dressing applied to the needle site. Patients are requested to refrain from physical exertion for the next 48 hours but should then attend early and intensive physiotherapy. The importance of physiotherapy is stressed to patients as it has been shown that combining physiotherapy with hydrodilatation significantly improves long term outcome [4]. Images for this section: Page 8 of 13
Fig. 1: Equipment required to perform ultrasound-guided hydrodilatation. Page 9 of 13
Fig. 2: The lateral position required for hydrodilatation of the right shoulder. Fig. 3: Images showing the position of the needle and ultrasound probe required for hydrodilatation of the right shoulder. Page 10 of 13
Fig. 4: The left hand image shows the position of the needle which should be visualised during the procedure. Annotations have been added on the right hand image. The red dashed line shows the path of the needle which should not be advanced too far once the capsule is entered in order to avoid damage to the glenoid labrum. The green dashed line shows the region along the humeral head which should be targeted with the needle in order to administer safe intra-articular injection. Page 11 of 13
Fig. 5: This video shows the appearance of the "flow artefact" which confirms the intraarticular position of the needle during injection. Fig. 6: Distention of the glenohumeral joint with saline solution. Page 12 of 13
Conclusion Ultrasound-guided hydrodilatation is a new, safe and effective treatment option for frozen shoulder and we have detailed the technique used at our institution. It has been shown to be superior to manipulation under anaesthesia with respect to range of movement up to 6 months, and does not carry the risks of anaesthetic or proximal humeral fracture [6], making this procedure attractive for clinicians and patients alike. Hydrodilatation is becoming an increasingly used first line treatment option for frozen shoulder and is gaining popularity among physical therapists, musculoskeletal radiologists and shoulder surgeons. At our institution fluoroscopic guided hydrodilatation has been very successfull with audited benefit in pain reduction and improved range of movement in up to 90% and 70% of patients respectively. We are currently in the process of auditing the outcomes of our ultrasound-guided hydrodilatation procedure but are seeing similar results to the fluroscopic group, without ionizing radiation or the risk of adverse contrast reactions. Ultrasound-guided hydrodilatation also seems better tolerated by patients than when using fluoroscopy. Personal information References 1. 2. 3. 4. 5. 6. Idiopathic adhesive capsulitis. A Prospective Functional Outcome Study of Non-operative Treatment. Griggs S, Ahn A, Green A. J Bone Joint Surg Am. Oct 200 82(10); 1398-1398 Diagnosis and Management of Adhesive Capsulitis. Manske R, Prohaska D. Curr Rev Musculoskelet Med. Dec 2008; 1(3-4): 180-189. Brief note. The natural history of "idiopathic" frozen shoulder. Grey, R. G. J. Bone and Joint, June 1978; Surg., 60-A: 564. Hydrodilatation (distension arthrography): a long#term clinical outcome series. Watson L, Bialocerkowski A, Dalziel R, Balster S, Burke F, Finch C. Br J Sports Med. Mar 2007; 41(3): 167-173. Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder; Park K, Nam H, Kim T, Kang S, Lim M, Park Y. (2012). Ann Rehabil Med.36; 88-97. Thawing the frozen shoulder; A randomised trial comparing manipulation under anaesthesia with hydrodilatation. Quraishi N, Johnston P, Bayer J,Crowe M, Chakrabarti A. J Bone Joint Surg [Br]; 2007; 89-B, 1197-200. Page 13 of 13