by Mohammad Waseem, Lutfi Suleiman
Arthrographic hydrodilatation: cost effectiveness and extended use.
A frozen shoulder is like a new balloon with a capsule which is too tight we expand it with fluid to give it a opportunity to move better.Below are the results of our initial experience we have now performed more than 500 cases successfully.
Frozen shoulder is a common problem where the etiology is still not clear and it can take two to three years to resolve. There has been different treatment options advocated but until now there is no clear evidence on the superiority of one treatment option over another. The options include physiotherapy, glenohumeral joint steroid injection, arthrographic hydrodilatation, manipulation under anaesthesia and arthroscopic release. We believe that a properly executed hydrodilatation should result in a very good outcome and is cost effective. The hydrodilatation technique can also be extended to other joints. We are presenting our experience and technique of hydrodilatation in our hospital and looking into the financial aspect of this procedure when compared with other invasive techniques and discussing the extended use of hydrodilatation.
Hydrodilatation was first decribed by Andren in 1965(1) which involves intra- articular injection of a large amount of normal saline to distend and rupture the capsular adhesions. Frozen shoulder or adhesive capsulitis is a self-limiting condition. According to Codman, It takes about 2 years without treatment (*******2). Reeves 1975 in his prospective study found that the course of the disease takes three consecutive stages: pain, stiffness, and recovery and it can last as long as 40 weeks(2). There are many studies looking at and comparing different treatment modalities. But, there has been no consensus on the best course of treatment. However, majority of shoulder surgeons would prefer the MUA and an arthroscopic release after a failed course of physiotherapy.
This technique is done under local anaesthetic and relying on injecting a radiographic dye in the GHJ under fluoroscopy guidance followed by injection of steroid and saline in to the joint until a capsular pop or crack happens. The volume of saline can be different between different patients. The patient then follows an intensive physiotherapy regime. We have used the same technique for other joints in the upper limb where the stiffness was a problem. This technique can be done in clinic or theatre. The radiologist can do it as well.
We have looked into the financial aspect of the hydrodilatation and compared it to more invasive procedures which requires GA. How much money it saves in comparison to Arthroscopic release.
Repeatability and outcomes
High pt satisfaction, Oxford score Mua group 23 point improve the with fu of 3-12 months. Surgery group 38 point increase followup 3-36 months. Hydro dilation 49 point increase 3-6 month followup.
Patients were sedated for the hydrodilatation procedure with a target controlled infusion of 1% propofol using a Diprifusor (AstraZeneca, Macclesfield, UK) which uses the Marsh pharmacokinetic model. Patients self positioned on the operating table and were given 4 Litres/minute oxygen by hudson face mask. Monitoring included ECG, pulsoximetry, NIBP and sidestream capnography. A 20G cannula was placed in the dorsum of the hand on the non-operative side. Plasma propofol concentration was set at 6 mcg/ml and the infusion was connected to a side port of a fluid giving set incorporating a one-way valve. Fluids were Hartman’s solution running freely. Patients were pre-treated at induction with intravenous Granisetron 1mg for anti-emesis and with both Paracetamol 1g and Parecoxib 40mg for analgesia.
Surgery commenced once the patient closed their eyes. The propofol infusion was stopped on completion of the procedure and patients were recovered in the PACU in the supine position.