Arthrographic Distension / Hydrodilatation
The procedure can be performed under flouroscopy (x-ray) or Ultrasound guidance. We recommend imaging guidance to be confident of correct needle placement, but some clinicians do it by feel alone.
The term 'arthrographic' refers to the use of flouroscopic radiological imaging to watch and guide the procedure. A small amount of contrast material is injected into the joint which allows the procedure to show up on an imaging device.The procedure can also be done under Ultrasound guidance, where contrast is not needed, as the clinician can see the fluid clearly enter the joint.
The injected fluid can be seen to expand the joint and sometimes flow out of the joint in a particular direction. Distension of the glenohumeral joint with fluid is thought to have a mechanical effect on the cells lining the joint and possibly disrupt adhesions (scar tissue), thereby opening or freeing up the joint allowing improved range of movement. However, the exact mechanism is not fully understood. From our own studies and others rupture of the capsule is not essential, but the mechanical effect probably is - see here.
The procedure is performed under local anaesthetic, takes about 15 minutes to complete and the patient goes home immediately afterwards. The procedure appears to be safe with transient pain during and after the procedure being the most common complaint. Most have included corticosteroid as part of the procedure but it is not known if this is necessary. It is also not known whether arthrographic distension using steroid and saline is better than intra-articular steroid injection alone (1).
There is some evidence that arthrographic distension provides benefits in pain, range of movement and function in Frozen Shoulder (1-7). Most studies are small and low powered, but distension with steroid appears to be more effective than a steroid injection alone (8). The current evidence suggests it is as effective as manipulation-under-anaesthesia (MUA), with less complications (9-12). Our own data has shown good results in selected patients. Also see presentation.
We offer a one-stop service (by prior arrangement) at The Arm Clinic. See here.
Patient Information
Why have I been offered this treatment?
Your specialist has diagnosed a frozen shoulder which is a painful condition which causes reduced movement of the shoulder joint.
What is involved?
Hydodilatation involves stretching the capsule of the joint by injecting a mixture of sterile saline, local anaesthetic and steroid. This opens up the joint and releases sticky adhesions within the joint. The Radiologist performs the procedure in the Xray department using Xray guidance to ensure the injection is accurately placed.
You will be asked to lie on your back with your hand by your side. The skin will be cleaned and local anaesthetic will be given to numb up the area. A fine needle will be introduced onto the surface of the shoulder joint under Xray guidance and a small volume of Xray dye (iodine contrast) will be injected to ensure safe positioning.
The saline, steroid and further local anaesthetic will then be given.
Below is a video showing the procedure. The first is a dye injection of a normal shoulder (arthrogram). The second shows a distension arthrogram. You can see how tight the joint is initially and then the dye 'ruptures' through the capsule releasing the tight joint capsule.
Is it safe?
It is generally a very safe procedure.
There is a very small risk of infection, as with any joint injection.
There is a risk that it may not work (in about 30%). There is a small risk of bleeding. You must inform the department if you are taking anti-coagulants eg Warfarin.
There are uncommon and temporary side effects of corticosteroids, including slight elevation in blood sugars in Diabetics, facial flushing, alteration in menstruation. These are all temporary and do not last longer than a few days at most after the injection. The procedure can be done without coorticosteroid if there are any concerns.
Rarely, you may have discomfort for 24 hours after the procedure. This is not common.
What can I expect to feel during and after the procedure?
Once the area is numbed up you should feel very little. There may be some pushing and pressure sensation. If you feel discomfort you must tell the doctor. Occasionally people have described a feeling of excess fluid in the shoulder. These symptoms should resolve quickly.
What happens after the procedure?
Some people do have moderate discomfort, which can last for thirty minutes after the procedure, due to the joint distension.
It is advised that you bring along someone to drive you home after the procedure, as we would advise that you do not to drive or "operate heavy machinery" for at least 6 hours after the procedure.
You can continue physiotherapy after the procedure and we would recommend you see your therapist approximately 3-5 days afterwards.
Our therapist rehab guide can be viewed and downloaded here - https://www.shoulderdoc.co.uk/article/1723
Does it work?
We have a success rate of over 70% in improving the movement of the shoulder and over 90% in improving pain. Many people feel immediate relief, but for some it can take a couple of weeks to achieve full benefit.
What if it fails?
Your specialist will discuss the option of a keyhole surgical release (arthroscopic arthrolysis) or MUA (Manipulation Under Anaesthetic).
In association with Musculoskeletal Radiologists - Dr Jonathan Harris, Dr Sarah Jackson, Dr Waqar Bhatti who provide the treatment in Manchester. For more information please contact us
References:
- Buchbinder R, Green S, Youd JM. Arthrographic distension for adhesive capsulitis (frozen shoulder). … Database Syst Rev. 2008.
- Vad VB, Sakalkale D, Warren RF. The role of capsular distention in adhesive capsulitis. Archives of physical medicine and …. 2003.
- Gavant ML, Rizk TE, Gold RE, Flick PA. Distention arthrography in the treatment of adhesive capsulitis of the shoulder. Journal of Vascular and …. 1994.
- Rizk TE, Gavant ML, Pinals RS. Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distension and rupture. Archives of physical medicine and …. 1994.
- Mulcahy KA, Baxter AD, Oni O. The value of shoulder distension arthrography with intraarticular injection of steroid and local anaesthetic: a follow-up study. British journal of …. 1994.
- FAREED DO, GALLIVAN WR. Office management of frozen shoulder syndrome: treatment with hydraulic distension under local anesthesia. Clinical orthopaedics and related …. 1989.
- Andrén L, Lundberg BJ. Treatment of rigid shoulders by joint distension during arthrography. Acta Orthop. 1965.
- Gam A, Schydlowsky P, Rossel IB. Treatment of“Frozen Shoulder”with Distension and Glucorticoid Compared with Glucorticoid Alone: A Randomised Controlled Trial. Scandinavian …. 1998.
- Jacobs LG, Smith MG, Khan SA, Smith K. Manipulation or intra-articular steroids in the management of adhesive capsulitis of the shoulder? A prospective randomized trial. Journal of shoulder and …. 2009.
- Quraishi NA, Johnston P, Bayer J. Thawing the frozen shoulder A RANDOMISED TRIAL COMPARING MANIPULATION UNDER ANAESTHESIA WITH HYDRODILATATION. Journal of Bone and …. 2007.
- Hsu S, Chan KM. Arthroscopic distension in the management of frozen shoulder. International Orthopaedics (SICOT). 1991.
- Ng CY, Min AK, McMullan L, McKie, S, Brenkel IJ, Cook RE. A prospective randomized trial comparing manipulation under anaesthesia and capsular distension for the treatment of adhesive capsulitis of the shoulder. Shoulder and Elbow. 4(2)95-99. 2012
