Diabetes linked to worse outcomes in patients undergoing US-guided hydrodistension of shoulder joint

The effect of diabetes on adhesive capsulitis (AC) and its impact on the outcomes of ultrasound (US)-guided hydrodistension of the glenohumeral joint are still unclear.

Sofa Dimitri Pinheiro et al aimed to identify predictors of US-guided hydrodistension outcomes, while assessing the performance of the method in diabetic compared to non-diabetic patients. The article has been published in "Skeletal radiology" journal. The authors found that - Diabetes is linked to more severe AC at presentation and worse outcomes in patients undergoing US-guided hydrodistension. In resistant cases, repeating the intervention is independently linked to worse outcomes for at least 6 months post-intervention.

The patient was placed in the lateral position with the affected shoulder up. Following an aseptic, no-touch technique with sterile gel applied over the disinfected skin, a 21-G needle was introduced in the capsule under US guidance using an anterior approach through the rotator cuff interval. Subsequently 30–50 mL of solution (0.9% NS, 1% lidocaine, 0.25% bupivacaine, 40 mg triamcinolone in a ratio of 90% NS: 2.5% lidocaine:5% bupivacaine:2.5% triamcinolone [initial solution concentration 40 mg/mL]) was injected to distend the joint capsule as required up to the point of maximum resistance but without capsular rupture.

Patients were re-evaluated at 1, 3, and 6 months after the initial treatment. At each visit, VAS and DASH scores were assessed and the treatment was repeated if the VAS score did not present a decline of≥2 cm compared to the previous time point (VAS score previous−VAS score current≤2 cm). A reduction in VAS score< 2 cm was used as the criterion to decide the need for additional treatment.

Post-procedural care included a supervision of around 30 min after the end of the procedure, with 30 min of physiotherapy with capsule manipulation after the procedure, including passive and active movements of shoulder abduction, internal rotation, external rotation, and adduction combined with internal rotation. One-thousand milligrams of Paracetamol and 20 min of cryotherapy every 8 h for 2–3 days were prescribed. Physiotherapy was performed by a radiologist who has received formal training in shoulder manipulations.

A total of 135 patients with AC who underwent US-guided hydrodistension were prospectively included. Demographics and factors linked to chronic inflammation and diabetes were recorded and patients were followed up for 6 months. Functionality and pain were evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) and the Visual Analogue Scale (VAS) score. Statistical analysis was performed with Mann–Whitney U test, linear, and binary logistic regression.

The observations of the study are:

• Diabetes was identified in 25/135 patients (18.5%).

• Diabetic patients had worse DASH and VAS score at presentation (P <0.0001) and lower range of motion (P<0.01) compared to non-diabetics.

• Higher DASH (P=0.025) and VAS scores (P=0.039) at presentation were linked to worse functionality at 6 months.

• Presence and duration of diabetes, and the number of hydrodistension repeats, correlated with worse VAS and DASH scores at 6 months.

• The number of procedure repeats was the only independent predictor of complete pain resolution at 6 months (OR 0.418, P=003).

The authors concluded that - the presence of diabetes is linked to worse outcomes in patients undergoing US-guided hydrodistension of the glenohumeral joint. In resistant cases, physicians should be aware that repeating the intervention may delay functional and pain improvement and is independently related to worse outcomes for at least 6 months post-treatment. The results indicate that patients with diabetes present with worse pain and functionality and are more resistant to US-guided intervention.

Further reading:

Ultrasound guided hydrodistension for adhesive capsulitis: a longitudinal study on the efect of diabetes on treatment outcomes

Sofa Dimitri Pinheiro, Michail E. Klontzas et al

Skeletal Radiology

https://doi.org/10.1007/s00256-022-04141-2