Short Term Outcome Of Double Side Injections Of Diprospan For The Treatment Of Early Stage Idiopathic Frozen Shoulder

Background and ObjectivesIdiopathic Frozen Shoulder(IFS) is a chronic and debilitating disease, characterized by insidious onset and gradual loss of shoulder function. It is a clinical syndrome whose incidence is 3%-5% in general population (mainly 50s-60s age group). However the pathogenesis of IFS remains unknown. As a result there is no universal criteria for the treatment and diagnosis for IFS. The corticosteroid therapy, as one of the most effective methods to treat primary frozen shoulder,has been widely used, which consists of two main parts: namely systematic medication and local injection. As to systematic medication, it refers to oral corticosteroid tablets or interavenous injection(IV). But since the huge dosages and long term use, systematic medication of corticosteroid have brought about many side effects: such as hypertention and increased susceptability to infctions, not to mention metabolism disorder resulted from corticoteroid. Considering the high risks of systematic medication, people turned to local injections of corticosteroid, which include: glenohumeral joint injection,subacromial injection and trigger point injections. Based on the previous experience of coricoteroid injections of our department,we managed to design an research in which we modified an arthroscopic approach to improve the accuracy of glenohumeral joint injection without a guidance and studied the short term outcome of double side injection(glenohumeral joint and subacromial injection) of Diprospan to treat early stage IFS.Materials and Methods1. Intra-articular injection of glenohumeral joint through modified Nevaiser approach without a guidanceBy moving the original entry spot of standard arthroscopic Nevaiser approach(NA) laterally, we find a new approach for glenohumeral joint injection which is 0.5cm medial to acromioclavicular(AC) join, and close to acromion. By selecting and randomizing the patients from the outpatient department, we set up three groups who received glenohumeral joint contrast material injection with three different techniques respectively, which were modified Nevaier approach(MNA) injection, anterior approach(AA) injection and posterior approach(PA) injection. After the injections, all patients underwent Magnetic Resonance Imaging(MRI) scanning, and according to the location of contrast material, we defined successful injections when the contrast materials were intra-articular(IA), while failed injections when the materials were extra-articular(EA).At the same time, any injection related complications were recorded and dealt with. The accuracy rate of each group was calculated and analyzed.2. Short term outcome of Diprospan double side injection for the treatment of early stage Idiopathic Frozen ShoulderAfter selection and randomization of the patients from outpatient department, we managed to include 126 patients of early stage IFS in all, in which there were 48 males(aged from 43-65y) and 78 females(aged 40-68y). The patients were allocated to three groups which were: group A: receiving 1ml diprospan +5ml lidocaine injection for both glenohumeral and subacromial injection, once a week for 5 weeks; group B: receiving 1ml diprospan +5ml lidocaine injection for glenohumeral injection only, once a week for 5 weeks; group C: receiving oral medication of celecoxib tablets, 200mg\once a day, for 5 weeks. All the patients were tutored with home exercises for shoulder rehabilitation(HER) and informed practicing frequency after their trial interventions. Patients were asked to come back for follow-up on the 6th week, 3rd month and 6th month after their enrollments. The outcomes were assessed with visual analog score(VAS), Modified Constant Score(MCS), and range of motion(ROM) of flexion and abduction.Results1. Glenohumeral joint injection through modified Nevaiser approach without a guidance.As to MNAgroup: 41cases were successful with an accuracy rate of 91.1%. 4 cases were failed, of which 2cases were seen contrast materials presence in supraspinatus muscle and another 2 in subacromial bursa.For the AA group: 10 cases were successful with an accuracy rate of 50%. 10 cases were failed, of which 6 cases were seen contrast materials presence in subscapualr muscle and the tendon, another 4 in deltoid.As for the PA group: 19 cases were succesful with an accuracy rate of 76%. 6 cases were failed, in which 4 cases were seen contrast materials presence in supraspinatus muscle ,1 in deltoid and 1 in teres minor muscle.Comparion of successful rate of three groups:λ2 value of the MNA group with AA and PA groups were: 13.85 (v=1 P=0.001)and 9.72(v=1,P=0.002) respectively.λ2 value between AA and PA groups was 0.45(v=1,P=0.502);of all three injection groups, MNA group ranked the highest in successful rate, while the AA and PA groups had seen little differnece.As for postinjection compilcations, 5 patients of AA group had reported injection spot pain lasting longer than 24 hours with VAS of 6-9. There were no occurance of complications such as bleeding, bunring sensation, exhaustion, dizziness, flustered, chest distress, infection or postinjection malfunction.2. Short term outcome of Diprospan double injection for the treatment of early stage Idiopathic Frozen ShoulderOf 126 enrolled patients, only 105 completed the checkpoint follow-up and all the treatment required, the follow-up results were as followed: On the 6th week of enrollment: Group A: VAS: 2.38±0.92 modified Constant Score(MCS%) :74.67±2.75 Flexion rang of motion(ROM°):141.62±10.92 Abduction ROM(°):138.79±10.24;Group B:VAS: 3.47±0.72 MCS(%): 64.80±1.93 Flexion ROM(°):129.74±10.52 Abduction ROM(°):126.84±11.63;Group C:VAS: 5.52±0.75 MCS( % ): 48.45±4.57 Flexion ROM(°) : 104.39±20.09 Abduction ROM(°) :90.91±19.38. All the data underwent analysis of variance, and the results indicated: there were significant differences among three groups concerning on VAS, MCS and ROM of flexion or abduction, p<0.05, in which group A exceled the other two, and group B did group C.On the 3rd month of enrollment: Group A:VAS: 1.47±0.86 MCS(%): 83.39±3.74 Flexion ROM(°):156.62±10.99 Abduction ROM(°):157.94±9.86;Group B:VAS: 2.45±0.80 MCS( % ): 73.38±2.42 Flexion ROM(°) : 144.47±11.08 Abduction ROM(°):146.05±10.60;Group C:VAS: 4.03±0.92 MCS(%): 58.12±5.36 Flexion ROM(°):113.64±24.54 Abduction ROM(°):105.30±20.08;All the data underwent analysis of variance, and the results indicated: there were significant differences among three groups concerning on VAS, MCS and ROM of flexion or abduction, p<0.05, in which group A exceled the other two, and group B did group C.On the 6th month of enrollment: Group A:VAS: 1.24±1.18 MCS(%):88.44±4.04 Flexion ROM(°):167.35±11.23 Abduction ROM(°):167.94±9.86;Group B:VAS: 1.39±1.05 MCS( % ): 83.34±2.93 Flexion ROM(°) : 162.89±11.31 Abduction ROM(°):161.05±11.52;Group C:VAS: 2.76±0.79 MCS(%): 69.78±4.77 Flexion ROM(°):122.73±24.88 Abduction ROM(°):120.30±20.08;All the data underwent analysis of variance, and the results indicated: there were no significant differences between Group A and B in VAS and Flexion ROM, but not with MCS and Abduction ROM, in which Group A exceled Group B. Both group A and B exceled group C in all aspects with obvious differences.Conclusions(1) As far as glenohumeral injection without any guidance is concerned, Modified Nevaier approach may provide more accuracy and security compared with conventional anterior and posterior ones.(2) Short term outcome of double side injection for the management of early stage IFS may excel that of single side injection and oral NSID tablets, but not likely in a long term.