Hydrodilatation, Manipulation under Anaesthetic (MUA) and Arthroscopic release

These techniques can be used in the treatment of frozen shoulders. A shoulder becomes frozen when the soft tissues around the joint become tight and short. This prevents the shoulder from moving and leads to the pain and stiffness with which you are familiar. The problem may resolve over time, but it can take up to two years.

The procedure

Hydrodilatation involves the insertion of a needle into the joint under X-ray guidance/ultrasound guidance. This is followed by injection of steroid, local anaesthetic and a large volume of saline. This stretches the contracted tissue. This can be performed under local anaesthetic in clinic or under sedation in the operating theatre.

The aim of the manipulation is to reduce the recovery time by stretching the joint by the surgeon in a controlled manner, to gain full range of movement and injecting local anaesthetic and steroid to reduce inflammation and pain.

There may be need to proceed and perform further arthroscopic release of the contracture, if the manipulation is not successful. This operation is done by keyhole surgery; usually through two or three 5mm puncture wounds. It involves examination of the shoulder joint using a tiny telescope with television camera introduced through a keyhole. It involves cutting of the contracted tissues in the shoulder with a special electro-cutting/radiofrequency device to release the contracture.

The MUA or arthroscopic release are performed under general anaesthetic and a nerve block (injection in your neck or upper chest) that will make your arm feel numb for 8-12 hours after surgery. This is to allow you to mobilise your shoulder immediately after surgery without pain. When this wears off, the shoulder may well be sore, and you will be given painkillers to relieve the pain. This can be done as a wide-awake procedure without any general anaesthesia where patient can actually see the procedure if they like! If they are not comfortable, they always have the option of having a full general anaesthetic along with a shoulder block. Mr Mohan has developed the concept of fully awake shoulder surgery in his practice in the NHS and in the private sector.

Complications

As with all surgery there is a risk of some complications. These are rare, but you should be aware of them before your operation.

They include:

• Complications relating to the anaesthetic.
• Infection.
• Injury to the nerves or blood vessels around the shoulder. Sometimes, the nerves become irritable resulting in pain and stiffness in the upper limb, a condition called reflex sympathetic dystrophy.
• Fracture or breaking of the arm bone (humerus). This is extremely rare.
• Failure of the operation in improving pain or movement in your shoulder.
• Prolonged stiffness and or pain.
• A need to redo the surgery.

What to expect afterwards

Pain

The shoulder will be sore when the nerve block wears off and this may last for the first few weeks. It is important that you continue to take the painkillers prescribed in hospital. Ice packs may also help reduce pain. Wrap frozen peas/crushed ice in a damp, cold towel and place on the shoulder for up to 15 minutes. 

Movement

It is of the utmost importance that you begin moving and exercising the arm on the day of the procedure. The sling should be discarded as soon as possible. Adequate pain relief will enable you to perform the exercises demonstrated by the physiotherapist. Try to use the arm for normal daytime activities where possible. There should be about 75% improvement in symptoms in the first four to six weeks.

Wearing a sling

You will return from theatre wearing a sling. The surgeon/physiotherapist will advise you on how long you are to continue wearing the sling. This is usually until the block wears off.

The Wound

If the keyhole operation is necessary, it is usually done through two or three 5mm puncture wounds. These should be kept dry until healed. This usually takes 10 to 14 days.

Driving

You may drive after one week.

Returning to work

If you have a desk job you will probably be able to return after one week. You may need slightly longer if your job involves lifting or manual work.

Leisure Activities

These will depend on the range of movement and strength in your shoulder. It is possible to do most things as long as your shoulder feels comfortable. Please discuss specific activities with your physiotherapist.

Follow up appointments

You will have a follow up appointment at about two weeks following your procedure. You will be reviewed by the surgeon/specialist physiotherapist who will check your progress.

Progress

This is variable. In the first few weeks your shoulder will be sore although your movements will have improved. Do not be surprised if the soreness affects your daily activities. You should continue to move and use your arm normally. Over the weeks following your surgery you will notice a gradual improvement in movement and pain.

Exercises

It is essential that you carry out the exercises regularly following your procedure, ideally four to five times per day increasing as able. It is quite normal for you to experience aching, discomfort and stretching when doing the exercises but decrease the exercises if you experience intense or lasting pain.