Is 'frozen shoulder' a genetic condition? Study finds links to specific genes

Frozen shoulder, or adhesive capsulitis, is a common cause of shoulder pain and immobility. New findings point to specific genes associated with an increased risk of this condition, reports the Journal of Bone & Joint Surgery.The risk genes are associated with nearly a sixfold increase in the odds of developing frozen shoulder—a stronger association for most known clinical risk factors, according to the new research by Mark T. Langhans, MD, Ph.D., of Hospital for Specialty Surgery, New York. The authors believe their findings may lend new insights into the causes, prevention, and treatment of adhesive capsulitis.

  

                                                                           

Genome-wide association study finds 'significant loci' affecting frozen shoulder risk

Patients with adhesive capsulitis develop painful and progressive loss of shoulder motion with associated pain. Frozen shoulder is one of the most common shoulder conditions, occurring in up to 10% of people at some time in their lives. Although the exact cause is unclear, frozen shoulder sometimes occurs after an injury, surgery, or other condition that reduces shoulder mobility. Loss of motion results from fibrosis (scarring or thickening) of the capsule around the shoulder joint.Certain clinical factors are associated with an increased risk of frozen shoulder, including diabetes, thyroid disease, and smoking. Recent studies have suggested that risk is also higher in people with affected relatives—suggesting a possible genetic predisposition. Dr. Langhans and colleagues performed a genome-wide association study to identify specific genes that might be related to the risk of frozen shoulder.

Data studied from large British database

The study used data from a large British database, the UK Biobank, which includes genetic and health data on approximately 500,000 patients. The analysis focused on 2,142 patients with adhesive capsulitis compared to those without this diagnosis. Possible genetic associations were adjusted for other factors, including sex, diabetes, thyroid disease, history of shoulder dislocation, and smoking.

The study identified three significant loci for frozen shoulder. The strongest association was found for gene variants located at a site called WNT7B.This finding was consistent with previous studies that reported a possible link between WNT7B and frozen shoulder, along with several other orthopedic-related conditions. Weaker associations were also found for two previously unreported genetic loci located near genes for POU1F1 and MAU2.

All three associations remained significant after adjustment for other factors. Together, the three variants carried nearly a sixfold increase in the odds of developing frozen shoulder. That was greater than the risk associated with diabetes (about four-fold) or thyroid disease (less than two-fold), and second only to smoking (about 11-fold).

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International Conference on Orthopedics and Sports Medicine, organized by the Pencis group. International Conference on Orthopedics and Sports Medicine is a discussion of common Bacteria, orthopedics conference are disorders caused by organisms The focal point of orthopedics Conferences is to bring forward discoveries, examine the system and strategic issues, assemble and keep forth basic systems between analysts, professionals, arrangement producers, and agents of orthopedics Associations. Essential orthopedics Conference put emphasis on its theme "Innovation through Information on Orthopedic and Sports Medicine" and intends to provide an impetus to health practice, administration, and training in connection to health inconsistencies and conjugation of other different points. Patients with access to a general essential care doctor have brought down available medicinal services cost than those without one, and Health results been better. orthopedics Conference is an opportunity to interact with specialists and to learn the latest Orthopedic and Sports Medicine and orthopedics conference related information.

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Orthopedic surgery patients can recover just as well without using opioid-based painkillers

                           Patients can recover from orthopedic surgery just as well without using opioid-based painkillers, says a McMaster University and Hamilton Health Sciences (HHS) study published by the Journal of the American Medical Association (JAMA).

                           Study results showed that by prescribing a combination of three non-opioid painkillers to patients, researchers successfully reduced approximately tenfold the amounts of opioids consumed over a six-week post-operative period, without altering their pain levels.

                           Co-principal investigator Olufemi Ayeni and his team gleaned their results by enrolling 193 patients between March 2021 and March 2022 from three Hamilton hospitals including HHS' McMaster University Medical Centre and Hamilton General Hospital, and St. Joseph's Healthcare Hamilton.

                          The patients were randomly assigned to either a control group of 98 receiving standard opioid-based painkillers or an opioid-free group (93) receiving a combination therapy of naproxen, acetaminophen and pantoprazole and a patient educational infographic. The opioid-free group did have access to opioid medication if required for pain. Each patient undergoing outpatient knee or shoulder arthroscopic surgery was monitored for six weeks after their operation.

                          After the six weeks, those in the control group had had an average of 72.6 mg of opioids, compared to 8.4 mg in the opioid-sparing group. Six patients in the control group and two patients in the opioid-sparing group asked for opioid medication after discharge. Difference in pain scores, patient satisfaction with care and number of adverse events were not significantly different.

                                                     

                        "Furthermore, by reducing the number of opioids prescribed, we can collectively reduce the development of a reservoir of unused medications that can cause harm to many in society," he said.

                        "By one estimate, there are at least 100,000 of these surgeries in Canada annually, meaning that shifting prescription practices to reduce opioid use can reduce patient exposure and, by extension, the potential for dependency on opioids."

                         Opioids remain the post-operative painkiller of choice for orthopedic specialists on both sides of the border, but North America's ongoing opioid epidemic is forcing a rethink among clinicians, Ayeni said, adding that orthopedic specialists at times prescribe more opioids than recommended by medical guidelines.

                         Ayeni said that by switching to non-opioid painkillers after surgery, surgeons can play their part in combatting the ongoing opioid epidemic and reduce the risk of dependency in patients recovering from orthopedic surgery.

                         Funding for the study was received from Physician Services Incorporated and Hamilton Health Sciences New Investigator Fund.

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PROMs data infrequently accessed by members of clinical care, study suggests

                           Even when patient-reported outcome measures (PROMs) are successfully incorporated into electronic health records (EHRs), these patient-centered data are infrequently accessed by members of clinical care teams, suggests a study in the November/December issue of American Journal of Medical Quality (AJMQ), official journal of the American College of Medical Quality (ACMQ). The journal is published in the Lippincott portfolio by Wolters Kluwer.

                           At one large orthopedic practice, care teams accessed PROMs data for less than 1% of visits by patients undergoing total knee or hip replacement surgery, according to the report by Jeanette Y. Ziegenfuss, PhD, of HealthPartners Institute, Minneapolis, and colleagues. They write, "Making PROMs available for care team review in the EHR...is not enough to encourage integration of PROMs into clinical care for patients."

                                          

                           A key focus of efforts to measure healthcare quality, PROMs are designed to capture data on outcomes important from the patient's perspective – for example, daily functioning, quality of life, and experience of care. Data from PROMs have mainly been used for public reporting of system-wide outcomes or quality improvement initiatives. Few studies have evaluated whether and how PROMs are being used to inform everyday patient care.

                         As part of a larger project at a Midwestern health network, the study orthopedic department made an investment to integrate PROMs into the electronic health records (EHRs). Starting in 2017, the clinic began collecting PROMs data on all patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA), including assessments of joint function, general health and functioning, and patient satisfaction.

                        How was this information used at the point of care? To find out, Dr. Ziegenfuss and colleagues analyzed how often the PROMs data included in the EHR were accessed by orthopedic surgeons and other members of the care team for patients undergoing TKA or THA over a 15-month period in 2019-20.

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Study assesses musculoskeletal health needs of underserved patients

                       To improve the health of a community, the first step is to identify its most pressing needs. To that end, in 2022 Hospital for Special Surgery (HSS) implemented a community-based participatory research (CBPR) approach to assess musculoskeletal health needs, identify health disparities and support the development of initiatives to address unmet needs.

                      Critical issues included a lack of health education and awareness in managing arthritis and other painful conditions; a high incidence of falls in the community; and limited access to care among underserved populations.

                      The study, "Assessing Musculoskeletal Health Needs of Underserved Patients & Community Members Using a Community Based Participatory Research Approach," was presented virtually at ACR Convergence 2022, the annual meeting of the American College of Rheumatology in Philadelphia.

                                                   

                             HSS researchers used a mixed-method approach to develop a Community Health Needs Assessment (CHNA). "For quantitative data, we distributed a community survey in four languages-;English, Spanish, Chinese and Russian-;to assess the socio-demographic characteristics of the populations we serve; health status and quality of life; health behavior and lifestyle; use of and access to care; and health education needs," explained Adeniran. "For qualitative data, we conducted interviews with 22 community partners, including community-based organizations, city and state agencies and universities."

                            The survey was distributed in various ways, including online, via email, using Alchemer panels, in person, and through the mail over a four-week period from January 15 to February 15, 2022. A total of 18,248 patients and community members completed the surveys, with 57% representing a diverse and underserved population.

                           In addition to the surveys, interviews with community partners provided valuable insights into unmet health needs, Adeniran noted. Community organizations represented all five boroughs of New York City, as well as surrounding areas serving racially/ethnically diverse populations. They represented all age, gender, and socioeconomic groups.

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Vertebral body tethering: Another option for treating scoliosis in children

 

                

                ROCHESTER, Minn. — Fusion surgery has been the long-standing treatment for people with scoliosis - a side-to-side curve of the spine. But other options have become available — including vertebral body tethering for children with scoliosis.\

               Mild scoliosis cases are monitored over time. Small curves in growing children can progress rapidly without treatment. Moderate scoliosis in growing children is treated with bracing. Until recently, severe scoliosis could only be treated with fusion surgery.

                 "Fusion had been a reliable treatment approach with a durable long-term result and powerful correction of the spinal curvature," Dr. Larson says. "But with fusion, the spine no longer grows, and there is no flexibility of the spine over the fused vertebrae. Some patients and families value spinal motion and growth, and would prefer another treatment approach for severe scoliosis."

                                      

                                When the cord is tightened during the surgery, the spine straightens. As the child grows, the spine may straighten even more. Growing children with moderate to severe scoliosis and certain curve types are eligible for the procedure.

                                 Although spinal motion and growth remains, there are potential downsides to the procedure. At this time, there is a higher risk for a second surgery compared with fusion surgery, due to overcorrection or undercorrection of the scoliosis. The long-term durability of the procedure is not known, and a fusion surgery may be required eventually.

                                 "Patients and families should be informed about their treatment options," Dr. Larson says. "Some families would like an alternative to fusion surgery. More information is coming out about nonfusion scoliosis surgery. If patients are interested in vertebral body tethering, I would encourage them to go to an experienced center, as this is an emerging technology."

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Dynamic sagittal tether may yield faster return to work vs. lumbar interbody fusion

 

                   CHICAGO — Results presented here showed decompression and dynamic sagittal tether stabilization for degenerative spondylolisthesis may yield faster return to work and activities of daily living compared with lumbar interbody fusion.

                                   “The reduction in disability and faster return to work and activities of daily living may indicate lower perioperative morbidity and faster recovery similar to decompression, while the sustained reduction in disability may indicate clinical durability similar to fusion,” William F. Lavelle, MD, professor of orthopedic surgery at Upstate University Hospital, said in a press release from Empirical Spine Inc. “These data indicate that LimiFlex [Dynamic Sagittal Tether] is a promising alternative to fusion for this large patient population.”

                      

Lavelle and colleagues propensity matched 136 patients with degenerative spondylolisthesis and lumbar spinal stenosis who underwent decompression and dynamic sagittal tether stabilization (LimiFlex Dynamic Sagittal Tether, Empirical Spine Inc.) with 131 patients who underwent decompression and transforaminal lumbar interbody fusion. Researchers collected work status, return to work, activities of daily living and change in disability preoperatively and at 12-month follow-up and compared the results between the two groups.

With regard to change in disability, disability is measured by the [Oswestry Disability Index] ODI, a great drop in ODI is potentially a better outcome, and we see that both the fusion group and the dynamic sagittal group had a drop in their ODI scores with a difference being toward the advantage of the dynamic sagittal tether,” Lavelle said in his presentation at the North American Spine Society Annual Meeting.


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              Theragen receives US patent for spinal fusion bone growth stimulator.

                                   Theragen has announced the issuance of a second U.S. patent for its ActaStim-S, a wearable and app-compatible postoperative bone growth stimulator for patients undergoing spinal fusion, according to a release.

The ActaStim-S device, a wearable which can be connected to the Sync app, helps patients undergoing spinal fusion track their usage, activity levels and pain entry reporting, according to the release.

“Receiving the patent is important. It's also validating seeing the ActaStim-S design so well received by patients and surgeons,” Chris McAuliffe, CEO of Theragen, said in the release. “Our first patent focused on device connectivity, while this patent protects our device design. ActaStim-S offers significant practical advantages [vs.] large, obtrusive devices that can constrain ambulation and mobility. ActaStim-S remains the innovation leader compared to devices that do not track compliance and activity levels, communicate, or engage patients toward therapeutic compliance. Patients and surgeons expect medical devices to collect and process data, to be digitally connected, ultra-modern and easy to use for all ages and lifestyles. Our device design delivers proven therapy at home, at work or on the go; for modern times and high expectations,” McAuliffe added.

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           Topical analgesics relieved pain , but deemed in ineffective for treatment of hand ,wrist OA.

                       Use of topical analgesics significantly improved pain scores in most patients with symptomatic hand and wrist osteoarthritis; however, according to researchers, the treatment is an undesirable long-term maintenance therapy option.

                        “Hand and wrist osteoarthritis (OA) is a highly prevalent upper extremity condition, with every one in two women and one in four men experiencing symptoms by the age of 85 [years], which strongly limits their activities of daily living,” Yuchen Liu, BS, said in her presentation at the American Society for Surgery of the Hand Annual Meeting.

                                  

                             Liu and colleagues distributed a 26-question survey to 100 adults with OA of the hand or wrist. Outcome measures included VAS pain scores, as well as patient-reported changes in swelling, stiffness and overall improvement of condition.


Of the 80 patients who completed the survey, 51 patients (63.75%) reported use of topical analgesics. Patients who used topical analgesics had higher pain scores (by an average of 18 points) compared with those who did not use topical analgesics, and their VAS pain scores improved an average of 24.8 points immediately after application of a topical analgesic. However, 63.46% of patients who used topical analgesics reported mild or no improvement in their condition; 39.6% of patients reported no improvement in stiffness; and 41.8% of patients reported no improvement in swelling.

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Artificial intelligence: Potential to improve knee arthritis care

                               Although artificial intelligence is upending medical care, its potential applications to orthopedic surgery haven't been widely studied. Mayo Clinic found that a deep learning algorithm can identify and classify knee osteoarthritis on radiographs as accurately as fellowship-trained knee arthroplasty surgeons.

                               "This technology has the potential to significantly decrease the likelihood of inaccurate assessment of radiographs in the diagnosis and treatment of knee arthritis," says Adam J. Schwartz, M.D., an orthopedic surgeon at Mayo Clinic in Phoenix/Scottsdale, Arizona. "There is currently no standardized approach, and quite a bit of variability, in reading these radiographs. Reducing that variability can facilitate clinical decision-making and improve outcomes for patients."

The surgeons' ratings were compared to one another and to the neural network's ratings of those 576 knees. Statistical analysis found broad agreement between the assessments from the surgeons and the artificial intelligence tool.

Deep visual learning                         

    A convolutional neural network is a type of deep learning tool that is commonly used to evaluate visual imagery. Deep learning is a method of artificial intelligence that processes raw data — such as images — with learning algorithms to create layers of nodes, each receiving information from, and learning from, the other.

"Before implementing this type of solution in clinical practice, we need more data and additional training, to minimize the potential for errors in classifying the severity of osteoarthritis," Dr. Schwartz says. "But once you have an artificial intelligence model, you can find all sorts of ways to improve efficiency and reduce variability."

       

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                                  On orthopedics surgeon specializing in hand and upper extremity surgery at Mayo Clinic's campus in Florida, first saw the young basketball player, he noted the boy was not experiencing pain, yet had significant issues with range of motion (ROM).

                                 "He had a pothole in his wrist joint," he says. "His wrist fracture healed in a bad position — and the carpal bones were stuck in the hole.

                                  The reason for the hole present in the boy's wrist joint was an impaction fracture. It was not initially recognized and progressed to a malunion.

 

              

                                        

  

                                Distinct from a nonunion, where there is no healing in the joint, a malunion indicates nonanatomic healing, which can be a complication from surgery or something that occurs when nonsurgical management doesn't maintain the appropriate position of the bones.

                                In the young basketball player's case, no surgery had been performed on his wrist initially, as his health care providers at the time did not recognize the extent of injury. He had a different injury pattern from what is commonly seen in the wrist. In this case, only one part of the joint surface was affected — appearing almost like a die punch in that location — where typical wrist injuries either impact a larger portion of the joint or are outside of the joint altogether. This was a fracture in the scaphoid fossa, part of the joint that supports the scaphoid bone. Though small, this injury and its subsequent malunion caused swelling and limited use of the wrist. In some patients, a wrist malunion can cause the wrist joint to become completely unusable.

Traditional versus cartilage graft wrist fracture repair

                   A traditional wrist fracture repair would include an osteotomy. However, this procedure, with its usual bone cutting and removal, would be difficult to perform in a contained defect in a small area of the joint surface, says Dr. Aziz.

Due to the nature of the malunion in the basketball player's case, Dr. Aziz elected to take a knee cartilage graft in a non-weight-bearing region to repair the wrist joint. Though this was a unique repair for the player's injury, his parents agreed to pursue it. As the young patient was still skeletally immature with his growth plates

Applications of the knee cartilage graft for wrist malunion repair

                   Surgeons can perform the same type of knee cartilage graft for wrist malunion for adults as the basketball player experienced. The procedure is easier to perform in this population — considering future growth is not necessary, as it is in pediatric patients. Wrist joint injury can occur through a number of mechanisms — whether a slip in the kitchen, loss of balance on a neighborhood walk, or a fall while skiing or performing another physical activity. Older adult patients, in particular, experience wrist fractures often and tend to have more significant injuries.

Recovery from the knee cartilage graft procedure to repair the wrist includes casting for a defined period and then a removable orthosis, typically with a 6- to 8-week healing time after which the surgeon will approve use of the joint.

                                                          

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                          Mayo Clinic is employing a new method of pain prevention as part of limb amputation, heading off post-amputation morbidity from the formation of neuromas, which contribute to residual limb pain (RLP) and phantom limb pain (PLP). Until recently, traditional interventions for post-amputation neuromas have been unsuccessful: Neuroma recurrence rates were high.

                         The new method, regenerative peripheral nerve interface (RPNI), has been studied both preclinically and clinically. It prophylactically reduces potentially symptomatic neuromas through autologous free muscle grafts, often from the amputated limb, implanting the ends of transected nerves into the graft and supplying regenerating axons, reinnervating end organs and creating new neuromuscular junctions.

   

                           

                         RPNI is active prevention of neuroma," says Shelley S. Noland, M.D., a hand and peripheral nerve surgeon at Mayo Clinic's campus in Arizona, and a major user of the RPNI technique. "Placing the nerve endings into muscle graft tissue gives the nerves somewhere to go and something to do."

Active, effective prevention versus inconsistent, passive prevention                

          The traditional method of deterring neuroma formation involved attempting to bury the nerve ends at the amputation site, effectively placing them away from the surface. However, Dr. Noland indicates high failure rates with these techniques, primarily because the buried nerves did not stay in place.

                          Physicians developed RPNI because former amputation techniques were inconsistently successful for pain prevention and did not offer the severed nerves a function, which all nerves instinctively seek.

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Results showed intra-articular injection of microfragmented adipose tissue or platelet-rich plasma had comparable low numbers of failures and adverse events without signs of disease progression in patients with knee osteoarthritis.

“[Microfragmented adipose tissue] MF-AT seems to represent a suitable strategy for knee OA, especially for more advanced cases,” the authors wrote.

                                           

Researchers randomly assigned 118 patients with symptomatic knee OA to receive either a single intra-articular injection of MF-AT or platelet-rich plasma. Researchers collected IKDC subjective scores, KOOS subscales, EuroQol-VAS, EuroQol-5D and VAS for pain prior to the injection and at 1, 3, 6, 12 and 24 months after the injection.

Researchers considered the IKDC subjective score and the KOOS pain subscore at 6 months as the primary outcome. Researchers also evaluated patients’ knees with radiography and high-resolution MRI using the Whole-Organ Magnetic Resonance Imaging Score at baseline and at 6, 12 and 24 months.

Potential risks and challenges for patients with 40-plus BMI

           BMI is independently associated with increased risk of postoperative complications after THA and TKA, says Dr. Bedard. He also indicates obesity usually does not occur in a vacuum, without other health consequences. In fact, it can be a marker of poor overall wellness: Individuals who have a 40-plus BMI tend to be overall less healthy, and often have other medical problems that can increase their risk of complications.

                    Soft tissue depth, which makes implant positioning more difficult for the surgeon

                    Increased risk of wound complications

                    Elevated infection risk

                    Increased risk of dislocation due to soft tissue impingement or tissue levering the joint out of place

 

Mayo Clinic's approach to helping individuals with high BMI who need TKA or THA

                What Dr. Bedard recommends, in light of risks for the patient with high BMI who needs pain alleviation and functional improvement, is optimizing the patient's weight and health pre-surgery. This typically includes the following process with a surgeon, patient and other physicians who specialize in weight loss:

                        

                      Discussing the patient's arthroplasty risks and any patient concerns

                      Setting reasonably attainable health improvement goals

                      Presenting options for how to reach the goals and pros and cons of each potential tool.

Referral considerations for physicians treating patients with high BMI who require arthroplasty

                      Dr. Bedard indicates multiple options exist for physicians to help patients with a high BMI become ready for a TKA or THA. Community physicians should apply similar pre-surgical optimization strategies as those employed by Mayo Clinic. If a physician does not have access to resources to help optimize patients, one option to consider is referring the patient to Mayo Clinic.

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International Conference On Orthopedics And Sports Medicine

     

                        Published results showed intra-articular injection provided significantly greater pain relief and functional improvement of thumb carpometacarpal joint arthritis at 3 months compared with extra-articular injection.

                         “A steroid injection given into the [carpometacarpal] CMC joint of the thumb will provide, on average, longer lasting relief than when it is given outside of the joint,” Brian M. Katt, MD, told Healio.

    

                                    

                         Katt and colleagues used wrist radiographs to visualize location of the CMC joint injection with triamcinolone and radiopaque contrast among 102 hands with thumb CMC joint arthritis. Researchers collected DASH questionnaires and VAS pain scores before injection and at 1 week and 1, 3 and 6 months after injection. Researchers constructed generalized linear regression models to identify variables associated with clinical outcomes.

                        Researchers found improvements in DASH and VAS scores after 1 week in both the intra-articular injection group and extra-articular injection group. Although both groups reported worse DASH and VAS scores at 3 months, researchers noted significantly lower DASH and VAS scores among patients in the intra-articular group.

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