The association between frozen shoulder and Dupuytren's disease

Evidence-Based Medicine: Options for Dupuytren's Contracture: Incise, Excise, and Dissolve

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand updates in the basic science, epidemiology, and treatment of Dupuytren's disease. 2. Understand treatment with needle aponeurotomy, collagenase, and fasciectomy. 3. Understand advanced needle techniques for Dupuytren's contracture. 4. Understand the safety and effectiveness of a new treatment, collagenase.

SUMMARY

The literature on Dupuytren's disease encompasses many specialties. Its treatment is generally by perforating, excising, or dissolving the affected tissues. This article reviews the changing understanding of this disease and treatment options.

Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments

Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. It is a debilitating condition that can occur spontaneously (primary or idiopathic adhesive capsulitis) or following shoulder surgery or trauma (secondary adhesive capsulitis). Here, we review the pathophysiology of adhesive shoulder capsulitis, highlighting its clinical presentation, natural history, risk factors, pathoanatomy and pathogenesis. Both current non-operative and operative treatments for adhesive capsulitis are described, and evidence-based studies are presented in support for or against each corresponding treatment. Finally, the review also provides an update on the gene expression profile of adhesive capsulitis and how this new understanding can help facilitate development of novel pharmacological therapies.

The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review

Background

Frozen shoulder is a common yet poorly understood musculoskeletal condition, which for many, is associated with substantial and protracted morbidity. Understanding the pathology associated with this condition may help to improve management. To date this has not been presented in a systematic fashion. As such, the aim of this review was to summarise the pathological changes associated with this primary frozen shoulder.

Methods

Databases: Medline, Embase, CINAHL, AMED, BNI and the Cochrane Library, were searched from inception to 2nd May, 2014. To be included participants must not have undergone any prior intervention. Two reviewers independently conducted the; searches, screening, data extraction and assessment of Risk of Bias using the Cochrane Risk of Bias Assessment Tool for non-Randomised Studies of Interventions (ACROBAT-NRSI). Only English language publications reporting findings in humans were included. The findings were summarised in narrative format.

Results

Thirteen observational studies (involving 417 shoulders) were included in the review. Eight studies reported magnetic resonance imaging or arthrography findings and 5 recorded histological findings. When reported mean ages of the participants ranged from 40.0 to 59.8 years. Duration of symptoms ranged from 0 to 30 months. The majority of studies (n = 7) were assessed to be of moderate risk of bias, two studies at high risk and the remaining four were rated as low risk of bias. Study characteristics were poorly reported and there was widespread variety observed between studies in respect of data collection methods and inclusion criteria employed. Pathological changes in the anterior shoulder joint capsule and related structures were commonly reported. Imaging identified pathological changes occurring in the coracohumeral ligament, axillary fold and rotator interval. Obliteration of the subcoracoid fat triangle also appeared to be pathognomonic. Histological studies were inconclusive but suggested that immune, inflammatory and fibrotic changes where associated with primary frozen shoulder.

Conclusions

This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. Further studies that use standardised inclusion and exclusion criteria and investigate changes in naïve tissue at different stages of the condition are required.

Comparison for efficacy of general exercises with and without mobilization therapy for the management of adhesive capsulitis of shoulder - An interventional study

OBJECTIVE

The aim of this work was to evaluate the effectiveness of exercise with manual therapy and exercise alone in adhesive capsulitis of the shoulder.

METHOD

This randomized study was conducted at institute of physical medicine and rehabilitation Dow University of Health Sciences, Karachi between January, 2014 and July, 2014. Forty four participant age between 25-40 years were recruited. Twenty two participants were allocated to exercise and manual therapy group and 22 participants were allocated to exercise only group. Exercise and manual therapy group received general exercises and Maitland mobilization on shoulder joint whereas exercise group only received general exercises. Both interventions were carried out 3 times a week for 5 consecutive weeks. Pre and post intervention scores of Visual analogue scale (VAS), range of movement and Shoulder Pain and Disability Index (SPDI) were recorded. Paired sample t-test was used to analyze the results within groups.

RESULTS

After 5 weeks of intervention both groups made significant improvements in all outcome measures (p < 0.001). Intra group analysis showed no significant difference between two groups (p > 0.05). Mean VAS and SPADI difference was 2.23 and 22 in General exercise & manual therapy group and 2.33 and 23 in General exercise group respectively.

CONCLUSION

Both exercises with manual therapy and exercises alone are equally effective in the management of adhesive capsulits of the shoulder joint.

Arthroscopic capsular release and manipulation under anaesthesia for frozen shoulders: A hot topic

A frozen shoulder is a common cause of shoulder pain and stiffness. The etiology and pathology of frozen shoulders is not fully understood yet. Frozen shoulder is characterized by a decrease in intra-articular volume and capsular compliance. This can lead to significant limitations in daily life. The majority of the patients can be treated conservatively, with functional recovery to be expected in two to three years. However, if conservative treatment fails, manipulation under anaesthesia and arthroscopic capsular release can both be considered as appropriate treatments. Manipulation is a traditionally well-established technique but in recent years it seems that arthroscopic capsular release has gained popularity. Manipulation is a relative time efficient and technically low-demanding procedure in which the glenohumeral joint is forced into different directions under general anaesthesia to release the capsular contracture, thereby increasing the range of motion of the joint. In arthroscopic capsular release the glenohumeral capsule can be released in a more controlled manner under direct vision. There are no prospective comparative trials available to display superiority of one procedure over the other. In addition, the optimal timing of both these interventions still has to be determined. An overview of the literature concerning this topic and a description of both procedures with its own advantages and disadvantages is provided.

Neuroinflammatory Mechanisms of Connective Tissue Fibrosis: Targeting Neurogenic and Mast Cell Contributions

Significance: The pathogenesis of fibrogenic wound and connective tissue healing is complex and incompletely understood. Common observations across a vast array of human and animal models of fibroproliferative conditions suggest neuroinflammatory mechanisms are important upstream fibrogenic events. Recent Advances: As detailed in this review, mast cell hyperplasia is a common observation in fibrotic tissue. Recent investigations in human and preclinical models of hypertrophic wound healing and post-traumatic joint fibrosis provides evidence that fibrogenesis is governed by a maladaptive neuropeptide-mast cell-myofibroblast signaling pathway. Critical Issues: The blockade and manipulation of these factors is providing promising evidence that if timed correctly, the fibrogenic process can be appropriately regulated. Clinically, abnormal fibrogenic healing responses are not ubiquitous to all patients and the identification of those at-risk remains an area of priority. Future Directions: Ultimately, an integrated appreciation of the common pathobiology shared by many fibrogenic connective tissue conditions may provide a scientific framework to facilitate the development of novel antifibrotic prevention and treatment strategies.

Epidemiological profile of Dupuytren's disease in Taiwan (Ethnic Chinese): a nationwide population-based study

BACKGROUND

The epidemiologic profile of ethnic Chinese patients with Dupuytren's disease is unknown. We therefore investigated the epidemiology of Dupuytren's disease using Taiwan's National Health Insurance Research Database.

METHODS

Patients who filed claims for treatment for Dupuytren's disease between January 2000 and December 2011 were identified in the database. Age- and gender-specific incidences were estimated by dividing the incidence number by population data.

RESULTS

We identified 1,078 patients with Dupuytren's disease (681 men, 397 women; male/female ratio: 1:1.72). The annual incidence rate ranged from 0.39-0.63/10(5) for men and 0.14-0.44/10(5) for women. A trend analysis revealed a rising trend in the annual incidence from 2001 to 2011 (p = 0.0199). The prevalence rate increased steadily from 0.46/10(5) in 2000 to 4.52/10(5) in 2011 (p = 0.0186). The mean age at onset was significantly higher in men than in women (60.7 ± 18.4 vs. 53.7 ± 15.5 years). Peak age at onset for men was 70-79 (28.1%) and for women was 50-59 (33.5%). Men > 60 years old had higher incidence rates than did women (incidence rate ratios: 2.0, 4.5, and 6.6 for those 60-69, 70-79, and ≥ 80, respectively). Hypertension (29.6%), diabetes mellitus (21.9%), hyperlipidemia (14.8%), ischemic heart disease (10.5%), and chronic obstructive pulmonary disease (8.0%) were the most common comorbidities.

CONCLUSIONS

The incidence and prevalence of Dupuytren's disease and the male/female ratio were significantly lower in ethnic Chinese than in Western ethnic groups. Moreover, the age at onset was significantly lower in ethnic Chinese women. However, the incidences of three comorbidities (hypertension, diabetes mellitus, and hyperlipidemia) were similar to those in other ethnicities.

A review of the classification of Dupuytren's disease

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

Association between Propionibacterium acnes and frozen shoulder: a pilot study

BACKGROUND

Frozen shoulder has not previously been shown to be associated with infection. The present study set out to confirm the null hypothesis that there is no relationship between infection and frozen shoulder using two modern scientific methods, extended culture and polymerase chain reaction (PCR) for bacterial nucleic acids.

METHODS

A prospective cohort of 10 patients undergoing arthroscopic release for stage II idiopathic frozen shoulder had two biopsies of tissue taken from the affected shoulder joint capsule at the time of surgery, along with control biopsies of subdermal fat. The biopsies and controls were examined with extended culture and PCR for microbial nucleic acid.

RESULTS

Eight of the 10 patients had positive findings on extended culture in their shoulder capsule and, in six of these, Propionibacterium acnes was present.

CONCLUSIONS

The findings mean that we must reject the null hypothesis that there is no relationship between infection and frozen shoulder. More studies are urgently needed to confirm or refute these findings. If they are confirmed, this could potentially lead to new and effective treatments for this common, painful and disabling condition. Could P. acnes be the Helicobacter of frozen shoulder?

Frozen shoulder contracture syndrome - Aetiology, diagnosis and management

Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. Although function improves overtime, full and pain free range, may not be restored in everyone. Frozen shoulder is also known as adhesive capsulitis, however the evidence for capsular adhesions is refuted and arguably, this term should be abandoned. The aim of this Masterclass is to synthesise evidence to provide a framework for assessment and management for Frozen Shoulder. Although used in the treatment of this condition, manipulation under anaesthetic has been associated with joint damage and may be no more effective than physiotherapy. Capsular release is another surgical procedure that is supported by expert opinion and published case series, but currently high quality research is not available. Recommendations that supervised neglect is preferable to physiotherapy have been based on a quasi-experimental study associated with a high risk of bias. Physiotherapists in the United Kingdom have developed dedicated care pathways that provide; assessment, referral for imaging, education, health screening, ultrasound guided corticosteroid and hydro-distension injections, embedded within physiotherapy rehabilitation. The entire pathway is provided by physiotherapists and evidence exists to support each stage of the pathway. Substantial on-going research is required to better understand; epidemiology, patho-aetiology, assessment, best management, health economics, patient satisfaction and if possible prevention.

The association of metabolic syndrome markers with adhesive capsulitis

BACKGROUND

Research has associated adhesive capsulitis with diabetes mellitus but suggests that glucose-mediated injury may begin before diabetes is diagnosed. The period preceding diabetes is often marked by metabolic syndrome.

METHODS

We investigated the relationship between metabolic syndrome components (insulin resistance, hypertension, dyslipidemia, and obesity) and the development of adhesive capsulitis using a case-control study. We retrospectively reviewed 150 consecutive adhesive capsulitis patient charts to determine the prevalence of obesity and of medications used for treating metabolic syndrome elements and compared these with previously reported nationwide values.

RESULTS

The prevalence of anti-hyperglycemia medications in the adhesive capsulitis cohort was 18.4% (95% confidence interval [CI], 12.9%-25.7%), twice the national rate of diagnosed diabetes of 7.6% (95% CI, 6.7%-8.5%). In the 20- to 39-year-old group, the prevalence of anti-hyperglycemic medications, 26.3% (95% CI, 11.8%-48.8%), was over 10 times the nationwide rate. The overall prevalence of hypertensive medication use in the adhesive capsulitis group, 33.1% (95% CI, 25.9%-41.2%), was notably higher than the nationwide rate, 21.6% (95% CI, 19.8%-23.4%). In the 40- to 64-year-old group, the prevalence of hypertensive medication use, 36.8% (95% CI, 28.6%-46.0%), was notably higher than the nationwide rate of 24.5% (95% CI, 22.2%-27.0%). The prevalence of anti-lipid medications and obesity was similar between the groups.

CONCLUSIONS

The relationship between adhesive capsulitis and metabolic syndrome remains unclear. Our results confirm previous work associating hyperglycemia with adhesive capsulitis. We have also shown a possible association of hypertension, part of metabolic syndrome and a proinflammatory condition, with adhesive capsulitis, which has not been previously described.

High-dosage tamoxifen as neoadjuvant treatment in minimally invasive surgery for Dupuytren disease in patients with a strong predisposition toward fibrosis: a randomized controlled trial

BACKGROUND

Tamoxifen, a synthetic nonsteroidal anti-estrogen known to modulate the production of transforming growth factor-beta (TGF-β), has demonstrated effectiveness on fibroblast activity in vitro and in vivo. The main purpose of this study was to investigate the effect of tamoxifen on the outcome of surgery for Dupuytren contractures in patients with a strong predisposition toward fibrosis.

METHODS

We used a prospective, randomized, double-blind study protocol (conforming to the CONSORT standards) to investigate the influence of tamoxifen compared with placebo on the total passive extension deficit in the finger and patient satisfaction after subtotal fasciectomy in thirty patients with a strong predisposition toward fibrosis (grade, >4 according to the Abe scale). High-dosage tamoxifen (80 mg/day) was administered from six weeks prior until twelve weeks after surgery, and patients were monitored for two years.

RESULTS

Three months after surgery, patients in the tamoxifen group had a smaller total passive extension deficit and higher satisfaction compared with the placebo group. This positive effect was lost over the two years following cessation of the medication.

CONCLUSIONS

This study demonstrated that the short-term outcome of Dupuytren disease treatment could be influenced by use of tamoxifen as a neoadjuvant from six weeks prior to three months after subtotal fasciectomy in patients with a strong predisposition toward fibrosis. However, the beneficial effect disappeared within two years after surgery, with worsening of the contractures after the medication was discontinued. Thus, tamoxifen may have a short-term effect on the outcome of surgery for Dupuytren disease.

Hyperthyroidism is a risk factor for developing adhesive capsulitis of the shoulder: a nationwide longitudinal population-based study

The purpose of this study was to investigate the prevalence and risk of adhesive capsulitis among hyperthyroidism patients. The data were obtained from the Longitudinal Health Insurance Database 2005 (LHID 2005) in Taiwan, using 1 million participants and a prospective population-based 7-year cohort study of survival analysis. The ambulatory-care claim records of patients diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes relating to hyperthyroidism between January 1, 2004 and December 31, 2007, were obtained. The prevalence and the adjusted hazard ratio (HR) of adhesive capsulitis among hyperthyroid patients and the control group were estimated. Of 4472 hyperthyroid patients, 162 (671/100 000 person-years) experienced adhesive capsulitis during the 24 122 person-year follow-up period. The crude HR of stroke was 1.26 (95% confidence interval [CI], 1.06 to 1.49), which was larger than that of the control group. The adjusted HR of developing adhesive capsulitis was 1.22 (95% CI, 1.03 to 1.45) for hyperthyroid patients during the 7-year follow-up period, which achieved statistical significance. The results of our large-scale longitudinal population-based study indicated that hyperthyroidism is an independent risk factor of developing adhesive capsulitis.

Frozen shoulder and the Big Five personality traits

BACKGROUND

In the past, several studies have suggested the existence of a "periarthritic personality" in patients with frozen shoulder. We conducted a study to determine differences in personality traits in patients with primary and secondary frozen shoulders.

MATERIALS AND METHODS

We prospectively evaluated 118 patients (84 women and 34 men; mean age, 53.8 years; SD 7.56) with a frozen shoulder. Of these patients, 48 had an idiopathic frozen shoulder and 70 had a secondary frozen shoulder. Personality traits were determined by the NEO Five-Factor Inventory (NEO-FFI) scale. This questionnaire measures the 5 major personality traits and is based on the norms determined in a neutral test situation for 2415 controls.

RESULTS

Compared with healthy controls, no differences in personality traits were found in patients with primary and secondary frozen shoulder, except for Conscientiousness and Extraversion, for which patients with secondary frozen shoulder scored significantly higher than healthy controls. Patients with primary frozen shoulder scored significantly higher on Openness to Experience than did patients with secondary frozen shoulder; on the other 4 Big Five personality traits, no significant differences were found between patients with primary and secondary frozen shoulder. More specifically, patients with idiopathic frozen shoulder did not score higher on the trait Neuroticism as would be expected from previous publications.

CONCLUSIONS

Our study results do not indicate that patients with an idiopathic frozen shoulder have a specific personality compared with healthy controls. Only a few differences were found in personality traits when the entire frozen shoulder group was compared with healthy controls and between patients with primary and secondary frozen shoulders. The results of this study suggest that these differences are not sufficient to speak about a specific "frozen shoulder personality."

Case control study of risk factors for frozen shoulder in China

AIM

Frozen shoulder is a common self-limiting regional skeletal problem of unclear pathogenesis. It usually has an insidious onset and follows a protracted course. The aim of this study was to assess the prevalence and related risk factors for frozen shoulder in Shanghai, China.

METHODS

We performed a hospital-based case-control study involving 182 patients with pathologically diagnosed frozen shoulder and 196 patients hospitalized during the same time period with non-shoulder related complaints who were recruited as controls. Information on potential risk factors was collected on both case and control groups through questionnaires and face-to-face interview. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Among the frozen shoulder patients, 24.2% had diabetes and 16.5% had history of shoulder trauma. Multivariate analysis suggested that diabetes and history of slight trauma were independent risk factors for the disease. The frozen shoulder patients also had a higher prevalence of thyroid disease, increased body mass index and cervical spondylosis than the controls. The incidence of frozen shoulder was higher in female compared to male patients. No significant difference was found in occupations, physical exercise, cholecystitis, history of surgical and ischemic heart disease between the frozen shoulder group and the control group.

CONCLUSIONS

The findings in the present study indicate that diabetes, history of slight shoulder trauma, thyroid disease, increased body mass index and cervical spondylosis are factors significantly associated with increased frozen shoulder risk among individuals within the area of Shanghai, China.

Outcomes of total hip arthroplasty in human immunodeficiency virus-positive patients

Today, patients with human immunodeficiency virus (HIV) live long enough to develop chronic degenerative and HIV-associated joint disease. There is a growing population of patients infected with HIV who are candidates for total hip arthroplasty (THA). A total of 31 HIV-positive, non-hemophilic patients undergoing 41 THAs at our institution between 2000 and 2012 were identified. In-hospital medical complications were reported in 5 of 41 hips, all of which resolved prior to discharge. Deep infection developed in 1 of 41 hips and revision was required in 3 of 41 hips. These results suggest that low rates of complications and revision can be achieved in the HIV-positive, non-hemophilic population. We believe that with careful patient selection, THA may improve the quality of life in the HIV-positive population.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

The frozen shoulder: myths and realities

Frozen shoulder is a common, disabling but self-limiting condition, which typically presents in three stages and ends in resolution. Frozen shoulder is classified as primary (idiopathic) or secondary cases. The aetiology for primary frozen shoulder remains unknown. It is frequently associated with other systemic conditions, most commonly diabetes mellitus, or following periods of immobilisation e.g. stroke disease. Frozen shoulder is usually diagnosed clinically requiring little investigation. Management is controversial and depends on the phase of the condition. Non-operative treatment options for frozen shoulder include analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections. Operative options include manipulation under anaesthesia and arthroscopic release and are generally reserved for refractory cases.

Risk factors in idiopathic adhesive capsulitis: a case control study

BACKGROUND

The etiology of idiopathic adhesive capsulitis (IAC) of the shoulder is poorly understood. In this case control study, we examine potential risk factors for the development of IAC.

METHODS

Consecutive patients who presented to the senior author with IAC between 2000 and 2009 were included retrospectively in this case control study. Complete data were available for 87 patients. An age- and sex-matched group of 176 patients who presented to the same practice during the same time period with non-shoulder related orthopedic complaints were recruited as the control group. Health records and patient-completed questionnaires were utilized to identify comorbidities and other risk factors.

RESULTS

Bivariate analyses demonstrated that diabetes, hypothyroidism, a lower body weight, a lower body mass index (BMI), and a positive family history of IAC were all risk factors for IAC. Diabetes, BMI, and positive family history of IAC remained independent variables with multivariate logistic regression analyses. There was a trend towards increased incidence of Dupuytren's disease in those with IAC, but this was not statistically significant. With regard to racial predilection, being born in the British Isles or having parents/grandparents born in the British Isles were risk factors for IAC.

CONCLUSION

We confirm diabetes as an independent predictor of IAC. In addition, we identify a possible racial predilection for the development of IAC. Future research is needed to confirm whether a specific genetic component or environmental factors is responsible.

Direct and indirect costs associated with Dupuytren's contracture

OBJECTIVE

To compare direct (medical and drug) and indirect (work loss) costs between privately insured US employees with Dupuytren's contracture (DC) and demographically matched controls without DC.

METHODS

Employees aged 18-64 with ≥ 1 DC diagnosis (ICD-9-CM: 728.6, 718.44) with service dates 1/1/2000-3/31/2009 were selected from a de-identified, privately insured claims database (n∼3,000,000). The index date was defined as the most recent DC diagnosis with continuous eligibility for 6 months prior (baseline period) and 1 year after (study period) diagnosis. Employees with DC were matched 1:1 on age, region, gender, and index date to controls without DC, Peyronie's, or Ledderhose disease diagnoses in their claims histories. Descriptive analyses compared demographic characteristics, comorbidities, resource utilization, direct costs, and indirect costs inflated to 2009 dollars.

RESULTS

DC employees (n=1406, mean age 49 years) with matched controls met the inclusion criteria. DC employees compared with controls had significantly (all p<0.05) higher baseline comorbidities, including hyperlipidemia (21.1% vs 15.6%), hypothyroidism (3.5% vs 2.0%), cancer (3.1% vs 1.5%), and diabetes (8.1% vs 3.6%). During the study period, DC employees had significantly (all p<0.01) higher rates of inpatient stays (7.7% vs 5.3%), emergency department visits (19.8% vs 13.9%), outpatient visits (100.0% vs 78.4%), physical therapy visits (30.2% vs 7.2%), and any prescription use (85.0% vs 69.2%), as well as higher mean work loss days (14.2 vs 7.3). DC employees had on average significantly (all p<0.01) higher annual direct costs ($5974 vs $3175), indirect costs ($2737 vs $1309), and total costs ($8712 vs $4485) compared with controls during the study period.

LIMITATIONS

Findings did not account for lost productivity at work and were based on a privately insured, employed population, which may not be generalizable to all DC patients.

CONCLUSIONS

Employees with DC had substantially higher comorbidity rates, utilization, and direct and indirect costs compared with demographically matched controls.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases

INTRODUCTION

Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined.

PATIENTS AND METHODS

This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements).

RESULTS

Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05).

DISCUSSION

The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.

Adhesive capsulitis: a review of current treatment

Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule. Variable nomenclature, inconsistent reporting of disease staging, and a multitude of different treatments have created a confusing and contradictory body of literature about this condition. Our purpose is to review the evidence for both nonsurgical and surgical management of adhesive capsulitis with an emphasis on level I and II studies when available. Significant deficits in the literature include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course. Recognition that the clinical stages reflect a progression in the underlying pathological changes should guide future treatments.

Molecular mechanisms and treatment strategies for Dupuytren's disease

Dupuytren’s disease (DD) is a common disease of the hand and is characterized by thickening of the palmar fascia and formation of tight collagenous disease cords. At present, the disease is incurable and the molecular pathophysiology of DD is unknown. Surgery remains the most commonly used treatment for DD, but this requires extensive postoperative therapy and is associated with high rates of recurrence. Over the past decades, more indepth exploration of the molecular basis of DD has raised the hopes of developing new treatment modalities. This paper reviews the clinical presentation and molecular pathophysiology of this disease, as well as current and emerging treatment. It also explores the implications of new findings in the laboratory for future treatment.

Arthroscopic capsular release for refractory shoulder stiffness: a critical analysis of effectiveness in specific etiologies

HYPOTHESIS

The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology.

MATERIALS AND METHODS

A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months).

RESULTS

At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively).

CONCLUSIONS

Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis

Patients with adhesive capsulitis were clinically evaluated to establish whether pain elicited by pressure on the coracoid area may be considered a pathognomonic sign of this condition. The study group included 85 patients with primary adhesive capsulitis, 465 with rotator cuff tear, 48 with calcifying tendonitis, 16 with glenohumeral arthritis, 66 with acromioclavicular arthropathy and 150 asymptomatic subjects. The test was considered positive when pain on the coracoid region was more severe than 3 points (VAS scale) with respect to the acromioclavicular joint and the anterolateral subacromial area. The test was positive in 96.4% of patients with adhesive capsulitis and in 11.1%, 14.5%, 6.2% and 10.6% of patients with the other four conditions, respectively. A positive result was obtained in 3/150 normal subjects (2%). With respect to the other four diseases, the test had a sensitivity of 0.96 and a specificity ranging from 0.87 to 0.89. With respect to controls, the sensitivity and specificity were 0.99 and 0.98, respectively. The coracoid pain test could be considered as a pathognomonic sign in physical examination of patients with stiff and painful shoulder.

Expression of matrix metalloproteinases and their inhibitors in cords and nodules of patients with Dupuytren's disease

INTRODUCTION

Dupuytren's disease is a fibroproliferative disorder characterized by thickening of the palmar fascia. Several studies indicate that MMPs and TIMPs may play a key role in the onset or progression of Dupuytren's disease and related disorders. In this study, we used a quantitative reverse-transcription PCR methodology to profile the expression of TIMP1, TIMP2, MMP2, and MMP9 in nodule and cord tissue from patients with Dupuytren's disease and compared this with normal palmar fascia taken at carpal tunnel release.

MATERIALS AND METHODS

Tissue from patients with Dupuytren's disease was taken at fasciectomy (n = 30; 23 men and 7 women; average age 61.3 +/- 9.5 years). Samples were divided into regions of nodule and cord according to gross morphology. Normal fascia was taken from patients without Dupuytren's contracture who had carpal tunnel release (n = 30; 14 men and 16 women; average age 63 +/- 11 years). Expression of mRNA was calculated using a relative quantification method (Pfaffl). Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be P < 0.05.

RESULTS

In comparison to normal fascia, the cords and nodules from patients with Dupuytren's disease showed significant upregulation for TIMP1 and TIMP2 (P < 0.05). The expression of TIMP1 was significantly higher in nodules in comparison to cord tissue (P < 0.05). The expression of MMP2 was significantly upregulated in tissue of patients with Dupuytren's contracture in comparison to normal tissue (P < 0.05). The expression of MMP2 was significantly higher in nodules in comparison to cord tissue (P < 0.05). There was no significant difference in the relative expression of MMP9 in nodules and cord tissue of patients with Dupuytren's contracture in comparison to normal fascia from patients with carpal tunnel syndrome.

CONCLUSIONS

The balance between MMPs and their natural inhibitors is disturbed in patients with Dupuytren's disease. The decrease in MMP-to-TIMP expression can cause increased synthesis and deposition of collagen, leading to palmar fibromatosis. The high expression of MMP2 may represent an unsuccessful attempt to reduce collagen deposition. In the future, a treatment that downregulates TIMPs but increases the activity of MMPs may be an appropriate therapy for Dupuytren's disease.

Epidemiological evaluation of Dupuytren's disease incidence and prevalence rates in relation to etiology

Dupuytren's Disease (DD) is a common, fibroproliferative disorder affecting the palmar surface of the hands which is often irreversible and progressive. Understanding the epidemiology of DD is important in order to provide clues to its etiopathogenesis. This review aims to evaluate the epidemiological studies carried out in DD since 1951. Studies evaluating the epidemiology of DD were searched using Medline, Pubmed, and Scopus which dated back from 1951 to current date. Inclusion criteria were any studies investigating the prevalence or incidence of DD in any population group. A total of 620 articles were cited. Forty-nine studies were subsequently identified as relevant to evaluating the epidemiology of DD. The prevalence of DD in all studies increased with age with a male to female ratio of approximately 5.9:1. Prevalence rates ranged from 0.2% to 56% in varying age, population groups, and methods of data collection. The highest prevalence rate was reported in a study group of epileptic patients. Although, only one study calculated the incidence (as opposed to prevalence) of DD to be equal to 34.3 per 100,000 men (0.03%). In conclusion, the prevalence of DD in different geographical locations is extremely variable, and it is not clear whether this is genetic, environmental, or a combination of both. The majority of the prevalence studies have been conducted in Scandinavia or the UK, and the vast changes in population structure, the changes in prevalence of associated diseases, and the change in diagnostic criteria of DD makes understanding the epidemiology of this condition difficult.

[Frozen shoulder. Diagnosis and therapy]

The condition of shoulder stiffness is often called adhesive capsulitis or frozen shoulder. It is regarded as a distinct clinical entity showing a benign and regular course. The major clinical feature is significant reduction in both active and passive range of motion (ROM) accompanied by stage-dependent pain, allowing for a clinical diagnosis. There are primary and secondary forms, the former having an unknown etiology and increased occurrence in patients with metabolic disorders and the latter being seen with prior injury or operation. Three stages, each lasting 4-6 months, mark the clinical course. The progression of the disease is self-limiting and may occasionally resolve in partial restitution. In the first stage ("freezing"), the shoulder continuously loses passive motion and causes worsening pain. Continuing stiffness and improvements in pain and inflammation are characteristic of the second stage ("frozen"). In the third stage ("thawing"), restriction of shoulder motion decreases, and ROM increases. Treatment should be adjusted to these stages. Recommendations include analgesics and joint injections in the first stage and physiotherapy in combination with manual therapy in the second and third stages. In cases of failure, passive exercise under interscalene block, manipulation under general anesthesia, or arthroscopic arthrolysis should be considered.

Revised Tubiana's staging system for assessment of disease severity in Dupuytren's disease-preliminary clinical findings

There are few objective staging systems to assess severity of Dupuytren's disease (DD). Previous methods to assess severity of DD were based primarily on the degree of contracture of an affected digit measured using a goniometer. Nonetheless, this method of assessment alone may be incomplete, and other factors should be considered. White (n = 92) patients diagnosed with DD from northwest of England were assessed for DD. Objective criteria for evaluating severity incorporated quantified variables. The revised severity stage was correlated to a known staging system of DD (Tubiana's staging system) which measures total flexion deformity for a single affected digit. Total revised severity staging scores ranged between 4 and 53 (mean = 18.7) and revealed significant positive correlation to Tubiana's original staging system (r (2) = 0.8, p < 0.001). There was significant difference between severity staging scores in those with a positive family history compared to those without (p < 0.01). In current practice, often, the degree of contracture in an affected digit is used solely as a measure of disease severity. Additional objective clinical information may provide useful prognostic indices for disease progression as well as postoperative outcome.

Long-term outcome of frozen shoulder

Two-hundred and sixty-nine shoulders in 223 patients with a diagnosis of primary frozen shoulder were studied. The main outcome measure was the Oxford shoulder score. The mean follow-up from symptom onset was 4.4 years (range, 2-20 years). The mean age at symptom onset was 53.4 years; with women affected more commonly than men (1.6:1.0). Twenty percent of patients reported bilateral symptoms, but there were no recurrent cases. In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. The majority of these persistent symptoms were mild (94%), with pain being the most common complaint. Only 6% had severe symptoms with pain and functional loss. Those with the most severe symptoms at condition onset had the worst long-term prognosis, P < .001.

A complete expression profile of matrix-degrading metalloproteinases in Dupuytren's disease

PURPOSE

Dupuytren's disease (DD) is a common fibrotic condition of the palmar fascia, leading to deposition of collagen-rich cords and finger contractions. The metzincin superfamily contains key enzymes in the turnover of collagen and other extracellular matrix macromolecules. A number of broad-spectrum matrix metalloproteinase inhibitors, used in cancer clinical trials, caused side effects of DD-like contractures. We tested the hypothesis that changes in the expression of specific metalloproteinases underlie or contribute to the fibrosis and contracture seen in DD.

METHODS

We collected tissue from patients with DD and used normal palmar fascia as a control. We profiled the expression of the entire matrix metalloproteinase (MMP), tissue inhibitor of metalloproteinases (TIMP), and a disintegrin and metalloproteinase domain with thrombospondin motif (ADAMTS) gene families in these tissues using real-time reverse-transcription polymerase chain reaction.

RESULTS

A number of metalloproteinases and inhibitors are regulated in DD. The expression of 3 key collagenases, MMP1, MMP13, and MMP14 is increased significantly in the DD nodule, as is the expression of the collagen biosynthetic enzyme ADAMTS14. The expression of MMP7, an enzyme with broad substrate specificity, is increased in the DD nodule and remains equally expressed in the DD cord. TIMP1 expression is increased significantly in DD nodule compared with normal palmar fascia.

CONCLUSIONS

This study measured the expression of all MMP, ADAMTS, and TIMP genes in DD. Contraction and fibrosis may result from: (1) increased collagen biosynthesis mediated by increased ADAMTS-14; (2) an increased level of TIMP-1 blocking MMP-1- and MMP-13-mediated collagenolysis; and (3) contraction enabled by MMP-14-mediated pericellular collagenolysis (and potentially MMP-7), which may escape inhibition by TIMP-1. The complete expression profile will provide a knowledge-based approach to novel therapeutics targeting these genes.

Dupuytren's diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence

PURPOSE

The term diathesis relates to certain features of Dupuytren's disease (DD) and dictates an aggressive course of disease. The initial description of DD diathesis included 4 factors: (1) ethnicity, (2) family history, (3) bilateral DD, and (4) ectopic lesions (DD outside the palm). The degree of diathesis is considered important in predicting recurrence and extension of DD after surgical management. Prognostic indicators of risks associated with surgery are important. We aimed to evaluate these 4 factors and known associated risk factors to formulate a statistical predictive value for DD diathesis.

METHODS

Caucasian patients diagnosed with DD between the ages of 25 and 90 years (n = 322) from Northwest England were assessed for DD diathesis with a clinical history and examination. DD diathesis assessment was analyzed by calculating the odds ratios of developing recurrent DD using logistic regression.

RESULTS

The observed recurrence rates in the presence of notable risk factors and corresponding odds ratios of recurrent DD were calculated. Of note, recurrent disease was observed in 121 (46%) males, 105 (47%) with bilateral DD, 68 (48%) with a family history of DD, 75 (47%) with age at onset younger than 50 years, 35 (52%) in those with ectopic lesions, and in 26 (63%) with Garrod's pads.

CONCLUSIONS

The original DD diathesis factors have been evaluated and modified. The original factors of family history, bilateral DD, and ectopic lesions now include 2 additional factors: male gender and age at onset of younger than 50 years. Family history and ectopic disease have now been modified to specify family history with one or more affected siblings/parents and ectopic lesions in the knuckles (Garrod's pads) alone. The presence of all new DD diathesis factors in a patient increases the risk of recurrent DD by 71% compared with a baseline risk of 23% in those DD patients with none of the earlier-described factors.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Beta-catenin signaling in fibroproliferative disease

BACKGROUND

Beta-catenin has been historically recognized as both an intermediate in the "canonical Wnt signaling pathway" and as a component of functional adherens junctions.

MATERIALS AND METHODS

Cellular accumulation of beta-catenin levels can result in transactivation of gene transcription and cellular proliferation during normal cellular and disease development. Recent evidence has identified beta-catenin in an additional role as a component of cutaneous wound healing.

RESULTS

This finding is in keeping with previous observations that post-translational modifications of beta-catenin that are associated with its cytoplasmic accumulation are frequently observed in fibroproliferative diseases with characteristics of dysregulated wound healing. These diseases include hypertrophic scar formation, aggressive fibromatoses, Lederhose disease, and Dupuytren's contracture (DC).

CONCLUSIONS

While its precise roles in disease initiation and progression remain to be explored, this review highlights our current knowledge of beta-catenin regulation and describes some potential upstream mediators of beta-catenin accumulation and signaling in fibroproliferative disease.

Upper extremity: emphasis on frozen shoulder

Adhesive capsulitis, or frozen shoulder syndrome, is a condition characterized by gradual loss of active and passive glenohumeral motion. The etiology of adhesive capsulitis is unknown. Treatment methods include supervised benign neglect, physical therapy, intra-articular corticosteroid injections, closed manipulation under anesthesia, arthroscopic capsular release, and open surgical release. Approximately 70% of patients presenting with adhesive capsulitis are women; however, the role of sex in the etiology, development, and outcome of treatment for adhesive capsulitis remains unclear. Individualized treatment is necessary following thorough evaluation of patient symptoms and stage of the disease.

Adhesive capsulitis of the shoulder: the rate of manipulation following distension arthrogram

To determine the rate of manipulation under anaesthesia (MUA) following distension arthrogram for adhesive capsulitis of the shoulder. Thirty-nine patients (42 shoulders) between 1998 and 2004 were treated with distension arthrogram for adhesive capsulitis diagnosed by the clinical picture of progressive pain and stiffness. Capsular disruption into the subscapular bursa was demonstrated in 40 of the 42 shoulders (95%). Thirty-seven of 42 (88%) shoulders were painfree following distension arthrogram. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram for stiffness although 10 of these (67%) were painfree. Prior to distension arthrogram, the range of external rotation (ER) was no different between those that had MUA and those that did not (P = 0.36). The improvement in ER was 33% (P = 0.28) in those that had MUA and 50% (P = 0.001) in those that did not. The only complication was a vasovagal episode during the procedure. Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the majority of adhesive capsulitis and decrease the rate of MUA of the shoulder.

The heritability of Dupuytren's disease: familial aggregation and its clinical significance

PURPOSE

Dupuytren's disease (DD) is a benign, fibroproliferative disease affecting the hands. The familial occurrence of DD and its presence in identical twins suggests a genetic basis for the condition. Our aims in this study were (1) to provide evidence for familial aggregation of DD by estimating the sibling recurrence-risk ratio and (2) to link previously associated environmental risk factors with family history of DD.

METHODS

Patients diagnosed with DD between the ages of 58 and 81 years (N = 92) were interviewed to assess potential risks and the severity of their conditions. A clinical history and examination were performed and we attempted to interview every family member either in person or through a postal questionnaire.

RESULTS

The sibling recurrence-risk ratio (lambda(s)) equaled 2.9 and ranged from 2.6 to 3.3 based on the 95% confidence intervals for the population prevalence. This suggests a high genetic basis for the causation of DD. A lower age of onset and greater severity of DD were associated significantly with a positive family history of DD. Other factors showed no statistical significance with familial aggregation of DD.

CONCLUSIONS

The familial clustering observed in DD likely is due to genetic influence rather than shared environment, as shown by the lack of association with exposure to environmental risk factors and family history. Understanding the genetic basis of DD is important for developing novel diagnostic, preventative, and therapeutic regimens in the future.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level II.

Frozen shoulder

Frozen shoulder is a painful, often prolonged, condition that requires careful clinical diagnosis and management. Patients usually recover, but they may never regain their full range of movement.