Clinics in Shoulder and Elbow最新文献

Background: Concomitant repair of the subscapularis (SSC) tendon in reverse total shoulder arthroplasty (RTSA) with a lateralized design remains controversial. The present study aimed to evaluate the effect of SSC repair (repair at native insertion, repair at superiorly migrated position, and no repair) on the glenohumeral arc of motion following RTSA in a cadaveric biomechanical setting.

Methods: RTSA was performed on eight cadaveric shoulders under six testing conditions as follows: unrepaired SSC/intact teres minor (TM); intact SSC/intact TM; superiorly repaired SSC/intact TM; unrepaired SSC/deficient TM; intact SSC/deficient TM; and superiorly repaired SSC/deficient TM. Increasing load (2.5-N increments) was applied to the middle deltoid (anterior, posterior; 10 N each, middle; 10-20 N). The resulting abduction and rotation positions were measured.

Results: Unrepaired SSC demonstrated greater abduction and reduced internal rotation (IR), whereas SSC repair increased IR, particularly in TM-deficient models. Superiorly repaired SSC had higher glenohumeral abduction and IR than original SSC repair. SSC repair caused excessive IR in the TM deficiency seen with massive rotator cuff tears.

Conclusion: Concomitant SSC repair in lateralized RTSA decreased glenohumeral abduction and increased IR. Concomitant SSC repair at the original and superiorly migrated footprints should be carefully considered following lateralized RTSA. Level of evidence: V.

Dynamic anterior stabilization (DAS) using the long head of the biceps tendon (LHB) is an arthroscopic option for recurrent anterior shoulder instability, especially with subcritical glenoid bone loss. This narrative review synthesizes biomechanical, technical, and clinical literature from PubMed, Embase, and Cochrane (2014-2025). LHB-based DAS augments an arthroscopic Bankart repair by transferring the patient's LHB to the anterior glenoid, creating a dynamic "hammock-sling-bumper" effect that resists anterior translation in vulnerable positions. Contemporary techniques use minimally morbid arthroscopy with onlay or inlay fixation. Clinical series report low recurrence (0%-13%) at 1-5 years. Functional outcomes improve substantially: Rowe scores typically rise from ~21-36 preoperatively to ~90-95 postoperatively, American Shoulder and Elbow Surgeons scores exceed 90, and WOSI improves by roughly 959 points. Return-to-sport rates reach 85%-95%, with range of motion generally comparable to standard Bankart repairs. In patients with subcritical bone loss (~10%-20% of glenoid width), DAS appears to enhance stability versus isolated soft-tissue repair while avoiding the complication profile of bone-block procedures (e.g., Latarjet). Suggested indications include recurrent instability with subcritical bone loss, failed prior soft-tissue repair, young high-demand athletes, and concomitant SLAP lesions. Contraindications and optimal thresholds for bone loss require clarification. Evidence remains limited by nonrandomized designs and short follow-up. Long-term outcomes beyond five years and high-quality comparative or randomized trials are needed to define durability, refine indications, and position LHB-based DAS within the broader algorithm for anterior shoulder instability management.

Background: Existing research on the influence of symptom duration on the outcomes of ultrasound-guided shoulder hydrodilatation for frozen shoulder remains limited. This prospective analytical study aims to investigate the associations between symptom duration and other potential factors and shoulder function following ultrasound-guided shoulder hydrodilatation.

Methods: This study was conducted at the Department of Rehabilitation Medicine, Tertiary Hospital, and involved patients with frozen shoulder who underwent ultrasound-guided shoulder hydrodilatation. Using convenience sampling, 72 participants were recruited, and 36 were classified into the early hydrodilatation group and 36 into the late hydrodilatation group. Outcome measures were the Oxford Shoulder Score (OSS), visual analog scale (VAS), and shoulder range of motion (ROM), which were assessed both before and 6 weeks after the hydrodilatation procedure.

Results: Duration of symptoms, age, sex, history of diabetes mellitus, physiotherapy, and baseline shoulder ROM did not exhibit any association with OSS changes. However, a high VAS score at baseline was associated significantly with improved shoulder function following ultrasound-guided shoulder hydrodilatation (P=0.004).

Conclusions: There was no association between the duration of symptoms and enhanced shoulder function after ultrasound-guided shoulder hydrodilatation in short-term assessments. Patients with higher baseline shoulder pain severity tended to experience greater improvements in shoulder function compared to those with milder pain levels. Level of evidence: III.

Background: This study evaluates the biomechanical effects of acellular dermal matrix (ADM) patch augmentation in a rotator cuff repair model and determines the effect of medial knot tying on time-zero stability.

Methods: A biomechanical study was conducted using a porcine flexor digitorum profundus tendon model. Eighteen specimens were assigned to three groups: non-patched repair with medial row knot tying (n=5), patch-augmented repair without medial row knot tying (n=4), and patch-augmented repair with medial row knot tying (n=4). All repairs were performed using a standardized double-row suture bridge technique. Biomechanical testing assessed elongation, strain, load to failure, and construct stiffness at time zero.

Results: Patch augmentation without medial row knot tying resulted in significantly greater tendon elongation (12.9±6.5 mm) than nonpatched repairs (5.0±5.3 mm, P=0.016) and patch-augmented repairs with medial row knot tying (4.4±4.4 mm, P=0.027). Similarly, strain was significantly higher in the patch-augmented group without medial knot tying (75.8%±42.9%) than in the non-patched repair (35.2%±38.9%, P=0.028) and patch-augmented repair with medial knot tying groups (29.1%±28.9%, P=0.052). However, load to failure did not differ significantly among the groups (P>0.05).

Conclusions: ADM patch augmentation did not enhance time-zero mechanical strength in the tested conditions, though biomechanical advantages might emerge after integration to the tendon. In addition, patch augmentation without medial row knot tying showed the highest elongation and strain among groups, potentially reducing the stability of the repair. Level of evidence: V, controlled laboratory study.

Background: Acromioplasty is frequently performed during arthroscopic rotator cuff repair (ARCR) to address subacromial impingement, though its clinical value remains debated. This meta-analysis examines whether acromioplasty improves functional outcomes, pain relief, or re-tear rates in patients undergoing ARCR for full-thickness rotator cuff tears.

Methods: A systematic search of PubMed, Embase, Cochrane Library, and Scopus was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify randomized controlled trials (RCTs) from 2011 to 2023. Six RCTs comparing ARCR with and without acromioplasty were included. Primary outcomes included functional scores of American Shoulder and Elbow Surgeons (ASES), Western Ontario Rotator Cuff Index, University of California, Los Angeles scores, pain levels (visual analog scale [VAS]), and re-tear rates. Data were pooled using a random-effects model. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results: Across 574 patients, both groups demonstrated improvement in functional outcomes. The acromioplasty group showed a modest advantage (e.g., ASES score: mean difference, 2.93), but these gains did not exceed the minimal clinically important difference. There were no significant differences in pain relief (as measured by VAS) or re-tear rates between groups. The risk of bias was moderate in some trials due to a lack of blinding. GRADE assessment rated evidence as high for ASES scores and moderate for other outcomes.

Conclusions: Acromioplasty offers statistically modest improvements in shoulder function but does not meaningfully enhance pain relief or reduce re-tear rates. Given these findings, the routine use of acromioplasty in ARCR is not supported; however, select patients may benefit based on individual anatomical or clinical factors. Level of evidence: I.

Background: The role of manipulation under anesthesia (MUA) without arthroscopic capsular release in patients with preoperative stiffness undergoing arthroscopic rotator cuff repair (ARCR) remains unclear. Additionally, the association between shoulder stiffness and tendon healing after ARCR is still controversial. This study aimed to compare the clinical outcomes and retear rates between patients with preoperative stiffness treated by MUA alone and those without stiffness.

Methods: This retrospective study included 322 patients who underwent ARCR for full-thickness tears between January 2012 and May 2022 with a minimum 2 years of follow-up. Clinical outcomes-including passive range of motion (ROM); the Japanese Orthopedic Association (JOA) score; and the University of California, Los Angeles (UCLA) score-were assessed preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients were divided into the stiffness group (MUA completed) and the non-stiffness group. Retears were evaluated using magnetic resonance imaging at 6 months postoperatively, and retear rates were analyzed by tear size (medium vs. large/massive).

Results: Eighty-eight patients with stiffness and 234 without stiffness met the study inclusion criteria. Preoperative ROM, JOA, and UCLA scores were significantly lower in the stiffness group. Both groups showed significant improvements at final follow-up, with greater gains in the stiffness group. Final outcomes were comparable, except for external rotation. In medium-sized tears, the retear rate was significantly lower in the stiffness group (1.9%) than in the non-stiffness group (10.8%) (P=0.042). No significant difference was observed for large/massive tears.

Conclusions: Patients with preoperative stiffness treated with MUA alone achieved comparable outcomes to those without stiffness, with improved tendon healing in medium-sized tears. Level of evidence: III.

In large posterosuperior rotator cuff tears, retear is more likely due to factors such as poor tendon quality, tendon loss, incomplete footprint coverage, and incomplete repair. To reduce the retear rate and promote healing, various strategies have been explored, including augmentation using a human acellular dermal matrix (HADM) allograft patch. However, the traditional patch augmentation with a suture-bridge configuration is complicated and time consuming. Another method to alleviate impingement between the repaired tendon and acromion, similar to the ballooning effect in the subacromial space, is the acromiograft technique. However, a thin acromion may lead to fractures, and such a graft is less likely to incorporate with the repaired tendon. To address these concerns, we developed a new technique that enhances healing through direct contact with the repaired tendon, alleviates impingement with a spacer effect, and simplifies the procedure while ensuring adequate medial coverage including the musculotendinous junction. This article describes our "patch cushioning technique" using an HADM allograft. The present report provides a purely technical description of the procedure.

Background: Cubital tunnel release (CuTR) relieves ulnar nerve compression; however, about 35% of patients who undergo this procedure develop persistent neuropathy and about 7% require revision. Type 2 diabetes mellitus (T2DM) worsens ulnar neuropathy, whereas glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may be neuroprotective. We compared short- (90-day) and mid-term (2-year) CuTR outcomes in diabetic patients who did or did not receive perioperative GLP-1 RA treatment.

Methods: TriNetX identified adults (≥18 years) with T2DM who underwent primary CuTR during the period 2015-2023, and who underwent at least 2 years of follow-up. The experimental cohort had received an active GLP-1 RA prescription at surgery, while the controls had not. Exclusion criteria were T1DM, pancreatitis, multiple endocrine neoplasia 2, systemic steroids, end-stage renal disease, or prior major CuTR. Propensity-score matching (1:1) balanced demographics, body mass index, glycated hemoglobin (HbA1c), creatinine, and comorbidities. Outcomes were captured using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) codes.

Results: After matching, 1,766 pairs of patients (mean age, 58 years; 46% female) were analyzed. At 90 days, fewer GLP-1 RA users had emergency-department visits than non-users (8.9% vs. 10.7%, P=0.048). Despite higher HbA1c at each timepoint, GLP-1 RA users showed a larger decline. At 2 years, GLP-1 RA exposure was associated with fewer reoperations (5.2% vs. 6.9%, P=0.028), less frequent neuropathy (23.4% vs. 30.4%, P<0.001), and fewer inpatient admissions (14.6% vs. 17.2%, P=0.030). Major medical complications did not differ in occurrence between the groups.

Conclusions: Perioperative GLP-1 RA therapy in diabetic patients undergoing CuTR correlated with fewer 90-day emergency visits and lower 2-year risks of revisional surgery and ICD-coded ulnar neuropathy (all-cause, non-adjudicated).. These findings support a potential protective role of GLP-1 RAs in this surgical population. Evidence: III.

Background: This systematic review and meta-analysis aimed to assess the efficacy of prolotherapy compared to control or placebo-based treatments.

Methods: A comprehensive search of PubMed, Ovid, and Scopus was conducted up to April 2025. Inclusion criteria encompassed clinical studies comparing prolotherapy with control or placebo treatments and evaluating outcomes such as pain, function, and range of motion.

Results: Eight studies involving 431 participants met the inclusion criteria. Patient-reported outcomes, including pain visual analog scale and Shoulder Pain and Disability Index, showed no statistically significant differences between prolotherapy and controls. Prolotherapy demonstrated a small but statistically significant improvement in shoulder abduction (mean difference, 7.08°; 95% CI, 2.49°-11.66°). Other range of motion measures, such as forward flexion, internal rotation, and external rotation, showed no significant differences. Radiographic outcomes, including tendon thickness and elasticity, suggested potential structural benefits but did not consistently translate to clinical improvements.

Conclusions: Prolotherapy is not superior to control treatments for rotator cuff tendinopathy. While it offers minor gains in shoulder abduction, its clinical benefits are limited. Level of evidence: III.