Clinics in Shoulder and Elbow最新文献

Background: The posterior interosseous nerve (PIN) is at risk of iatrogenic nerve injury during elbow surgery when using a lateral or posterolateral approach. Results of cadaveric studies indicated that maintaining forearm pronation throughout the surgery can help move the PIN away from the surgical window. However, in vivo dynamic migration of the PIN in response to changes in the elbow and forearm position is unclear. This study aimed to clarify the in vivo dynamic migration pattern of the PIN in response to changes in the elbow and forearm position using ultrasound imaging.

Methods: This study included 43 upper extremities of 22 healthy volunteers (16 females; mean age, 29 years). Using ultrasound imaging, we measured the shortest distance from the radial head (RH) to the point where the PIN crossed the lateral aspect of the radial axis in six positions of the elbow and forearm: 90° forearm supination, 90° pronation, and neutral forearm position, each at 135° of elbow flexion and 0° of elbow extension.

Results: The RH-to-nerve distance was greater during elbow extension than during elbow flexion regardless of the forearm position. However, the maximum migration distance was 3.5 mm when transitioning from elbow extension and forearm pronation (25.1 mm) to elbow flexion and forearm supination (21.6 mm).

Conclusions: Although forearm pronation may help move the PIN away from the surgical window, care should be taken not to injure the nerve when performing elbow surgery using a lateral or posterolateral approach. Level of evidence: Level III.

We present two cases of symptomatic chronic long head of the biceps tendon (LHBT) ruptures treated with reconstruction of the tendon with an allograft due to native tendon shortening in one case and complete native tendon loss in the other. A gracilis allograft was Pulver-Taft weaved through the biceps muscle belly to reconstruct the LHBT and provide sufficient working length to perform a subpectoral tenodesis. In cases of chronic, symptomatic LHBT rupture with a shortened or absent tendon, a gracilis allograft can be used to reconstruct the biceps tendon and to perform a subpectoral tenodesis, providing symptom relief and reversing a Popeye muscle.

Background: Total shoulder arthroplasty (TSA) in patients with rheumatoid arthritis (RA) can present unique challenges. The aim of this study was to compare both systemic and joint-related postoperative complications in patients undergoing primary TSA with RA versus those with primary osteoarthritis (OA).

Methods: Using the TriNetX database, Current Procedural Terminology and International Classification of Diseases, 10th edition codes were used to identify patients who underwent primary TSA. Patients were categorized into two cohorts: RA and OA. After 1:1 propensity score matching, postoperative systemic complications within 90 days following primary TSA and joint-related complications within 5 years following anatomic TSA (aTSA) and reverse shoulder arthroplasty (RSA) were compared.

Results: After propensity score matching, the RA and OA cohorts each consisted of 8,523 patients. Within 90 days postoperation, RA patients had a significantly higher risk of total complications, deep surgical site infection, wound dehiscence, pneumonia, myocardial infarction, acute renal failure, urinary tract infection, mortality, and readmission compared to the OA cohort. RA patients had a significantly greater risk of periprosthetic joint infection and prosthetic dislocation within 5 years following aTSA and RSA, and a greater risk of scapular fractures following RSA. Among RA patients, RSA had a significantly higher risk of prosthetic dislocation, scapular fractures, and revision compared to aTSA.

Conclusions: Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. Knowledge of the risk profile of RA patients undergoing TSA is essential for appropriate patient counseling and education. Level of evidence: III.

Biconcave (B2) glenoids, characterized by significant posterior glenoid bone loss and a biconcave wear pattern, are a challenging pathology in shoulder surgery. Significant bone defects present in B2 glenoids increases the risk of complications and rates of failure for operative patients with glenohumeral osteoarthritis. Diagnosing this entity is of pivotal importance, and can be accomplished with imaging and a comprehensive clinical investigation. There are no clear-cut guidelines for management, but options include hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty. In recent years, modern techniques such as corrective reaming, bone grafts, and the use of augmented components have improved patient outcomes. Educating prospective patients is essential for reaching a shared management decision, setting appropriate expectations, and optimizing prognostic outcomes.

Background: This study aimed to evaluate the changing experiences of shoulder surgeons working in a district general hospital.

Methods: A consecutive series of 395 shoulders (225 male, 170 female) over a 19-year period (2000-2019) with a minimum follow-up of 2 years were analyzed. Outcome measures were length of stay, operating time, satisfaction visual analog score (VAS), pain VAS, Oxford Shoulder Score (OSS), Constant-Murley score, range of movement, complications, and implant survival.

Results: The incidence of a diagnosis of osteoarthritis as the surgical indication increased over time. The number of cases by surgeon per year increased from three cases in 2,000 to a peak of 33 in 2011. Up to seven implant manufacturers were used. The incidence of hemiarthroplasties decreased, and more numerous reverse polarity and anatomic arthroplasties were performed (P<0.001). More glenoid and humeral components were cemented and more short-stem implants were used in later years (P<0.001). Length of stay was a median of 1 day with a trend towards daytime surgery in recent years. Patients were satisfied (VAS 8/10) and OSS improved by 8 points on average throughout the observation period.

Conclusions: Despite frequent introductions of new implants, patient outcome, satisfaction, and complication rates remained good. There appears to be a need for large-scale, generalizable studies to understand why technological advancements leading to changes in implants do not influence clinical outcomes. Level of evidence: III.

Background: This study aims to investigate the trend of doctor shopping among patients with rotator cuff tear (RCT) before undergoing surgery and to examine the relevance of these findings to the public.

Methods: A survey was conducted of 326 patients from 10 hospitals (male, 176; female, 150) who underwent arthroscopic rotator cuff repair (ARCR) for symptomatic RCT between September 2019 and February 2020. A questionnaire was used to obtain data regarding the type of medical care service, medical institutions visited before surgery, number of treatments received, and cost of treatment.

Results: A total of 326 patients (87%) received treatment at least once at another medical institution before visiting the hospital where the surgery was performed. Patients visited an average of 9.4 health providers or physicians for shoulder pain before visiting the hospital where surgery was performed. Among the 326 patients, 148 (45%) visited more than two medical institutions and spent an average of 641,983 Korean won (KRW; $466, 50,000-5,000,000 KRW) before surgery. Medical expenses before surgery were proportional to the number of medical institutions visited (P=0.002), symptom duration (P=0.002), and initial visual analog scale (VAS) pain score (P=0.007) but were not associated with sex, age, VAS pain score immediately before surgery, or RCT size.

Conclusions: Medical expense before ARCR was associated with the severity of preoperative pain and duration of symptoms. After onset of shoulder symptoms, patients should visit as soon as possible a hospital that has surgeons who specialize in shoulder repair to prevent unnecessary medical expense and proper treatment. Level of evidence: IV.

Background: The aim of this study was to evaluate the impact of mental health attributes, such as the presence of psychiatric comorbidities or psychological comorbidities (low resilience), on outcomes after rotator cuff repair (RCR) and total shoulder arthroplasty (TSA).

Methods: PubMed, Cochrane, and Google Scholar (results pages 1-20) were searched up to November 2023. Mental health problems of interest included the presence of psychiatric comorbidities (depression, anxiety) or indicators of poor psychological functioning, such as low resilience or the presence of distress. Patients were assigned to poor or good mental health groups in this study based on their grouping in the original study.

Results: Fourteen studies were included in the meta-analysis. Patients with good mental health had greater improvements in postoperative American Shoulder and Elbow Surgeons and Simple Shoulder Test scores in the TSA cohort (P=0.003 and P=0.01), RCR cohort (P<0.001), and the combined TSA and RCR cohort (P<0.001). No difference was found in visual analog scale score, satisfaction, external rotation, or flexion between the two mental health groups. Patients with poor mental health undergoing RCR experienced higher rates of adverse events and transfusions (P<0.001). Patients with poor mental health also had greater rates of revision and emergency department visits in the TSA cohort (P<0.001), RCR cohort (P=0.05 and P=0.03), and combined cohort (P<0.001). Patients with poor mental health undergoing TSA had a higher rate of re-admission (P<0.001).

Conclusions: Patients with poor preoperative mental health showed inferior patient-reported outcome scores and increased rates of adverse events, revisions, and re-admissions. Level of evidence: III.

Background: While initial reports of surgical repair of ulnar collateral ligament tears are promising, studies detailing post-repair outcomes are lacking. This study explores the effectiveness of ulnar collateral ligament (UCL) repair in returning professional baseball players to their pre-injury level of play. Our hypothesis is that professional baseball players undergoing UCL repair will have successful outcomes and high return to sport rates after surgery.

Methods: Publicly available databases were utilized to search for data on professional baseball players who underwent UCL repair from 2016 to 2021. Players undergoing primary UCL repair with an internal brace were included. Amateur players were excluded as were those undergoing revision UCL repair or UCL reconstruction.

Results: Of the 11 pitchers who underwent UCL repair, minor league baseball (MiLB) pitchers returned to the sport at an average of 17.5 months. MiLB pitchers had similar earned run averages (ERAs), games played, innings pitched, and walks plus hits per inning pitched ratios (WHIPs) before and after surgery. Four major league baseball (MLB) pitchers (80%) returned to the sport at 9.55 months. MLB pitchers played fewer games and pitched fewer innings than before the surgery, but their ERAs and WHIPs were similar before and after surgery. Pitch velocity and spin rates after surgery varied based on pitch type. The seven positional players who underwent UCL repair showed no differences in batting or fielding performance before and after surgery.

Conclusions: UCL repair can successfully return both pitchers and positional players at both the MiLB and MLB levels to play at pre-injury performance levels. Repair can be considered as an option for qualifying injuries in players hoping to maximize performance after surgery with minimal recovery time. Level of Evidence: IV.

Background: Subscapularis repair has recently garnered significant interest. A thorough understanding of the tendon's anatomy is essential for precise and safe repair. Our objectives were to describe the anatomy of the subscapularis insertion, define its landmarks, and analyze nearby structures to guide arthroscopic repair.

Methods: We conducted an anatomical study, dissecting 12 shoulders. We evaluated the distance from the footprint to the axillary nerve, the dimensions, and shape of the footprint, and its relationship with the humeral cartilage.

Results: The distance to the axillary nerve was 32 mm (standard deviation [SD], 3.7 mm). The craniocaudal length of the footprint was 37.3 mm (SD, 4.6 mm). Its largest mediolateral thickness was 16 mm (SD, 2.2 mm), wider at the top and narrower distally. The distance between the footprint and the cartilage varied, being 3.2 mm (SD, 1.2 mm) in the upper part, 5.4 mm (SD, 1.8 mm) in the medium, and 15.9 mm (SD, 2.9 mm) in the lower part.

Conclusions: When performing a repair of the subscapularis tendon, the distance to the cartilage should be carefully evaluated as it varies proximally to distally, and the shape of the footprint (wider proximally, tapered distally) should be considered for implant positioning. The distance to the axillary nerve is approximately 30 mm. Anterior visualization guarantees direct control of all landmarks and allows accurate implant positioning with safe tendon release. Level of evidence: IV.

Background: This study sought to determine if preoperative forward elevation (FE) weakness affects outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients with rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA).

Methods: A retrospective review of a single institution's prospectively collected shoulder arthroplasty database was performed between 2007 and 2020, including 333 aTSAs and 155 rTSAs for primary RCI-GHOA with a minimum 2-year follow-up. Defining preoperative weakness as FE strength ≤4.9 lb (2.2 kg), three cohorts were matched 1:1:1 by age, sex, and follow-up: weak (n=82) to normal aTSAs, weak (n=44) to normal rTSAs, and weak aTSAs (n=61) to weak rTSAs. Compared outcomes included range of motion, outcome scores, and complication and revision rates at latest follow-up.

Results: Weak aTSAs and weak rTSAs achieved similar postoperative outcome measures to normal aTSAs and normal rTSAs, respectively (P>0.05). Compared to weak rTSAs, weak aTSAs achieved superior postoperative passive (P=0.006) and active external rotation (ER) (P=0.014) but less favorable postoperative Shoulder Pain and Disability Index (P=0.032), American Shoulder and Elbow Surgeons (P=0.024), and University of California, Los Angeles scores (P=0.008). Weak aTSAs achieved the minimal clinically important difference and substantial clinical benefit at a lower rate for abduction (P=0.045 and P=0.003) and FE (P=0.011 and P=0.001). Weak aTSAs had a higher revision rate (P=0.025) but a similar complication rate (P=0.291) compared to weak rTSAs.

Conclusions: Patients with RCI-GHOA and preoperative FE weakness obtain postoperative outcomes similar to patients with normal preoperative strength after either aTSA or rTSA. Preoperatively, weak aTSAs achieved greater ER but lower rates of clinically relevant improvement in overhead motion compared to weak rTSAs. Level of evidence: III.