Clinics in Shoulder and Elbow最新文献

Background: Successful total shoulder arthroplasty (TSA) relies on accurate placement of implants, which is difficult in the setting of bone loss or deformity. Technologies are becoming available to provide intraoperative assistance to better execute the preoperative plan. The purpose of this study was to compare patient outcomes following TSA utilizing either computer navigation or conventional techniques.

Methods: This retrospective review included 180 Primary Exactech TSA cases with a minimum 2-year follow-up. There were 40 anatomic (12 non-navigated, 28 navigated) and 140 reverse (80 non-navigated; 60 navigated) TSA procedures. Patient groups were similar in age, sex, side involved, and prior surgery. Patient-reported outcome measures, complications, revisions, and reoperations were assessed and compared between non-navigated and conventional groups.

Results: Of available patients, the navigated anatomic cohort had statistically significant improvements compared to the non-navigated cohort in American Shoulder and Elbow Surgeons (ASES), Oxford, and pain scores. For the navigated reverse cohort, significant improvements were seen in Oxford score. In multivariate analysis, all outcomes favored the navigated cohorts, with ASES, Oxford, and patient function scores reaching statistical significance. Complications occurred more frequently in the non-navigated reverse cohort. Revisions and/or reoperations were more frequent in non-navigated shoulders.

Conclusions: The use of computer navigation in TSA may be associated with decreased complication rates and improved patient outcomes, a benefit to surgeons and their patients. However, the lack of radiographic assessment is a limitation, and as with all new technology, further research with longer follow-up is needed to fully define the role of navigation in TSA. Level of evidence: III.

Background: Pre-osteoarthritic posterior subluxation of the humeral head (PPSHH), also referred to as a Walch B0 glenoid, is characterized by pathologic posterior subluxation of the humeral head without degenerative bony changes on plain radiographs. The purpose of this study was to describe the imaging findings of PPSHH and to assess the relationship between glenoid retroversion and HH subluxation.

Methods: This was a retrospective case series of patients with symptomatic PPSHH. Retroversion was measured on magnetic resonance imaging based on both Friedman's line and the scapular axis line. HH subluxation was measured based on the glenohumeral index (GHI) and the scapulohumeral index (SHI). The relationship between retroversion and HH subluxation was evaluated. The difference in glenoid cartilage thickness between the anterior and posterior aspects of the glenoid was compared.

Results: Eight patients were included (mean age, 34.0±4.7 years). Mean retroversion was 17.2°±5.8° based on Friedman's line and 14.0°±5.6° based on scapular axis line. Mean HH subluxation was 63.7%±6.2% based on GHI and 77.5%±9.9% based on SHI. Cartilage thickness was less in the posterior glenoid compared to anterior glenoid, and all patients had selective chondral wear on the posterior glenoid with a posterior labral tear. There was a direct relationship between the degree of glenoid retroversion and HH subluxation.

Conclusions: PPSHH is characterized by posterior glenoid chondral thinning and posterior labral tears in the setting of HH subluxation without erosive osseous changes. This pathology can present with varying degrees of retroversion and HH subluxation, and increasing retroversion is associated with more severe subluxation. Level of evidence: IV.

Frozen shoulder (FS) is a challenging disorder defined by persistent shoulder pain and progressively reduced joint motion. Despite its clinical significance, the underlying pathophysiology remains incompletely understood, posing challenges to optimal management. This review examines current treatment strategies, encompassing conservative approaches as well as procedural options. Evidence comparing the outcomes, complications, and recovery profiles of these techniques is critically analyzed to guide decision-making based on patient-specific factors and disease stage. Furthermore, recent advancements in understanding the molecular mechanisms of FS and the potential for novel therapeutic approaches are discussed. This comprehensive review underscores the importance of tailored treatment strategies and calls for further high-quality research to address persistent knowledge gaps in managing FS.

Background: This systematic review evaluates the clinical outcomes of two distinct, arthroscopic techniques for the surgical repair of massive rotator cuff tears; lower trapezius tendon (LTT) transfer and muscle advancement (MA).

Methods: Eleven studies, involving 433 patients, selected based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, were analyzed.

Results: MA significantly improves functional outcomes, demonstrated by higher Constant-Murley scores (mean difference: 26.26 vs. 18.31, P<0.001), University of California, Los Angeles shoulder scores (14.95 vs. 8.3, P<0.001), acromiohumeral distance (AHD; 1.94 mm vs. 0.40 mm, P<0.001), and greater abduction recovery (46.48° vs. 31.86°, P=0.030). However, visual analog scale score was better reduced in the LTT transfer groups (-3.69 vs. -2.33, P<0.001), with greater external rotation improvement (25.67° vs. 7.74°, P<0.001) and lower retear rates (11.89% vs. 19.42%, P=0.031). The complication profiles differed between techniques: LTT transfer carried a higher risk of graft rupture (2.64% vs. 0%, P=0.031), while arthroscopic MA was associated with increased postoperative stiffness (2.91% vs. 0%, P=0.011).

Conclusions: Arthroscopic MA is recommended for younger, active patients with mobile residual tissue to optimize abduction and AHD restoration. In contrast, LTT transfer is better suited for cases involving massive defects requiring dynamic stabilization and external rotation recovery. These findings emphasize the importance of individualized surgical planning that considers tear severity, tissue viability, and patient functional demands. Despite limitations stemming from retrospective study designs and clinical heterogeneity, this review highlights the distinct clinical advantages and appropriate indications for both techniques.

Background: Acellular dermal matrix (ADM) patch augmentation in rotator cuff repair reinforces the repaired tendon and provides additional structural support. This study aimed to compare outcomes based on rotator cuff tear size.

Methods: We retrospectively reviewed patients who underwent ADM-augmented rotator cuff repair at two hospitals between April 2021 and April 2023. After excluding subjects with <2 years of follow-up or no magnetic resonance imaging (MRI) at 6 months, patients were grouped based on tear size: ≤30 mm (group 1) and >30 mm (group 2). Outcomes were American Shoulder and Elbow Surgeons score, Constant-Murley score, University of California, Los Angeles score, pain visual analog scale score, and range of motion (ROM). Retear was defined based on Sugaya type 4-5 on 6-month MRI.

Results: Both groups showed significant improvement in postoperative clinical outcomes compared with preoperative outcomes, with no significant intergroup differences. ROM gains were limited overall, with significant increases only in group 1 for forward flexion and scaption. Stiffness occurred in 4.8% of group 1 and 17.9% of group 2 patients. Retear was found in 1 of 21 patients (4.8%) in group 1 and 7 of 28 (25.0%) in group 2.

Conclusions: Arthroscopic rotator cuff repair with ADM patch augmentation showed reduced retear rates and improved clinical outcomes across tear sizes. Postoperative ROM improvements were limited, and stiffness tended to occur more frequently in larger tears. Thus, the success of ADM patch augmentation depends on patient selection and appropriate graft application. Level of evidence: III.

Background: A cadaveric biomechanical study was used to analyze arm positions that could lead to increased risk of subscapularis tears due to subcoracoid impingement.

Methods: Six cadaveric shoulders (two male and four female; mean age, 68.4±2.3 years) were evaluated for subcoracoid external impingement using a custom shoulder testing system with a pressure-mapping sensor. The contact area and the mean and peak contact pressures between the subcoracoid arch and the subscapularis complex were measured. Eight arm positions were assessed, including 20° and 60° forward flexion (FF) and abduction (ABD) with maximal internal rotation (IR) and external rotation (ER).

Results: The overall incidence of subcoracoid impingement was 52.1% across all tests, with no contact observed at 20° ABD in the maximal IR position. Except for 20° ABD with maximal IR, the mean contact area significantly differed across the seven arm positions (P=0.009). However, mean and peak contact pressures did not show significant differences (P=0.188 and P=0.065, respectively). The highest mean contact pressure was recorded at 60° ABD with maximal ER (25.7±17.4 kPa), followed by 20° FF with maximal IR (23.2±12.5 kPa), 60° FF with maximal IR (18.2±8.3 kPa), and 60° ABD with maximal IR (18.3±12.0 kPa). The contact area and peak contact pressure exhibited similar trends to mean contact pressure.

Conclusions: This cadaveric study demonstrated increased subcoracoid arch contact when shoulders were at 20° and 60° FF with IR and at 60° ABD with both ER and IR. These findings suggest potential external subscapularis impingement in these positions, although not all comparisons were statistically significant. Level of evidence: Cadaveric biomechanical study.

Background: Little is known about the potential negative or positive effects of peritendinous infiltration with corticosteroids in the non-surgical treatment of partial distal biceps tendon tears. Peritendinous fluid, synovitis, and bursitis often accompany partial tears and can be a source of persistent pain. We hypothesize that peritendinous corticosteroid infiltration is a safe non-surgical treatment option for complaints related to a partial distal biceps tendon rupture.

Methods: A single-center retrospective analysis was performed on a cohort of 52 patients with partial distal biceps tears (<50% of the footprint involved), as confirmed by magnetic resonance imaging. All patients received an ultrasound-guided intrabursal peritendinous infiltration with 1 mL of triamcinolone acetonide (10 mg/mL) and 4 mL of 2% lidocaine HCl. Patient files were reviewed for demographic information, date of injury, injury mechanism, treatment modality (operative or nonoperative), clinical follow-up (2011-2021), and complications, including progression to a complete rupture.

Results: The median duration of follow-up after infiltration was 15 months (1.2-45 months). No infiltration-related complications were observed following infiltration therapy. Surgical reconstruction was ultimately performed in 65% of the patients with a partial tear. One patient sustained a trauma to the elbow in the weeks following infiltration, resulting in a complete tear.

Conclusions: Infiltration with corticosteroids is a safe treatment option for patients with a partial tear of the distal biceps who failed progressive exercise therapy. Surgical reconstruction was avoided in 35% of patients following infiltration treatment. Level of evidence: IV.

Midshaft clavicular fractures account for approximately 80% of all clavicle fractures in pediatric and adolescent populations and represent up to 15% of all fractures in adolescents. These injuries commonly result from falls, sports-related trauma, or motor vehicle accidents, with adolescent males experiencing fractures at rates up to three times higher than females. This review examines the diagnosis, classification, and management of these fractures, highlighting the nuances between pediatric and adult treatment approaches. Historically, nonoperative management has been favored, leveraging the adolescent clavicle's remodeling capacity. Recent trends reflect increasing operative interventions, driven by adult studies demonstrating faster recovery and improved functional outcomes in displaced fractures. While nonoperative treatment, using slings or figure-of-8 braces, remains effective for most cases, operative fixation, including open reduction and internal fixation or elastic stable intramedullary nailing, is indicated for open fractures, neurovascular injury, or significant displacement. Studies demonstrate high union rates with both methods, but operative treatment offers quicker return to activity, albeit with higher risks of hardware- related complications. The Function after Adolescent Clavicle Trauma and Surgery study notably supports nonoperative management, showing similar long-term functional outcomes compared to operative treatment. Future research should focus on refining patient-reported outcome measures specific to adolescents and identifying subsets of patients who may benefit from surgery. Shared decision-making remains crucial for optimal patient-centered care.

Background: Patient-related outcomes are increasingly emphasized in anatomic (ATSA) or reverse total shoulder arthroplasty (RTSA). Identifying patients at risk of adverse outcomes is key to mitigating complications. Comorbidity indices such as the American Society of Anesthesiologists Physical Status (ASA), classification, modified Charlson Comorbidity Index (mCCI), Elixhauser Comorbidity Measure (ECM), and 5-Factor Modified Frailty Index (mFI-5) can predict postoperative complications but were developed primarily for inpatient populations. Whereas studies have assessed these indices for total joint arthroplasty, few have assessed their performance for complications following TSA. This study compared their prognostic values for 30-day adverse outcomes after TSA.

Methods: Using the National Surgical Quality Improvement Program database, 39,810 patients who underwent ATSA or RTSA (2011- 2022) were analyzed. Logistic regression evaluated six outcomes: non-home discharge, length of stay greater than 1 day, major or minor complications, readmission, and mortality. Predictive performance was assessed using the concordance statistic (C statistic), where values greater than 0.7 indicate good discrimination and those greater than 0.8 indicate excellent discrimination.

Results: Of all the indices, only the mCCI was a good predictor of non-home discharge (C statistic, 0.713; 95% CI, 0.705-0.722). The ASA, ECM, and mFI-5 demonstrated limited predictive value for all outcomes.

Conclusions: Among the indices analyzed, only the mCCI demonstrated acceptable predictive accuracy and only for discharge destination. None of the indices effectively identified patients at risk for adverse outcomes, underscoring the need for a TSA-specific scoring system. Level of evidence: III.