Clinics in Shoulder and Elbow最新文献

Background: Shoulder arthroscopy is associated with a steep learning curve. Virtual reality (VR) arthroscopic simulator training has recently gained prominence as a promising training modality for shoulder arthroscopy. However, there is a lack of high-quality evidence regarding its efficacy. Thus, in this study we perform a systematic review to investigate the effects of VR simulator in shoulder arthroscopy training.

Methods: We performed a systematic search of four databases (PubMed, Embase, Scopus, and Cochrane Library). Studies that compared outcomes pre- and post-VR training as well as outcomes between VR groups and control (non-VR/low fidelity) groups were included. Primary outcomes between VR and control consisted of time to completion and arthroscopic evaluation score. Additionally, pre- versus post-training improvement in arthroscopic evaluation score was evaluated.

Results: Seven studies were included in this systematic review. Total cohort size was 143, with 93 in the VR group and 50 in the control group. Studies that compared time to completion in VR and control groups all showed significantly shorter time to completion in the VR group, with individual study standardized mean difference (SMD) ranging from -0.24 to -1.37. In terms of arthroscopic evaluation score, several studies showed pre- to post-training improvement in (individual SMD range, 0.32 to 2.32) but no difference between VR and control groups (individual SMD range, -0.02 to 0.82).

Conclusions: In this study we found that VR training results in shorter task completion time for trainees, whereas there are no differences in arthroscopic evaluation scores between VR versus control groups. Hence, VR simulator training improves arthroscopic efficiency for orthopedic trainees, with limited improvement in quantitative skills. Level of evidence: II.

Shoulder instability, particularly anterior instability, remains a significant clinical and socioeconomic burden, especially in young, active populations. Recent advancements have refined our understanding of critical and subcritical bone loss, bipolar lesions, and dynamic stabilization concepts. This review synthesizes current evidence by analyzing recent clinical studies, biomechanical research, and technological developments related to the management of anterior shoulder instability. While traditional soft-tissue procedures such as the Bankart repair maintain a role in select low-risk patients, emerging data support earlier consideration of bony augmentation or dynamic stabilization in high-risk cohorts. Moreover, technologies such as dynamic anterior stabilization, arthroscopic Latarjet procedures, suture-button fixation, and biologic augmentation strategies are redefining treatment algorithms. Recent advances have reshaped the approach to shoulder instability, emphasizing individualized strategies based on bone loss, patient risk profile, and dynamic stabilizing techniques. An evidence-based framework is essential for optimizing clinical outcomes.

Background: This cadaveric study investigated whether radiolucent lines (RLLs) in x-rays of uncemented polyethylene (PE) glenoid implants with a thin titanium layer at the back can appear or disappear due to tilting of the x-ray projection.

Methods: Eight RM Pressfit Vitamys glenoids (Mathys) were implanted in cadaveric scapulae. A computed tomography (CT) scan confirmed where the PE implant was flush with bone and where a gap was present. In addition to the 0° projection as a starting point, the glenoid was tilted in 10° and 20° retro- and anteversion and superior and inferior tilt directions. The glenoid was subdivided into five zones. Each zone was quantified with no RLLs or RLLs.

Results: In all zones, tilting from 0° to 10° inferior tilt (P=0.028), 10° retroversion (P<0.001), and 20° anteversion (P<0.001) caused RLLs to appear or disappear. Tilting from 0° to 20° inferior tilt (P=0.087), 10° (P=0.218) and 20° superior tilt (P=0.484), and 10° anteversion (P=0.126) did not cause any RLLs to appear or disappear. The RLLs always disappeared at 20° retroversion.

Conclusions: True anteroposterior images should be obtained during x-ray assessment following uncemented glenoid component implantation. A CT scan is advised to confirm or exclude the presence of RLLs. Level of evidence: Laboratory cadaveric study.

Background: The aim of this study is to assess the diagnostic value of the alpha-defensin lateral flow (ADLF) test in a group of patients with suspected shoulder periprosthetic joint infections (PJIs) and its usefulness and correlation with other diagnostic tests in the decision-making process.

Methods: This retrospective single-center study was conducted between 2018 and 2023. Alpha-defensin was measured using an ADLF test kit. The final diagnosis of shoulder PJI was confirmed or ruled out based on the Musculoskeletal Infection Society criteria.

Results: After selecting patients based on the exclusion criteria, the final study group comprised 22 patients. Of all patients, the test was positive in five cases. The ADLF test was false-positive in two patients and was false-negative in zero patients. The test was truly negative in 17 cases, resulting in a sensitivity of 100.00% (95% CI, 100.00%-100.00%) and a specificity of 89.47% (95% CI, 76.65%-102.30%). The positive predictive value was 60.00% (95% CI, 39.53%-80.47%) and the negative predictive value was 100.00% (95% CI, 100.00%-100.00%). The accuracy of the α-defensin test was found to be 90.9%.

Conclusions: Although this study has limitations such as small sample size and research design, the ADLF test has proven to be a useful diagnostic tool. It can serve as a supplement to traditional tests, providing additional support to orthopedic surgeons in both preoperative and intraoperative diagnosis, especially in its ability to exclude the possibility of a PJI. Level of evidence: III.

Background: Acromioclavicular (AC) joint (ACJ) dislocation can lead to superior clavicular instability when the AC and coracoclavicular (CC) ligaments are torn. No previous study has assessed the effects of combined AC-CC ligament resections in fresh-frozen cadavers with preserved soft tissues around the thorax and shoulder girdle. This study aimed to develop such an ACJ dislocation model and evaluate stability following ligament resections.

Methods: Nine fresh-frozen cadaver shoulders (mean age, 86.6 years) without clavicular fractures or ACJ osteoarthritis were used. Each specimen included the thoracic spine, scapula, clavicle, and shoulder. Biomechanical testing was performed with a customized system to assess displacement and evaluate superior and posterior stability. Three conditions were compared: intact ligaments, AC ligament resection, and AC-CC ligament resection.

Results: Superior translations were 0.0 mm (intact), 1.1 mm (AC resection), and 9.6 mm (AC-CC resection). Posterior translations were 0.0 mm, 3.2 mm, and 9.0 mm, respectively. The AC-CC resection group showed significantly increased translations compared to the intact and AC resection groups. No significant difference was observed between the intact and AC resection groups in superior translation. Posterior translation increased progressively from intact to AC and then AC-CC resection.

Conclusions: This is the first study to assess both superior and posterior ACJ stability using cadavers with preserved soft tissues. Our findings demonstrate the importance of the AC and CC ligaments in maintaining ACJ stability. Notably, the AC ligament contributes to posterior stability, indicating the need for reconstruction to achieve overall joint stability. Level of evidence: Controlled laboratory study.

Management of anterior glenohumeral instability in adolescents remains challenging, and optimal modalities and timing of interventions continue to be individualized. Recent evidence favors surgical stabilization after the first episode of instability in certain situations. This review offers an approach to the evaluation, diagnosis, and treatment of anterior glenohumeral instability, summarizing recent changes and updates in management for adolescents between 10 and 18 years of age. There is need for continued prospective longitudinal studies with long-term follow-up focusing on shoulder instability in adolescent populations.

Background: Humeral version is a key parameter in preoperative planning for reverse total shoulder arthroplasty (RTSA). Although computed tomography (CT) of the entire humerus is required to measure humeral version accurately, standard preoperative imaging typically includes only the scapula and proximal humerus, leading to additional radiation exposure. Ultrasound-assisted humeral torsion measurement using the bicipital groove has shown strong correlations with CT but lacks clinically applicable angle calculation methods.

Methods: In this study, we evaluate whether humeral version can be accurately calculated using proximal humerus CT combined with ultrasound without additional imaging of the distal humerus. Thirty-nine patients who underwent RTSA between March 2021 and May 2022 were included. Preoperative whole-humerus CT and ultrasound-assisted version measurements were compared.

Results: Intra- and inter-tester reliability of the ultrasound-assisted measurements showed intraclass correlation coefficients (ICCs) of 0.924 (95% CI, 0.857-0.960) and 0.872 (95% CI, 0.727-0.942), respectively. The mean humeral version measured by CT was 30.4°±15.1°, and 32.8°±14.5° by the ultrasound-assisted method. A strong correlation was observed between the two methods (Pearson's r=0.915, P<0.001; concordance correlation coefficient=0.903). The ICC between the two methods was 0.905 (95% CI, 0.813-0.951). Bland-Altman analysis showed a mean difference of 2.38°, with 95% limits of agreement from -14.37° to 9.61°, indicating high agreement.

Conclusions: These findings suggest that ultrasound-assisted measurement combined with proximal humerus CT is a reliable and accurate alternative to whole-humerus CT, reducing radiation exposure and cost. Level of evidence: III.

Background: Distal humerus fractures (DHFs) are challenging orthopedic injuries requiring tailored management. Surgical options primarily include open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA) for non-reconstructable fractures. While clinical considerations typically guide treatment, recent studies have shown better surgical incentives for arthroplasty compared to ORIF. This study aims to investigate compensation differences across treatment options for DHFs and to evaluate the potential association of financial incentives with clinical decisions in orthopedic surgical care.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was conducted for DHF cases from 2006 to 2022. Patients undergoing ORIF or TEA were matched 1:1 using propensity score matching, controlling for demographics and comorbidities. Work relative value units (wRVUs), operative times, Medicare reimbursement rates, and 30- day postoperative complications were compared.

Results: Among the 506 matched patients (253 ORIF, 253 TEA), mean operative time was similar (P=0.903), while TEA procedures had significantly higher wRVUs per minute (0.15±0.06 vs. 0.11±0.05, P<0.001) and revenue per case ($684.05±$89.73 vs. $469.48±$36.04, P<0.001). No significant differences in 30-day postoperative complication rates, including bleeding requiring transfusion, surgical site infections, or major complications, were observed.

Conclusions: This study demonstrates that ORIF generates lower surgeon reimbursement than TEA for DHFs despite similar short-term outcomes, suggesting that financial incentives do not favor TEA when surgically indicated. These findings underscore the need to evaluate RVU assignment to procedures, aligning physician incentives with patient care priorities. Level of evidence: IV.

Background: Terrible triad injury (TTI) poses therapeutic challenges in joint stability and functional recovery. While surgery has traditionally been preferred, recent interest in nonoperative management for select cases has emerged, with studies suggesting positive outcomes for carefully chosen patients.

Methods: This retrospective study, conducted at a tertiary medical center, included patients treated conservatively for TTI between 2014 and 2022. Patients younger than 18 years with open or pathological fractures or multiple injuries were excluded. Conservative treatment was chosen for elbows with good alignment, minimal displacement, and no motion block. Progress was monitored clinically and radiographically. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results: Thirty-nine patients (59% male; mean age, 44.7±18.3 years) were included, with a mean follow-up of 78.5±29.4 months. Falls (46%) and scooter accidents (36%) were the primary injury mechanisms. Radial head fractures comprised Mason type 1 (36%), type 2 (54%), and type 3 (10%), while coronoid fractures were Regan-Morrey type 1 (69%), type 2 (28%), or type 3 (3%). Final range of motion averaged 128.2° flexion, with an 8.2° extension deficit and 85° forearm rotation. The MEPS was excellent in 11, good in 19, and fair in 9 patients; the mean DASH score among all fractures was 12.6. Five patients (13%) required subsequent surgery, and mechanical clicking was reported in 16 patients (41%).

Conclusions: Nonoperative treatment of TTI might be a viable option for selected patients, yielding generally satisfactory outcomes and an acceptable complication rate. Level of evidence: IV.

Humeral head avascular necrosis (AVN) can cause significant shoulder morbidity and represents the second most common site of nontraumatic osteonecrosis after the femoral head. The pathophysiology centers on disrupted blood supply, ultimately leading to bone death and structural compromise. It is associated with various etiologies, including trauma, iatrogenic factors, hematologic conditions, lifestyle factors, certain environmental exposures, and systemic diseases. Diagnosis relies on a combination of clinical assessment and radiographic evaluation, with magnetic resonance imaging serving as the most sensitive modality for early detection. The Cruess classification system guides treatment decisions. Although conservative measures are used in early stages, they carry a risk of progression, as they do not alter the disease course-unlike surgical techniques such as core decompression. Arthroplasty is reserved for later stages with evidence of collapse, with research suggesting that the use of pyrocarbon in hemiarthroplasty may help reduce glenoid erosion. This review provides a comprehensive overview of humeral head osteonecrosis, emphasizing its etiology, clinical evaluation, imaging findings, and treatment strategies. It highlights the growing support for early operative intervention over conservative management, emerging treatment modalities such as biologic augmentation and allografting, and promising new materials like pyrocarbon in hemiarthroplasty to mitigate glenoid erosion.