Clinics in Shoulder and Elbow最新文献

Posterolateral impingement is sometimes diagnosed as a cause of refractory elbow pain, often after other treatments have been tried for common conditions such as lateral epicondylitis (tennis elbow) or subtly different conditions common in throwing athletes, such as valgus extension overload syndrome. Arthroscopic surgical treatment is effective when targeting abnormal anatomy such as plical folds. Partial excision of the olecranon must be undertaken with caution because it can lead to instability. This systematic review of the current literature uses a narrative synthesis to identify anatomical morphological variations of the olecranon, humeral and capitellar geometry, and overloading of the lateral part of the elbow as causative factors for this condition and discusses how arthroscopic techniques can resolve symptoms. Further understanding of the static and dynamic anatomy of the lateral part of the elbow will help to develop future treatment and preventive strategies.

Background: Our study aimed to evaluate the clinical and radiologic results of all-arthroscopic treatment of terrible triad injuries followed-up for a minimum of 5 years and investigate how arthroscopic partial excision for radial head fractures affects the results at the final follow-up.

Methods: We retrospectively reviewed consecutive patients with terrible triad injuries who underwent all-arthroscopic treatment between January 2011 and June 2018. In group I, we performed conservative or arthroscopic fixation of stable radial head fractures, while in group II, arthroscopic partial excision of unstable radial head fractures involving <30%-50% of the articular surface area was performed. Clinical outcomes were measured by visual analog scale score and assessment of instability, range of motion (ROM), and Mayo Elbow Performance Score. Radiological outcomes were evaluated using x-rays, and the integrity of the repaired lateral collateral ligament complex was confirmed through magnetic resonance imaging.

Results: Thirty-two patients with an average age of 49.5±16.2 years met the inclusion criteria and were followed-up for a mean of 82.7±22.2 months. Twenty patients were assigned to group I and 12 patients to group II. Clinical outcomes showed no significant differences between the two groups at the final follow-up (P>0.05). On radiological evaluation, more heterotopic ossifications were found in the radial head excision group (group II, 66.7% vs. group I, 35%; P=0.02); however, there was no significant difference in ROM between the two groups (P>0.05).

Conclusions: In all-arthroscopic treatment of terrible triad injuries, arthroscopic partial excision of the radial head did not seem to have a significant impact on elbow joint stability. Level of evidence: III.

Background: Aimed to report the prevalence and predisposing factors affecting subscapularis muscle atrophy and fatty infiltration (MAFI) in patients without a subscapularis tear, and to analyze the effect of this condition on surgical outcomes.

Methods: Between 2020 and 2022, 153 patients (mean age 58.1 ± 10.2 years; 84 men and 69 women) who underwent repair of posterosuperior cuff tears, with no subscapularis tears identified during arthroscopy were retrospectively analyzed. Baseline characteristics, preoperative and follow-up (6 months) magnetic resonance imaging findings, arthroscopic findings, and clinical outcomes (>1 year) were recorded.

Results: The prevalence of subscapularis MAFI (Goutallier grade 1 or 2) was 73.9% (113/153), of which the prevalence of Goutallier grade 2 was 23.5% (36/153). From multivariable logistic regression analysis, female sex (odds ratio [OR], 5.6; 95% CI, 1.7-18.6; P=0.005), older age (OR, 1.1; 95% CI, 1.0-1.1; P=0.052), advanced supraspinatus MAFI by Goutallier grade (OR, 3.2; 95% CI, 1.5-6.9; P=0.004), and synovitis (OR, 2.8; 95% CI, 1.1-7.9; P=0.030) were identified as independent predisposing factors for subscapularis MAFI. However, patients with preoperative subscapularis MAFI exhibited similar final range of motion, pain and function, and belly press strength compared to those without preoperative subscapularis MAFI.

Conclusions: Subscapularis MAFI is frequently observed conditions even in the absence of subscapularis tears, and this condition could be affected by supraspinatus MAFI, female sex, older age, and synovitis. However, because subscapularis MAFI does not affect the surgical outcome, surgeons need not be concerned about this condition when repairing posterosuperior rotator cuff tear. Level of evidence: IV.

Overhead throwing athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions.

Background: To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER).

Methods: We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications.

Results: We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was -14°, while mean preoperative ER in lateralized RSA alone was -11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone.

Conclusions: Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence: IV.

Background: This study aimed to investigate the impact of microfractures generated within the footprint of the greater tuberosity (GT) on postoperative cuff healing following arthroscopic rotator cuff repair (ARCR).

Methods: A retrospective analysis was conducted on patients who underwent ARCR for full-thickness rotator cuff tear (FTRCT) between April 2020 and October 2023 at our institution. A total of 73 patients was categorized into two groups based on the presence of microfractures: a microfracture group (group M, n=33) and a non-microfracture group (group N, n=40). Six months post-surgery, magnetic resonance imaging was performed to assess cuff healing and retear rates between the two groups. Furthermore, patients were stratified into retear and healing groups based on cuff integrity to analyze the factors influencing retear.

Results: There was no significant difference in retear rates between groups M and N (18.2% vs. 10.0%, P=0.332). Among demographic factors, age showed a significant difference between the retear and healing groups (67.4±8.5 vs. 61.6±6.1, P=0.044). ML tear size (3.1±1.7 vs. 2.0±1.1, P=0.015), AP tear size (2.4±1.2 vs. 1.6±1.0, P=0.332), FI of the supraspinatus (2.3±1.3 vs. 1.4±1.0, P=0.029), and FI of the infraspinatus (1.6±1.3 vs. 0.9±0.8, P=0.015) exhibited significant differences between the retear and healing groups.

Conclusions: ARCR with concurrent microfracture of the GT footprint did not significantly impact cuff healing in patients with FTRCT. However, older age and larger ML tear size were associated with an increased risk of retear. Level of evidence: III.

Epithelioid hemangioma of bone is a rare benign vascular tumor. Because of the locally destructive clinical presentation and the presence of atypical histologic features with increased mitotic activity and necrosis, it is often misdiagnosed as low-grade malignant epithelioid hemangioendothelioma or high-grade malignant epithelioid angiosarcoma. Correct diagnosis through imaging studies and histopathological examination is mandatory to determine the appropriate course of treatment, as the prognosis differs from that of other malignant hemangioma tumors. A 69-year-old male who presented with intractable shoulder pain caused by epithelioid hemangioma in the acromion of the scapula was treated with tumor curettage. This paper reports a good result with a review of the relevant literature.

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: III.

Background: The purpose of this study was to examine the radiographic and clinical outcomes of stemless reverse total shoulder arthroplasty (RTSA) after a minimum 2-year follow-up.

Methods: Between July 2018 and March 2023, 50 patients underwent 50 stemless RTSA with the Lima component. Twenty-eight patients with a follow-up of more than 2 years were reviewed. The average age was 71.9 years (range, 61-85 years), and the average follow-up period was 2.2 years (range, 2.0-5.1 years). Bone marrow density of the proximal humerus was measured before RTSA. We evaluated preoperative and postoperative range of motion, clinical score, radiographic change, and postoperative complications.

Results: Significant increases were observed postoperatively in forward flexion (112.0°-162.5°, P<0.01) and internal rotation (from L3 to T12 level, P<0.05). No changes were observed in external rotation (from 43.0° to 45.2°, P=0.762). The clinical scores improved for Korean Shoulder Scoring system (from 64 to 93, P<0.01) and American Shoulder and Elbow Surgeons score (from 17.5 to 27.3, P<0.01). Although radiolucent lines of less than 2 mm were observed in all cases, no osteolysis and loosening of the stemless humeral component was found. Scapular notching was observed in 18 cases (64.3%).

Conclusions: Stemless RTSA showed good radiographic and clinical results after a minimum 2-year follow-up. Level of evidence: IV.

Background: The popularity of the Latarjet procedure (LP) for the treatment of anterior shoulder instability continues to rise. However, LP is technically demanding and associated with complications. This study aims to determine the learning curve for the open LP (oLP) and the threshold for proficiency.

Methods: This was a retrospective study of all oLPs performed by a single surgeon in a single institution from 2016 to 2021. Operative time, defined as time from incision to closure, was the primary outcome of this study, and 1-year postoperative complications were the secondary outcome. After listing oLP cases in chronological order, they were classified into groups of 15, and the average operative time for each group was determined. Demographics, operative duration, and postoperative complications were compared across groups.

Results: Seventy-five oLPs were included in this study, and operative times decreased after the first 15 procedures. While operative times continued to decrease with increasing case number, the learning curve began to plateau after 30 procedures. After 75 procedures, there was a total decrease in average operative time of 31.5 minutes relative to that of the first 15 cases. There were no differences in complication or revision rates among procedure groups.

Conclusions: Establishing learning curves provides important insight into the complexity of surgical procedures. Our study demonstrates that the oLP has a steep learning curve with significant improvement in operative time after the first 15 cases. Operative time plateaus after 30 cases, indicating proficiency in this procedure. Level of evidence: IV.