Journal of Shoulder and Elbow Surgery最新文献

Background: More older adults with displaced proximal humerus fracture (PHF) are managed non-surgically and referred to supervised rehabilitation, but its effectiveness is unknown. The primary objective of this trial was to investigate if supervised rehabilitation is superior to a single session of advice on patient-reported shoulder pain and function at 6 months post-injury, in older adults with displaced proximal humerus fracture treated non-operatively.

Methods: This is a pragmatic, single center randomized controlled trial conducted in an orthopedic outpatient clinic at a Danish university hospital. 80 adults aged ≥60 with displaced PHF treated non-operatively were screened between May 5, 2022 and November 11 2023. People were excluded if they presented with competing injuries. 60 patients (mean age 75 years, 44 (73%) female) were enrolled. All patients received a session of advice on gradual return to daily activities. After randomization, 30 patients were allocated to referral to the experimental supervised rehabilitation by physiotherapists in the municipalities (usual care). The remaining 30 patients did not receive further training (comparator group). All patients received routine clinical follow-up with radiographs at six weeks and six months. The primary outcome was patient-reported shoulder function measured with Oxford Shoulder Score 6 months after injury. A 95% confidence interval (95%CI) excluding differences greater than 10 units between groups was prespecified as indicating the absence of a clinically meaningful difference. Secondary outcomes included Oxford Shoulder Score at 12 months, quality of life assessed with EQ-5D-3L at six and 12 months, conversion to surgery, and adverse events at any time point. Analyses were on an intention to-treat basis adjusted for age, sex, and fracture type.

Results: 56 (93%) completed the primary outcome score (n = 29 allocated to advice and supervised rehabilitation, n = 27 allocated to advice only). The least squares mean Oxford Shoulder Score at 6 months was 33.9 in the supervised rehabilitation group and 33.8 in the advice-only group. Consequently, in the main analysis, there was no difference between groups (mean difference, 0.05; 95% CI, -4.5 to 4.6 p = 0.98), potentially corresponding to a negligible effect size <0.01. All secondary outcomes aligned with the primary endpoint. At 12 months, four patients had converted to surgery (three supervised rehabilitation vs one single advice session). Adverse events were similar across the two groups.

Conclusions: The self-reported outcomes of supervised rehabilitation were comparable to those of a single advice session. Routine referral to supervised rehabilitation may not be necessary for all patients.

Level of evidence: Level I; Randomized Controlled Trial; Treatment Study.

Background: Accurate positioning of the glenoid baseplate and peripheral screws is critical in reverse total shoulder arthroplasty (rTSA). Patient-specific instrumentation (PSI) has been introduced to improve surgical accuracy, but its benefits over conventional free-hand techniques remain uncertain. This study aimed to evaluate the accuracy of glenoid baseplate and peripheral screw placement between PSI-assisted and conventional free-hand rTSA.

Methods: We conducted a prospective, multicenter, parallel-group, single-blinded, superiority randomized controlled trial across seven tertiary centers between March 2022 and December 2024. Patients aged ≥65 years undergoing primary rTSA were randomized 1:1 to PSI or free-hand group through a centralized web-based electronic case report form. No cross-over occurred, and all analyses were performed on an intention-to-treat basis. A standardized implant system (Exactech, Gainesville, FL, USA) was used in all cases. The primary outcome was the proportion of patients with postoperative CT-based deviation error from preoperative planning, including version (≥5°), inclination (≥5°), or position offset (≥2.5 mm) errors. The secondary outcomes included continuous deviation values and accuracy of peripheral screw placement (anteroposterior gap, superoinferior gap, and length gap deviations). Effect sizes with 95% confidence intervals (CI) were reported.

Results: Of 106 patients, 53 were included in the PSI and free-hand groups each. Baseline demographics and clinical characteristics were comparable between the groups. Baseplate positioning was similar between the groups, with version error 5 ± 5° vs. 5 ± 5°, inclination error 6 ± 5° vs. 5 ± 4° (mean difference +0.9°, 95% CI -0.8 to +2.6; p=0.309), and positional offset 3 ± 2 mm vs. 4 ± 2 mm (mean difference -0.3 mm, 95% CI -1.1 to +0.5; p=0.496). Conversely, PSI significantly improved peripheral screw placement accuracy, including anteroposterior gap (-1 ± 3° vs. 1 ± 6°; mean difference -1.9°, 95% CI -3.7 to -0.1; p=0.041), superoinferior gap (-2 ± 4° vs. 1 ± 6°; mean difference -2.7°, 95% CI -4.7 to -0.8; p=0.008), superior length gap (1 ± 6 mm vs. -2 ± 8 mm; mean difference +3.0 mm, 95% CI 0.2 to 5.8; p=0.039), and inferior anteroposterior gap (1 ± 6° vs. -3 ± 6°; mean difference +4.2°, 95% CI 2.0 to 6.4; p<0.001). Additionally, clinically relevant errors (>5°) were significantly less frequent in the PSI group for anterior (11.3% vs. 43.4%; p<0.001) and superior (20.8% vs. 41.5%; p=0.035) superoinferior gap.

Conclusion: In primary rTSA, PSI did not improve glenoid baseplate positioning compared to the free-hand technique but significantly enhanced the accuracy of peripheral screw placement.

Level of evidence: Level II; Randomized Controlled Trial; Treatment Study.

Background: The majority of patients with symptomatic Sternoclavicular Joint (SCJ) osteoarthritis (OA) can be successfully treated non-operatively. For patients that remain symptomatic an arthroscopic or open SCJ excision arthroplasty is usually successful. However, a standard SCJ excision arthroplasty is contra-indicated in patients with associated instability. We have developed an open intracapsular excision arthroplasty and augmented capsular plication technique to treat patients with SCJ OA and associated instability.

Materials & methods: Between 2018 and 2022 patients that underwent an open excision arthroplasty and augmented capsular plication for symptomatic SCJ OA with associated instability, diagnosed by MRI scan, were reviewed. Patient reported outcomes were assessed by: Rockwood SCJ, OSIS, Quick-DASH and SANE scores. Survivorship was defined as no instability or ongoing pain and no revision surgery.

Results: A total 27 patients who underwent surgery and were available at final follow-up were included in the study. The mean age at surgery was 53.4 years (range 30-76) and mean follow-up of 45.8 months (range 25-79). At final follow-up the mean Rockwood score had risen from 7.2 (6-9) to 14.1 (10-15 sd1.2), the Quick-DASH score had dropped from 33.2 (45.0-18.2) to 4.3 (0-12.2), the mean OSIS score had risen from 21.7 (18-37) to 45.3 (36-48) and the mean SANE score had risen from 51.0 (30 - 70) to 88.8 (55 - 100). These all reached statistical significance. The repair/construct survivorship was 98%. All of the patients, apart from 2, were satisfied with the results of their procedure.

Conclusion: Undertaking an open excision arthroplasty and augmented capsular repair for patients with symptomatic SCJ OA and associated instability refractory to non-operative treatment provides a satisfactory outcome with regards to joint instability, pain and clinical outcomes.

Purpose: Repair and augmentation techniques have been successfully applied in the treatment of acute ligament injuries causing elbow instability. This study evaluates whether the chronicity of elbow instability affects postoperative outcomes following ligament repair with augmentation using suture tape internal bracing.

Methods: A retrospective study was conducted on 40 patients (mean follow-up 42.5 months; range, 9-99 months) who underwent ligament repair with suture tape augmentation for traumatic elbow instability between 2013 and 2019. Functional outcomes (DASH, Oxford Elbow Score, MEPS, and VAS) and range of motion (ROM) were assessed. Patients were stratified by chronicity using 6 weeks and 12 weeks as thresholds.

Results: Across the cohort, median postoperative scores were: DASH 5.0 (IQR 1.5-12.7), Oxford 41.0 (IQR 35.0-47.0), MEPS 90.0 (IQR 75.0-100.0), and VAS 1.0 (IQR 0.0-2.0). ROM improvements included flexion-extension arc increase from 135° (IQR 70-145) to 145° (IQR 140-150). No significant differences in functional or ROM outcomes were found between acute and chronic groups using either the 6- or 12-week thresholds.

Conclusion: Ligament repair with suture tape internal brace augmentation for traumatic elbow instability achieves favourable outcomes in both acute and chronic presentations.

Background: Lateral epicondylitis (LE) is commonly treated with triamcinolone injections, but ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), may offer a safer alternative. This non-inferiority trial evaluated whether ketorolac is non-inferior to triamcinolone in LE patients for pain relief measured by Visual Analog Scale (VAS) at 24 weeks (primary outcome, non-inferiority margin: 1 cm).

Methods: In this randomized, controlled trial, 200 patients with LE were randomized to receive triamcinolone (2 mL, 40 mg/mL) or ketorolac (2 mL, 30 mg/mL) injections using peppering or single-injection technique, with or without ultrasound guidance. Primary outcome was VAS (visual analogue scale) pain at rest change at 24 weeks. Secondary outcomes included Patient-Rated Tennis Elbow Evaluation (PRTEE), Disabilities of the Arm, Shoulder, and Hand (DASH) scores, strength parameters, and adverse events at 4, 12, 24, and 52 weeks. Non-inferiority was assessed using one-sided 95% confidence intervals (CI), with linear mixed-effects models and subgroup analyses performed.

Results: At 24 weeks, ketorolac was non-inferior to triamcinolone for VAS pain at rest [mean change: -1.08 ± 2.04 vs. -1.01 ± 2.31; mean difference: 0.072; 95% CI: -0.538 to 0.681; (upper bound < 1 cm)]. Both treatments showed comparable functional outcomes across secondary measures. Subgroup analysis suggested ketorolac approached non-inferiority in patients with symptom duration <12 months, whereas patients having chronic symptoms (≥12 months) showed superior response to triamcinolone. Adverse events (mild pain/swelling) were comparable in both groups (10.6% in ketorolac and 14.4% in triamcinolone group), though transient post-injection pain was more frequent with ketorolac.

Conclusion: Ketorolac injection provides pain relief and functional outcomes comparable to triamcinolone for LE, offering a safe and effective steroid-sparing alternative, particularly for patients with shorter symptom duration or contraindications to corticosteroids.

Level of evidence: Level I; Randomized Controlled Trial; Treatment Study.

Background: Medial elbow injuries, particularly ulnar collateral ligament (UCL) injuries, are a major concern in youth and adolescent pitchers. Elbow varus torque (EVT) is commonly used as an index of medial valgus load. We examined whether the Forearm Whip Angle (FWA)-defined as the sagittal-plane inclination of the throwing-forearm segment relative to the horizontal-relates independently to EVT and which phase-specific lower-extremity/trunk motions determine FWA.

Methods: Seventeen healthy high-school pitchers were analyzed with 3-D motion capture. Across the pitching cycle (0-100%, 1% bins), we mapped pointwise Pearson correlations between FWA and six kinematic variables and controlled multiplicity using the Benjamini-Hochberg false discovery rate (FDR) with a ≥3-bin continuity criterion. Two prespecified multiple linear regressions were then fitted: (Model 1) EVT ∼ FWA + ball velocity; (Model 2) FWA ∼ phase-averaged kinematics identified a priori from the FDR screen.

Results: Mean (±SD) values were: FWA 163° ± 17°, EVT 57 ± 13 Nm, and ball velocity 129 ± 8 km/h (n = 17). After FDR correction, one significant window was identified: a positive association between FWA and pivot-leg hip abduction/adduction (hip_y) at 67-77% of the cycle. In Model 1, FWA was a strong, independent negative predictor of EVT (standardized β = -0.844; P < .001), whereas ball velocity was not significant (β = 0.195; P = .219). Model fit: R² = .690; adjusted R² = .646; LOOCV R² = .526; RMSE = 8.62 Nm. In Model 2, hip_y (67-77%) was the only independent predictor of FWA (β = 0.749; P = .002); thorax_x (80-90%) and pelvis_y (39-63%) were not significant. Model fit: R² = .524; adjusted R² = .414; LOOCV R² = .284; RMSE = 18.6°.

Conclusion: Greater FWA-an index of "whip-like" kinetic-chain coordination-was associated with lower medial elbow valgus load independent of ball velocity. Phase-specific control of pivot-leg hip abduction/adduction (67-77%) appears to be a key determinant of FWA. These findings support incorporating FWA and targeted hip-control strategies into screening and training; causal inference awaits longitudinal or interventional studies.

Background: The COVID-19 pandemic accelerated the demand for remote assessment tools in rehabilitation, especially the need for accurate and reliable technologies to measure shoulder range of motion (ROM) outside of clinical environments. Emerging tools such as smartphone apps, wearable sensors, and markerless motion capture systems are increasingly being adopted, yet their accuracy and reliability compared to reference standards remains unclear.

Objective: To systematically evaluate the accuracy and reliability of existing remote shoulder ROM measurement technologies, quantify measurement bias, and assess their agreement with reference standards.

Methods: A systematic review and meta-analysis was conducted on 26 studies evaluating remote ROM measurement tools. Pooled mean bias (in degrees) was calculated as the primary effect size for agreement, with reliability assessed using intraclass correlation coefficients (ICCs). Subgroup analyses were performed by motion type, technology category, population health status, and data acquisition method. Risk of bias was assessed using the QUADAS-2 tool.

Results: Remote measurement methods showed a small but consistent overestimation of ROM compared to reference standards (pooled mean bias = 2.63°, 95% CI: 1.52°, 3.74°), particularly in flexion, internal rotation, and external rotation. No significant bias was observed in abduction or extension. Both IMU and non-IMU technologies demonstrated comparable levels of overestimation. Pathological populations exhibited greater variability (bias = 4.33° vs. 2.37° in healthy subjects). Self-measurements showed lower and non-significant bias compared to assessor-guided methods. Reliability was generally high, especially for test-retest assessments (ICCs > 0.90), though more variable in inter-rater and pathological settings.

Conclusion: Remote shoulder ROM measurement technologies tend to slightly overestimate joint angles but remain within clinically acceptable limits. These tools are reliable for tracking ROM trends and suitable for remote monitoring in clinical and research settings. However, increased variability in pathological populations warrants caution. Broader validation in diverse patient cohorts is needed to strengthen clinical implementation.

Background: Patients with massive irreparable rotator cuff tears sometimes experience significant functional impairment due to external rotation deficits, categorized as isolated loss of external rotation (ILER) or combined loss of elevation and external rotation (CLEER). Existing shoulder measurement tools primarily assess range of motion or power, overlooking specific deficits in activities of daily living (ADLs) related to external rotation. The ADLER (Activities of Daily Living in External Rotation) score was developed to address this gap, focusing on active external rotation disability.

Methods: The aim of the study was to validate the ADLER score using the Kirshner and Guyatt framework, encompassing item selection, scaling, reduction, reliability, validity, and responsiveness. The target population included patients with ILER or CLEER, identified with specific clinical signs (external rotation lag, dropping arm and Hornblower's sign) and CT-arthrogram or MRI-confirmed irreparable rotator cuff tears with Goutallier grade 3 or 4 fatty infiltration of infraspinatus and teres minor. Ten items were derived from patient-reported deficits, each scored from 0 to 3 (total 30 points). Interobserver reliability was assessed in 13 patients by two blinded orthopedic surgeons using Pearson's correlation coefficient and intraclass correlation coefficient (ICC). Validity was evaluated against the Constant-Murley Score and Subjective Shoulder Value (SSV), and responsiveness was measured by comparing pre and postoperative scores following L'Episcopo tendon transfer (seven tendon transfers alone and six with reverse shoulder arthroplasty).

Results: The ADLER score demonstrated excellent interobserver reliability (Pearson's r = 0.98, p < 0.001; ICC = 0.98, 95% CI: 0.948-0.993, p < 0.001) with a mean absolute difference of 1.23. Validity was confirmed through face and construct validity, with prior data showing a significant postoperative improvement (mean ADLER score from 4 to 27, p < 0.05) correlating with Constant-Murley and SSV outcomes. Responsiveness was evident, with a mean functional improvement of 23 points (p < 0.05) across three studies, reflecting enhanced ADLs post-intervention.

Conclusion: The ADLER score is a reliable, valid, and responsive surgical tool for assessing external rotation deficits in ADLs, applicable not only to patients undergoing reverse shoulder arthroplasty with L'Episcopo transfers but also to various procedures addressing external rotation deficits, such as latissimus dorsi or lower trapezius transfers.

Background: Reverse total shoulder arthroplasty (rTSA) has become the standard surgical option for managing complex proximal humerus fractures (PHFs) in elderly patients. Despite its widespread use, postoperative functional outcomes remain inconsistent, and patient selection criteria are not well defined.

Methods: A retrospective cohort study was conducted including 117 patients ≥75 years who underwent rTSA for Neer 3- or 4-part PHFs between 2012 and 2023 at a single tertiary hospital. Preoperative clinical and epidemiological variables were recorded, including Charlson Comorbidity Index (CCI), ASA score, cognitive status, level of dependence, and availability of social support. Functional outcomes at 12 months were assessed using the Constant and ASES scores. Poor outcome was defined as Constant <45 or ASES <50. Univariate and multivariate logistic regression analyses were performed to identify predictors of poor outcome, and a therapeutic decision algorithm was developed and internally validated.

Results: The mean age was 79 ± 7 years (range 75-92), and 80.2% were female. At 12-month follow-up the mean Constant and ASES scores were 55.85 ± 17.7 and 54.6 ± 13.2, respectively. Severe cognitive impairment was the strongest predictor of poor outcome (p < 0.001), followed by partial dependence (OR 3.6; 95% CI: 1.5-8.4; p = 0.004), lack of social support (OR 4.1; 95% CI: 1.2-13.6; p = 0.022), and Charlson Index >5 (OR 2.7; 95% CI: 1.1-6.3; p = 0.027). In multivariate analysis, ASA score remained the only statistically significant independent predictor (OR 0.36; 95% CI: 0.16-0.80; p = 0.012), while CCI showed a near-significant trend (OR 1.34; 95% CI: 0.996-1.81; p = 0.053). The resulting predictive model showed good discrimination (AUC = 0.78).

Conclusion: Preoperative patient-related factors such as ASA score, cognitive status, comorbidity burden, and functional independence significantly influence functional outcomes after rTSA for PHFs in elderly patients. The proposed decision algorithm may enhance surgical decision-making and improve individualized patient care.

Background: The purpose of this investigation was to evaluate the impact of scapular neck length (SNL) on outcomes following reverse total shoulder arthroplasty (rTSA) using a lateralized 135° implant (Univers Revers; Arthrex, Inc; Naples, FL). Our hypothesis was that increased postoperative scapular neck length would be associated with improved range of motion following rTSA.

Methods: A multicenter retrospective study was performed on a prospectively collected database. Inclusion criteria were patients undergoing primary rTSA with minimum two-year follow-up. Preoperative radiographs were analyzed for SNL and glenoid height. Postoperative radiographs were analyzed for scapular notching, inferior glenosphere overhang, effective SNL defined as the distance from medial glenosphere to lateral column of scapula (MGLS), lateralization shoulder angle (LSA), and distalization shoulder angle (DSA). Patient reported outcomes (PROs), range of motion (ROM), and strength at 2 years postoperatively were correlated with outcomes controlling for demographic variables. MGLS was stratified by 0-5 mm, 5-10 mm, and >10 mm for analysis.

Results: A total of 485 patients met inclusion criteria for this investigation. Preoperative scapular neck length was negatively associated with external rotational strength at 2 years postoperatively (p = .039), but was not found to influence PROs, ROM, or the incidence of scapular notching (p > .05). Increased postoperative MGLS was positively associated with IRSpine (p = .024) and belly press strength (p < .001). Improved abduction strength was observed with MGLS > 10 mm (p = .011) and improved belly press strength was observed with a postoperative MGLS of > 5 mm (p < .001). Internal rotation was higher in the > 10 mm group compared to the 0-5 mm (L3 vs. L4; p <.001). External rotation at 90° (ER90) was higher in the > 10 mm compared to the 5-10 mm group (73° vs. 57°; p = .013).

Conclusion: Increased effective postoperative SNL, or MGLS, is positively associated with rotational range of motion and shoulder strength and following rTSA with the Arthrex Univers Revers. Postoperative MGLS of >10 mm is associated with increased Constant strength and belly press strength compared to an MGLS of 0 to 5 mm. The differences in ER90 in the > 10 mm group compared to the 5 to 10 mm group and for the internal rotation in the 10 mm group compared to the 0 to 5 mm group met criteria for a substantial clinical benefit.

Level of evidence: Level III; Retrospective Cohort Comparison; Prognosis Study.