Journal of Shoulder and Elbow Surgery最新文献

Background: Prior studies suggest familial clustering of rotator cuff tears (RCT) but are limited by sample size or by approach and no study has estimated narrow-sense heritability of RCT. We perform a comprehensive assessment on the familial heritability of RCT.

Methods: We utilized data from three studies: the cuffGen study, BioVU and UK Biobank (UKB). In cuffGen, imaging confirmed RCT cases and controls completed a baseline questionnaire inquiring about their family history of RCT. In BioVU and UKB, RCT status was identified using electronic health record (EHR) data, while family relatedness was estimated empirically with genome-wide genetic array data. We then evaluated the association between family relatedness and RCT status in all three studies using multivariable-adjusted logistic regression models while adjusting for age, sex, race/ethnicity, and genetic principal components (when appropriate). Then utilizing genetic data in BioVU and UKB, we estimated narrow-sense/SNP-based heritability for RCT, employing linkage disequilibrium score regression approach.

Results: In the cuffGen study, RCT cases were more likely to report any family history of RCT (Adjusted Odds Ratio [AOR]: 1.82; 95%CI 1.23-2.70) than controls. The association was stronger in first-degree relatives (AOR- 1.59; 95%CI 1.12-2.26), than in second-degree relatives. In BioVU and UKB, familial relatedness is also associated with increased odds of RCT (BioVU: AOR- 1.21; 95%CI 1.13-1.30; UKB: AOR- 1.09; 95%CI 1.04-1.15). However, the strongest associations were observed in third-degree relatives in BioVU (AOR: 1.56; 95%CI 1.10-2.14) and second-degree relatives in UKB (AOR: 1.25; 95%CI 1.12-1.39) rather than first-degree relatives. In SNP-based heritability analyses, we observed less than 1% of heritability of RCT was explained by SNPs (0.2% in BioVU, 0.75% in UKB) suggesting minimal contribution of genetic factors in heritability of RCT.

Conclusion: While rotator cuff tears (RCT) cluster within families, SNP-based heritability explains less than 1% contribution to heritability of symptomatic RCT. These data suggest that genetic factors alone may have a minimal impact on symptomatic RCT susceptibility, while non-genetic familial factors, such as environmental or healthcare-related factors represent plausible alternative explanations that warrant further investigation.

Level of evidence: Prognostic Level III.

Background: Assessment of bony parameters-such as glenoid version, glenoid concavity, and the bony shoulder stability ratio (BSSR)-has gained increasing attention after anterior shoulder dislocation, as they may contribute to persistent instability. Although computed tomography (CT) remains the gold standard for bony assessment, MRI is the primary imaging modality in many patients. Yet evidence comparing CT and magnetic resonance imaging (MRI) for these specific parameters remains limited. This study aimed to evaluate the agreement between MRI and CT in measuring glenoid version, glenoid concavity, and BSSR following anterior shoulder dislocation. We hypothesized that MRI provides measurements to those obtained with CT, demonstrating good agreement without clinically meaningful differences following anterior shoulder dislocation.

Methods: A retrospective case-series study was conducted at a Level I trauma center, screening patients who sustained anterior shoulder dislocation between 2011 and 2020. Glenoid version, glenoid depth, humeral head radius, and BSSR were measured using standardized multiplanar reconstructions by two independent raters. Interrater reliability was calculated using the intraclass correlation coefficient (ICC). Agreement between modalities was assessed using Student's t-tests, Pearson correlation coefficients, concordance correlation coefficients, and Bland-Altman analysis.

Results: Sixty-one patients (mean age, 45 ± 19 years; 75% male) met inclusion criteria. Interrater reliability was excellent for glenoid version (ICC, 0.92) and good for glenoid depth (ICC, 0.87) and humeral head radius (ICC, 0.82). No significant differences were observed between CT and MRI for glenoid version (3.7° ± 4.0° vs 3.4° ± 3.7°; P = 0.10), glenoid depth (1.4 ± 0.7 mm vs 1.3 ± 0.7 mm; P = 0.49), humeral head radius (23.1 ± 2.0 mm vs 22.5 ± 4.9 mm; P = 0.33), or BSSR (34.8% ± 10.1% vs 33.5% ± 11.2%; P = 0.34). Bland-Altman plots demonstrated good agreement, with MRI showing only minimal underestimation across parameters.

Conclusion: MRI provides reliable measurements of glenoid version, glenoid concavity, and BSSR that closely align with CT following anterior shoulder dislocation. These findings support MRI as a viable modality for assessing key bony stability parameters, potentially reducing the need for supplemental CT in many clinical scenarios. Prospective studies are warranted to validate these results and explore their implications for surgical decision-making and recurrence risk stratification.

Background: Cannabis use has become increasingly common in the general population, with cannabis use disorder (CUD) defined as clinically significant impairment and/or distress related to cannabis consumption. Prior studies have associated CUD with increased postoperative pain and opioid use, but its impact following arthroscopic rotator cuff repair (RCR) remains unclear. This study aimed to compare short- and long-term surgical outcomes following RCR between patients with and without CUD.

Methods: Using the TriNetX database, we conducted a retrospective cohort study of patients who underwent arthroscopic RCR for full-thickness rotator cuff tears. Patients diagnosed with CUD within three months prior to surgery were compared to patients without any documented history of CUD. 1:1 propensity-score matching was performed to control for demographics and comorbidities, resulting in two matched cohorts. Outcomes within 90 days included postoperative pain, opioid use, mean number of opioid prescriptions, shoulder stiffness, and physical therapy (PT) utilization. Long-term outcomes assessed within two years included upper limb mononeuropathies, shoulder pain or stiffness, conversion to total shoulder arthroplasty, revision RCR, arthroscopic debridement, and new-onset opioid-related disorders.

Results: After matching, 3,012 patients remained in each cohort with no significant differences in baseline characteristics. In the first 14 days postoperatively, CUD patients had higher rates of opioid use (42.0% vs. 35.9%, p < 0.0001), acute pain (4.2% vs. 2.6%, p = 0.0008), and a greater number of opioid prescriptions (0.677 ± 1.137 vs. 0.539 ± 0.959, p < 0.0001). These differences persisted through postoperative days 15-42, during which CUD patients also attended fewer PT sessions (2.685 ± 1.941 vs. 3.158 ± 2.334, p < 0.0001). From days 43-90, opioid-related outcomes were similar between groups, though CUD patients continued to have fewer PT visits (3.858 ± 3.187 vs. 4.584 ± 3.719, p < 0.0001). No significant differences were observed in long-term complications at two years.

Conclusion: For patients undergoing arthroscopic RCR, a coded diagnosis of CUD was associated with increased early postoperative pain, greater opioid requirements, and lower PT participation within 90 days of surgery. More research is required to investigate the nature of this association.

Background: Previous studies have reported that human dermal allograft (HDA) augmentation can improve clinical outcomes and reduce retears in large-to-massive rotator cuff tears (LMRCTs). However, its effectiveness in cases with anterior cable disruptions has not been well established. The purpose of this study was to evaluate whether patch augmentation is still effective in the presence of anterior cable disruption.

Methods: We retrospectively reviewed patients who underwent arthroscopic repair with HDA augmentation for repairable LMRCTs between March 2020 and May 2023. Patients were divided into two groups according to the integrity of the anterior rotator cable, including intact cable group (Group A) and the anterior cable disruption group (Group B). Patients with a minimum of 24 months of follow-up were included. Clinical outcomes were assessed using the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), University of California, Los Angeles (UCLA) score, and range of motion (ROM). Structural evaluations included the acromiohumeral interval (AHI), combined tendon-graft thickness, and retear rate.

Results: A total of 78 patients were included with a mean follow-up of 39.0 months (range, 25.2-56.1 months). The mean age was 64.7 years (range, 44-82 years), and 35 patients (44.9%) were male. Both groups demonstrated significant postoperative improvement in VAS (P < .001), ASES (P < .001), and UCLA scores (P < .001) with no significant difference between groups. Overall, 92.5% of patients achieved the minimum clinically important difference (MCID) for VAS, 85.0% for ASES, and 97.5% for UCLA scores, with no significant differences between groups (P > .05). Postoperative active ROM, including forward flexion, external rotation, and abduction, improved significantly in both groups (all P < .05) with no significant intergroup differences (all P > .05). The AHI increased significantly in both Group A (from 8.8 to 9.7 mm; P < .001) and Group B (from 8.5 to 9.7 mm; P < .001). Follow-up MRI demonstrated a significant decrease in combined tendon-graft thickness, with a mean reduction of 29% (from 8.0 to 5.6 mm; P < .001). The overall retear rate was 7.7% (6 of 78 patients), with no significant difference between Group A (6.1%) and Group B (10.3%) (P = .665).

Conclusions: Arthroscopic rotator cuff repair with HDA augmentation for LMRCTs resulted in improved clinical outcomes and a low retear rate regardless of anterior cable integrity. The postoperative increase in AHI suggests improved glenohumeral joint stability following restoration of rotator cuff function. These results indicate that patch augmentation is a viable treatment option for repairable LMRCTs with anterior cable disruption.

Introduction: Cervical spine pathology frequently coexists with shoulder pathology, which may contribute to referred pain and muscle weakness that can compromise shoulder function. This study aimed to evaluate clinical outcomes of patients with prior cervical fusion undergoing total shoulder arthroplasty (TSA).

Methods: A retrospective review of prospectively collected data was performed for patients undergoing anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) by two fellowship-trained shoulder surgeons between 2017 and 2023. Patients with a history of cervical fusion were matched 1:1 with controls without prior fusion based on age, sex, BMI, preoperative diagnosis, and procedure. Outcomes included Visual Analog Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and range of motion (ROM), assessed preoperatively and at a minimum 24 months follow-up. Independent and paired t-tests were used for comparisons, with significance defined as p<0.05.

Results: A total of 112 patients were included (56 with prior cervical fusion, 56 controls), including 26 aTSA patients (n=13 per group) and 86 rTSA patients (n=43 per group). Across the entire cohort, both groups achieved significant improvement in pain and function from baseline (all p<0.001). No differences were observed in postoperative VAS (1.78 vs. 1.15, p=0.128), ASES (76.2 vs. 80.4, p=0.254), SST (8.2 vs. 9.0, p=0.222), or ROM outcomes (all p>0.05). The magnitude of improvement was also comparable between groups. In the aTSA subgroup, patients with prior cervical fusion achieved significantly lower postoperative ASES (76.3 vs. 91.7, p=0.038) and SST scores (8.1 vs. 11.2, p=0.025), though preoperative to postoperative improvements were not significantly different (ASES p=0.426, SST p=0.259). In the rTSA subgroup, no differences were observed in the improvement of pain, function, or ROM.

Conclusion: Prior cervical fusion was not associated with inferior outcomes following TSA at short-term follow-up. Although patients with cervical fusion undergoing aTSA demonstrated lower absolute postoperative functional scores, their improvements were comparable to controls.

Background: In osteochondritis dissecans (OCD) of the humeral capitellum, defect location and size were important in surgical planning. Recently, it was reported that posterior or large osteochondral defects of the humeral capitellum on preoperative sagittal computed tomography affected outcomes of arthroscopic debridement for OCD in adolescent baseball players. Here, we investigated radiocapitellar joint contact pressure for anterior and posterior osteochondral defect positions in the sagittal section of the humeral capitellum.

Methods: An anterior or posterior osteochondral defect of the humeral capitellum (10 mm in diameter) was created on each side in 7 matched pairs of fresh-frozen cadavers. Radiocapitellar joint contact pressure was measured with and without valgus stress at 0°, 30°, 60°, and 90° of elbow flexion and with and without varus stress at 0° of elbow extension.

Results: In the posterior defect group, comparison of radiocapitellar joint contact pressure was significantly greater when the elbow joint was at 0° extension and 90° flexion than at other angles with valgus and varus stress (P < 0.05). Lower locations in posterior defects in the sagittal section showed significantly greater radiocapitellar joint contact pressure at 0° extension and 90° flexion of elbow joint with valgus stress. (both P < 0.05).

Conclusion: Radiocapitellar joint contact pressure with valgus and varus stress was significantly greater with a posterior osteochondral defect than with an anterior defect when the elbow joint was at 0° extension and 90° flexion. For posterior defects, the contact pressure increased at lower locations in defects in the sagittal section.

Background: Reverse total shoulder arthroplasty (rTSA) consistently improves pain and function; however, the biomechanical mechanisms underpinning postoperative function and joint-level adaptations remain incompletely defined. Advanced measurement tools, including motion capture, electromyography (EMG), inertial measurement units (IMU), and accelerometry, enable objective assessment of joint motion, muscle activation, and real-world arm use. This systematic review synthesizes evidence from studies using advanced biomechanical methods to evaluate postoperative kinematics, upper-limb activity, and muscle activation after rTSA.

Methods: Seven databases (1985-2025) were searched for observational studies reporting quantitative biomechanical outcomes after rTSA, compared with preoperative baselines, contralateral shoulders, or healthy controls. Outcomes were categorized as kinematics, real-world upper-limb activity, or neuromuscular activation. Methodological quality was assessed using Joanna Briggs Institute criteria, and levels of evidence were classified according to Journal of Shoulder and Elbow Surgery guidelines.

Results: Twenty-four studies (10 cohort and 14 case-control; all Level III) met inclusion criteria. Twenty-one had moderate risk-of-bias and three high risk. Implant designs, surgical indications, and follow-up durations were heterogeneous. High-rigor optical and electromagnetic motion capture studies showed consistent gains in forward elevation, while glenohumeral contribution, axial rotation, and scapulohumeral rhythm remained reduced relative to contralateral or healthy shoulders. Elevation occurred predominantly through increased scapulothoracic upward rotation, retraction, and posterior tilt. Laboratory-based IMU studies showed similar patterns of greater scapular contribution despite non-standardized coordinate systems. Wearable sensors reported increased postoperative arm use and improved interlimb symmetry, although time spent above shoulder height remained limited. EMG studies demonstrated increased deltoid and upper-trapezius activation with limited posterior cuff recruitment.

Conclusion: rTSA restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics. Standardized, longitudinal studies integrating high-fidelity kinematics, EMG, and real-world activity monitoring, with explicit reporting of implant construct parameters, are needed to clarify how surgical technique and implant design influence postoperative biomechanics and functional recovery.

Background: The minimal clinically important difference (MCID) helps interpret whether changes in patient-reported outcomes reflect meaningful benefit. For adhesive capsulitis, an MCID for the University of California, Los Angeles (UCLA) Shoulder Score has not been established for patients treated nonoperatively.

Methods: We performed a retrospective observational cohort study of consecutive patients with idiopathic adhesive capsulitis treated between 2020 and 2024 at a single outpatient center. A standardized conservative program (supervised physiotherapy with home exercises; analgesic optimization) was used; 42% additionally received serial suprascapular nerve blocks as part of a separate RCT protocol. The UCLA Shoulder Score and pain measured by visual analog scale (VAS) were collected at baseline and 2, 4, and 6 months (primary endpoint). MCID was estimated using (1) an anchor-based method with the UCLA satisfaction item (satisfied vs not satisfied), (2) distribution-based indices (0.5 SD; minimum detectable change [MDC] assuming r=0.84), and (3) receiver operating characteristic (ROC) analysis with Youden index. Multivariable logistic regression explored predictors of 6-month satisfaction.

Results: A total of 226 patients completed 6-month follow-up (mean age 54.2±9.2 years; 66.7% female). Median UCLA improved from 18.0 to 35.0 (p<0.001); VAS decreased from 8.0 to 0.0 (p<0.001). Range of motion improved significantly in all planes (all p<0.05). At 6 months, 200/226 (88.5%) were satisfied. Median UCLA change was 17 points (Interquartile Range - IQR 4) in satisfied vs 8 points (IQR 6.5) in unsatisfied patients; the between-group median difference was 9 points (95% CI 6-10; p<0.001), defining the anchor-based MCID. ROC analysis identified a 14-point improvement as optimal (AUC 0.900; sensitivity 90.5%; specificity 84.6%), whereas distribution-based estimates were smaller (0.5 SD=1.41; MDC=3.12). Integrating anchor-based and ROC findings, we recommend an MCID of 11.5 points for the UCLA score in nonoperative adhesive capsulitis. In multivariable analysis, higher baseline UCLA was the strongest independent predictor of patient satisfaction (OR = 1.37, 95% CI 1.13-1.66; p=0.001) CONCLUSION: In patients undergoing conservative management for adhesive capsulitis, we recommend a UCLA Shoulder Score improvement of 11.5 points as the clinically meaningful threshold, with anchor-based (9 points) and ROC (14 points) analyses providing convergent validity. This benchmark can guide clinical interpretation, sample-size planning, and comparative effectiveness studies in frozen shoulder.

Introduction: It has previously been considered that approximately 30% of acute traumatic posterior sternoclavicular joint (SCJ) injuries are associated with a significant injury to the retrosternal structures. However, over the past 50 years there have only been a handful of such cases described in the literature. We have undertaken a CT arteriogram (CTA) within 48 hours on a series of patients that have sustained an acute posterior SCJ injury to assess the incidence of associated retrosternal vascular injuries.

Materials & methods: Between May 2016 and December 2023 patients that had sustained an acute posterior SCJ injury and underwent a CT arteriogram within 24-hours of admission to hospital were reviewed. At the time of injury, the patients were specifically assessed for any associated clinical mediastinal or vascular symptoms. For the patients that underwent operative reduction and stabilisation the retrosternal vascular structures were visualised and assessed. Patient reported outcomes were assessed at final follow-up by the following scores: Quick-DASH, Rockwood SCJ, Constant and SANE score. Patients were also asked whether that had any specific retrosternal or vascular symptoms.

Results: A total of 24 patients were available at final follow-up. Sixteen patients had a posterior SCJ dislocation and 8 had a posteriorly displaced Salter-Harris 2 fracture of the medial end of the clavicle. The mean age at the time of injury was 27.6 years (15-69) and the mean follow-up was 77.8 months (25 - 131). One patient had mediastinal symptoms in the form of dyspnoea at the time of injury. On CTA there was no evidence of a vascular injury, pseudoaneurysm or bleeding in any of the patients. Five patients had a haematoma associated with the capsular injury, 13 patients had evidence of compression of the left brachiocephalic vein and 1 patient had additional compression of the aortic arch. There was no evidence of any vascular injury on inspection in the 20 patients that underwent operative reduction and stabilisation. At final follow-up the mean Quick-DASH score was 2.0 (0 - 20.3), Rockwood SCJ Score was 14.5 (11 - 15), Modified Constant Score was 96.7 (69 - 100) and SANE score was 98.7 (80 - 100). None of the patients described any associated mediastinal or vascular problems.

Conclusion: Following an acute posterior SCJ injury, the incidence of retrosternal vascular injuries is less than had previously been considered. This should allow an adequate window of time for the management of this injury to be undertaken in an appropriate specialist unit.

Background: Olecranon fractures are common fractures of the elbow and may lead to symptomatic post-traumatic osteoarthritis (OA). The incidence and risk factors for ulnohumeral OA after an olecranon fracture remain uncertain. Therefore, this review aimed to: 1) determine the incidence of OA following isolated olecranon fractures; 2) assess the role of instability and comminution in the development of OA, and 3) assess the impact of OA on patient-reported outcome measures (PROMs).

Methods: Multiple medical databases were searched for studies containing the terms "olecranon", "osteoarthritis", and "fracture". Studies were screened for predetermined inclusion and exclusion criteria, including a minimum follow-up of 24 months and radiographic assessment of OA. Patient and treatment characteristics were collected alongside clinical and functional outcomes. The studies' methodological quality was assessed using the MINORS criteria. The Mayo classification was used to assess olecranon fractures for comminution and instability, categorizing them into three types: type 1 (non-displaced, stable), type 2 (displaced, stable), and type 3 (displaced, unstable). Each type is subdivided into A (non-comminuted) or B (comminuted). Due to a high degree of heterogeneity, pooling of the data was avoided; instead, results were summarized using ranges, medians, and interquartile ranges.

Results: Eleven studies were included, comprising a total of 362 patients with a median follow-up of 41 months (Range: 27-240; IQR: 29-74). The MINORS scores for these studies ranged from poor to moderate. The median OA incidence across these studies was 19% (Range: 0%-35%; IQR: 3%-26%). The median OA incidence was 25% (Range: 0%-50%; IQR: 13%-38%) for Mayo type 1 fractures, 16% (Range: 0%-30%; IQR: 0%-25%) for type 2, and 50% (Range: 40%-100%; IQR: 45%-75%) for type 3. For non-comminuted fractures (type 2A), the median OA incidence was 16% (Range: 0%-28%; IQR: 0%-18%), while for comminuted fractures (type 2B), the median was 24% (Range: 0%-38%; IQR: 17%-30%). Mayo Elbow Performance Score (MEPS) scores for patients with OA were reported in 3 studies with a median score of 93 (Range: 83-94). The median MEPS across all included studies was 92 (Range: 86-98; IQR: 90-96).

Conclusion: This review identified a median OA incidence of 19% at a median follow-up of 41 months following isolated olecranon fractures. However, final PROMs ranged from good to excellent regardless of fracture type or the presence of OA. Given that all studies were heterogeneous and of poor to moderate quality, additional larger studies with preferably prospective designs are needed to assess if comminution or instability affects the development of ulnohumeral OA even after appropriate surgical treatment.