Background: The subcoracoid space includes the subcoracoid bursa (SCB) and subscapular bursa (SSB). We aimed to clarify the relationship between the presence or amount of SCB effusion and other structures around the SCB on magnetic resonance imaging (MRI) and to discuss the pathological formation of SCB effusion.
Methods: Medical records and MR images of patients who had undergone MRI examinations for shoulder pain were retrospectively reviewed. The presence or absence of SCB, SSB, and subacromial-subdeltoid bursa (SASDB) effusion was evaluated. If SCB effusion was present, the largest diameter of the effusion was measured on sagittal images to represent the amount of SCB effusion. The presence or absence of communication between the SCB and SASDB or SSB effusion were also evaluated on sagittal and axial MRI.
Results: Eighty shoulders in 70 patients were analyzed. The mean age was 70.4 ± 10.4 (range, 50-87) years. Thirty-three of the 80 shoulders (41.3%) showed SCB effusion on MRI. The clinical diagnoses of these 33 shoulders were rotator cuff tear (RCT), n = 23; frozen shoulder, n = 6; subacromial impingement, n = 3; and calcific tendinopathy, n = 1. Multivariate logistic regression analysis showed that RCT (P = 0.015) and SSB effusion (P = 0.036) were significantly associated with the presence of SCB effusion, but SASDB effusion was not. In shoulders with RCT, the SCB communicated with the SASDB in 65.2%, and with the SSB in 4.3%. In other shoulders, the SCB communicated with the SASDB in 60.0%, and with the SSB in 40.0%. The rate of SCB-SSB communication was significantly higher in shoulders without RCT than in shoulders with RCT (P = 0.021). The largest diameter of SCB effusion was normally distributed in 33 shoulders (4.7-34.8 mm), and mean 19.6 ± 7.4 mm. The largest diameter of SCB effusion was 21.9 ± 6.3 mm in 23 shoulders with RCT, and 13.5 ± 6.8 mm in 10 other shoulders (P < 0.05). Multiple regression analysis showed that RCT (P = 0.002) and SSB effusion (P = 0.029) were significantly associated with the largest diameter of SCB effusion, but SASDB effusion was not.
Conclusion: SCB effusion can be recognized and extended by inflow from SASDB effusion in RCT. Without RCT, SCB effusion may occasionally be visible due to inflow from SSB effusion.
Background: Pain-relief plays a major deterministic role when assessing postoperative patient satisfaction; however, whether anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) provides the most durable pain-relief has not been studied. The purpose of this study was to evaluate the durability of pain-relief after aTSA compared to rTSA in patients undergoing surgery for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA).
Methods: A retrospective review of a multicenter shoulder arthroplasty database (Exactech Equinoxe) was performed. We included 1,848 aTSAs and 1,464 rTSAs performed for RCI-GHOA between 2007 and 2023. Pain after surgery was assessed postoperatively at 3-months, 6-months, and yearly thereafter. Average postoperative pain on a daily basis and pain at worst were compared between aTSA and rTSA up to 8-years postoperatively. Kaplan-Meier survivorship analysis for pain-relief maintenance was performed to compare the maintenance of clinically-relevant pain-relief defined as pain scores that achieved the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS). Maintenance of favorable patient satisfaction over time was also evaluated. Multivariable cox regression was performed to determine whether the type of prosthesis (aTSA vs. rTSA) was independently associated with pain recurrence.
Results: Maintenance of achievement of the MCID and SCB for both daily pain and pain at worst as well as favorable patient satisfaction was similar between aTSAs and rTSAs. However, aTSA had longer maintenance of average daily pain below the PASS compared to rTSA (P=.024). This was confirmed on multivariable cox regression analysis which found that rTSAs had a 34% greater likelihood of recurrence of postoperative average daily pain exceeding the PASS (VAS rating 1/10) compared to aTSAs.
Conclusion: Patients that undergo either aTSA or rTSA for RCI-GHOA and achieve initial pain-relief postoperatively can expect to maintain their clinically-relevant pain improvement at similar rates up to 8-years postoperatively. However, recurrence of low levels of daily pain was significantly higher after rTSA.
Background: Normal Constant score values for healthy shoulders can vary between regions and change over the years as life expectancy increases and physical condition improves. Spain's population is one of the healthiest and has one of the highest life expectancies in the world, which could be reflected in its normal Constant score values. The purpose of this study is finding the normal Constant score values in the Spanish population.
Methods: Cross-sectional study completed between 2023-2024, including subjects older than 18 years of age without any previous or ongoing shoulder condition. Constant score was taken for both shoulders of every subject. A stratified analysis of total and subtotal scores was performed, grouping subjects by age and sex.
Results: A total of 505 subjects and 1010 shoulders were included, with a mean age of 52.3 ± 18.6 years and men/women ratio of 39.6%/60.4%. Five groups were formed according to age: 18-30 years-old (18.4%), 31-45 years-old (16.4%), 46-60 years-old (29.8%), 61-75 years-old (23.7%), and over 75 years-old (11.7%). Each of these groups were divided in two groups according to sex, making a total of 10 groups. Mean Constant score was 88.9 ± 10.9, the group of men between 18-30 years-old having the highest mean score (99.2 ± 3.0) and the group of women over 75 years-old having the lowest mean score (75.3 ± 8.8). A statistically significant inverse correlation was found between total score and age (r = -.47, p < .001). Total score was also significantly lower in the women (84.5 ± 8.2 vs 92.6 ± 8.5, p < .001). The decrease in mobility (r = -.45, p < .001) and strength (r = -.40, p < .001), and the difference in strength between the men and the women (10.6 ± 3.8 vs 6.0 ± 2.0, p < .001) were the main underlying causes of the difference in total Constant score between groups.
Conclusion: Normal values of the Spanish version of the Constant score in healthy shoulders of the Spanish population decrease with age and are lower in women, the main differences being found in shoulder mobility and strength. Global scores found in this population are higher than those previously published for English, American, and Swiss populations.
Background: The increasing incidence of proximal humeral fractures (PHF) poses complex challenges in determining the optimal therapeutic strategies due to the diverse fracture patterns and individual patient characteristics. Traumatologists and orthopedic surgeons face significant decisions, as potential consequences such as pain, functional limitations, and complications may significantly affect patients' quality of life. Given the varying viewpoints on appropriate treatment modalities, a thorough examination of current care practices is crucial.
Methods: An adaptive online survey was conducted to present realistic case scenarios, aimed at elucidating decision-making processes in the management of proximal humeral fractures. This survey encompassed relevant patient and fracture-related variables, employing a dynamic querying algorithm that featured up to 48 conceivable case scenarios.
Results: Analysis of 7012 case scenarios unveiled significant differences in treatment preferences across distinct patient age groups. Plate osteosynthesis emerged as the preferred modality for individuals under 50 years of age with complex fracture patterns. On the other hand, a balanced consideration between plate osteosynthesis and reverse shoulder arthroplasty was observed in the 50-70 age cohort. Notably, respondents favored reverse shoulder arthroplasty as the treatment modality of choice for individuals over 70 years of age. A treatment algorithm was developed to outline decision pathways concisely, considering these patient age groups and the option of reverse shoulder arthroplasty.
Discussion and conclusion: This study provides clinically relevant insights into therapeutic decision-making processes in the management of proximal humeral fractures. The illustration of treatment preferences through a visualized algorithm serves as a crucial tool for evidence-based clinical decision-making, offering potential in enhancing the individualized care spectrum for patients with PHF.
Introduction: Periscapular fractures specifically acromial and scapular spine fractures, have been identified as one of the leading complications of RSA. However, very little is known of the etiology of these postoperative fractures, or how variations in humeral designs correlates with risk of postoperative fracture development. Therefore, the purpose of this study was to analyze the prevalence, timing, and relationship of humeral component design to acromial or scapular spine fractures.
Methods: A retrospective study of primary reverse total shoulder arthroplasty (RSA) performed for elective and traumatic indications from two tertiary institutions. Exclusions consisted of primary oncologic reconstructions, diagnosis of osteogenesis imperfecta, and less than 1 year of clinical follow-up. A total of 3,018 primary RSAs were included with a cohort of 1,739 (57.6%) females, a mean age of 71 years (range, 20 - 94 years), a mean BMI of 30.6 ± 6.6 kg/m2, and a mean follow-up of 6.4 ± 3.8 years. The implants utilized varied based on surgeon preference and included 9 different types. The humeral component of the RSA were categorized as an inlay design (n = 762; 25.2%), defined as a humeral component where the tray is seated within the metaphysis, or an onlay design (n = 2256; 74.8%) defined as a humeral component where the humeral tray sits on the metaphysis at the level of the humeral neck cut.
Results: A fracture of the acromion or scapular spine was radiographically identified in 64 of 3,018 (2.1%) RSA at an average of 8.5 months ± 12.6 months after surgery. The majority of fractures included the acromion (n = 57; 89.1%) and scapular spine (n = 7; 10.9). Non-operative management (n = 60; 93.8%) was the predominant treatment strategy for fractures, while 4 (6.2%) RSA underwent open reduction and internal fixation. When compared by humeral component design (inlay versus onlay), there was no differences in rates of acromial or scapular spine fractures (2.6% vs. 2.0%; P = .264). Similarly, there were no treatment differences between non-operative (90% vs. 95.5%) or operative management (10% vs. 4.5%) of the fractures based on the type of humeral component design (P = .403).
Conclusions: Acromial and scapular spine fractures complicated the postoperative course of 2.1% of primary RSA when performed across two high volume shoulder arthroplasty centers with multiple surgeons including a wide range of implant types. Most of the fractures involve the acromion, with less frequent involvement of the spine of the scapula. When comparing by inlay versus onlay humeral component design, the rates of postoperative acromial or scapular spine fractures were statistically similar.
Background: Subacromial osteolysis is a typical complication following hook plate fixation for acromioclavicular (AC) dislocation. Many factors can affect the occurrence and progression of subacromial osteolysis (SAO). The objective of this study was to investigate the predictive value of the implant removal time and acromion-hook angle for subacromial osteolysis following hook plate fixation for AC dislocation.
Methods: We conducted a retrospective study of 66 patients who underwent hook plate fixation for AC dislocations. The presence and severity of subacromial osteolysis were assessed at the time of implant removal. Univariate and multivariate logistic regression analyses were conducted to identify the characteristics associated with subacromial osteolysis. Receiver operating characteristic (ROC) analysis was performed to evaluate the predictive performance of the implant removal time and acromion-hook angle.
Results: Of the 66 patients, 48 had subacromial osteolysis. Univariate analysis revealed that the implant removal time and acromion-hook angle were associated with subacromial osteolysis. Multivariate analysis revealed that the acromion-hook angle was the only factor independently associated with subacromial osteolysis. In the ROC analysis, the optimal cut-off values of implant removal time were 5.5 months for predicting the occurrence of osteolysis and 11.9 months for predicting the severity of osteolysis. The acromial-hook angle cut-off values were 10° for predicting the occurrence of osteolysis and 16° for predicting the severity of osteolysis.
Conclusion: The implant removal time and acromion-hook angle were significant risk factors for subacromial osteolysis following hook plate fixation. We recommend removing the implant within 5.5 months to minimize osteolysis risk and no more than 11.9 months to prevent severe osteolysis. Maintaining the acromion-hook angle at 10° or less is advised, whereas an angle of 16° or more may indicate a greater risk of severe osteolysis.