Journal of Shoulder and Elbow Surgery最新文献

Background: Hand-behind-back (HBB) motion is commonly used to assess shoulder internal rotation; however, it involves multiple joint movements, including scapulothoracic, glenohumeral, and elbow joint motions, thus complicating the interpretation of the HBB position. This study aimed to investigate 3-dimensional joint alignment during HBB motion of the bilateral shoulders in patients with frozen shoulder and to identify which joint motions primarily contribute to motion limitation.

Methods: Seventeen patients with unilateral frozen shoulder underwent bilateral shoulder computed tomography scans in the neutral and HBB positions using an upright multidetector computed tomography. Bone surface models of the thorax, scapula, humerus, and forearm were created to calculate the rotation of the scapulothoracic, glenohumeral, thoracohumeral, and elbow joints. The affected and unaffected sides were compared, and the correlation between the HBB reach level (vertebral level) and the thoracohumeral internal rotation angle was analyzed.

Results: No significant differences in joint rotation were observed between the sides in the neutral position. The affected side demonstrated significantly reduced glenohumeral internal rotation (31° vs. 66°, P < .001), abduction (10° vs. 22°, P < .001), and elbow flexion (74° vs. 115°, P < .001) during HBB motion. The scapulothoracic joint on the affected side had less internal rotation (18° vs. 21°; P = .045) and more anterior tilt (24° vs. 19°; P = .003). The HBB reach level was negatively correlated with the thoracohumeral internal rotation angle in the unaffected and affected sides (r = -0.518 and r = -0.675, respectively).

Conclusion: This study clarified that limited internal rotation of the glenohumeral joint is the main cause of restricted HBB motion in frozen shoulder, which supports the use of the thumb-to-spinous process as a valid measure of thoracohumeral internal rotation in patients with frozen shoulder.

Background: Olecranon fractures occur more commonly in older individuals. For patients aged ≥70 years, operative management is often considered standard of care, although recent evidence has supported nonoperative treatment in frail and/or elderly patients. With evolving treatment indications, more granular evidence is beneficial to guide patient-specific decision-making. The aim of this investigation was to explore patient and treatment factors associated with outcomes after displaced, closed olecranon fractures in older individuals.

Methods: This retrospective cohort study with prospective data collection included 113 patients (mean age 81; 81% female) aged ≥70 years with displaced, stable olecranon fractures (Mayo 2A/2B). Patients were treated operatively via precontoured olecranon locking plates (n = 68) or tension band wiring (n = 6) or nonoperatively (n = 39) with progressive mobilization. Frailty was quantified using the Clinical Frailty Scale. The primary outcome was Quick Disabilities of the Arm, Shoulder, and Hand score. Secondary outcomes included range of motion, Patient-Reported Outcomes Measurement Information System (PROMIS) global health, and complications. Mean time from injury to outcome collection was 16 ± 2 months.

Results: Mean Quick Disabilities of the Arm, Shoulder, and Hand was lower in the operative cohort (mean difference -8.3; 95% confidence interval: 0.4-16.2; P = .021), although the difference was not clinically meaningful (minimal clinically important difference = 15). Subgroup analysis by frailty revealed no differences between operative and nonoperative management in the mildly frail and moderate to severely frail subgroups. Linear regression identified frailty was associated with limb-specific disability (β = 4.86; P = .001); age was not a significant predictor when controlling for frailty. In the plate fixation group, engaging the proximal fragment fixation with <3 screws was associated with proximal fragment escape (β = 3.13, standard error = 0.94, odds ratio = 22.9, 95% confidence interval: 3.63-144.8, P = .001) independent of fragment size, comminution, and triceps reinforcement. In the nonoperative group, increasing immobilization duration was associated with decreased arc of motion (β = -4.1, standard error = 1.3, R² = 0.29, P = .006).

Conclusion: This study reinforces recent Level I evidence suggesting that operative management of displaced olecranon fractures does not result in superior long-term functional outcomes for the average older patient. Frailty, rather than chronological age, is a primary driver of limb-related disability. Early mobilization is a low-risk alternative to operative management. When surgery is pursued to achieve faster recovery or improved early elbow extension, surgeons should ensure robust proximal fragment fixation with at least 3 screws to minimize the risk of failure.