Journal of Shoulder and Elbow Surgery最新文献

Objective: This retrospective, observational study aimed to assess the revision rates and survival curves in total shoulder arthroplasty (TSA) and hemi-shoulder arthroplasty (HSA) patients, including a sub analysis to investigate the impact of pyrocarbon humeral head in revision rates.

Methods: Data from 92 primary HSA and 508 primary TSA patients performed by seven surgeons at a large private clinic, were analyzed. The study focused on revision rates and identified factors leading to revisions, including rotator cuff insufficiency, dislocation, aseptic loosening, implant material, and glenoid erosion.

Results: The overall revision rate for HSA was found to be significantly higher at 7.6% compared to TSA at 1.2% with a maximum follow-up of seven years. Sub-analysis within the HSA group revealed a notably higher revision rate in cases involving a metal head (cobalt-chrome or titanium) at 12.8% compared to those with a pyrocarbon head (2.3%).

Conclusion: This study underscores the importance of distinguishing between TSA and HSA when evaluating shoulder arthroplasty outcomes. The significantly higher revision rate in HSA, particularly with metal heads, suggests the need for careful consideration of implant selection to optimize long-term success in shoulder arthroplasty procedures.

Background: Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty.

Methods: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 RESULTS: A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90^th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90^th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90^th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001).

Conclusion: Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

Background: The objective of this study is to evaluate the outcomes of arthroscopic capsulolabral repair in patients with structural dynamic posterior instability (Moroder classification B2), analyzing factors associated with inferior clinical outcomes or recurrence. The primary hypothesis is that this surgical approach in patients without static structural changes such as excessive glenoid retroversion or dysplastic glenoids will result in satisfactory clinical outcomes and low failure rates.

Methods: We conducted observational retrospective analysis in patients diagnosed with posterior structural dynamic instability who underwent arthroscopic capsulolabral repair. Demographic, clinical, and radiologic characteristics were registered, as well as patient-reported outcomes, satisfaction, complications, and failure, with a minimum 2-year follow-up. The association between these outcomes and preoperative factors was investigated.

Results: 21 patients were included, with an average age of 38.1 years (range: 27-51 years) and a mean follow-up of 68.7 months (range: 24-127 months). At the final follow-up, the degree of instability was 0 in 19 (90.5%) patients. The overall outcome assessment demonstrated a mean Subjective Shoulder Value score of 82.3 (±15.2), a mean Western Ontario Shoulder Instability score of 460.1 (±471), and a mean Rowe score of 91.5 (±13). Furthermore, a significant portion of patients returned to sport: 71.4% at any level and 57.1% at the previous level, and 71.4% reported satisfaction with treatment, whereas 5 (23.8%) patients had criteria for failure.

Conclusion: Arthroscopic capsulolabral repair in selected patients with type B2 posterior shoulder instability without static posterior findings yielded satisfactory clinical outcomes and low failure rates.

Background: Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI 2) untreated BPBI or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of eight patients who underwent shoulder reanimation.

Methods: A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion. To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For external rotation, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol.

Results: Eight patients (13.8±5.6 years, 35±24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction. Preoperatively, patients generally had 0-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90-180°) of abduction. Preoperatively, patients had 0-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients' FF increased to an average of 91° (20-170°).

Conclusion: This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

Background: In the past decade, the prevalence of end-stage inflammatory elbow arthritis has declined with consequential changes in indications and utilization of total elbow arthroplasty (TEA). Current literature lacks future projections for the utilization of TEA. The aim of this study is to review the trends in the utilization of TEA in the last 2 decades and determine the projections of utilization for TEA (primary and revision) through 2060.

Methods: This analysis used the publicly available 2000-2019 data from the CMS Medicare Part-B National Summary. Procedure volumes including TEA, and revision TEA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Using these volumes, log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to generate projections from 2020 to 2060. The Poisson model was chosen to display the data based on error analysis and prior literature.

Results: The projected annual growth rates from 2020 to 2060 for primary and revision TEAs are 1.03% (95% confidence interval: 0.82%-1.25%) and 5.17% (95% confidence interval: 3.02%-6.97%), respectively. By 2060, the demand for primary TEA and revision TEA is projected to be 2084 procedures (95% forecast interval: 1995-2174) and 3161 procedures (95% forecast interval: 3052-3272), respectively. The procedure volume for revision TEA is estimated to outnumber primary TEA by year 2050.

Conclusion: The overall procedural volume of primary TEA and revision TEA continues to be low. Although it is estimated that the incidence of primary and revision TEAs will continue to increase in the next 40 years, the utilization trends only show a mild increase, which is 5 times higher for revision TEA than primary TEA.

Introduction: The treatment of complex radial head fractures remains controversial with open reduction and internal fixation (ORIF), radial head arthroplasty, and radial head excision being the most common treatment options. While ORIF is the preferred treatment strategy for Mason type II fractures, the optimal treatment of Mason type III fractures is debated.

Purpose: To report minimum 10-year outcomes after ORIF of Mason type II and type III radial head fractures. We hypothesized that both Mason Type II and Type III fracture patients would demonstrate satisfactory clinical outcomes at minimum 10-year follow-up.

Methods: All patients with Mason type II or III radial head fractures who were treated with ORIF by a single surgeon between 2005 and 2010 were included. Fractures with significant bone defects were treated with bone grafts and elbow ligament injuries were treated with either primary ligament repair or reconstruction. Patient reported outcome (PRO) questionnaires were administered at the time of last clinical follow-up and at a minimum of 10 years postoperatively.

Results: Twenty-four patients, including 13 male and 11 female patients with an average age of 39 (range 19-60) at the time of surgery met inclusion criteria. Thirteen patients suffered from Mason type II and 11 patients from Mason type III fractures. At initial follow-up, 21 out of 24 fractures (88%) demonstrated radiographic union. Three non-unions, 2 of which were Mason type III fractures, were treated with revision ORIF and iliac crest bone grafting. 11 patients developed postoperative elbow stiffness and required capsular release surgery. At last clinical follow-up, average flexion was 139 degrees, average extension was 4 degrees, average supination was 77 degrees, and average pronation was 81 degrees. The median DASH score was 7 (ranging from 0 - 32). Minimum 10-year follow-up (mean: 14.6 years) was collected on 18 of 24 (75%) of the patients. At a minimum of 10 years postoperatively, the median QuickDASH score was 4.5 (range: 0 to 25) and the median SANE score was 96.5 (range: 75-100). Median satisfaction with the surgical outcome was 10/10 (range: 3-10).

Conclusion: ORIF of Mason type II and III radial head fractures results in high union rates with good functional outcomes at a mean of 14.6 years postoperatively. The study results suggest that ORIF of Mason type II and III radial head fractures leads to long-term positive functional outcomes.

Background: Subscapularis tendon (SSc) dysfunction following total shoulder arthroplasty (TSA) results in poor functional outcomes. There have been numerous SSc repair constructs tested biomechanically and clinically, however, none has been demonstrated as superior. Newer techniques and implants have emerged, but have not been fully tested.

Hypothesis: We hypothesized that the unicortical button (UB) fixation will provide significantly improved restoration of the anatomic footprint and biomechanical properties when compared to transosseous (TO) repair of the SSc.

Methods: A digital footprint of SSc humeral insertion was obtained in 6 pairs of fresh-frozen cadaveric shoulders using a three-dimensional (3-D) digitizer. A complete SSc tear was created, and each pair of shoulders was randomized to either SSc repair with UB or TO repair. Each specimen underwent a cyclic loading protocol followed by pull-to-failure. The failure load, elongation at failure, gapping failure, number of cycles until failure, the load at key gapping points (1 mm, 3 mm, 5 mm, and 10 mm) and the failure mode were recorded using high-resolution video recording. 3-D surfaces of the insertion footprint and repair site were obtained, and surface areas were calculated using a custom MATLAB script and laser scanner. Paired t-tests were conducted to compare differences between two repair groups.

Results: Failure load was significantly higher in the UB group (382.4 N ± 56.5 N) than in the TO group (253.6 N ± 103.4 N, p=0.005). TO repair provided higher gapping at failure (28.8 mm ± 8.2 mm) than UB repair (10.4 mm ± 6.8 mm, p=0.0017). UB repair had significantly higher load at the 1-mm, 5-mm, and 10-mm gapping compared with TO repair with p=0.042, p=0.033, and p=0.0076, respectively. There were no significant differences between elongation failure, the difference in footprint area from native to repair states, or the percentage of restored footprint area between groups. (p=0.26, p=0.18 and p=0.21 respectively) CONCLUSION: The UB fixation showed a significantly lower gap at failure, higher failure load and number of cycles until failure, and higher gap loads compared with the traditional TO repair for SSc. Although more clinical research is necessary, the UB fixation that utilizes cortical bone presents promising results.

Background: Fixation of displaced radial head fractures using miniplates is technically challenging and has some drawbacks like hardware prominence and limitation of forearm rotation. Fixation by headless compression screws has emerged as a less invasive alternative to miniplates. This study compares the radiological and functional outcomes of both methods of fixation.

Methods: This single-center, prospective, randomized controlled trial was conducted at an academic level 1 trauma center. Sixty patients with displaced isolated radial head fractures were randomized to treatment using either headless compression screws or miniplates in 2 parallel groups. At the final follow-up of 18 months, patients were evaluated radiologically for union and clinically using the Mayo Elbow Performance Score (MEPS), elbow range of motion, grip strength, the visual analogue scale (VAS) for pain, and the Disabilities of the Shoulder, Arm, and Hand (DASH) score.

Results: Union was achieved after 8 ± 1.7 weeks in the screw group and after 8.5 ± 2.7 weeks in the plate group. The MEPS was significantly better in the screw group (87.7 ± 10.7) than in the plate group (80.5 ± 13.9). However, this difference is below the minimum clinically important difference (MCID) for the MEPS and as such may not be clinically meaningful. No significant differences were observed between both groups regarding flexion, extension ranges, VAS, grip strength, or the DASH score. However, supination and pronation were significantly better in the screw group. The rate of complications was higher in the plate group (26.7%) than in the screw group (3.3%).

Conclusion: Both techniques yielded comparable outcomes with better forearm rotation, a lower complication rate, and a lower hardware removal rate in the screw group.

Background: To identify the potential role of humeral retrotorsion (HRT) and range of motion (ROM) as a risk factor for shoulder overuse injury in elite youth handball players. The hypothesis was that increased HRT is associated with an increased risk of shoulder overuse injury.

Methods: Over 2 seasons, 258 elite youth handball players (52% boys; age:14 ± 0.8 years) were included. Preseason assessment included HRT and glenohumeral internal and external (ER) rotational ROM using ultrasound and a manual goniometer. Sports-specific adaptations between male and female athletes and the dominant and nondominant shoulder were calculated. In addition, players completed standardized questionnaires over the 2018-2019 or 2019-20 season and reported any shoulder overuse symptoms using the Western Ontario Shoulder Index questionnaire.

Results: Comparing male and female players showed significantly decreased HRT and decreased internal ROM in the dominant side of male athletes (P ≤ .027). No other difference was found. Significant side-to-side differences between the dominant and nondominant shoulder were found for HRT, internal rotation, and ER, regardless of sex (P < .001). For total range of motion, only female athletes showed a significant increase in the dominant arm (P = .032). The dominant side showed a significantly higher glenohumeral internal rotation deficit in male athletes than in female athletes (10° ± 17° vs 5° ± 10°, P = .011). Adaptations in HRT, ER gain, and total range of motion gain were not significant. Over the course of the 2 seasons, 20 athletes reported shoulder overuse injuries. Although glenohumeral internal rotation deficit was borderline nonsignificant (P = .056), none of the parameters tested were significantly associated with shoulder overuse injuries.

Conclusion: Despite significant side-to-side differences and sport-specific adaptations, individual preseason screening of humeral retrotorsion and soft tissue adaptations does not identify elite youth handball athletes at increased risk of shoulder overuse injury.