Journal of Shoulder and Elbow Surgery最新文献

Background: There has been a recent push to transition procedures previously performed at hospital-based outpatient surgical departments (HOPDs) to ambulatory surgery centers (ASCs). However, limited data regarding differences in early postoperative complications and care utilization (eg, emergency department visits and unplanned admissions) may drive increased overall costs or worse outcomes.

Purpose/hypothesis: The purpose of this study was to examine differences in early 90-day adverse outcomes and postoperative emergency department visits associated with shoulder surgeries excluding arthroplasties that were performed in HOPDs and ASCs in a closed military health care system. We hypothesized that there would be no difference in outcomes between treatment settings.

Methods: We retrospectively evaluated the records for 1748 elective shoulder surgeries from 2015 to 2020. Patients were considered as 1 of 2 cohorts depending on whether they underwent surgery in an ASC or HOPD setting. We evaluated groups for differences incomplexity, surgical time, and medical risk. Outcome measures were emergency department visits, unplanned hospital admissions, and complications within the first 90 days after surgery.

Results: There was no difference in 90-day postoperative emergency department visits between procedures performed at HOPDs (n = 606) and ASCs (n = 1142). There was a slight increase in rate of unplanned hospital admission within 90 days after surgery in the HOPD cohort, most commonly for pain or overnight observation. The surgical time was significantly shorter (105 vs. 119 minutes, P < .01) at the ASC, but there was no difference in case complexity between the cohorts (P = .28).

Discussion/conclusion: Our results suggest that in appropriate patients, surgery in ASCs can be safely leveraged for its costs savings, efficiency, patient satisfaction, decreases in operative time, and potentially decreased resource utilization both during surgery and in the early postoperative period.

Background: Overprescription of opioids in the United States increases risks of opioid dependence, overdose, and death. Increased perioperative and postoperative opioid use during orthopedic shoulder surgery is a significant risk factor for long-term opioid dependence. The authors hypothesized that a multidisciplinary perioperative pain management program (Transitional Pain Service [TPS]) for major shoulder surgery would lead to a reduced amount of opioids required postoperatively.

Methods: A TPS was implemented at a Veterans Affairs Medical Center focused on nonopioid pain management and cessation support. Opioid consumption during the implementation of the TPS was compared to a historical cohort. All patients undergoing total shoulder arthroplasty (TSA) or rotator cuff repair (RCR) were included. The primary outcome was the proportion of patients continuing opioid use at 90 days postoperatively. Secondary outcomes included postoperative pain scores, time to opioid cessation, and median opioid tablets consumed at 90 days. A multivariable model was developed to predict total opioid use at 90 days postoperatively. Kaplan-Meier curves were calculated for time to opioid cessation.

Results: The TPS group demonstrated decreased persistent opioid use at 90 days postdischarge (12.6% vs. 28.6%; P = .018). Independent predictors associated with increased total opioid tablet prescriptions at 90 days included length of stay (β = 19.17), anxiety diagnosis (β = 37.627), and number of tablets prescribed at discharge (β = 1.353). TSA was associated with decreased 90-day opioid utilization (β = -32.535) when compared to RCR. Median time to cessation was shorter in TSA (6 days) when compared with RCR (8 days). Pain scores were reduced compared with population mean by postdischarge day 2 for TSA and by postdischarge day 7 for RCR. Median number of postdischarge opioid tablets (oxycodone 5 mg) consumed under TPS management was 25 in both RCR and TSA surgery groups (180 morphine milligram equivalents).

Discussion and conclusions: This study demonstrates that a TPS reduces the amount of opioid use of patients undergoing shoulder arthroplasty or cuff repair at 90 days when compared with a historical control. Multivariable regression indicated that fewer opioid tablets at discharge was a modifiable factor that may aid in reducing opioid consumption and that anxiety diagnosis, increased length of stay, and cuff repair surgery were other factors independently associated with increased opioid consumption. These data will assist surgeons in counseling patients, setting narcotic use expectations, and minimizing overprescribing. Use of a similar multidisciplinary perioperative pain management program may greatly reduce opioid overprescriptions nationally.

Background: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown.

Methods: The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. 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 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at P ≤ .00023.

Results: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort.

Conclusion: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall.

Hypothesis: The purpose of this study was to systematically review complications arising from intramedullary nailing (IMN) of proximal and humeral shaft fractures. This study hypothesized that there would be a low rate of complications and revision among patients treated with IMN for humerus fractures.

Methods: Two independent reviewers performed a literature search in the PubMed database based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported on outcomes following the use of intramedullary nails for proximal humerus fractures or humeral shaft fractures. Variables that were collected included complications, visual analog scale pain scores and revision operations.

Results: Overall, 179 studies met the inclusion criteria, with 7984 shoulders. The average age of patients in this study was 55.2 years and 60.7% of patients were female. The mean follow-up was 16.6 months. The overall complication rate for all fractures treated with intramedullary nails was 18.9%, and the overall revision rate was 6.8%. Among the complications were fracture complications (7.5%), hardware complications (7.2%), soft tissue complications (1.8%), neurovascular complications (1.6%), and infection (0.8%). Four-part proximal humerus fractures (52.9%) and open fractures (36.7%) had the highest rates of complication. Among the reasons for revision were hardware removal or replacement (5.0%), conversion to arthroplasty (0.6%), and other (1.2%). The mean visual analog scale pain score at last follow-up was 1.6.

Conclusion: Overall, there was a moderate rate of complications but low rate of revision following IMN of humerus fractures. Open fractures and 4-part proximal humerus fractures had the highest complication rates.

Background: Glenoid version is a critical anatomic parameter relied upon by many surgeons to inform preoperative planning for shoulder arthroplasty. Advancements in imaging technology have prompted measurements of glenoid version on various imaging modalities with different techniques. However, discrepancies in how glenoid version is measured within the literature have not been well characterized.

Methods: A literature search was performed by querying PubMed, EMBASE, CINAHL, and Cochrane computerized databases from their inception through December 2023 to identify studies that assessed the relationship between preoperative glenoid version and at least one clinical or radiologic outcome following shoulder arthroplasty. Study quality was assessed via the Methodologic Index for Nonrandomized Studies criteria. Imaging modalities and techniques for measuring glenoid version, along with their association with clinical outcomes, were aggregated.

Results: Among 61 studies encompassing 17,070 shoulder arthroplasties, 27 studies (44.3%) described explicitly how glenoid version was measured. The most common imaging modality to assess preoperative glenoid version was computed tomography (CT) (63.9%), followed by radiography (23%); 11.5% of studies used a combination of imaging modalities within their study cohort. Among the studies using CT, 56.5% utilized two-dimensional (2D) CT, 41.3% utilized three-dimensional (3D) CT, and 2.2% used a combination of 2D and 3D CT. The use of 3D CT increased from 12.5% of studies in 2012-2014 to 25% of studies in 2018-2020 to 52% of studies in 2021-2023 (p_trend = 0.02). Forty-three (70.5%) studies measured postoperative version, most commonly on axillary radiograph (22 [51.2%]); 34.9% of these studies used different imaging modalities to assess pre- and postoperative version.

Conclusions: This systematic review revealed marked discrepancies in how glenoid version was measured and reported in studies pertaining to shoulder arthroplasty. A temporal trend of increased utilization of 3D CT scans and commercial preoperative planning software was identified. Improved standardization of the imaging modality and technique for measuring glenoid version will enable more rigorous evaluation of its impact on clinical outcomes.

Background: In patients with glenohumeral osteoarthritis and posteriorly eccentric wear patterns, the early to midterm results of total shoulder arthroplasty (TSA) using conservative glenoid reaming with no attempt at version correction have been favorable at early follow-up. The purpose of this study is to compare the clinical and radiographic outcomes of TSA using this technique for patients with and without eccentric wear patterns at a minimum 5-year follow-up.

Methods: Patients who underwent TSA with minimum 5-year follow-up were identified from an institutional registry. Preoperative and postoperative radiographs were used to determine humeroglenoid alignment (HGA-AP), humeroscapular alignment (HSA-AP), version, Walch classification, and glenoid component seating. The outcome measures were the Simple Shoulder Test (SST), glenoid component radiolucencies, and the occurrence of complications or revisions.

Results: Two hundred ten patients were included in the study, of which 98 (47%) had posteriorly decentered humeral heads and 108 (51%) had centered humeral heads. There were 77 shoulders with Walch type A glenoids and 122 with Walch type B glenoids. At a mean 8-year follow-up, the final SST score, change in SST score, and percentage of maximal improvement was not correlated with pre- and postoperative humeral head centering, Walch classification, or glenoid version. There were no preoperative predictors of a low final SST score. Two patients (1%) underwent open reoperations during the study period. In patients with Walch B1 and B2 glenoids (n = 110), there were no differences in outcome measures between patients with postoperative retroversion of more and less than 15°. Although 15 of 51 patients (29%) with minimum 5-year radiographs had glenoid radioluciences, these radiographic findings were not associated with inferior clinical outcomes. On multivariable analysis, glenoid component radiolucencies were most strongly associated with incomplete component seating (OR 3.3, P = .082).

Conclusion: The results of TSA with conservative glenoid reaming without attempt at version correction are favorable at a minimum 5-year, and mean 8-year, follow-up. There were no differences in clinical and radiographic outcomes between patients with eccentric and concentric wear patterns. Incomplete glenoid component seating was the greatest predictor of glenoid component radiolucency, but these radiolucencies were not associated with inferior clinical outcomes.

Background: Current options for reconstruction of large glenoid defects in reverse total shoulder arthroplasty (RTSA) include structural bone grafting, use of augmented components, or 3D-printed custom implants. Given the paucity in the literature on structural bone grafts in RTSA, this study reflects our experience on clinical and radiographic outcomes of structural bone grafts used for glenoid defects in RTSA.

Methods: We identified 33 consecutive patients who underwent RTSA using structural bone grafts for glenoid bone loss between 2008 and 2019. Twenty-six patients with a mean clinical follow-up of 4.4 ± 3.9 years and a mean radiographic follow-up of 2.7 ± 3.2 years were included. Patient demographic data, perioperative functional outcomes, radiographic outcomes, complications, and reoperation rates were determined.

Results: Between 2008 and 2019, 26 RTSAs were performed using structural autograft or allograft for glenoid defects. There were 20 females (77%) and 6 males (23%), with a mean presenting age of 68 years (range 41-86), mean BMI of 29 (range 21-44), and mean Charlson Comorbidity Index of 3 (range 0-8). There were 19 cases of central glenoid defects, and 7 were combined central and peripheral defects. Structural grafts included humeral head autograft (7), proximal humerus autograft (7), iliac crest autograft (7), distal clavicle autograft (2), and femoral head allograft (3). All 18 revision RTSA cases had simultaneous humeral-sided revision. There was significant postoperative improvement in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (27.0 ± 12.6 preoperation vs. 59.8 ± 24.1 postoperation; P < .001) and visual analog scale scores (8.1 ± 3.6 preoperation vs. 3.0 ± 3.2 postoperation; P < .001). Range of motion improved significantly for active forward elevation (63° ± 36° preoperation vs. 104° ± 36° postoperation; P < .001) and external rotation (21° ± 20° preoperation vs. 32° ± 23° postoperation, P = .036). Eighty-eight percent of cases (23 of 26) had successful reconstruction of the glenoid, defined as no visible radiolucent lines nor glenoid component migration at final follow-up. The reoperation rate was 19% (5 of 26). Postoperative complications included 2 cases of acromial stress fractures that were treated nonoperatively, for a total complication rate (including reoperation) of 27% (7 of 26 cases).

Conclusions: The use of structural bone autografts and allografts in RTSA was associated with improved outcome scores and range of motion. A reoperation rate of 19% and total complication rate of 27% were reported for these challenging cases. However, 86% of these complications were not related to structural glenoid reconstruction failure. Structural grafts are a reasonable option for glenoid reconstruction in RTSA cases with glenoid bone loss.

Background: Post-traumatic capsular contracture is a common complication of joint injury and surgery. Post-traumatic capsular contracture is associated with fibrosis characterized by excessive differentiation and proliferation of myofibroblasts and abnormal secretion and accumulation of extracellular matrix. Previous studies have suggested that interleukin 11 (IL11) plays a role in myocardial fibrosis. We thus hypothesized that IL11 may play a fibrotic role during capsular contracture, in order to discover new targets for preventing joint capsule contracture.

Methods: We constructed a post-traumatic contracture model by excessively extending the knee joint and fixing the joint in the flexion position, and a post-traumatic joint capsule contracture model was constructed in the wild-type, IL11^-/-, IL11 R ^-/-, α-SMA-cre-IL11^fl/fl, α-SMA-cre-IL11R^fl/fl mouse strain, with wild-type mice without any treatment of the knee joint as the control group. Fibrotic markers and the expression of IL11 and IL11 R in knee joint tissue were detected in each group of mice. The NIH3T3 cell line was used for in vitro analyses. The expression of fibrosis markers, IL11, transforming growth factor-β, and ERK1/2 were detected by western blot, enzyme-linked immunosorbent assay, and real time quantitative polymerase chain reaction.

Results: Inhibition of IL11 inhibited ERK1/2 phosphorylation, reduced the secretion of collagen in the joint capsule, and inhibited the excessive differentiation and proliferation of myofibroblasts in the post-traumatic joint capsule contracture, thus alleviating the joint capsule contracture and obtaining better joint mobility.

Conclusion: Downregulation of IL11 in traumatic joint capsule contracture inhibits ERK1/2 phosphorylation, thus significantly relieving joint capsule contracture. Our findings indicate the transforming growth factor-β/IL11/ERK1/2 axis is an important pathway for the differentiation of fibroblasts into myofibroblasts. Anti-IL11 treatment is an effective means to prevent traumatic joint capsule contracture.

Background: The utilization of stemless anatomic total shoulder arthroplasty is on the rise. Epiphyseal fixation leads to radiological bone remodeling, which has been reported to exceed 40% in certain studies series. The aim of this study was to present the clinical and radiological outcomes of a stemless implant with asymmetric central epiphyseal fixation at an average follow-up of 31 months.

Materials and methods: This retrospective multicenter study examined prospective data of patients undergoing total anatomic arthroplasty with intuitive shoulder arthroplasty Stemless implant and followed up at least 2 years. Clinical assessment included preoperative and final follow-up measurements of active range of motion, Constant score, and Subjective Shoulder Value. Anatomical epiphyseal reconstruction and bone remodeling at the 2-year follow-up were assessed by standardized computed tomography scanner (CT scan). Statistical analysis employed unpaired Student's t-test or chi-squared test depending on the variable type, conducted using EasyMedStat software (version 3.22; www.easymedstat.com).

Results: Fifty patients (mean age 68 years, 62% females) were enrolled, with an average follow-up of 31 months (24-44). Primary osteoarthritis (68%) with type A glenoid (78%) was the prevailing indication. The mean Constant score and Subjective Shoulder Value improved significantly from 38 ± 11 to 76 ± 11 (P < .001) and from 31% ± 16 to 88% ± 15 (P < .001) respectively at the last follow-up. Forward elevation, external rotation, and internal rotation range of motion increased by 39° ± 42, 28° ± 21 and 3,2 ± 2,5 points respectively, surpassing the Minimally Clinically Important Difference after total shoulder arthroplasty. No revisions were necessary. CT scans identified 30% osteolysis in the posterior-medial calcar region, devoid of clinical repercussions. No risk factors were associated with bone osteolysis.

Conclusions: At an average follow-up of 31 months, intuitive shoulder arthroplasty Stemless implant provided favorable clinical results. CT analysis revealed osteolysis-like remodeling in the posterior-medial zone of the calcar (30%), without decline in clinical outcomes and revisions. Long-term follow-up studies are mandated to evaluate whether osteolysis is associated with negative consequences.