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 three-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 (CT) scans in the neutral and HBB positions using an upright multidetector CT. 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 < 0.001), abduction (10° vs. 22°, P < 0.001), and elbow flexion (74° vs. 115°, P < 0.001) during HBB motion. The scapulothoracic joint on the affected side had less internal rotation (18° vs. 21°; P = 0.045) and more anterior tilt (24° vs. 19°; P = 0.003). 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 ≥70 years of age, operative management is often considered standard of care, although recent evidence has supported non-operative 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) ≥70 years of age 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 non-operatively (n=39) with progressive mobilization. Frailty was quantified using the Clinical Frailty Scale. The primary outcome was Quick Disability of the Arm, Shoulder, Hand (QuickDASH) score. Secondary outcomes included range of motion, PROMIS global health, and complications. Mean time from injury to outcome collection was 16 ± 2 months.

Results: Mean QuickDASH was lower in the operative cohort (mean difference -8.3; 95% CI 0.4 to 16.2; p = 0.021) although the difference was not clinically meaningful (minimal clinically important difference = 15). Subgroup analysis by frailty revealed no differences between operative and non-operative 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=0.001); 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, SE=0.94, OR=22.9, 95% CI 3.63 to 144.8, p=0.001) independent of fragment size, comminution, and triceps reinforcement. In the non-operative group, increasing immobilization duration was associated with decreased arc of motion (β=-4.1, SE=1.3, R²=0.29, p=0.006).

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 three screws to minimize the risk of failure.

Background: Rotator cuff repair (RCR) is increasingly performed due to advancements in surgical techniques and an aging population. While generally successful, complications like re-tear, stiffness, infection, and thromboembolic events remain concerns. The rising use of testosterone replacement therapy (TRT) in middle-aged and older men raises questions about its impact on surgical outcomes, as its effect on RCR complications remains unclear.

Methods: A retrospective cohort study was conducted using the PearlDiver Database. Patients who underwent arthroscopic RCR between January 2010 and April 2023 were identified using Current Procedural Terminology (CPT) code 29827. Those with at least two years of continuous follow-up were included, while patients under 21 or with unknown procedural laterality were excluded. Patients were categorized into two cohorts: those who received TRT within three months preoperatively and a control group who did not. Propensity score matching (1:1, caliper = 0.001) was performed to control for age, gender, Charlson Comorbidity Index, obesity, tobacco use, and hypogonadism. The primary outcomes included 2-year postoperative complications and reoperations. Secondary outcomes included 90-day major medical complications such as surgical site infection (SSI), pneumonia, pulmonary embolism, deep vein thrombosis, urinary tract infection, wound dehiscence, sepsis, acute kidney injury, and readmissions. Statistical analyses were performed using chi-square tests, and odds ratios with 95% confidence intervals were calculated.

Results: A total of 8,241 TRT users and 673,982 control patients were identified before matching. After propensity score matching, 5,109 patients remained in each cohort with no significant baseline differences. No significant differences were observed in 90-day postoperative complications, including SSI (0.5% vs. 0.4%, p = 0.64), pneumonia (0.6% vs. 0.5%, p = 0.79), sepsis (0.4% vs. 0.3%, p = 0.51), acute kidney injury (0.7% vs. 0.5%, p = 0.18), or readmissions (1.2% vs. 1.0%, p = 0.29). Similarly, no significant differences were found in pulmonary embolism or deep vein thrombosis. Over the two-year follow-up, TRT use was associated with a higher incidence of total shoulder arthroplasty (TSA) (0.7% vs. 0.4%, p = 0.037) but a lower incidence of lysis of adhesions (0.5% vs. 0.9%, p = 0.032). No significant differences were observed in revision RCR rates (2.6% vs. 2.3%, p = 0.41).

Conclusion: Preoperative TRT use was not linked to increased short-term complications after arthroscopic RCR. Over two years, TRT was associated with higher rates of TSA but lower rates of lysis of adhesions, with no difference in revision RCR.

Background: Glucagon-like peptide-1 agonists (GLP-1s) are increasingly prescribed for type 2 diabetes mellitus (T2DM) and obesity, with over 12% of the United States population reported to being using this medication. While GLP-1s have been associated with reduced complication rates in total hip and knee arthroplasty populations, their association with outcomes after shoulder surgery remains unclear. The purpose of the current study was to perform a systematic review and meta-analysis of studies comparing adverse events between GLP-1 users and non-users following shoulder surgery.

Methods: A PRISMA-compliant literature search of PubMed, Embase, and Scopus was performed in August 2025. Comparative studies (Level of Evidence I-III) assessing postoperative adverse events in GLP-1 and non-GLP-1 users undergoing total shoulder arthroplasty (TSA) or shoulder arthroscopic procedures were included. Data pertaining to 90-day and 2-year complication rates were extracted. Random effects meta-analyses were conducted independently for TSA studies and pooled odds ratios with confidence estimates were quantified. Outcomes of studies examining arthroscopic procedures were described narratively given limited data.

Results: Six studies encompassing outcomes of 43,415 patients were included. Four (66.7%) studies evaluated TSA, while one evaluated arthroscopic RCR and one manipulation under anesthesia/capsular release for adhesive capsulitis (AC). The overall pooled 90-day complication rate following TSA was 18.1% for GLP-1 users and 15.9% for non-users (OR 0.86, 95% CI 0.36-2.07, p=0.74). The overall pooled 2-year complication rate following TSA was 3.8% in the GLP-1 group and 3.7% in the non-GLP-1 group (OR 1.24, 95% CI 0.73-2.00, P = 0.42). The RCR and AC studies reported significantly lower 90-day complication rates for GLP-1 users (11.0% vs. 27.4%) and (2.5% vs. 4.8%), respectively. A lower re-tear rate was observed in GLP-1 users compared with non-users by two-years postoperatively (12.5% vs. 18.3%).

Conclusion: GLP-1 agonist use is not significantly associated with 90-day or two-year adverse events following TSA. Based on this data, GLP-1 agonist use should not be a contraindication for proceeding with TSA. Lower complication rates were observed in both studies concerning arthroscopic intervention for non-arthritic shoulder conditions.

Background: Extraction of well-fixed humeral implants during revision shoulder arthroplasty is difficult and prone to complications, especially humeral fracture (up to 12% in anatomical stem revision and 30% in reversed stem revision). To prevent this complication, we perform a Vertical Incomplete Humerotomy (VIH) and use cerclages with suture loops and Nice Knots for fixation.

Purpose: To describe the VIH technique with suture cerclage fixation, report the perioperative complications, and evaluate the radiological and clinical results outcomes.

Methods: We performed a retrospective monocentric study of consecutive patients who underwent revision shoulder arthroplasty with a VIH at a single institution (2007-2022). A straight longitudinal humeral osteotomy was created posterior and parallel to the bicipital groove. This allows for extraction of the humeral stem and cement mantle. Osteotomy closure was performed with 2 to 6 cerclages with suture loops (Nice Loop, Tornier-Stryker, Kalamazoo, MI, USA) and a non-sliding knot ("Nice knot"). The primary outcome was assessment of intraoperative and postoperative complications. The secondary outcome was osteotomy healing at 6 months and clinical results at two years.

Results: A cohort of 47 patients (mean age of 67.34 years, range 33-86) with a mean follow-up was 37.9 months who underwent revision shoulder with VIH were analyzed. There were 21 Hemiarthroplasty (HA), 11 Total Shoulder Arthroplasty (TSA) and 15 Reversed Shoulder Arthroplasty (RSA). There were 5 revisions to TSA, 26 revisions to RSA, 3 humeral stem revision and 13 revisions to spacers secondary to periprosthetic joint infection (PJI). One intraoperative humeral fracture occurred during stem removal. No postoperative complication related to the humerotomy occurred and no patients required surgical revision secondary to the humerotomy. Primary osteotomy healing and callus formation were evident in all cases by 6 months. In 12 cases of PJI, a second stage revision was performed, there were 3 reinterventions (2 instability and 1 infection). At the last follow-up, 82% of patients were satisfied after the intervention; the mean Subjective Shoulder Value (SSV) was 58%, and the VAS score was 3.4/10.

Conclusion: (1) VIH facilitates extraction of well-fixed cemented or uncemented humeral components and prevents iatrogenic humeral fractures in revision shoulder arthroplasty, and (2) Suture fixation, using suture loops (Nice Loop; Tornier-Stryker, Kalamazoo, MI, USA) and a non-sliding knot ("Nice knot"), provides constant bone healing and is an alternative to wire for cerclage fixation of humerotomy.

Background: Scapular dyskinesis is an alteration in scapular position and movement that disrupts glenohumeral kinematics. Among its causes, pectoralis minor retraction induces scapular protraction and internal rotation, altering shoulder biomechanics. Often asymptomatic, scapular dyskinesis may also cause pain and reduced joint mobility, compromising function. Initial management relies on targeted rehabilitation, which generally ensures recovery. However, when conservative treatment fails, surgery may be considered. This study evaluates the clinical outcomes of arthroscopic pectoralis minor tenotomy in patients with painful shoulder and scapular dyskinesis due to pectoralis minor retraction.

Methods: A retrospective monocentric study included patients operated on between 2020 and 2024 for painful shoulder syndrome associated with scapular dyskinesis secondary to excessive pectoralis minor tension. Patients undergoing concomitant or subsequent surgery on the same shoulder were excluded. We conducted a longitudinal intra-subject study comparing pre- and postoperative outcomes. Patients were assessed preoperatively and at their last follow-up for active range of motion, pain (VAS), Constant score, and Simple Shoulder Value (SSV). Complications were recorded.

Results: Thirty-seven patients met the entry criteria and were enrolled in the study with a mean follow-up 19.9 months (range, 6 to 44). All patients were women (mean age 43.8), with 49% reporting trauma and 57% practicing sports. Among the 37 patients, information on preoperative corticosteroid injections was missing for 2 patients. Of the remaining 35, 34 (97%) received at least one injection. Functional scores and pain improved significantly postoperatively. The Constant score increased from 55.3 to 73.27 (p < 0.001), the VAS decreased from 7.51 to 2.62 (p < 0.001), and the SSV rose from 46.75 to 74.73 (p < 0.001). Active elevation improved significantly from 128.38 degrees to 143.9 degrees (p = 0.013), while external and internal rotations showed no significant difference. Four cases of adhesive capsulitis were reported; three resolved with rehabilitation, while one patient retained stiffness in elevation at last follow-up.

Conclusion: When conservative treatment fails, arthroscopic tenotomy is an effective surgical option for patients with painful shoulder and scapular dyskinesis due to pectoralis minor contracture. This study demonstrates significant improvement in functional scores, pain, and anterior elevation range, while external and internal rotations remain unchanged. However, randomized studies with longer follow-up are needed to confirm result durability.

Background: Online physician review websites are being increasingly utilized by patients when choosing their surgeon. Although most reviews are positive, extremely negative reviews can significantly compromise a physician's online reputation. The purpose of this study was to analyze factors that contribute to negative reviews for orthopedic shoulder surgeons.

Methods: One hundred orthopedic shoulder surgeons were randomly selected from the "find a doctor" tool on the American Shoulder and Elbow Surgeons (ASES) website. A search was performed for all reviews listed under the selected surgeons on the following sources: Google Reviews, Healthgrades, Vitals, and Yelp. For each website, a surgeon's average rating, total number of reviews, and number of 1-star reviews was recorded. One-star reviews with comments were then reviewed to categorize the complaint(s), determine whether they referenced a clinical or non-clinical issue, and determine whether the complaint referenced a surgical or non-surgical episode of care. Categorical variables were analyzed using a chi-square test.

Results: A total of 7616 reviews were analyzed and 722 (9.5%) were identified as one-star. After application or exclusion criteria, 329 single-star reviews with 837 total complaints were included for analysis. Of the 329 single-star reviews, 237 (72.0%) were from non-surgical patients and 92 (28.0%) were from surgically treated patients. Non-surgical patients had a significantly higher rate of total complaints per each review than surgical patients (1.76 vs. 0.78, p=0.034). The most common complaints were regarding bedside manner (160 complaints), insufficient time with the provider (82 complaints), uncontrolled pain (73 complaints), and rude staff (72 complaints). Poor surgical outcomes were noted in terms of complication (66 complaints), reoperation (26 complaints) and readmissions (2 complaints).

Conclusion: For orthopedic shoulder surgeons, the most common complaints are non-clinical and include poor bedside manner, wait time, and insufficient time with the provider. Relatively few negative reviews referenced objective measures of healthcare quality such as complications or surgical outcomes. These results provide a deeper understanding of the reasons for patient dissatisfaction in shoulder surgery, which can be considered when striving to maintain a favorable online reputation.

Background: Dislocation of the sternoclavicular joint (SCJ) is the most common SCJ condition reported to be managed surgically. However, primary SCJ osteoarthritis is substantially more common. There are few reports in the literature on the outcome of surgical management of primary SCJ osteoarthritis. We have successfully adopted sternal docking allograft reconstruction for SCJ instability and have now expanded the technique to patients with primary SCJ osteoarthritis. This is our first report on the outcome of the sternal docking technique specifically for patients with primary SCJ osteoarthritis.

Methods: Between 2012 and 2023, one fellowship trained shoulder surgeon consecutively performed surgical resection of the medial end of the clavicle and semitendinosus allograft ligament reconstruction using the sternal docking technique in 29 patients with SCJ osteoarthritis. Seven patients were lost to follow-up (one declined participation, and six could not be contacted). The remaining 22 patients form the study cohort. There were 17 females and 5 males with a mean age of 49 ± 11 years at the time of surgery (range, 32-71 years). Their electronic medical records were reviewed to collect demographics, pain using a Visual Analog Scale (VAS), complications and reoperations. Patients were also contacted at most recent follow-up to record VAS for pain, subjective shoulder value (SSV) and American Shoulder and Elbow Surgeons (ASES) shoulder score. The procedure was considered successful when patients experienced pain relief and did not develop any complications or required reoperation. The mean length of follow-up was 4 ± 3 (range, 1-12) years.

Results: SCJ reconstruction was associated with significantly improved pain relief and overall shoulder function. Preoperatively, the mean VAS was 6 ± 1.5 (range, 4-9) points. At the most recent follow-up, the mean pain score was 0.5 ± 1.5 (range, 0-6) points, with median scores of 90 (IRQ 60-98) for SSV and 80 (IQR 70-81) points for ASES. 21 of 22 patients reported high satisfaction rates with their postoperative outcomes, with one patient endorsing partial satisfaction due to limited shoulder range of motion. Persistent peri-incisional numbness was reported by one patient. There were no re-operations at the time of the most recent follow-up.

Conclusion: Medial clavicle resection and ligament reconstruction seems to be associated with good overall outcomes, a high degree of patient satisfaction, and a low reoperation rate in patients with primary SCJ OA.

Background: Frozen shoulder (FS) is a common fibroinflammatory disorder of the glenohumeral joint capsule, characterized by persistent pain and progressive restriction of range of motion. The fibroblast-to-myofibroblast transition is a central pathological event driving capsular fibrosis, yet the molecular regulators underlying this process remain poorly defined. Protein tyrosine phosphatase 1B (PTP1B) has emerged as a key regulator of fibrosis in multiple organs, but its role in musculoskeletal fibrosis, particularly in FS, has not been investigated.

Methods: In this prospective case-control study, glenohumeral capsular tissues were collected from 21 patients with idiopathic FS and 21 matched controls with rotator cuff tears during arthroscopic surgery. Tissue samples were evaluated using histology, immunofluorescence, and Western blotting. Clinical function was assessed preoperatively using the American Shoulder and Elbow Surgeons and Constant-Murley scores.

Results: FS patients exhibited significantly worse functional outcomes across all domains, including pain, range of motion, and activities of daily living. Histopathological analysis revealed pronounced fibroblast proliferation, dense collagen deposition, hypervascularity, and perivascular adipocyte accumulation in FS capsules compared to controls. Critically, PTP1B expression was significantly upregulated in FS tissues. PTP1B immunoreactivity was prominently localized to α-SMA⁺ myofibroblasts. Co-localization studies confirmed an enrichment of PTP1B within activated myofibroblasts, indicating its specific involvement in fibrotic transdifferentiation.

Conclusion: This study identified PTP1B as a novel biomarker that was upregulated in FS and was specifically associated with myofibroblast activation and capsular fibrosis. These findings position PTP1B as a promising therapeutic target for mitigating fibrosis and functional impairment in FS.