Journal of Shoulder and Elbow Surgery最新文献

Background: Reverse total shoulder arthroplasty (RTSA) is effective in treating massive irreparable rotator cuff tears (mRCT) and cuff tear arthropathy (CTA); however, improving internal rotation (IR) remains challenging. Tendon transfers have been introduced to improve active IR alongside RTSA, yet no clinical studies have compared their effectiveness. This study compares the clinical efficacy of RTSA combined with latissimus dorsi and teres major (LDTM) and pectoralis major (PM) transfers in improving IR in patients with mRCT and CTA who have a loss of active IR.

Methods: This retrospective study included 60 patients with mRCT or CTA who experienced a loss of active IR. 37 patients underwent RTSA with LDTM transfer, and 23 underwent RTSA with PM transfer. Clinical evaluations included the American Shoulder and Elbow Surgeons, Activities of Daily Living requiring active Internal Rotation scores, and measurements of active range of motion (aROM), subscapularis-specific examination, and the ability to perform the toileting activities. IR strength was assessed using a dynamometer. Radiologic assessments involved preoperative magnetic resonance imaging, as well as postoperative radiographs and ultrasonography.

Results: Both groups showed significant improvements in all clinical scores and aROM postoperatively (p < .001). No differences were found between the groups in overall clinical scores or forward flexion and external rotation aROM. However, the LDTM group demonstrated significantly greater IR aROM with the arm behind the back (6.4 ± 2.0 vs. 4.6 ± 1.3, p < .001) and better performance in toileting activities (p < .001). By contrast, the PM group had significantly higher IR strength (28.8 ± 3.6 N vs. 24.7 ± 4.0 N, p < .001). The minimal clinically important difference analysis indicated that LDTM more frequently met the IR aROM threshold, whereas PM more frequently reached the IR strength threshold (p = .010, .019, respectively). One case of transient axillary nerve palsy and one acromial fracture was noted in LDTM group, all managed conservatively. Additionally, a traumatic dislocation was observed in the PM group.

Conclusion: Both LDTM and PM transfers combined with RTSA significantly improve clinical outcomes in patients with mRCT and CTA who had a loss of active IR. The LDTM transfer is superior in IR aROM with the arm behind the back, while the PM transfer more effectively improves IR strength in front of body. Preoperative counseling could consider the patient's specific functional needs to guide the selection of the appropriate tendon transfer.

Background: Studies comparing anatomic and reverse total shoulder arthroplasty (aTSA, rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) frequently fail to control for selection bias secondary to glenoid bone loss. Comparisons of similar patient populations without glenoid deformity may better evaluate potential differences in outcomes. The purpose of this study is to compare the outcomes of a matched cohort of aTSA and rTSA patients with RCI-GHOA and no glenoid bone loss.

Methods: A retrospective review of primary aTSA/rTSA for RCI-GHOA with an A1 or B1 glenoid between 2007-2020 was performed. Matched cohorts were conceived based on age, sex, follow-up, Walch class, prior surgery, preoperative shoulder arthroplasty smart (SAS) score, preoperative forward elevation, and preoperative abduction. Range of motion, outcome scores, and rates of complications and reoperations were compared.

Results: A total of 310 matched shoulders (155 aTSA, 155 rTSA) were evaluated at a mean 3.2 years follow-up. Postoperatively, aTSAs had more favorable abduction (146±27° vs. 133±26°, P<.001), internal rotation score (4.6±1.3 vs. 4.1±1.3, P=.004), external rotation (53±15° vs. 43±14°, P<.001), Constant score (73.6±10.5 vs. 70.5±12.8, P=.039), and SAS score (81.1±9.7 vs. 77.2±10.2, P=.002). However, when assessing improvement from preoperative state, only abduction remained significantly greater in the aTSA cohort (60° vs. 47°, P=.024). Patients undergoing aTSA achieved substantial clinical benefit at a higher rate for abduction (78% vs. 64%, P=.034) and external rotation (61% vs. 45%, P=.034). There was no difference in the incidence of complications (3.9% vs. 1.9%, P=.501) or revision surgery (3.2% vs. 0.6%, P=.214).

Conclusion: In patients with RCI-GHOA with no bone loss, treatment with rTSA demonstrated similar improvements compared to a matched aTSA cohort except for less improvement in abduction. rTSA does not appear to offer functional benefits over aTSA in this population. Longer term follow-up of this cohort needs to be considered to assess the longitudinal functional and revision rates of these patients.

Background: Inferior subluxation of humeral head following shoulder trauma, osteosynthesis or rotator cuff repair has been considered as a benign or temporary phenomenon due to muscle fatigue or capsular injury. However, the clinical impact is still unclear as to their occurrence after plating for proximal humerus fractures. This study aims to investigate their patterns and identify associated risk factors as well as clinical outcomes.

Methods: The research included patients who received locking plate surgery following an acute proximal humerus fracture with a minimum follow-up of 12 months. Pathologic fractures, history of previous shoulder surgery or associated with neuromuscular diseases were excluded. Patients were grouped based on the onset and duration of subluxation. Differences between groups regarding patient characteristics, fracture patterns, reduction quality and clinical outcomes were analyzed.

Results: There are 303 patients included in this study, with 28 patients (9.2%) in the pseudo subluxation group, showing subluxation in the first month and self-recovered before 6 months after surgery, 18 patients (5.9%) in the delay subluxation group, showing normal radiograph in first month but presented subluxation 3 or 6 months after surgery, 12 patients (3.9%) in the sustained subluxation group, showing persistent subluxation throughout the 6-month follow-up. Older age significantly correlated with delayed subluxation; greater BMI correlated with sustained subluxation. Male sex and Neer 3-part fracture correlated with lower incidence of all types of subluxations. Besides, female, smaller neck-shaft angle, and screw perforation correlated with subluxation 6 months after surgery. Moreover, patients with delayed onset of subluxation showed higher rate of loss of reduction (16.7%) and requiring reverse shoulder arthroplasty (22.2%).

Conclusion: Presence of subluxation after plate surgery for proximal humerus fracture is not always benign. Delayed presentation may indicate migration of greater tuberosity, loss of reduction and screw perforation. Secondary procedure may be required. Female patients or those with a decreased neck-shaft angle may experience a longer duration of inferior subluxation which would not spontaneously recover. Closer follow-up would be recommended beyond 6 months for these patients regarding the necessity of secondary interventions.

Background: This retrospective study aimed to compare the clinical results of reverse total shoulder arthroplasty (rTSA) and combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with non-arthritic anterosuperior irreparable rotator cuff tears (ASIRCTs) with loss of active internal rotation (aIR).

Methods: Using propensity score matching based on demographic variables, 29 patients were included in each group (rTSA and aLDTM) with a minimum follow-up period of two years. Clinical results were evaluated using the visual analog scale (VAS) score, Constant-Mueley score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, activities of daily living requiring active internal rotation (ADLIR), active range of motion (aROM), subscapularis (SSC)-specific examinations, rotational strength, and the ability to perform toileting activities. The progression of arthritic changes in the shoulder joint was evaluated by the acromiohumeral distance (AHD) and Hamada grade.

Results: Significant improvements of clinical results were confirmed in both groups. However, the Constant-Murley score (58.4±10.5 vs. 69.1±8.2, p<.001), ASES score (64.5±12.3 vs. 78.5±10.9, p<.001), UCLA shoulder score (22.9±5.3 vs. 28.2±4.1, p<.001), forward elevation (134.1±35.7 vs. 162.4±15.5, p<.001), and IR at the back (4.6±1.1 vs. 6.9±2.2, p<.001) were significantly better in the aLDTM group compared with the rTSA group. The SSC-specific physical examination (p<.001), IR strength (p<.001), and the ability to perform toileting activities (p<.001) were significantly better in the aLDTM group compared with the rTSA group. There was no significant change in the AHD (preoperative 8.3±1.3 to postoperative 8.5±1.8, p=0.367) and no significant progression of arthritic change (Hamada grade preoperative 1.4±0.5 to postoperative 1.5±0.6, p=0.458) in the aLDTM group.

Conclusion: Both rTSA and aLDTM improved overall patient outcomes postoperatively. However, combined aLDTM tendon transfer was superior in terms of clinical scores, IR aROM, IR strength, and the ability to perform toileting activities in patients with ASIRCTs and loss of aIR. This study suggests that combined aLDTM tendon transfer could be a first-line joint-saving treatment for patients with non-arthritic ASIRCTs and loss of aIR, considering the longevity and related complications of arthroplasty.

Background: Dysfunctional features of distal ulnar collateral ligament (UCL) tears remain unclear. We aimed to clarify the characteristics of valgus and rotational alignment of the ulnohumeral joint at rest in distal UCL tears compared with those in proximal tears.

Methods: The participants were baseball and softball players diagnosed with UCL tears, classified as proximal, middle, or distal. Valgus and rotation alignment of ulnohumeral joint were measured using computed tomography (CT)-like images and a three-dimensional (3D) image analysis system. For valgus alignment, the medial joint space (MJS) was measured as the distance between the medial epicondyle and the ulnar coronoid processes. For rotational alignment, the medial distance (MD) and lateral distance (LD) of the ulnohumeral joint were measured in the reconstructed axial views at the medial epicondyle and trochlear levels. MD was measured as the distance between the medial edges of the olecranon fossa and trochlear notch, whereas LD was measured as the distance between the lateral edges of the olecranon fossa and trochlear notch.

Results: Of the 20 included cases, six (30%) were distal and 14 (70%) were proximal UCL tears. The MJS results showed no significant difference between the two groups. The MD was significantly higher in the distal tear than the proximal tear only at the trochlea level. The LD showed no significant difference at either level.

Conclusion: Distal tears did not show hypervalgus malalignment compared to proximal tears using conventional measurements. In contrast, distal tears showed hyperinternal rotation malalignment of the ulnohumeral joint only at the distal side of the joint compared to proximal tears.

Background: Total elbow arthroplasty has become a common surgical procedure. However, a certain percentage of patients may require revision due to unsatisfactory outcomes or complications. This study aimed to compare the clinical outcomes and patient satisfaction between primary and revision total elbow arthroplasty, considering factors such as etiology and causes for revision.

Methods: The study utilized a retrospective analysis of medical records from a cohort of 33 and 18 cases of primary and revision total elbow arthroplasty, respectively, with a minimum follow-up of 2 years from the primary procedure. Clinical outcomes were assessed by measuring the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder, and Hand score, range of motion, numeric rating scale, the Single Assessment Numeric Evaluation questionnaire, and patient satisfaction.

Results: Significant differences were observed between primary and revision groups in the Mayo Elbow Performance Score (79.5 vs. 65.0), Disabilities of the Arm, Shoulder, and Hand scores (32.6 vs. 53.7), and elbow range of motion (107.6° vs. 85.8°). The patients' subjective assessment via the numeric rating scale score, Single Assessment Numeric Evaluation score, and satisfaction did not show significant differences. The average numeric rating scale score was 1.6 for both groups; however, the Single Assessment Numeric Evaluation score (63 vs. 54) and patient satisfaction (4.0 vs. 4.1) were not significantly different between groups.

Conclusion: The clinical outcomes of primary versus revision total elbow arthroplasty were significantly worse in the revision group. Patient satisfaction scores were not different between the primary and revision groups despite differences in outcome scores, suggesting that revision patients may be satisfied with their outcomes despite lower clinical scores. These findings underscore the importance of considering both patient-reported outcomes and satisfaction levels in addition to objective clinical measures when evaluating the success of primary versus revision total elbow arthroplasty procedures.

Background and hypothesis: Polyethylene wear debris has long been known to be important for the development of osteolysis and aseptic loosening in total joint replacements. Evaluation of shoulder hemiarthroplasty (HA) specimens provided a unique opportunity to study the histopathologic response when a polyethylene-bearing surface was absent. We hypothesized that HAs would exhibit no significant inflammatory periprosthetic tissue response due to the absence of significant numbers of wear particles from the articulation.

Methods: We analyzed 13 shoulder HAs. The explants were examined for damage to the bearing surface and taper damage using a stereo-microscope. The periprosthetic tissues were examined histologically for wear debris and cellular biological response. Fourier Transform Infrared Spectroscopic imaging (FTIR-I) and scanning electron microscopy (SEM) with energy dispersive x-ray spectroscopy (EDS) were used to characterize debris, if present, within tissue samples.

Results: The average patient age at the time of implantation was 57.2 ± 7.3 and the average time in situ was 34.1 ± 29.4 months. The metal-bearing surface damage was primarily mild, with an average score of 1.5±0.7. The same was true for taper damage on both humeral stem and head tapers, with average scores of 1.7±0.5 and 1.7±0.9, respectively. The histopathological analysis revealed the considerable presence of metal debris in 11 (91.7%), cement debris in 4 (33.3%), and suture debris in 11 (83.3%) cases. SEM/EDS revealed titanium alloy debris to be the most dominant type of metal particle present, while FTIR-I scans suggested polyester to be the most commonly occurring type of suture debris. Particles were mostly found within and around macrophages. The mean macrophage score was 3.1 ± 0.8 and the mean foreign-body giant cell (FBGC) score was 2.3±1.1. There was, on average, no significant lymphocyte or neutrophil presence, except for a single septic case.

Discussion and conclusion: This surgically retrieved shoulder HA cohort exhibited a considerable macrophage and FBGC response within the periprosthetic environment. Interestingly, given the low amount of damage to metallic surfaces and the absence of a polyethylene bearing, the tissue response does not appear to be driven by wear particles from the metal-bearing surface or taper junctions but rather from suture and, to a much lesser degree, cement and metal debris. Overall, these findings highlight the potential impact that high-tensile suture material, frequently used in high quantities around shoulder arthroplasty, may have on the periprosthetic environment and identify these materials as a potential driver of osteolysis.

Background: Dynamically tensioning suture is now available as an alternative to traditional static tendon-repair sutures. The purpose of this study was to compare rotator cuff repair (RCR) patient-reported outcomes (PRO) between repairs performed using dynamic and static suture.

Methods: A retrospective review was performed for patients who underwent rotator cuff repair by a single surgeon at an academic institution between 2016 and 2022. Patients who underwent RCR with either dynamically tensioning suture or traditional static suture were included. Intraoperative variables included tear width, tear retraction, number of anchors used in repair, repair construct, and Goutallier grades for supraspinatus, infraspinatus, teres minor and subscapularis evaluated on preoperative MRI. Patient Reported Outcomes (PRO) collected preoperatively and at a minimum of two-years postoperatively included the American Shoulder and Elbow Surgeons (ASES) score, Visual analogue scale (VAS) pain score, and the Subjective Shoulder Value (SSV) score. We used both univariable and multivariable regression models, where the multivariable models estimated the dynamic suture effect controlling for a set of predictors selected a priori.

Results: A total of 424 patients (441 shoulders) were included, with 2-year outcomes available for 78% (344/441). Patients were divided into dynamic (47.1%) and static (52.9%) tensioning suture groups. There were no significant preoperative differences in demographics, preoperative PROs, or intraoperative findings between the groups, except for acromial undersurface characteristics (p < 0.001). Postoperatively, there were no significant differences between the groups in ASES, VAS, or SSV scores. Multivariable regression analysis revealed preoperative ASES was independently associated with postoperative ASES, and preoperative VAS and tear size were independently associated with postoperative VAS. There were no differences in postoperative outcomes between the dynamic and static groups.

Conclusion: Patient-reported outcomes did not differ significantly between the dynamic tensioning and static tensioning sutures in arthroscopic rotator cuff repair.

Background: The revision rates of four modern (currently used) polyethylene glenoid designs in anatomic total shoulder arthroplasty (stemmed and stemless) for osteoarthritis (OA) are compared from a national arthroplasty registry to model predictive variables.

Materials and methods: The study period was 1^st January 2008 to 31^st December 2023. The study population included all primary anatomic total shoulder arthroplasty (aTSA) procedures undertaken for OA. We classified the designs of modern polyethylene glenoids (glenoid component types) into four cohort groups: cemented all polyethylene glenoids (CPG), polyethylene glenoids with modified central pegs (MCPG), non-modular metal backed glenoids (NMBG) and hybrid glenoids (HG). The cumulative percent revision (CPR) was defined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age, sex, humeral head size, humeral fixation, primary type (stemmed or stemless), and mean surgeon volume. Only prostheses with all known variables were analyzed. Possible interactions were examined. A sub-analysis was undertaken capturing additional patient demographics from 1 January 2017.

Results: There were 9,332 primary aTSA procedures. The CPR at 8 years for CPG (n=5,048) was 5.5% (95% confidence interval (CI) 4.6, 6.4), 3.8% (95% CI 2.9, 5.1) for MCPG (n=2,217), and 9.4%(95% CI 7.4, 11.9) for HG (n=1,658). The NMBG (n=409) had a 2year CPR of 4.7% (95% CI 2.1, 10.1). The glenoid component type (CPG, MCPG, NMBG, HG) influenced the rate of revision of aTSA (p<0.001). There is evidence for interaction term between age and glenoid type (p=0.009), with a better model (Akaike Information Criterion (AIC) 6205.9) than main effects only (AIC 6211.5) There was no difference at sub-analysis, while the patient sex, type of primary, polyethylene type, ASA, BMI, glenoid fixation, glenoid morphology and mean surgeon volume were less predictive than glenoid component type alone.

Conclusion: Modern aTSA outcome for OA is affected by the polyethylene glenoid design implanted, with the result only modified further by patient's age. Informed decision making about aTSA current prostheses survival is more accurate if age of the patient is included.