Journal of Shoulder and Elbow Surgery最新文献

Background: Margin convergence repair is a technique that embraces the philosophy of "harnessing the ox rather than roping the bull" for the repair of massive rotator cuff tears and has been shown to provide satisfactory functional outcomes. However, previous studies have generally relied on traditional scoring systems, leaving the clinical relevance of the outcomes from the patient's perspective and the effect of patient characteristics on these results largely unknown. Therefore, this study aimed to evaluate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who underwent arthroscopic margin convergence repair for massive rotator cuff tears and to analyze the impact of patient-related factors on functional recovery.Regarding predictors, we hypothesized that patients with older age and larger sagittal tear size would be less likely to achieve clinically meaningful outcomes.

Methods: This retrospective case series study was conducted on patients who underwent arthroscopic repair for massive rotator cuff tears between 2014 and 2023. Patients who underwent partial margin convergence repair using a combination of tendon-to-tendon sutures and anchor fixation were included in the study. The evaluation comprised the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), and Range of Motion (ROM) measurements. The proportion of patients who achieved the thresholds for the MCID, SCB, and PASS were identified based on the ASES, SSV, and VAS. Regression analysis was conducted to determine the predictors of achieving these thresholds.

Results: The study included 60 patients (mean age 62.5 ± 9.2 years; mean follow-up 66.0 ± 36.1 months). The thresholds for MCID, PASS, and SCB were 24.5, 69.0, 41.5 for ASES; 25.0, 62.5, 32.5 for SSV; and 2.0, 2.5, 4.5 for VAS, respectively. The proportions of patients who achieved these thresholds were as follows: ASES (83%, 75%, 68%), SSV (78%, 73%, 72%), and VAS (83%, 77%, 63%). Older age was associated with lower odds of achieving MCID, PASS, and SCB, similarly a larger sagittal tear size and longer symptom duration reduced the odds of reaching PASS and SCB.

Conclusion: Partial repair using the margin convergence procedure is an effective treatment for massive rotator cuff tears, with the majority of patients achieving clinically meaningful outcomes at a minimum follow-up of two years. Lower rates of clinical success can be expected in patients with older age, longer symptom duration, and larger sagittal tear size.

Background: Failed shoulder arthroplasty often presents with glenoid bone loss, posing a challenge for both surgeons and patients. This study aimed to evaluate the available revision strategies for failed shoulder arthroplasty in the presence of severe glenoid bone loss. Severe bone loss was defined as a glenoid that is not capable of reconstruction using a standard reverse total shoulder glenoid or augmented baseplate.

Methods: Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PubMed and Google Scholar were systematically searched for revision -shoulder- arthroplasty - glenoid bone loss by two authors independently. Statistical analysis was performed using RevMan software.

Results: Initially, 249 references were retrieved. After duplicate removal and abstract and title screening, 40 full-text studies comprising of 656 patients met eligibility criteria. The mean patient age was 67.7 years (range 62.4-71.2), with a mean follow-up of 33 months (range 16-50). Regarding functional outcomes, custom glenoid implants demonstrated the greatest improvements in ASES and Constant scores, with mean differences (MDs) of 42.4 and 35.8, respectively (P < .001 for both). Custom implants also provided the best pain relief (MD 5.79, P < .001). For range of motion, bone grafting with reverse total shoulder arthroplasty (rTSA) provided the best improvements in external rotation (MD 21.0°) and forward flexion (MD 67.4°) (P < .001 for both).

Conclusion: Custom glenoid implants provided the best functional outcomes and pain relief in revision shoulder arthroplasty with glenoid bone loss. The findings of this study would suggest that given in the short term of superior performance in improving pain, with higher ASES and Constant scores, custom glenoid components warrant further long term study of these issues and long term survival of the implants.

Background: Current patient-reported outcome measures (PROMs) are long, have complex scoring systems, suffer from ceiling and floor effects, are not universally applicable, and have a high administrative burden. In response, we have developed the Subjective Shoulder Scale (S3), a novel PROM designed to overcome these limitations and provide a comprehensive, efficient, and patient-centered evaluation of 7 key domains.

Methods: Items for S3 were generated by reviewing existing questionnaires and refined using input from patients and an expert panel. Seven questions assess pain, range of motion, strength, shoulder stability, activities of daily living, sports and leisure activities, and mental well-being. After pilot testing in 20 participants, test-retest reliability was evaluated in 100 participants by calculating Cronbach's alpha and the intraclass correlation coefficient. To test validity and responsiveness, 124 participants completed both the S3 and the American Shoulder and Elbow Surgeons questionnaire before and after undergoing various shoulder procedures. Pearson's correlation coefficients, exploratory factor analysis, and responsiveness were determined by calculating the effect size and establishing thresholds for the minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptom state.

Results: Pilot testing confirmed clarity, relevance, readability, and ease of use. In the full psychometric evaluation cohort of 244 participants (mean ± standard deviation age 59 ± 13 years; 50% females), the S3 exhibited excellent test-retest reliability (intraclass correlation coefficient = 0.96) and high internal consistency (Cronbach's α = 0.93). No ceiling or floor effects were observed. Exploratory factor analysis supported a unidimensional structure, and convergent validity was established through a strong positive correlation with the American Shoulder and Elbow Surgeons questionnaire (r = 0.71, p < .001). S3 is also responsive, with thresholds of 12.4 points for minimal clinically important difference, 19.9 points for substantial clinical benefit, and 38-83 points for patient acceptable symptom state.

Conclusion: S3 is a reliable, valid, responsive PROM for capturing the effects of diverse shoulder conditions. By addressing weaknesses of existing questionnaires, S3 may facilitate personalized treatment planning through more efficient, meaningful patient evaluations.

Introduction: Proximal humerus fractures (PHFs) account for 5-6% of all adult fractures. The optimal surgical management for PHFs remains under debate with two of the most common operations being open reduction and internal fixation (ORIF) and reverse total shoulder arthroplasty (rTSA). Social determinants of health (SDOH) has gained particular attention in many medical fields due to its relationship to health outcomes with the Social Vulnerability Index (SVI) as an example of an adopted measure of geographic disadvantage. The purpose of this study was to investigate the associations between SVI percentiles and insurance status to adverse postoperative outcomes following surgical treatment of PHFs using either ORIF or rTSA.

Methods: This was a retrospective chart review of patients with PHFs who were treated surgically with either ORIF or rTSA between 2016 to 2023 at a large metropolitan healthcare system. Patient demographics were recorded, and SVI percentiles were determined using patient addresses. Demographic variables were descriptively analyzed based on type of surgery and SVI quartile group. Univariate and multivariate logistic regression analyses were conducted to investigate associations between SVI percentiles and insurance status to adverse postoperative outcomes.

Results: A total of 215 patients with PHFs were included in this study, with 118 in the ORIF group and 97 in the rTSA group. From the multivariate analysis in the ORIF group, there was an association with increasing SVI percentiles and higher odds of returning to the emergency department (ED) (OR = 1.023, p value = 0.002) and having a hospital readmission (OR = 1.028, p value = 0.001). Additionally, patients in the ORIF group with private insurance had lower odds of hospital readmission (OR = 0.077, p value = 0.001) compared to patients who had Medicaid. Patients in the rTSA group did not have significant associations with adverse postoperative outcomes based on increasing SVI percentiles or insurance status.

Conclusion: This study demonstrated that higher SVI percentiles and Medicaid status were associated with adverse postoperative outcomes in patients who underwent ORIF for treatment of their PHFs. Higher SVI percentiles and insurance status did not appear to be associated with adverse postoperative outcomes in the rTSA group. This study highlighted the way in which SDOH and choice of surgery relate to adverse postoperative outcomes in patients with PHFs.

Background: The lateral para-olecranon approach preserves triceps integrity while providing adequate exposure for unlinked total elbow arthroplasty (TEA). However, its effectiveness in patients with rheumatoid arthritis (RA) remains unclear. This study aimed to evaluate midterm clinical and radiographic outcomes of unlinked TEA performed via the lateral para-olecranon approach in patients with RA, focusing on triceps function, range of motion (ROM), strength, and complications.

Methods: Among 43 elbows (39 patients) undergoing unlinked TEA with the Kudo prosthesis via the lateral para-olecranon approach, 2 were excluded because of death and 1 underwent implant removal for deep infection. The final clinical cohort comprised 40 elbows in 36 patients (27 women, 9 men; mean age, 64 ± 13 years; mean follow-up, 73 ± 33 months). Preoperative radiographs showed Larsen grade III in 12 elbows (30%) and grade IV in 28 elbows (70%). Outcomes included active ROM; flexion and extension strength measured by handheld dynamometry; manual muscle testing (MMT); Mayo Elbow Performance Score (MEPS); and radiographic assessment.

Results: All ROM parameters improved significantly: flexion, 121° ± 17° to 137° ± 6°; extension, -34° ± 17° to -26° ± 10°; pronation, 64° ± 16° to 76° ± 15°; and supination, 59° ± 28° to 73° ± 24° (P < .001 for flexion and pronation; P = .0022 for extension; P = .0010 for supination). Flexion and extension strength increased from 16 ± 14 to 26 ± 20 N (P = .0016) and from 13 ± 12 to 23 ± 16 N (P < .001). All elbows maintained MMT grade 5 triceps strength. Mean MEPS increased from 55 ± 9 to 92 ± 8 (P < .001). Among 40 elbows with implants in situ, radiographic evaluation revealed no type III or IV lucency. Kaplan-Meier analysis of 41 elbows demonstrated 97.1% implant survival (95% confidence interval, 81.4%-99.6%). Complications included 2 intraoperative medial epicondyle fractures (5%) and 1 deep infection requiring implant removal (2%). No triceps insufficiency, subluxation, or nerve palsy occurred.

Conclusions: Unlinked TEA performed via the lateral para-olecranon approach provides favorable midterm outcomes in patients with RA and Larsen grade III-IV disease, preserving triceps function while achieving significant improvements in pain, ROM, strength, and overall elbow function. Complete absence of triceps insufficiency and the favorable outcomes support the present approach as a viable treatment option for appropriately selected patients with RA.

Background: Glenohumeral arthritis (GHA) decreases shoulder range of motion, yet the extent of glenohumeral motion loss and accompanying whole-body compensations are not well quantified.

Methods: Eighty-six patients with GHA completed an overhead reach task using both symptomatic and asymptomatic shoulders in a motion-tracking laboratory. Range of motion and peak angles of symptomatic to asymptomatic contralateral shoulders were compared.

Results: The symptomatic shoulder demonstrated 38° less flexion (84° symptomatic vs 122° asymptomatic, p <0.001), 4° less abduction (25° vs 29°, p <0.001), and 22° less internal rotation (21° vs 43°, p <0.001) compared to the asymptomatic shoulder. Patients compensated for these deficits via greater lumbar extension (6° vs 5°, p <0.01), greater lumbar rotation (9° vs 3°, p <0.001), contralateral pelvic rotation (6° vs 2°, p <0.001), reduced cervical flexion (9° vs 18°, p<0.001) with altered lateral bending (7° vs 11°, p<0.001), and greater elbow flexion (26° vs 4°, p 0.001).

Conclusions: GHA is associated with substantial loss of shoulder motion during an overhead reach task that mimics daily activities, which leads to compensatory increases in cervical, lumbar, pelvic, and elbow kinematics.

Clinical relevance: GHA is associated with decreased shoulder motion that results in an increase in compensatory spine motion during daily tasks. This increased compensatory spine motion may place the spine at increased risk for long term pathology.

Purpose: The purpose of this study was to evaluate the Latarjet coracoid graft status using CT at minimum 5-year follow-up in a population with less than 5% glenoid bone loss preoperatively. We hypothesized that complete graft lysis would occur in accordance with Wolff's law.

Methods: This retrospective multicenter study included patients treated with an open Latarjet procedure across eight centers who had less than 5% preoperative glenoid bone loss and available preoperative and follow-up CT scans. Glenoid bone defects were measured using the best-fit circle method on 2D CT. The preoperative glenoid articular surface was compared with the follow-up useful glenoid surface. Three-dimensional CT reconstructions with humeral head subtraction were analyzed to assess graft consolidation, resorption patterns, and screw coverage in sagittal, coronal, and anterior planes.

Results: Thirty-four patients met the inclusion criteria, with a mean follow-up of 98.7 ± 32 months (range 60-172). Four patients experienced graft failure (1 fracture, 3 non-unions), resulting in a graft consolidation rate of 97%. Among the 30 patients with consolidated grafts, the mean useful glenoid surface increased by 1.28 ± 0.97 cm² (p < 0.001), corresponding to a mean glenoid articular surface augmentation of 20.9 ± 23.9%. Three-dimensional CT reconstructions were available in 24 cases and demonstrated consistent graft resorption, predominantly affecting the superomedial aspect of the graft, with partial exposure of the superior screw in most cases.

Conclusion: At a mean follow-up of 8 years, the coracoid graft remained present in 97% of cases, even in patients with minimal preoperative glenoid bone loss (<5%). 2D CT showed a mean glenoid surface augmentation of 20.9%, while 3D analysis revealed consistent superomedial resorption. These findings demonstrate graft consolidation with a low complication rate, suggesting that the Latarjet procedure can be effective in this population.

Level of evidence: Level IV, Case Series, Treatment Study.