Journal of Shoulder and Elbow Surgery最新文献

Background: Massive proximal humeral bone loss (PHBL) poses a technical challenge during reverse shoulder arthroplasty (RSA). Surgical treatment strategies include allograft-prosthetic composite (APC) reconstructions, endoprostheses, and other reverse shoulder arthroplasty constructs, however, there is a paucity of literature summarizing the outcomes and complications unique to this complex patient population. This study aimed to systematically review the literature to evaluate (1) patient-reported outcome measures (PROMs), (2) functional outcomes, and (3) complications according to surgical treatment strategy for patients with massive PHBL who undergo primary or revision shoulder arthroplasty.

Methods: A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes and complications of reverse shoulder arthroplasty in patients with significant PHBL. Methodological quality was assessed for included studies. PROMs, radiographic outcomes, and postoperative functional outcomes were collected.

Results: Eleven studies evaluating clinical outcomes and complications of reverse shoulder arthroplasty in the setting of PHBL comprising 277 patients were included for review. The mean age was 66 years (range, 60-79 years). American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS), and range of motion (ROM) were the most common outcomes collected, and patients exhibited significant improvements in mean scores postoperatively. Of the types of prostheses reported, there were 155 reverse shoulder arthroplasty (RSA) with allograft-prosthetic composite (APC) reconstructions, 48 proximal humeral replacement (PHR) endoprostheses, 41 RSA, 15 custom RSA, and 2 RSA with fibular strut allografts. The overall pooled complication rate was 30.1% (82/272) with revision/reoperation as the most common complication at 21% (57/272). The overall complication rate for RSA-APC reconstructions was 51% (79/155). The overall complication rate for PHR endoprostheses was 64.6% (31/48). Revision/reoperation rates were the most complication for both RSA-APC and PHR endoprostheses with rates of 20% and 31.3%, respectively.

Conclusions: Treatment by APC reconstruction is the most common surgical technique described in the setting of massive PHBL. While shoulder arthroplasty can yield acceptable results for patients with substantial PHBL, such patients are at increased risk for complications and revision surgery.

Background: Total humeral replacement (THR) is one of the few options for reconstruction when the humerus is extensively involved or with skip lesions. However, there are few studies focusing on the long-term outcomes of THR for primary sarcomas, and the function and endoprosthesis survival remains uncertain.

Questions/purposes: The purposes of this study were to answer the following questions: 1) What are the oncological and functional outcomes of total humeral replacement? 2) What are the overall survival and revision-free survival rates of total humeral replacement? 3) What are the failure mechanisms of total humeral replacement?

Methods: A retrospective cohort study was conducted on 34 patients (22 males, 12 females) between January 1997 and December 2021. The average age was 30.1 ± 20.1 years (7 to 72) and the pathological type included osteosarcoma (24), chondrosarcoma (6), Ewing's sarcoma (2) and undifferentiated pleomorphic sarcoma (UPS, 2). The oncological outcomes included local recurrence, metastasis, and overall survival. The functional outcomes were assessed by the Musculoskeletal Tumor Society Score (MSTS-93), the Toronto Extremity Salvage Score (TESS) , the American Shoulder and Elbow Surgeons (ASES) score and the range of motion (ROM) of the shoulder. All modes of failure were recorded in the follow-up. The significance level was adjusted to 0.025 after Bonferroni correction.

Results: The mean follow-up of all patients was 78.5 ± 72.6 months (range, 9 to 292 months) and 103 ± 71.6 months (range, 32 to 292 months) in all survivors. Fourteen patients (41.7%) died in the last follow-up. The 5-year, 10-year, and 15-year overall survival rate of the endoprosthesis was 94% (95% CI 66.6%-99.1%). The average MSTS-93 score was 78% (range, 53% to 86%), the average TESS was 80% (60% to 90%) and the average ASES was 79% (63% to 93%), respectively. The most common failure mechanisms were tumor progression (type 5, 17.6%, 6/34), followed by soft tissue failure (type 1, 14.7%, 5/34), and structural failure (type 3, 2.9%, 1/34).

Conclusions: THR is a long-term reconstructive option for patients with massive tumors requiring complete resection of the humerus. The most common failure mechanisms were tumor progression (type 5) and soft tissue failure (type 1). Overall functional outcomes were acceptable with good hand and elbow function, but shoulder function was limited.

Background and objectives: Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, yet there is insufficient evidence from randomized controlled trials (RCTs) to determine the most appropriate interventions for their management. This study presents the long-term results of the first prospective RCT comparing surgical treatment with reverse shoulder arthroplasty (RSA) versus nonoperative treatment in displaced PHFs in elderly patients.

Materials and methods: Patients from a previously published RCT of 62 patients, in which RSA was compared with nonoperative treatment, were followed up long term. All patients were aged 80 years or older with 3- or 4-part displaced PHFs. Functional (Constant, DASH, SF-12, and VAS) and radiographic outcomes were assessed.

Results: From the initial series, 12 patients treated conservatively and 17 with RSA were included, with mean ages of 88 and 92 years (p=.004) and mean follow-up of 7.4 and 7.6 years (p=.171), respectively. Functional outcomes for RSA versus conservative treatment were as follows: Constant 62/51 (p=.039), DASH 16/25 (p=.069), SF-12 Physical 42/43 (p=.808), SF-12 Mental 59/60 (p=.690), and VAS 1.5/1.4 (p=.274). All nonoperatively treated fractures healed in malposition, but none required revision to RSA. Among patients treated with RSA, one required revision surgery due to prosthesis dislocation.

Conclusions: These results suggest that long-term treatment with RSA for displaced 3- or 4- part PHF provides better functional outcomes compared to nonoperative treatment. This difference is attributed to the deterioration of functional outcomes of the non-operative treatment over time.

Introduction: Anterior shoulder instability in adults over the age of 40 is frequently managed non-operatively. There is limited published evidence for the surgical management of these patients. This study aims to assess the risk of recurrence and functional outcomes in older adults after Arthroscopic Bankart Repair (ARB).

Methods: A retrospective review of patients who underwent ARB under a single surgeon with a minimum of 2-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) for pain, satisfaction, Subjective Shoulder Value (SSV), Rowe and Constant scores, along with rate, level and timing of return to work and sport were evaluated.

Results: Overall, 51 patients who underwent ABR were included, there were 35 males (69%). The mean age was 46.9 ± 6.4 years, with mean follow-up of 77.9 ± 32.6 months (range 25-138 months). At final follow-up 88% (45/51) were either satisfied/very satisfied. The mean SSV was 87.4 ± 14, the mean Constant score was 80.4 ± 19.6, the mean Rowe score was 80.4 ± 19.6, while the mean VAS score was 2.2 ± 2.6. Overall, 45 of 47 (95.7%) patients returned to work at a mean of 5.7 ± 4.6 (0-16 weeks). Of the 43 patients playing sport preoperatively, 81.4% returned to play at a mean of 6.5 ± 3.8 months, 53.5% returned at the same level. However, only 27.3% of collision and 42.9% of overhead athletes returned at the same level. There were 4 patients (7.8%) who had a postoperative dislocation, all of which were traumatic. There were two revision (3.9%) arthroscopic stabilisations, whilst a total 8 patients (15%) had further procedures.

Conclusion: Arthroscopic stabilisation in patients older than 40 years of age results in a high rate of satisfaction, good functional outcomes and low pain scores at medium-to-long term follow-up. There was a high rate of return to play and work, although most returned to play at a lower level. There was a low rate of recurrent instability and a moderate rate of re-operation, with contact sports being the primary cause of recurrence.

Background: In acute radial head (RH) fractures (RHFs), an RH prosthesis can be considered if open reduction and internal fixation are not technically feasible. This study provides the largest long-term clinical and radiological follow-up study of cemented bipolar Judet prostheses implanted to manage acute RHFs, either isolated (IRHFs) and associated with other elbow fractures (ARHFs). We compare their functional and radiographic outcomes to test the hypothesis that the bipolar design can achieve similar results in both groups.

Methods: We reviewed the data of 63 consecutive patients implanted with a bipolar prosthesis (The articulation between the stem and the cup is semiconstrained and gives the radial cup a double range of movement) to treat unreconstructable RHFs with/without other fractures. Fifty-two patients had more than 10-year follow-up. Assessments included range of motion and stability using the Mayo Elbow Performance Score (MEPS) and the QuickDash questionnaire score, pain with a visual analog scale, and overall satisfaction with an interview. X-rays were examined to check the correct seating of the implant and periprosthetic loosening, prosthetic disassembly, heterotopic ossification, and capitellum and ulnohumeral degenerative changes.

Results: At a mean follow-up of 150 months, 90% of patients were satisfied, with a mean MEPS of 89 (range, 70-100) and a mean QuickDash score of 6.8 (range, 0-18.2). The mean arc of motion was 113° (range, 70°-140°) in flexion-extension and 149° (range, 100°-160°) in pronation-supination. Nineteen patients (30%) patients required reoperation in the first 3 years.

Conclusions: The bipolar Judet prosthesis is a viable implant for acute irreducible RHFs. Clinical and radiological outcomes and complications leading to reoperation were not significantly different between IRHF and ARHF patients.

Background: Subscapularis tendon (SSC) tears have recently become an area of current research focus. However, the risk factors for atraumatic isolated SSC tears, particularly anatomical factors, remain poorly determined. Therefore, the purpose of this study was to identify the associated factors contributing to isolated SSC tears.

Methods: This study involved single shoulders of 605 subjects drawn from a cohort of rural residents. The inclusion criteria required each subject to sign an informed consent document and to have a complete clinical evaluation. The exclusion criteria comprised the absence of a complete MRI study, current medication use that might have affected serum lipid levels, a history of shoulder trauma or surgery, and the presence of osteoarthritis, calcific tendinitis, frozen shoulder, or superior or posterosuperior rotator cuff tear. Diagnoses of isolated SSC tear were based on MRI findings. Logistic regression analysis was conducted using demographic, physical, social, anatomical, comorbidities, and serological parameters. Anatomical variables included the supraspinatus fossa glenoid angle on axial (SGAX), a method to measure glenoid version, coracohumeral distance on axial and sagittal plans, and coracoid index. When multicollinearity among studied variables was detected, separate multivariable analyses were performed to address this issue, with each analysis including only one of those multicollinear variables along with the other significant variables obtained from univariate analyses.

Results: Among anatomical variables, coracohumeral distance on axial and sagittal planes, as well as the coracoid index, did not show significant associations. However, SGAX, an index of glenoid version, was found to be significantly associated with atraumatic isolated SSC tears. Greater glenoid retroversion is significantly associated with atraumatic isolated SSC tears, along with age, waist circumference, dominant side involvement, manual labor, diabetes, metabolic syndrome, and biceps tendon injury (p≤0.013).

Conclusions: The SGAX, serving as an index for glenoid version, is an independently associated factor for atraumatic isolated subscapularis tendon tears, with greater glenoid retroversion being an anatomical risk factor for these tears, along with overuse-related factors such as dominant-side involvement and manual labor, as well as metabolic factors such as obesity, diabetes, and metabolic syndrome, and biceps tendon injury.

Background: Previous literature has demonstrated high rates of Cutibacterium acnes (C. acnes) colonization in patients undergoing primary shoulder arthroplasty. Residing primarily within the dermal layer, C. acnes poses a major threat to intraoperative wound contamination with subsequent risk of developing periprosthetic joint infection. Discovering an effective perioperative prophylaxis strategy is imperative. To date, no such regimen has shown the ability to reliably suppress C. acnes from the deeper tissues. This study was designed to investigate whether intraoperative Irrisept irrigation would result in a lower positive culture rate of C. acnes versus standard prophylaxis alone in primary total shoulder arthroplasty.

Methods: Patients undergoing primary shoulder arthroplasty were randomized to the standard control group or the experimental Irrisept group. Intraoperative cultures were obtained from the incision site, dermis, inferior glenohumeral recess, and sterile kidney basin (control). All specimens were collected by one surgeon at one institution. Samples were shipped to ACM Global Laboratories. All cultures were observed for 14 days. Statistical analysis of the control and experimental quantitative values were compared via Fisher's exact test. Nominal variables were evaluated using the chi-square test. Multivariate analysis was performed to evaluate for differences in age, body mass index, smoking history, diabetic status, VAS, and ASES scores. Significance for all comparisons was p ≤ 0.05.

Results: Final analysis included 56 patients and 223 cultured specimens. Baseline demographics were similar between cohorts, indicating successful randomization. C. acnes positive culture rate of the control group did not significantly differ from the Irrisept group (5.77% versus 10.08%; P=0.49). No differences were noted in subgroup analysis. The total positive culture rate of all specimens was 8.07% (18/223). Incision site cultures had the highest rate of positivity (14.2%), followed by the dermis (7.14%), deep tissue (5.5%), and control (5.4%). No difference in culture rates were detected regarding age, BMI, smoking history, diabetic status, VAS, or ASES scores. There was 98.2% follow-up at two weeks, 91.1% at six weeks, 83.9% at three months, and 71.4% at six months. No additional complications or adverse events were noted in either cohort.

Conclusion: The addition of intraoperative Irrisept irrigation did not significantly differ from standard perioperative prophylaxis for C. acnes positive culture rates in patients undergoing primary shoulder arthroplasty. While the findings should be cautiously interpreted due to the limited sample size, this pilot study provides a useful framework to inform a larger randomized controlled trial, emphasizing the importance of perioperative infection prophylaxis.

Background: Postoperative physical therapy (POPT) is a critical aspect of patient recovery following orthopedic shoulder surgery. Despite the importance of POPT, some patients do not complete their course of physical therapy, which can affect postoperative recovery and outcomes. This study aimed to identify risk factors that influence patient adherence and attendance of POPT.

Methods: Patients >90 days postop from elective shoulder surgery were retrospectively recruited for this study from an urban, academic tertiary medical center. Patient charts were reviewed for demographic factors with eligible patients being contacted via telephone call to answer a questionnaire concerning their use of POPT. Inadequate levels of POPT were defined as stopping formal physical therapy earlier than the physical therapist recommended. Final analysis cohorts were compared using Fisher's Exact Test and Wilcoxon Rank Sum Test.

Results: A total of 104 patients were included in the final analysis with 84 completing POPT and 20 reporting having stopped therapy early. Patient medical history including elevated BMI (mean significance difference 3.8, [0.018 to 7.6 95% CI]) p=0.026)), being a smoker (p=0.027), having diabetes (p<0.001), and having Medicaid as their primary insurance (p=0.008) were significantly associated with stopping physical therapy earlier than recommended by the physical therapist (Table I). Demographic factors such as requiring additional assistance to get to medical appointments (p=0.012) and living farther away from a physical therapy center (p=0.007) were also substantially associated with a greater risk of stopping physical therapy earlier than recommended by the physical therapist (Table II).

Conclusion: Elevated BMI, tobacco use, diabetes, Medicaid enrollment status, requiring additional assistance to get to PT appointments, and living farther away from their physical therapy center are risk factors associated with patients stopping PT after elective shoulder surgery earlier than recommended by a physical therapist. Knowledge of these patient-specific risk factors should be considered by orthopedic surgeons and physical therapists when tailoring a POPT protocol.

Background: Osteoporosis, a prevalent bone density disorder, introduces a complex dynamic in the context of total shoulder arthroplasty (TSA). However, despite the well-established association between osteoporosis and an elevated risk of revision, the existing literature lacks comprehensive insights into the impact of anti-osteoporotic therapy on surgical outcomes in the setting of TSA. Thus, the purpose of this study was to investigate whether anti-osteoporotic therapy correlates with improved revision outcomes following TSA.

Methods: A retrospective cohort analysis was performed using a national all payer's claims database. Patients who underwent TSA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) procedure codes. Patients with a preoperative diagnosis of osteoporosis were included, then stratified into two groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (Anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (No Anti-OP cohort). Primary outcomes included the incidence of 2-year all-cause revision, periprosthetic fracture (PPF), periprosthetic joint infection (PJI), and mechanical loosening. Univariate and multivariable regression analysis was conducted to compare outcomes between the two cohorts.

Results: In total, 40,532 osteoporotic patients were included in this study, with 11,577 (28.5%) having undergone anti-osteoporotic treatment. Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision (Odds Ratio [OR]: 1.31; P < 0.001) and mechanical loosening (OR: 1.25; P < 0.001) following TSA when compared to those treated for osteoporosis.

Discussion: This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following TSA. Orthopedic surgeons should recognize the heightened risk of early implant failure in the absence of osteoporosis therapy. This underscores the imperative for increased screening initiatives given the high prevalence of undiagnosed or untreated osteoporosis in the TSA population. These results also emphasize the importance of integrating osteoporosis management strategies into the broader context of surgical decision-making, thereby contributing to enhanced patient outcomes and quality of care in shoulder surgery.