Journal of Shoulder and Elbow Surgery最新文献

Background: Introduction of reverse total shoulder arthroplasty (rTSA) has contributed to a large increase in primary rTSA volume. The impact of rTSA on revision TSA has not been well described. This study aims to describe the change of 1) the volume of revision and re-revision TSA, 2) the indications for revision TSA, and 3) patient reported outcomes related to revision indication.

Methods: This is a retrospective review of a prospectively collected single surgeon database from 2002 to 2022. Patients undergoing revision TSA were identified using CPT codes 23472 and 23332 (before 2014) and 23474 (2014 and later). The primary outcome was the change in the rate of revision surgery year-over-year. Secondary outcomes include type of revision preformed, revision indication, re-revision rate, and patient reported outcomes.

Results: Eight hundred fifty-nine patients underwent 1,030 revision surgeries, averaging 52 revisions per year (range 14-66). This reflects 20% of the surgeon's overall shoulder arthroplasty volume. Average time to revision was 41 months (range 0-229). Three hundred fifty-eight failed hemiarthroplasties (HA), 312 failed anatomic total shoulder arthroplasties (aTSAs), 358 failed reverse shoulder arthroplasties (rTSAs) and 2 failed resection arthroplasties were revised. Revisions of failed HA decreased; revisions of both failed aTSA and rTSA increased. Most patients were revised to rTSA (85%); revisions to hemiarthroplasty (8%), aTSA (6%), and resection arthroplasty (<1%) were less common. The most common revision indication by implant type was HA failed because of rotator cuff failure (45%) and glenoid wear (34%); aTSA failed because of glenoid loosening (41%) and rotator cuff failure (33%); rTSA failed because of instability (32%), baseplate failure (27%), and infection (22%). The mean American Shoulder and Elbow Surgeons score improvement from pre-to-postoperative was highest in revisions for aTSA with glenoid loosening and rotator cuff failure, HA with osteoarthritis progression, and rTSA with baseplate failure. A total of 131 patients required multiple revisions, an overall 15% re-revision rate. The re-revision rate by implant was 15% HA, 13% aTSA, and 21% rTSA. Humeral loosening, infection, and instability had the highest rates of re-revision.

Discussion: There is an increasing burden of revision TSA; aTSA and rTSA failures are rising. Patients revised for both glenoid loosening and rotator cuff failure (aTSA), baseplate failure (rTSA), and osteoarthritis progression (HA) had the largest clinical benefit by American Shoulder and Elbow Surgeons score improvement. Revisions performed for humeral loosening, infection, and instability had the highest rate of multiple revisions. These failures pose unique challenges and are opportunities for innovation.

Background: Although risk factors for recurrent instability following arthroscopic Bankart repair (ABR) have been extensively investigated in the general population, research focusing specifically on military cohorts remains scarce. This study aimed to assess the predictive value of the Instability Shoulder Index (ISI) score and distance to dislocation (DTD) for recurrent instability following ABR in a military population.

Materials and methods: We conducted a retrospective single-center cohort study of military personnel who underwent ABR between 2009 and 2022, with a minimum follow-up of 2 years. Recurrent instability was assessed as the primary outcome. Clinical and radiologic parameters were analyzed. Univariate and multivariate logistic regression analysis identified independent predictors of recurrence, and receiver operating characteristic (ROC) curves were used to quantify predictive performance. A subgroup analysis stratified by age was also performed.

Results: A total of 152 patients (147 male) with a mean age of 24.2 ± 4.9 years and a mean follow-up 88.8 ± 40.9 months were included. Recurrent instability occurred in 24 patients (15.8%). Patients with recurrence had comparable ISI score to those without (P = 0.078) but exhibited significantly and shorter DTD (P < 0.001). Multivariate logistic regression analysis identified DTD as an independent predictor of recurrence. The ROC curve showed that the area under the curve (AUC) for DTD was 0.754, with an optimal cutoff value of 5.3 mm. Additionally, the AUC for DTD in patients aged ≤ 20 years and > 20 years were 0.863 and 0.725, respectively.

Conclusion: In military personnel, a shorter DTD was predictive of recurrent instability following ABR, and alternative stabilization procedures should be considered when DTD is ≤ 5.3 mm. Furthermore, ISI score had no association with recurrence; however, this analysis was underpowered.

Background: Revision total elbow arthroplasty (rTEA) is increasing as more primary TEA are performed. Bone loss in the proximal ulnar can provide a complex challenge in the revision setting. Limited options are discussed in the literature including use of impaction grafting, strut allograft and allograft prosthetic composite. Custom ulna megaprosthesis (CUMP) is another viable option for this problem but there remains a significant lack of evidence on its use in revision TEA for non-tumor indications. We present our institution's experience with custom ulna megaprosthesis use for revision TEA for non-tumor indications.

Methods: Records were reviewed for all patients who had undergone CUMP at our tertiary referral center. Variables collected included: patient demographics, indication, number of previous surgeries, follow-up, range of movement, complications, Oxford Elbow Score, Pain, EQ5D and SANE scores. Bone loss was graded using Mansat's grading. Radiographic implant stability and integration scoring was agreed by all authors. For completeness, patients were telephoned for outcome data when variables were missing.

Results: The cohort comprised 15 elbows. The mean age was 67.6 years (range 54-78). The median follow-up for the cohort was 2 years (range 6 months- 6 years). The mean number of prior surgeries was 3 (SD 0.92). Indications for the rTEA were 8 for infection, 4 for periprosthetic fracture and 3 for aseptic loosening. Radiographic bone loss grading: Type 1- 3, Type 2- 7, Type 3- 5. Postoperative implant fixation assessment: Type A- 5 Type B- 6, Type C-4. The mean postoperative arc of movement was 118 degrees (SD 18.31). The cohort demonstrated improvements in the mean Oxford elbow score, SANE, EQ5D and their pain score. There have been two complications to date, with both patients having recurrent deep infection requiring a two-stage revision to another CUMP. It was noted that in both cases the CUMP remained well fixed, and it was the humeral component that was loose.

Discussion: The use of CUMP for rTEA has evolved due to the challenges associated with alternative strategies for these patients. However, there is a lack of data in the literature regarding outcomes for CUMP. We report good early to mid-term clinical and radiographic outcomes. Complications are relatively low, and patient reported outcomes are satisfactory. The use of CUMP offers a reliable solution in challenging rTEA cases but requires careful planning.

Background: Retear following rotator cuff repair is relatively common. Onlay biological grafts offer a potential solution, as a source of addition healing.

Purpose/hypothesis: The purpose of this study was to determine whether the addition of an onlay bioinductive implant would improve repair integrity and examiner-measured and/or patient-rated shoulder function at ≥2 year post revision arthroscopic rotator cuff repair in workers' compensation patients. We hypothesized that the addition of the onlay bioinductive implant in arthroscopic revision rotator cuff repairs would improve repair integrity and functional outcomes at minimum two years follow up compared to standard repair.

Methods: A post hoc matched-cohort study was conducted on prospectively recruited workers' compensation patients who had revision rotator cuff repair with an onlay bioinductive implant (Regeneten bioinductive implant) (n=16). The control group was workers' compensation patients who had revision rotator cuff repair without the bioinductive implant and was matched for age and tear size (n=24). Kaplan-Meier curves were used to compare the primary outcome of repair integrity.

Results: No adverse effects with the bioinductive implant were identified. The retear rate in the bioinductive implant group was 50% (8/16) compared to 38% (9/24) in the control group at minimum 2 year follow up (P = 0.522). There were no significant differences in patient-rated or examiner-measured outcomes between the groups at a median of 2.3 years follow up.

Conclusion: The addition of a biological patch to revision rotator cuff repair offered no advantage at 6 months follow up. This study amplifies those findings and shows that revision rotator cuff repairs continue to fail from 6 months to ≥2 years, with the onlay bioinductive implant having no additional benefit to the longer term health of the repair in this difficult population.

Background: Despite extensive study of the treatment of glenohumeral osteoarthritis (GHOA), there has been little investigation of the progression of the pathoanatomy and associations between longitudinal radiographic changes and clinical manifestations of GHOA remain poorly understood. The purpose of this study was to evaluate the progression of plain radiographic features of GHOA, as well as the effect on clinical presentation.

Methods: Plain radiographs of 135 shoulders with primary GHOA and minimum 5-year (mean 8.60 years, range 5 - 16.5 years) follow up were retrospectively analyzed. The mean age at initial presentation was 62.5 ± 8.33 years. Radiographic assessments were conducted using the Kellgren-Lawrence (KL), Samilson-Prieto (SP), and Walch classifications, in addition to other radiographic measurements. Associations between classification and radiographic parameters and range of motion (ROM), and patient-reported outcome measures (PROMs) in subgroups of patients were evaluated with multivariable regression analysis. After Benjamini Hochberg multiple comparison analyses significance was determined to be p<0.01.

Results: There was a significant deterioration in classification grades and radiographic parameters (all p<0.001). In subgroup analysis, a larger initial humeral spur size was significantly linked to lower future ASES scores (b = -0.56; p = 0.009). Both initial and final larger spur sizes were associated with reduced ROM at the latest follow up (p <0.001). Progression of humeral medialization was significantly correlated with decreased active forward elevation (b = -0.95; p = 0.007) and active external rotation (b = -0.79, p = 0.005). On the latest radiographs, a grade 4 KL was significantly associated with lower ASES scores (b = -22.34; p = 0.001), lower SST scores (b = -32.61; p = 0.001), increased VAS pain (b = 2.27; p = 0.006), and reduced ROM (p <0.001).

Conclusion: The long-term follow up of GHOA showed significant radiographic progression, which correlated with more severe clinical manifestations. Notably, early radiographic indicators, along with aspects of both progressive and final pathoanatomy, were linked to poorer clinical outcomes. These findings offer insights into the natural progression of GHOA and may be useful in setting expectations and determining treatment strategies for patients with GHOA.

Background: Reverse total shoulder arthroplasty (rTSA) is an alternative to anatomic total shoulder arthroplasty for the treatment of primary glenohumeral osteoarthritis (GHOA) with intact rotator cuff. The utility of subscapularis (SC) repair in rTSA remains controversial. The purpose of this study was to investigate the effect of an SC repair treatment protocol on the outcome of rTSA for treating GHOA with an intact rotator cuff using a lateralized glenoid and inlay humerus rTSA system (Enovis/DJO RSP and AltiVate).

Methods: This was a retrospective study of 80 patients with GHOA and intact rotator cuff who underwent rTSA with a lateralized glenoid and inlay humerus design. SC repair was performed in 50 patients (62.5%) when it did not limit intraoperative passive external rotation (PER). Outcomes were assessed at a minimum of 1-year follow-up. Mixed effects models assessed associations between SC repair and patient-reported outcome measures (PROMs), internal rotation activities of daily living (IR-ADL), range of motion (ROM), and strength.

Results: There were no differences in the characteristics of the repaired and unrepaired groups. At minimum 1-year follow-up, there were no significant differences in the PROMs between the repaired and unrepaired groups. However, the repair group had significantly better PROMs at the 3- and 6-month follow-up. The repair group had greater mean preoperative active external rotation (AER) (11.9° ± 20.0° vs. -1.3° ± 23.1°, P = .017). There was no difference in postoperative mean AER (32.5° ± 15.3° vs. 31.2° ± 13.6°, P > .99). The no repair group had greater improvement in AER (32.5° ± 20.5° vs. 20.8° ± 20.7°, P = .032). The repair group had significantly greater internal rotation (IR) ROM and strength at all follow-ups. A greater proportion of patients in the repair group achieved the patient acceptable symptom state (PASS) for IR ROM (93.8% vs. 75.9%; P = .024), whereas a greater proportion of the unrepaired group achieved substantial clinical benefit (SCB) for AER (90.0% vs. 60.4%, P = .005). Although there were no differences in IR-ADLs at 1-year minimum follow-up, the repair group was better at the 3- and 6-month follow-ups. There were no cases of instability.

Conclusion: There are trade-offs to SC repair in rTSA for patients with GHOA and intact rotator cuff. Selective SC repair was associated with greater early outcomes without meaningful PROM differences at minimum 1-year follow-up. However, SC repair that does not limit intraoperative PER results in better IR motion and strength compared with cases in which repair without limiting PER ROM is not possible. On the other hand, if SC repair limits PER, foregoing repair improves AER ROM without affecting PROMs or stability.

Background: The available data on heterotopic ossification (HO) following implantation of reverse total shoulder arthroplasty (rTSA) is limited. It was the aim of this study to determine occurrence of HO following rTSA and the impact on clinical outcome.

Methods: A prospectively followed rTSA database of a tertiary referral center was retrospectively analyzed between September 2009 and February 2018 to evaluate the prevalence of HO in primary rTSA cases at minimum follow-up of 2 years. All basic demographic data, clinical outcomes (Constant-Murley score (CS), Subjective Shoulder Value, range of motion), complications and reinterventions were collected. HO was classified as type 1a (islands of bone within the soft tissue), type 1b (bone spurs on the inferior scapular neck), type 1c (incomplete ankylosis), type 2 (combination of bone spur and islands of bone), and type 3 (complete ankylosis). Further, an association between complications/reinterventions and occurrence of HO was evaluated.

Results: A total of 663 rTSAs (627 patients, mean age 72 ± 9 years, 60% female) were available for analysis at a mean follow-up of 6 ± 4 years. Of those, 16% (104/663) had at least one complication and 8% (53/663) needed a reintervention. At 2 years, HO was seen in 59% (392 of 663) of the cases with type 1a in 108 (16%), type 1b in 226 (34%), type 1c in 19 (2.9%), and type 2 in 39 (5.9%). Overall, occurrence of HO had minimal impact on absolute CS with values of 68 ± 15 (no HO), 70 ± 13 (type 1a), 67 ± 13 (type 1b), 64 ± 13 (type 1c), and 68 ± 14 (type 2) (P = .043). The most relevant effect was seen on abduction with 117 ± 35° in type 1c vs. 136 ± 30° without HO (P = .02). The effect on other functional parameters was not statistically significant with a tendency for inferior results in type 1c. Further risk factor analysis revealed that complications and reinterventions were not associated with occurrence of HO (P = .443 and P = .930) but female gender (coefficient -0.37, P < .001), moderate alcohol consumption (coefficient 0.35, P = .001), secondary fracture treatment (coefficient 2.96, P < .001), and osteoarthritis (-0.48, P < .001).

Conclusion: The occurrence of HO is very common with progress over time. Male gender, moderate alcohol consumption, and secondary fracture treatment seem to be associated with higher HO rates. It affects mainly abduction and to some extent the overall clinical outcome, with inferior results especially for type 1c. There was no association with other complications and revision surgery.

Background: There has been a trend toward the use of shorter humeral components with the goal of preserving bone, decreasing operative time, and a theoretical decrease in stress shielding. The purpose of this study was to compare the clinical and functional outcomes of anatomic total shoulder arthroplasty among standard-length stem, short-stem, and stemless humeral components, with a minimum of 2-year follow-up.

Methods: A retrospective review of a multicenter international database was performed for anatomic total shoulder arthroplasty with a minimum of 2-year follow-up between 2018 and 2021 using Standard Equinoxe stems, Equinoxe Preserve (Short) stems, or Equinoxe Stemless components (Exactech, Inc., Gainesville, FL, USA). Outcome measures included range of motion and patient-reported outcome measures (PROMs). Postoperative radiographic findings including the presence of glenoid and humeral radiolucent lines in zones specific to the stem design were evaluated. Complication and revision rates were recorded.

Results: A total of 825 patients were included (164 standard-length stem, 356 short-stem, and 305 stemless). The mean follow-up was 37.9 ± 12.6 months. There was no significant difference in previous shoulder surgeries or medical comorbidities among the groups. The mean final forward elevation for standard-length stem, short-stem, and stemless components was 156°, 158°, and 156°, respectively (P = .636). Final external rotation for standard-length stem, short-stem, and stemless components was 58°, 57°, and 51°, respectively (P < .001). Final internal rotation scores were similar across groups (P = .090). Final PROMs did not meet the minimal clinically important difference across cohorts. The mean operative time for the standard-length stem group was 101.8 minutes, for the short-stem group 92.7 minutes, and for the stemless group 89.2 minutes (P < .001). There was no statistically significant difference in complication rate or revision rate. The rate of humeral component radiolucent lines was greater for standard-length stems (P < .001) with a rate of 11.9% for standard-length stem, 1.7% for short-stem, and 1.6% for stemless components. Patient satisfaction was also similar among the 3 cohorts (P = .757).

Conclusions: Our findings demonstrate similar postoperative motion and PROM scores irrespective of the humeral stem component used. Complication and revision rates were similar for all 3 cohorts. Radiolucent lines were lowest with the stemless component. Early data support the use of stemless and short-stem humeral components that may be advantageous in decreasing operative time and preserving humeral bone for potential revision. Longer term studies are needed to confirm the survivability and durability of these shorter components.

Background: Strut allograft reconstruction represents an appealing option to address bone deficiency in revision total elbow arthroplasty (TEA), offering immediate structural support and potential for graft incorporation to restore bone stock. However, evidence supporting its efficacy is limited to small case series studies. This study aimed to assess strut allograft incorporation, complication, and re-revision rates in a large series of elbows that underwent revision TEA with strut allograft augmentation.

Methods: Adult patients who underwent revision TEA with strut allograft augmentation between 1990 and 2024, with >2-year follow-up, were identified using our Institutional Total Joint Registry database. Those who had previously undergone TEA with strut augmentation and revisions performed using allograft prosthetic composites or custom-made implants were excluded. A total of 178 elbows (mean age 61 ± 12 years, 73% female) were included. The most common indications for revision TEA were aseptic loosening (55%), periprosthetic fracture (24%), and mechanical failure (10%). 60% had undergone one prior TEA procedure, with the remaining having undergone two or more. Cortical strut allografts were most frequently used for humeral-sided reconstruction (48%), followed by ulnar-sided (38%) and both sides (13%). Medical records and radiographs were reviewed to confirm study eligibility and record demographic information, surgical indications, postoperative outcomes, and graft incorporation. Survivorship analyses were performed to determine cumulative incidences of re-revision TEA with death as a competing risk. The mean follow-up time was 9 ± 6 years.

Results: Strut allograft augmentation allowed satisfactory implantation of off-the-shelf implants in all elbows. However, 55 (31%) eventually underwent re-revision at a mean of 6 ± 5 years postoperatively. Among the 121 elbows with available follow-up radiographs, 113 (93%) demonstrated graft incorporation. Cumulative incidences of re-revision TEA at 1, 2, 5, and 10 years were 5% (95% confidence interval [CI] 2 - 9), 7% (95% CI 4 - 12), 18% (95% CI 13 - 24), and 24% (95% CI 19 - 32), respectively. Aseptic loosening (44%), infection (29%), and periprosthetic fracture (18%) were the most common indications for re-revision. Of the periprosthetic fractures, the majority occurred in cases where the strut and implant ended at the same level (46%) or when the strut had failed to incorporate (31%).

Discussion: Deficient bone stock can be effectively managed with strut allograft augmentation in revision TEA with high rates of graft incorporation. Risk of subsequent periprosthetic fracture may be related to the strut and implant ending at the same level. Despite early success within the first two years, survivorship free of revision declines to 75% at 10 years.

Aim: To evaluate the parallelism between the base of the coronoid axis(BCA) and the elbow flexion-extension axis of rotation, known as the humeral interepicondylar axis (HIEA), using a cadaveric model.

Background: Coronoid fracture characterization is crucial in treatment decision-making. The base of the coronoid is a fundamental reference used for fracture classification and to perform measurements to quantify fragment size, both of which guide the decision to proceed with surgical intervention. Furthermore, computed tomography (CT) used for fracture analysis relies on the acquisition of planar images aligned with specific anatomical axes, which should be referenced to the ulna rather than the humerus to minimize variability introduced by the flexion-extension positioning or ulno-humeral alignment. We defined the BCA as the line connecting the posterior limits of the sublime tubercle and the lesser sigmoid notch, proposing it as a reference for ulnar-based CT planar reconstructions and to be used as a reference for coronoid measurement. Based on empirical observations, we hypothesized that the BCA may be parallel to the HIEA, supporting the BCA not only as a reliable reference for image studies, but also as a surrogate for locating the elbow flexion-extension axis of rotation relative to the forearm. Our Aim was to evaluate this hypothesis.

Methods: Ten Thiel-embalmed cadaveric arms were instrumented with Kirschner wires(K-wires) placed along the BCA and the HIEA axes. The full arc of elbow flexion-extension arc of motion as recorded simultaneously using three cameras positioned laterally, superiorly, and posteriorly. The angle between the two K-wires (angular variation) was measured in the videos using analysis software (Kinovea) capturing changes in angular variation between axes at millisecond intervals. Axial parallelism was defined as an angular variation of less than 5°(parallel axes) and/or a statistical range of less than 5° (indicating the axes lie within parallel planes) throughout the entire range of motion.

Results: Ninety percent and eighty percent of specimens demonstrated an angular variation of less than 5° in the superior and posterior views, respectively. In both video recordings, all specimens exhibited a statistical range of less than 5°.

Conclusion: The line intersecting the posterior aspects of the sublime tubercle and the lesser sigmoid notch - defined as the base of the coronoid axis (BCA)- and the elbow joint's axis or rotation - represented by the interepicondylar axis (HIEA)- were either parallel in 85% of the recordings or lay in parallel planes in the remaining cases throughout the entire flexion-extension arc of motion.