Journal of Shoulder and Elbow Surgery最新文献

Background: Arthroscopically-assisted lower trapezius tendon (aLTT) transfer has emerged as an effective surgical option for patients with posterior superior irreparable rotator cuff tears (PSIRCTs) who primarily complain of external rotation weakness and lag signs, in the absence of arthritis. The purpose of this study is to compare the clinical and structural outcome among different age groups in aLTT transfer for PSIRCTs.

Methods: We retrospectively reviewed patients who underwent aLTT transfer for PSIRCTs between May 2017 and September 2021. We included patients with PSIRCTs, minimal glenohumeral arthritis (Hamada grade ≤ 2), poor muscle quality (Goutallier grades ≥ 3), and a minimum follow-up of 2 years. Patients lacking a minimum of 2-year follow-up data and a postoperative MRI were excluded. For the purpose of the study, three groups were created: Group Total includes all ages, Group A consists of patients aged 60 and below, and Group B consists of patients aged 70 and above. We compared patient-reported outcome scores (VAS, Constant, UCLA, ASES, ADLER), pre- and postoperative range of motion (ROM), acromiohumeral distance (AHD), Hamada grade, graft integrity on postoperative MRI, and complications among the groups.

Results: Eighty-four patients underwent aLTT transfer (51 with Achilles tendon allografts and 33 with fascia lata autografts), with a mean follow-up of 43.7 ± 14.6 months. There was significant improvement in VAS, Constant, UCLA, ASES, ADLER scores, and ROM in the entire cohort. When comparing Group A (n=23) and Group B (n=19), there were no significant differences in patient-reported outcomes, ROM, AHD, and Hamada grade. Additionally, we observed comparable clinical results, with similar rates of complications such as re-tear, postoperative stiff shoulder, and revision surgery between the groups.

Conclusion: The current study demonstrates that aLTT transfer for PSIRCTs with minimal glenohumeral arthritis yields similar results between Group A and Group B. Additionally, the two different age groups did not show significantly different clinical results when compared to the entire cohort. Our findings contribute to a more comprehensive understanding of the applicability of aLTT transfer across different age groups, emphasizing its potential as a viable treatment option for a broader patient population.

Background: Shoulder fusion after nerve injury can improve overall arm function, however high revision and low patient satisfaction rates have been described. The purpose of this study is to describe a two-stage shoulder fusion, first pinning in a position of function and then converting to a shoulder fusion. Our hypothesis is that temporary pinning improves overall satisfaction after shoulder fusion in comparison to satisfaction reported in the literature.

Methods: A retrospective review was performed for patients receiving two-stage shoulder fusion between 2020 and 2023. Patient demographics and clinical outcomes were recorded. Univariate statistics were performed to compare pre- and postoperative values.

Results: Eighteen patients with an average age of 47 +/- 17.3 years and average follow-up of 23.7 +/- 4.5 months were included. Preoperative diagnoses included brachial plexus injury (n=13; 72%), late presentation obstetric brachial plexus injury (n=2; 11%), traumatic brain injury (n=1; 14.2%), cervical spinal cord injury (n=1; 14.2%) and iatrogenic axillary nerve injury with advanced arthritis (n=1;14.2%). Twelve (67%) patients received unilateral shoulder fusion 2.7 +/- 1.9 days after their initial pinning. Six patients (28.6%) did not receive a second stage fusion. Reasons for not continuing with fusion were attributed to perceived hand function and arm position. Three patients received two shoulder pinnings prior to their fusion to adjust the fusion position to accommodate more internal rotation. After fusion, both SSV (5.2 +/- 5.5% versus 71.6 +/- 10.4%; p<0.001) and pain (2.3 ± 4.0 vs 0.5 ± 0.71; p=0.56) improved. Forward elevation (5 +/- 12 versus 108 +/-35; p=0.01), abduction (10 +/- 15 versus 78 +/-9; p<0.001)), and external rotation (5 +/- 12 versus 22 +/- 17; p=0.26) all improved postoperatively while internal rotation remained limited (1.3 +/- 0.9 versus 1.2 +/- 0.5; p=0.84). Time to union was 15.4 +/- 15.4 weeks confirmed with CT scan. There was one (5.5%) reoperation for non-union, and patient satisfaction was 92% (n=11/12).

Conclusion: Shoulder fusion after neurologic injury provides improved function and patient outcomes, however some patients may be unsatisfied with their new arm position. Percutaneous pinning prior to fusion is tolerated and allows patients to trial potential fusion positions. This method may improve patient satisfaction and avoid excess morbidity in those that would not be satisfied with a shoulder fusion.

Background: Despite the introduction of new implants and biomechanical improvements for proximal humerus fractures (PHF), the complication rate remains significant, particularly in older adults. This study aimed to identify risk factors for complications and failure following plate osteosynthesis for PHF and discuss an age cut-off that surgeons should consider for complications.

Methods: Adults with PHF treated with the proximal humerus internal locking system (PHILOS) at our large tertiary academic referral center between 2015 and 2020 were retrospectively identified. Univariate analysis was used to compare patients with and without complications. Then, a multivariate regression analysis was conducted to assess the possible complication risk factors. The receiver operating characteristic (ROC) curve of age was drawn to predict complication-free and favorable functional outcomes at the most recent follow-up. Oxford Shoulder Score (OSS) was considered favorable if OSS<10.

Results: A total of 135 patients were identified, with a mean age of 44 years (range 18-85 years) and a mean follow-up duration of 4.6 years (range 2-8 years). Complications were observed in 19 cases (14.1%), namely nonunion (n=5), avascular necrosis (n=1), infection (n=1), intra-articular screw perforation (n=1), arthritic changes (n=5), and superior humeral head migration (n=5). Eight patients (5.9%) needed revision surgery. Older age (OR=1.09) and Neer IV class (OR= 8.3) were associated with an increased likelihood of complication (P<0.001, P=0.02, respectively) in logistic multinominal regression analysis. The ROC curve for age in predicting complication-free cases had an area under the curve (AUC) of 0.829, indicating age as a significant predictor of ORIF outcomes in PHF (P<0.05). The optimalcut-off for age was 44 years, which yielded a sensitivity of 100% and a specificity of 65.7. The age ROC curve for predicting favorable OSS (OSS<10) had an of 0.829, indicating that age could predict the favorable OSS outcomes of ORIF in PHF. The optimal age cut-off was 46 years, yielding a sensitivity of 70.0% and a specificity of 78.6%.

Conclusion: The outcomes of ORIF for PHF in patients older than 45 years are associated with significantly higher complication rates and poorer functional outcomes. Surgeons should possibly consider other treatment options for PHF in each older patient individually, especially with Neer type IV fractures.

Background: Physical therapy remains a ubiquitous treatment modality for the management of frozen shoulder (adhesive capsulitis) despite limited high-level evidence supporting its use. Leveraging patient-reported outcome measures (PROMs) and healthcare costs, this study compared patient outcomes and value achieved through watchful waiting (WW) versus physical therapy (PT) for conservative management of frozen shoulder.

Methods: Patients in this prospective, parallel randomized controlled trial who were diagnosed with frozen shoulder were randomized 1:1 to WW or PT. All patients were offered therapeutic, intra-articular corticosteroid injections (CSIs). The primary outcome was the American Shoulder and Elbow Surgeons (ASES) Score. Secondary outcomes included patient value (i.e., 12-month ASES score divided by healthcare costs), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and Visual Analog Scale pain. Due to the confidentiality of internal hospital data, all economic outcomes were divided by an undisclosed constant to set the normalized study mean for direct costs to 1,000; similarly, patient value was normalized to set the study mean to 100. Outcomes were assessed at baseline, 6 weeks, 3 months, 6 months, and 12 months using mixed-effects models, with sensitivity analyses adjusting for nonlinear improvement trajectories and CSIs.

Results: Between November 2014 and November 2022, 175 patients were screened, 61 of whom (34.9%) were randomized to WW (31 patients) or PT (30 patients). Forty-seven patients (96%) received at least one CSI, with no significant difference in CSI administration between cohorts (p=0.29). Relative to baseline scores, patients from both cohorts improved significantly at each time point for all PROMs (p<0.05 for all), with no significant differences in PROMs between groups at any time point (p>0.05 for all). However, compared to those assigned WW, patients randomized to PT incurred 10.0x higher costs (normalized mean difference: 1,636; 95% CI: 967, 2,304; p<0.001) and achieved only 16.9% of the patient value (normalized mean difference: -147.0; 95% CI: -207.5, -86.5; p<0.001). These results held across all sensitivity analyses.

Conclusion: Relative to WW, patients randomized to PT reported similar PROMs but incurred significantly higher direct costs (10.0x) and imposed a greater economic burden on the healthcare system (3.4-6.0x). Accordingly, WW resulted in significantly higher (5.9x) patient value than PT. Although additional high-level, multicenter studies are needed to corroborate these findings, the present study may support physicians and patients in pursuing the most appropriate treatment plan for each patient based on their individualized needs and preferences.

Introduction: Reverse total shoulder arthroplasty (rTSA) has become the procedure of choice for a failed aTSA. Little data exists regarding outcomes; the few studies published to date have small numbers, short follow-up, and most do not have a control group or use first generation implants. The purpose of this study is to compare the clinical and radiographic outcomes of failed aTSA revised to rTSA to primary rTSA.

Methods: A prospective multicenter shoulder registry was used to conduct a retrospective review of patients that received a primary rTSA for osteoarthritis and rotator cuff disease and compare them to those that had an aTSA revised to a rTSA using the same implant between 2007 and 2021 with a minimum follow-up of two years. Cohorts were matched 3:1 (primary:revision) by age, gender, body mass index and length of follow-up. Those that underwent revision for humeral fracture, infection, or an unknown reason were excluded. Preoperative and postoperative range of motion (ROM) and patient reported outcome measures (PROMs) were compared. Outcomes included rates of scapular notching, complications, revision, and patient satisfaction.

Results: There were 88 aTSA revised to rTSA compared to 264 matched primary rTSA. In both cohorts, the mean age was 68 years, 59% were female, and the mean follow-up was 56 months. The most common reason for revision was rotator cuff tearing (53%), followed by aseptic glenoid loosening (34%), instability (9%), aseptic humeral loosening (6%) and glenoid component dissociation (3%). At latest follow-up, patients in both groups had statistically significant improvements in all outcome scores, exceeding the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB). The revision cohort had significantly less postoperative abduction (P<0.001) and forward elevation (P=0.001) compared to the primary rTSA cohort. All PROMs in the revision cohort were significantly worse than those in the primary rTSA cohort. Patient satisfaction rate in the revision cohort was significantly lower than the primary cohort (P<0.001). Complication (P=0.005) and revision rates (P=0.013) were significantly higher in the revision cohort, while scapular notching was similar.

Conclusion: Patients undergoing revision of a failed aTSA to rTSA have worse clinical outcomes compared to those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief and patient satisfaction, with higher complication and revision rates. While patients in the revision group had significant improvements that exceeded the MCID and SCB, they do not achieve the same outcomes as patients who undergo primary rTSA.

Background: Glucagon-like peptide-1 (GLP-1) receptor agonists, increasingly used for diabetes management and weight loss, have been linked to lower readmission rates after knee and hip arthroplasty. However, their impact on total shoulder arthroplasty (TSA) outcomes remains unclear. This study investigates the effects of GLP-1 receptor agonists on major complications and revisions following TSA.

Methods: A retrospective query of the TriNetX database from 2010 to 2023 was performed to identify patients who underwent anatomic or reverse TSA and were prescribed GLP-1 receptor agonists. GLP-1 receptor agonist users were 1:1 propensity score-matched to controls for demographic factors and comorbidities, yielding 1,259 patients in each group. Outcomes included 90-day postoperative medical complications and readmission and revision surgery at 2 years. Odds ratios (ORs), 95% confidence intervals, and P values were calculated. After Bonferroni correction, P < 0.005 was considered significant.

Results: GLP-1 receptor agonist users (n = 1,259) experienced significantly higher rates of deep vein thrombosis (1.6% vs. 0.9%; OR 3.0; P = 0.001), myocardial infarction (1.60% vs. 0.9%; OR 2.84; P = 0.003), pneumonia (3.34% vs 1.50%; OR 2.25; P = 0.003), transfusion (7.1% vs. 4.3%; OR 1.7; P = 0.003), and readmission (8.1% vs 5.2%; OR 1.6; P = 0.004) in the 90-day postoperative period compared to patients not taking GLP-1 receptor agonists. There were no differences in the rates of stroke, pulmonary embolism, postoperative anemia, or renal failure. In patients with a minimum 2-year follow-up (n = 776), there was no difference in revision rate (3.2% vs 1.8%; OR 1.8; P = 0.07).

Conclusion: GLP-1 receptor agonist use during TSA was associated with an increased risk of deep vein thrombosis, myocardial infarction, pneumonia, need for transfusion, and readmission. Further investigation into the perioperative risk assessment and medical optimization of patients utilizing GLP-1 receptor agonists may be warranted.

Introduction: Despite the established importance of the United States Medical License Exam (USMLE) and Alpha Omega Alpha (AOA) status in orthopedic residency selection, their significance in the fellowship match remains unknown. This study evaluates the influence of USMLE scores and AOA status on interview invitation rates and match positions for shoulder and elbow surgery fellowship applicants.

Methods: This is a retrospective analysis of data from the San Francisco Match database from 2018 to 2023. The study included matched applicants for shoulder and elbow surgery fellowship, excluding unmatched applicants, osteopathic, and international medical graduates. USMLE scores were categorized into four tiers, and interview invitation rates were examined based on USMLE tier and AOA status. Additionally, the association between USMLE scores and AOA status were analyzed by applicant and fellowship rank positions. Statistical analysis included descriptive statistics, linear regression, and analysis of variance.

Results: Data from 218 matched applicants were included. On average, applicants submitted 23.3± 9.7 applications, with an average interview rate of 76%. The mean Step 1 and 2 score was 247 ± 11 (n = 141) and 253 ± 12 (n = 171), respectively. USMLE scores showed a positive correlation with interview rates (Step 1: p < 0.0001, B = 0.768; Step 2: p < 0.0001, B = 0.727), indicating that higher scores were associated with increased interview opportunities. AOA members accounted for 38% of applicants (of 183 with available data), and they demonstrated a higher average percentage of interviews compared to non-AOA applicants (79% vs 75%, p < 0.001). While no significant difference in the average Step 1 (p = 0.17) or Step 2 score (p = 0.79) was observed across applicant rank positions, AOA membership was more prevalent among applicants in higher rank tiers (p < 0.001). Additionally, AOA applicants (p < 0.001) and those with higher Step 2 scores (p=0.04) were more likely to be ranked higher by their matched fellowship program.

Conclusion: USMLE scores and AOA status correlate with interview invitation rates and applicant ranking for shoulder and elbow surgery fellowships. Future work should examine the influence of residency reputation and research productivity on shoulder and elbow surgery fellowship match outcomes.

Background: The risk factors associated with recurrent instability following Latarjet procedure remain poorly understood. The purpose of this study was to conduct a systematic review to elucidate risk factors contributing to therapeutic failure after the Latarjet procedure.

Methods: A comprehensive literature search was performed using the PubMed/MEDLINE and Embase databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies that evaluated risk factors for recurrence of instability following the Latarjet procedure that were published after 2000 were included.

Results: A total of 24 studies, encompassing 3,166 patients, were included in the analysis, identifying 13 risk factors. Four studies, comprising 206 patients, evaluated the role of epilepsy as a risk factor for recurrence, with 75% (3) finding a statistically significant increased risk. Meta-analysis demonstrated a recurrence rate of 16.7% (7/42) in epilepsy patients compared to 2.5% (3/119) for those without (p=0.003). Previous stabilization surgery was evaluated in three studies, with 50% (2) finding increased risk. Meta-analysis revealed a recurrence rate of 17.5% (45/257) for patients with a previous stabilization surgery compared to 5.1% (26/512) for patients undergoing a primary Latarjet procedure. Two studies investigated coracoid width, with 50% (1) finding an increased risk for narrow coracoid measurements. One study found a fourfold increased risk of recurrence in patients with an engaging Hill-Sachs' lesion. However, another study found no difference in recurrence rate for patients with engaging Hill-Sachs' lesions with glenoid bone loss greater than 25%.

Conclusion: The rate of recurrent instability following the Latarjet procedure is inherently low. However, epilepsy and previous stabilization surgery appear to be significant risk factors for recurrence. Other reported risk factors include fixation technique, glenoid bone loss, off-track Hill-Sachs' lesions, and bilateral shoulder instability.

Introduction: Understanding the impact of Social Drivers of Health (SDOH) on shoulder arthroplasty is pivotal for the development of equitable value-based payment models that enhance the quality of patient care. This investigation aims to understand the influence of Area Deprivation Index (ADI) on hospital admissions, readmissions, and associated costs post-shoulder arthroplasty.

Methods: We conducted an analysis using US Medicare claims data from 2019 to 2021, identifying patients who received shoulder arthroplasty in either an inpatient or outpatient setting using Current Procedural Terminology (CPT) codes. Our primary outcomes were 90-day unplanned readmissions and post-procedure 90-day care costs. The ADI was our primary exposure variable, calculated at the census block level. Our analysis adjusted for multiple factors using a stepwise modeling approach including patient demographics, 29 Elixhauser comorbid conditions, Medicaid-dual eligibility, and end-stage renal disease status using logistic regression models.

Results: A total of 145,435 patients were included in our study. The average age of patients in our cohort was 74.5 years old, with 59.5% being female. Patients in the high ADI group had a higher readmission rate than the lowest ADI group (8.5% vs. 6.0%, p<0.001).When controlling for confounding factors, there was an indepdentent association between high ADI and readmission (OR: 1.28 [95% CI 1.12, 1.46]). Overall, we saw a dose-dependent relationship between ADI and readmission, with the association growing stronger as ADI increased. Conversely, we found a negative association with ADI and high-costs. (High ADI Group OR: 0.80 [95% CI 0.70, 0.91]). Patients in the high SES group had higher healthcare contact days during the 90-day follow-up period, with a median of 16 visits (IQR 8, 23), compared to 13 visits (IQR 6, 22) in the middle SES group and 10 visits (IQR 5, 20) in the low SES group (p<0.001).

Conclusion: Socioeconomic disparities significantly influence the outcomes of primary shoulder arthroplasty, as indicated by higher readmission rates for low SES patients. Notably, our analysis shows a strong, independent association between ADI and readmission. Moreover, patients with higher SES incurred greater costs within a 90-day period potentially due to increased resource utilization.

Background: Medial epicondyle fractures of the distal humerus are common pediatric fractures, which are increasing in frequency among pediatric and adolescent athletes. Residual elbow stiffness is a feared complication of both surgical and non-operative treatment. The purpose of this study is to investigate the association of the relevant variables with the ability of patients to regain full elbow range of motion (FROM).

Methods: Patients 8-18 years-old enrolled in the Medial Epicondyle Multicenter Outcomes (MEMO) prospective cohort with ≥3 mm of displacement and >1 year of follow-up data were included. Bilateral elbow range of motion (ROM), complications, length of immobilization following definitive treatment (surgical vs. non-operative), participation in formal physical or occupational therapy (PT/OT), and weeks from injury to treatment were recorded.

Results: The study cohort consisted of 202 patients (aged 12.7±2.3 years; 59% male). A greater proportion of surgically managed patients regained FROM compared to non-operatively managed patients (71% vs. 56%, P=0.05). Immobilization time was significantly shorter in surgical than non-operative patients (2.0 ±1.1 weeks vs. 3.0±1.2 weeks, P<0.001). In multivariable logistic regression analysis, only immobilization time was an independent predictor of regaining FROM (β=-0.353, P=0.02), which remained statistically significant while controlling for PT/OT (β=0.079, P=0.829) and treatment strategy (β=-0.375, P=0.35). While controlling for treatment strategy and whether a patient received PT/OT, each week of prolonged immobilization decreased the chance of regaining full ROM by 35%.

Conclusions: This large multicenter cohort study found that of the variables studied, increased immobilization time was the only independent predictor of residual elbow stiffness following medial epicondyle fractures in children, independent of treatment strategy and receiving PT/OT. With surgical treatment often warranting shorter post-treatment immobilization times, surgery may provide an avenue for consistently regaining FROM when treating these fractures, even in the setting of concomitant dislocation. In cases of minimally displaced fractures, implementing protected early ROM in non-operative cases could be considered. However, when nonoperatively-treated patients in this study were analyzed separately, earlier mobilization was not associated with a protective effect against residual stiffness. Further prospective study into the nuances of surgical indications as well as nonoperative and postoperative immobilization and early motion strategies is therefore warranted.