Journal of Shoulder and Elbow Surgery最新文献

Background: Dislocation of the sternoclavicular joint (SCJ) is the most common SCJ condition reported to be managed surgically. However, primary SCJ osteoarthritis is substantially more common. There are few reports in the literature on the outcome of surgical management of primary SCJ osteoarthritis. We have successfully adopted sternal docking allograft reconstruction for SCJ instability and have now expanded the technique to patients with primary SCJ osteoarthritis. This is our first report on the outcome of the sternal docking technique specifically for patients with primary SCJ osteoarthritis.

Methods: Between 2012 and 2023, one fellowship trained shoulder surgeon consecutively performed surgical resection of the medial end of the clavicle and semitendinosus allograft ligament reconstruction using the sternal docking technique in 29 patients with SCJ osteoarthritis. Seven patients were lost to follow-up (one declined participation, and six could not be contacted). The remaining 22 patients form the study cohort. There were 17 females and 5 males with a mean age of 49 ± 11 years at the time of surgery (range, 32-71 years). Their electronic medical records were reviewed to collect demographics, pain using a Visual Analog Scale (VAS), complications and reoperations. Patients were also contacted at most recent follow-up to record VAS for pain, subjective shoulder value (SSV) and American Shoulder and Elbow Surgeons (ASES) shoulder score. The procedure was considered successful when patients experienced pain relief and did not develop any complications or required reoperation. The mean length of follow-up was 4 ± 3 (range, 1-12) years.

Results: SCJ reconstruction was associated with significantly improved pain relief and overall shoulder function. Preoperatively, the mean VAS was 6 ± 1.5 (range, 4-9) points. At the most recent follow-up, the mean pain score was 0.5 ± 1.5 (range, 0-6) points, with median scores of 90 (IRQ 60-98) for SSV and 80 (IQR 70-81) points for ASES. 21 of 22 patients reported high satisfaction rates with their postoperative outcomes, with one patient endorsing partial satisfaction due to limited shoulder range of motion. Persistent peri-incisional numbness was reported by one patient. There were no re-operations at the time of the most recent follow-up.

Conclusion: Medial clavicle resection and ligament reconstruction seems to be associated with good overall outcomes, a high degree of patient satisfaction, and a low reoperation rate in patients with primary SCJ OA.

Background: Frozen shoulder (FS) is a common fibroinflammatory disorder of the glenohumeral joint capsule, characterized by persistent pain and progressive restriction of range of motion. The fibroblast-to-myofibroblast transition is a central pathological event driving capsular fibrosis, yet the molecular regulators underlying this process remain poorly defined. Protein tyrosine phosphatase 1B (PTP1B) has emerged as a key regulator of fibrosis in multiple organs, but its role in musculoskeletal fibrosis, particularly in FS, has not been investigated.

Methods: In this prospective case-control study, glenohumeral capsular tissues were collected from 21 patients with idiopathic FS and 21 matched controls with rotator cuff tears during arthroscopic surgery. Tissue samples were evaluated using histology, immunofluorescence, and Western blotting. Clinical function was assessed preoperatively using the American Shoulder and Elbow Surgeons and Constant-Murley scores.

Results: FS patients exhibited significantly worse functional outcomes across all domains, including pain, range of motion, and activities of daily living. Histopathological analysis revealed pronounced fibroblast proliferation, dense collagen deposition, hypervascularity, and perivascular adipocyte accumulation in FS capsules compared to controls. Critically, PTP1B expression was significantly upregulated in FS tissues. PTP1B immunoreactivity was prominently localized to α-SMA⁺ myofibroblasts. Co-localization studies confirmed an enrichment of PTP1B within activated myofibroblasts, indicating its specific involvement in fibrotic transdifferentiation.

Conclusion: This study identified PTP1B as a novel biomarker that was upregulated in FS and was specifically associated with myofibroblast activation and capsular fibrosis. These findings position PTP1B as a promising therapeutic target for mitigating fibrosis and functional impairment in FS.

Background: Glenohumeral internal rotation deficit (GIRD) has been associated to shoulder injuries in overhead athletes. The glenohumeral posterior capsule stretching techniques, such as the sleeper stretch and cross-body stretch, are used to improve range of motion (ROM) and reduce pain. However, there are no studies comparing these techniques in symptomatic overhead athletes with GIRD. This study aimed to compare the effects of sleeper stretch and cross-body stretch on shoulder pain and shoulder ROM in overhead athletes with GIRD and shoulder pain.

Methods: This is a randomized, double-blind, controlled clinical trial. Overhead athletes aged 18 to 40 years who were actively engaged in their sport at a competitive level, with shoulder pain and GIRD were randomly allocated into two groups: the Cross-body Stretch Group (CBG), and the Sleeper Stretch Group (SSG). Both groups received interventions three times a week for four weeks. The primary outcomes were shoulder pain intensity and glenohumeral internal rotation range of motion. Secondary outcomes included affective response to interventions, adherence, and reported co-interventions.

Results: Thirty-five athletes participated in the study, with 17 allocated to the CBG and 18 to the SSG. No significant differences were observed between groups for shoulder pain and GIRD. SSG showed a decrease of -2.17 in pain intensity (95% CI = -3.13 to -1.21), while CBG reduced pain by -1.54 (95% CI = -2.53 to -0.55). Additionally, GIRD was attenuated in both treatment groups, with the SSG showing a reduction of -14.69 (95% CI = -19.48 to -9.89) and the CBG showing a reduction of -14.77 (95% CI = -19.70 to -9.84).

Discussion: The results of this study suggest that both the sleeper stretch and the cross-body stretch significantly reduced pain and improved glenohumeral internal rotation in overhead athletes with shoulder pain and GIRD after four weeks, with no significant difference between them. Affective responses, adherence, and the occurrence of co-interventions were similar, indicating good tolerance and safety of both techniques. These findings provide clinical support for the use of either strategy in the conservative management of these athletes. Future research should focus on the long-term effects and the investigation of multimodal treatment strategies.

Conclusion: Both sleeper stretch and cross-body stretch showed similar effects in reducing pain and glenohumeral internal rotation deficit.

Introduction: Preoperative planning software enables virtual implantation of reverse total shoulder arthroplasty (rTSA) and assessment of impingement-free range of motion (ROM). Recent studies have shown that scapular resting position varies significantly among individuals and impacts impingement-free ROM. The resting position of the arm also varies between individuals, yet its impact on simulated outcomes and whether this parameter should be integrated into planning programs remains unclear. The objective of this study was to assess the effect of the resting arm position in the coronal plane on simulated impingement-free ROM and on implant positioning metrics, specifically the lateralization shoulder angle (LSA) and distalization shoulder angle (DSA) in rTSA planning.

Methods: A prospective computational modeling study was conducted using a commercially available 3D planning software (Imascap, Plouzané, France). Thirty CT scans of patients with primary osteoarthritis or cuff tear arthropathy were planned independently by nine experienced surgeons. The resting abduction angle (RAA) was implemented as proxy for the resting arm position in the coronal plane and determined by the humeral diaphyseal axis and vertical scapular axis. Each plan was simulated with 10 distinct resting arm positions (between -5° and 40° of abduction), resulting in 2700 virtual cases. Impingement-free ROM, LSA, and DSA were evaluated for each resting arm position. One-way ANOVA and Pearson correlation analyses were conducted to determine the relationship between RAA and key planning outcomes.

Results: RAA significantly influenced simulated ROM parameters across all tested arm positions (p<0.0001). Increasing RAA, resulted in greater adduction (R² = 0.72, p<0.0001), internal (R² = 0.23, p<0.0001) and external rotation (R² = 0.23, p<0.0001), while inversely affecting abduction (R² = 0.44, p<0.0001), forward flexion (R² = 0.26, p<0.0001) and extension (R² = 0.31, p<0.0001). Significant differences were found in LSA and DSA values across the different simulated resting arm positions (p<0.0001). LSA showed a weak positive correlation with RAA (R² = 0.34, p<0.0001), whereas DSA exhibited a strong inverse relationship (R² = 0.63, p<0.0001), indicating that a more abducted resting arm position led to higher LSA and lower DSA values without altering implant position.

Conclusion: The resting arm position significantly affects virtual impingement-free ROM in Imascap planning software, highlighting the importance of incorporating humeral position into rTSA preoperative planning. Additionally, because LSA and DSA measurements are substantially influenced by the arm position despite an unchanged implant configuration, consideration of humeral orientation may be necessary when interpreting these metrics.

Background: Stemless anatomic total shoulder arthroplasty (aTSA) has gained considerable traction as an alternative to traditional stemmed implants for the management of glenohumeral arthritis, particularly for patients where bone preservation is a priority. However, some surgeons remain cautious employing a lesser tuberosity osteotomy (LTO) when using stemless implants due to concerns of metaphyseal fixation and implant stability. This study evaluates clinical, radiographic, and functional outcomes of a novel transosseous suture-cable repair for LTO in stemless aTSA.

Methods: A retrospective review identified 55 stemless aTSAs performed in fifty-two patients by a single surgeon from September 2022 to September 2024. Patients ≥18 years old who underwent stemless aTSA with LTO were included, while revisions or patients with prior metal hardware were excluded. All patients underwent a transosseous suture-cable LTO repair anchored to the bicipital groove. Patient charts were reviewed to assess clinical, radiographic, and patient-reported outcomes. Radiographic LTO healing was classified as fully healed, partially healed, or not healed, and reoperation and implant-related complications were assessed. Functional outcomes included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Pain was evaluated using the visual analog scale (VAS). Range of motion (ROM) was measured for abduction, forward flexion, external rotation, and internal rotation (IR) preoperatively and at final follow-up.

Results: At the latest follow-up, 87.3% (n=48) of LTOs demonstrated full bony healing, 10.9% (n=6) were partially healed, and 1.8% (n=1) did not heal. Follow-up time for this study was 26.7 ± 8.3 months. No implant loosening or malposition was observed. There were no reoperations. Postoperatively, glenohumeral abduction improved from 58.6° ± 28.7° to 104.5° ± 49.8° (p<0.001), forward flexion from 110.0° ± 27.0° to 149.3° ± 33.6° (p<0.001), and external rotation from 17.8° ± 18.3° to 50.4° ± 16.4° (p<0.001). Of the patients with "poor" IR, approximately 22% (7/32) improved to "acceptable" or "normal" IR (p=0.027). Mean postoperative ASES and SANE scores were 94.0 ± 7.4 and 88.2 ± 9.2, respectively, with a mean VAS pain score of 0.1 ± 0.6.

Conclusion: Transosseous suture-cable fixation for LTO in stemless aTSA achieves high healing rates, excellent functional outcomes, and minimal complications. Patients showed significant improvements in pain, motion, and internal rotation, supporting the role of LTO in preserving subscapularis function.

Background: Lower trapezius transfer has been demonstrated to restore external rotation in patients with brachial plexus palsies. In certain cases of cuff tear arthropathy, patients exhibit preserved forward elevation but lack active external rotation. This study evaluates the clinical outcomes of lower trapezius transfer, augmented with a semitendinosus tendon autograft and anchored to the infraspinatus insertion using an arthroscopically assisted technique and, to determine whether pain relief and functional improvement are maintained at minimum 7.5-year follow-up compared to the 11-month follow-up.

Methods: Between March 2014 and February 2024, 23 patients (15 men, 8 women; mean age 55 years, range 32-75) underwent surgical reconstruction of irreparable posterosuperior rotator cuff tears involving the supraspinatus, infraspinatus, and non-functional teres minor. A 6 cm horizontal incision was made just inferior to the scapular spine to harvest the lower trapezius tendon, which was augmented with the semitendinosus tendon. The extended tendon was fixed laterally to the greater tuberosity at the infraspinatus insertion via arthroscopy. The proximal stump was fixed medially into the lower trapezius muscle belly with the arm in maximum external rotation. Clinical outcomes were assessed using the Constant-Murley score, Visual Analog Scale (VAS), active Range of Motion and, Subjective Shoulder Value (SSV).

Results: Twenty-three patients were included, with a first mean follow-up of 11 months (range: 5-19 months). Twelve patients had a second mean follow-up of nine years and four months (range: 92-128 months). At the first follow-up, the average increase in external rotation in adduction was 40°, and 70° at ninety degrees of abduction (p<.001). The Constant-Murley score improved from 46 to 82 points (p<.001), the SSV increased from 40% to 67% (p<.001), and VAS pain decreased from 5 to 1 (p<.001). Both the lag sign and Hornblower sign were negative post-transfer. The subgroup with a follow-up of at least 7.5 years showed slight improvements in functional outcomes, including active range of motion (aROM), Constant score, VAS, and SSV, but no statistically significant differences compared to the 11-month follow-up. Complications included two hematomas, only one requiring revision due to infection.

Conclusion: Lower trapezius transfer is an effective treatment for irreparable posterosuperior rotator cuff tears with external rotation deficiency. This procedure results in significant improvement in pain and active external rotation in adduction and at 90° of abduction. Functional results remain stable over a long-term follow-up of minimum 7.5 years.

Background: Reverse shoulder arthroplasty (rTSA) and anatomic total shoulder arthroplasty (aTSA) treat glenohumeral osteoarthritis (GHOA) with comparable early outcomes. Given increasing utilization of rTSA for GHOA, we sought to evaluate outcomes of rTSA and aTSA for GHOA at early and midterm follow-up.

Methods: A retrospective propensity-matched cohort study of patients undergoing aTSA and rTSA for GHOA with early and midterm follow-up was performed. Matching included age, sex, body mass index, preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative forward elevation, and Walch glenoid morphology. Baseline patient characteristics, range of motion, ASES, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain scores, complications and revision rTSAs/aTSAs were assessed at early and midterm follow-up.

Results: One hundred twenty-two patients (61 per group) were included with early and midterm follow-up. Baseline characteristics, comorbidities, preoperative ASES, SANE, VAS pain scores, and range of motion were similar (P > .05). Both groups showed significant improvements in ASES, SANE, and VAS scores at both time points (P < .001); >96% achieved minimal clinically important difference for ASES. While more aTSA patients met substantial clinical benefit early (95.1% vs. 80.3%, P = .027); there was no statistically significant difference at midterm follow-up (P = .074). aTSA patients had better early internal (5.0 vs. 3.3, P < .001) and external rotation (63.0° vs. 57.0°, P = .036), with no difference at midterm follow-up. Complication rates were similar; however, aTSA had more revisions and radiolucencies.

Conclusion: aTSA and rTSA yield similar clinical outcomes for GHOA at early and midterm follow-up. Early differences in substantial clinical benefit, internal, and external rotation with aTSA diminished by midterm follow-up. Complication rates were similar between the cohorts. One patient in the aTSA group was revised to rTSA and no patients with primary rTSA required revision. While rTSA and aTSA result in excellent clinical outcomes, longer follow-up is needed to determine durability.

Background: Intra-articular corticosteroids are widely used for adhesive capsulitis, but alternatives are needed for patients with contraindications. Hyaluronic acid (HA) and ketorolac have demonstrated individual benefits; however, evidence regarding their combined use remains limited. This study aimed to evaluate and compare the clinical outcomes of intra-articular injection of combined moderate -molecular-weight HA and ketorolac versus ketorolac alone in patients with adhesive capsulitis, focusing on shoulder function, pain reduction, and improvement in range of motion (ROM). We hypothesized that the HA + ketorolac combination would provide superior improvement in function, pain, and ROM compared with ketorolac alone.

Methods: In this randomized, double-blind controlled trial, 56 patients were allocated to HA + ketorolac (n = 28) or ketorolac alone (n = 28). Each received a single intra-articular injection followed by standardized rehabilitation. Outcomes included the Thai Shoulder Pain and Disability Index (Thai SPADI), visual analog scale (VAS), passive ROM, and analgesic use, assessed at baseline and at 2, 6, 12, and 24 weeks.

Results: Both groups improved significantly in SPADI and VAS over time, with no between-group differences at any visit (24-week SPADI: 9.8 ± 12.5 vs 12.1 ± 17.8; P = .932; VAS: 0.8 ± 1.1 vs 1.4 ± 2.2; P = .501). The HA + ketorolac group demonstrated greater recovery in specific ROM planes, including significantly better external rotation at 24 weeks (mean difference 9°, 95% confidence interval [CI] 0 -18; P = .039) and greater improvement in adduction at both 2 weeks (mean difference 5°, 95% CI 0 -10; P = .039) and 24 weeks (mean difference 8°, 95% CI 2 -14; P = .012). Analgesic consumption was comparable between groups, and no serious adverse events were reported.

Conclusion: Both HA + ketorolac and ketorolac alone significantly improved pain and function in adhesive capsulitis. Combination therapy provided small but statistically significant advantages in recovery of external rotation and adduction. Both treatments represent reasonable options, particularly for patients in whom corticosteroids are contraindicated.

Background: The requirements for medical device approvals are based on the classification and the associated risks. Based on the type of approval, there can be a higher risk of recall for orthopedic medical devices. The purpose of this study is to analyze the risk of recall for shoulder/elbow devices.

Materials and methods: A retrospective review was conducted of publicly available U.S. Food and Drug Administration databases to identify cleared for market and recalled shoulder and elbow devices. Nonorthopedic and unrelated devices were excluded. Data on approval date, recall date, and reason for recall were extracted. Recall reasons were categorized using a previously published classification into device design, manufacturing, processing, packaging, sterility, software, or marketing. Descriptive statistics were used to calculate recall rates, categorize recall types, and assess time from approval to recall.

Results: A total of 669 shoulder and elbow medical devices were cleared through a 510(k) from 1979 to 2025. Out of this list, 128 devices had at least one recall within this time period. Majority of these recalls were classified as a Class II risk with device design listed as the most common reason for recall stating issues such as increased risk of fracture, wear, loosening, and misalignment.

Conclusion: Food and Drug Administration clearance for shoulder and elbow devices has steadily increased since 1979, with nearly all devices classified as Class II and cleared through the 510(k) clearance. No devices were found to be approved through premarket approval or De Novo pathways. Overall, 19.1% of devices had at least one recall, most commonly due to design flaws and classified as Class II recalls. These findings align with trends seen in other orthopedic subspecialties and highlight limitations in premarket testing under the 510(k) process. As most Class II devices are cleared without additional pivotal trials, surgeons should remain cautious when adopting new technologies.

Background: Arthroscopic Bankart repair (ABR) using the knotless double-row technique, called the knotless double anchor footprint fixation (DAFF), involves inserting anchors into the scapular neck, passing sutures through the anterior inferior glenohumeral ligament complex, and using face anchors to secure the ligament complex under increased tension. In single-row arthroscopic Bankart repair, a postoperative reduction in glenoid width is frequently observed. This phenomenon is associated with mechanical stress shielding at the anterior glenoid rim, particularly in the area situated anterior to the anchor insertion. Few studies have examined morphologic changes in the glenoid after ABR using the double-row technique. The purpose of this study was to investigate the change of glenoid bone morphology following ABR using the knotless DAFF technique.

Materials and methods: Thirty patients (26 males, 4 females) with anterior shoulder instability involving a total of 32 shoulders treated with knotless DAFF were included. Of the 32 shoulders, 10 had bony Bankart lesions, and 22 were classified as erosion type. The 1.4 mm JuggerKnot anchors were used as neck anchors, and the GRYPHON BR anchors were used as face anchors. The Rowe score and the glenoid bone loss using the best-fit circle method on 3D-computed tomography scans were evaluated. Statistical analysis was performed using the Wilcoxon rank-sum test, with statistical significance set at P < .05.

Results: The mean patient age was 24.0 years (range, 15-54 years). The mean follow-up period was 25.4 months (range, 24-50 months). One patient experienced apprehension and pain 50 months postoperatively. The mean Rowe score significantly improved from 22.5 ± 6.6 points preoperatively to 95.5 ± 8.8 points postoperatively (P < .0001). Among the 10 cases with a bony fragment, bony union was achieved in all cases. The mean glenoid bone loss significantly decreased from 17.5 ± 7.0% preoperatively to 4.8 ± 4.0% at a mean of 24.7 months postoperatively (P = .004). In the 22 cases without a bony fragment, the mean glenoid bone loss significantly decreased from 12.0 ± 6.3% preoperatively to 10.2 ± 5.5% at a mean of 24.6 months postoperatively (P = .03).

Conclusion: Using the knotless DAFF technique for arthroscopic Bankart repair, fragment-type cases showed that reliable bony union was achieved in fragment-type cases. Erosion-type cases demonstrated either minimal glenoid bone loss or evidence of glenoid remodeling. These results indicate that the knotless DAFF technique may contribute to the preservation of glenoid morphology and consequently reduce the risk of postoperative shoulder instability.