Journal of Shoulder and Elbow Surgery最新文献

Background: The authors observed an association between cervical spine mobility and arm injury risk in baseball players; however, there is a need to assess the generalizability of cervical measurement data. Assessing the downstream associations of cervical dysfunction on shoulder and elbow injuries can inform clinical interventions to help reduce future arm injuries. The purpose of this study was to assess the generalizability of neck range of motion measures as arm injury prognostic factors in professional baseball pitchers.

Methods: A prospective cohort of professional baseball pitchers in one Major League Baseball Organization was studied. Pitchers underwent preseason neck range of motion including cervical flexion, extension, rotation, lateral flexion, and the flexion-rotation test, and were followed for the season. The outcome was the occurrence of a shoulder or elbow injury. A Cox proportional hazards analysis was performed and reported as hazard ratios with 95% confidence intervals (95% CIs).

Results: A total of 88 pitchers were included (age: 24.2 [2.4] years; left-handed: 21 [23%]; fastball velocity: 92.3 [1.8]), with 15,942 athlete exposure days collected over the season. Pitcher neck range of motion was assessed (flexion: 64° [10°]; extension: 69° [11°]; difference in lateral flexion: -1° [7°]; difference in neck rotation: -2° [9°]; difference in cervical flexion-rotation test: -1° [7°]). A total of 20 arm injuries (shoulder: 9 [10%]; elbow: 11 [13%]; combined rate: 1.3 [95% CI: 0.7, 1.7] per 1000 exposure days) were suffered by pitchers during the season. For every degree increase in the difference in dominant (rotating to dominant shoulder) vs. nondominant (rotating to nondominant shoulder) neck rotation, there was a 4-fold increase in arm injury hazard (hazard ratio: 4.0 [95% CI: 1.1, 13.9], P = .031). No other neck measurements demonstrated prognostic value.

Conclusions: A deficit in dominant vs. nondominant neck rotation was prognostic for a pitching arm injury. However, the cervical rotation test did not have prognostic value in this sample. Further research is required to assess the generalizability and scalability of neck range of motion assessment in relation to baseball shoulder and elbow injuries across different competition levels.

Objective: The bare area is defined as a transverse region within the trochlear notch, serving as an optimal entry point for olecranon osteotomy due to the absence of articular cartilage coverage. However, there is limited research on the morphology and location of the bare area, and there is a lack of intuitive visual description. Thus, the purpose of this study is to delineate anatomical features of the bare area and visualize its morphology and refine the olecranon osteotomy approach.

Method: Thirty-six cadaveric elbow joints (comprising 18 pairs) were meticulously dissected. Measurements encompassed the lateral (radial side) and medial (ulnar side) widths, proximal and distal lengths, and the distance from the corresponding dorsal cortical point of the bare area to the triceps insertion. Post-dissection, the humeral ulnar joint was realigned, followed by randomized transverse or chevron osteotomy. Subsequent CT scans were conducted pre- and post-osteotomy to delineate the shape of the bare area and osteotomy fracture line, facilitating the generation of superimposed and heat maps for visualization.

Results: The bare area was present in all specimens, exhibiting a lateral (radial) width of 7.09 ± 4.86 mm, a medial (ulnar) width of 12.08 ± 3.66 mm, a proximal length of 15.70 ± 8.06 mm, and a distal length of 16.49 ± 7.06 mm. The distance from the triceps insertion to the corresponding dorsal cortical point of the bare area averaged 18.12 ± 3.21 mm. Notably, considerable variability was observed in both the position and shape of the bare area. Visualization through superimposed and heat maps revealed a bow-tie configuration, with the medial side wider than the lateral side, situated at the narrowest segment of the proximal ulna in the coronal plane, analogous to its waist. The superimposed map of fracture lines reveals that the fracture lines from transverse osteotomies are more concentrated than those from chevron osteotomies.

Conclusion: The position and shape of the bare area demonstrates notable diversity, manifesting not as a strictly transverse shape nor a consistently contiguous region. Rather, the bare area generally assumes a bow-tie configuration, rendering the conventional definition of its width along the sagittal plane inadequate and potentially misleading. Based on the typical position of the bare area, we can propose that when the precise morphology and position of a patient's bare area are unknown, targeting this region via an osteotomy from the proximal ulna's narrowest segment provides an effective approach.

Background: Recurrent shoulder dislocations often lead to multiple encounters for reduction and eventual surgical stabilization, both of which involve exposure to opioids and potentially increase the risk of chronic opioid exposure. The purpose of our study was to characterize shoulder instability and compare pre- and post-reduction opioid usage in singular dislocators (SD) and recurrent dislocators (RD).

Methods: This retrospective study was performed at a single academic institution using a prospective database. Patients were included if they were 1) age 18 or older and 2) sustained a shoulder dislocation evaluated within our institution. Electronic medical records were reviewed for patient demographics, emergency department management, and opioid exposure (number and mean morphine equivalent [MME] of opioid prescriptions) both pre- and post-reduction. Cohorts were compared using Wilcoxon rank sum tests for continuous variables and chi-squared or Fischer's exact tests for categorical variables with statistical significance set at p<0.05.

Results: 222 patients were included with mean follow-up 4.4 months (range: 0-70.1 months). 53 (23.8%) patients sustained recurrent dislocations. RDs were significantly younger (median age 26.7 years, IQR: 21.6-44.9) than SDs (55.3 years, IQR: 32.8-70.4; p<0.001) and more likely to have sustained a prior shoulder fracture (n=11 [21.2%] vs. n=3 [1.8%], p<0.001). There were no differences in sex, laterality, or follow-up duration. 18 (34.0%) RDs and 18 (10.7%) SDs underwent surgery including shoulder stabilization procedures, rotator cuff repairs, and fracture fixation (p<0.001). RDs used significantly more opioids at the first follow-up in both the prescribed number of opioids (mean 0.23± 0.5 prescriptions vs. 0.10 ± 0.3, p=0.038) and MME (mean 38.3 ± 96.2 MME vs. 10.7 ± 66.4 MME, p=0.013). This difference is not appreciated from the 30-day postoperative visit onwards. Emergency Room opioid MME prescription and consumption was similar between cohorts.

Conclusion: Patients who sustain recurrent shoulder dislocations exhibit a higher likelihood of consuming significantly greater amounts of opioids following shoulder reduction and ultimately undergoing surgical intervention. The proportion of opioid tolerance and pre-reduction total MME up to 90-days prior to reduction in the recurrent dislocator cohort trended towards significance, but there were no differences observed between rates of opioid usage during ED encounters or at the 30-, 60-, and 90-day timepoints. Patients with chronic shoulder instability should be counseled regarding the increased risk of opioid prescription patterns in the immediate post-reduction period however this risk may decrease over time.

Introduction: Primary glenohumeral arthritis is typically associated with glenoid retroversion and posterior bone loss. Glenoid component fixation remains a weak link in the survivorship of anatomical total shoulder arthroplasty, particularly in the B2 glenoid. The aim of this study was to compare biomechanical properties of two glenoid preparation techniques in a B2 glenoid bone loss model.

Methods: This was a biomechanical cyclic loading study. Thirty sawbone shoulder models were generated from a CT scan of a scapula with a B2 glenoid and 15^o retroversion. The study consisted of two groups with 'low' correction (A groups), two groups with 'high' correction (B groups), and a control. Group A1 consisted of a 7⁰ eccentric ream and a standard component; group A2 consisted of a 15^o posteriorly augmented glenoid component (7⁰ correction); group B1 consisted of a 12^o anterior ream and standard component; group B2 used a 25^o posteriorly augmented component (12^o correction); group C (control) consisted of a standard component inserted in retroversion with no correction. Mechanical stability testing was performed through cyclic loading and resulting displacement was determined at 1, 10, 1000, 10,000, 50,000, and 100,00 cycles to assess for loosening.

Results: A total of 26 samples were included in the analysis, all reaching 100,000 cycles. Displacement increased significantly from baseline to 100,000 cycles in all groups (p<0.05). At 100,000 cycles, the B1 group (1.4mm ±0.19) had significantly less displacement then the A2 (2.0mm ±0.29) and B2 (2.2mm ±0.49) (p=0.0.005) groups. There were no significant differences in translational forces between any of the groups at 100,000 cycles.

Conclusions: Our data demonstrated that the use of higher-degree posteriorly augmented components resulted in statistically greater translational displacement over time compared with high-side reaming and use of a standard component. Further prospective clinical studies are needed to confirm these findings.

Background: There has been an increase in both primary anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) over the last decade, with rates peaking for patients aged 75 years and older. Despite aTSA being the mainstay of treatment for patients with glenohumeral arthritis in the absence of rotator cuff insufficiency, there has been an upward trend of rTSA utilization in the elderly due to concerns about rotator cuff integrity, regardless of deformity. The purpose of this study is to evaluate outcomes including pain, function, range of motion, satisfaction, and complications in patients 80 years or older following primary anatomic and reverse total shoulder arthroplasty for osteoarthritis without full thickness rotator cuff tears.

Methods: A retrospective query of our institution's shoulder and elbow surgery repository identified patients treated with aTSA or rTSA between 11/2006 and 2/2022. Patients > 80 years old with minimum 2-year follow-up who underwent surgery for a primary indication of osteoarthritis without a full thickness rotator cuff tear were included. Patient-reported outcome measures (PROMs; American Shoulder and Elbow Surgeons [ASES], Simple Shoulder Test [SST], Single Assessment Numeric Evaluation [SANE], Visual Analog Score [VAS] Function and VAS Pain scores), range of motion, and strength were evaluated at the visit immediately before surgery and at most recent follow-up. Patient satisfaction was also evaluated at most recent follow-up. Complications and revisions were reported.

Results: A total of 130 patients (77 aTSA and 53 rTSA) met inclusion criteria. There were no significant differences in demographics between cohorts. At most recent follow-up, there were no significant differences in PROMs between cohorts. aTSA patients achieved greater postoperative motion in external rotation (50^o vs. 40^o; p=.003) and internal rotation (8 vs. 5; p=.001), with no difference in forward elevation. There were six complications amongst aTSA patients (7.8%): four with subscapularis insufficiency, one humeral shaft periprosthetic fracture treated with open reduction and internal fixation, and one with prosthetic joint infection revised to a functional composite spacer. Three rTSA patients (5.6%) sustained complications - all acromion/scapular spine fractures (2 Type 2; 1 Type 3) which were treated non-operatively. There was no significant difference in the rate of complications or revisions between groups.

Conclusion: Both anatomic and reverse shoulder arthroplasty for osteoarthritis yield similarly high patient satisfaction, good functional outcomes and low complication rates in patients over the age of 80 years.

Background: Few comparative studies on the correlation between stem length, stem alignment, and/or stress shielding have been conducted in reverse total shoulder arthroplasty (rTSA). This study aimed to investigate the effects of different humeral stem lengths on stem alignment and proximal stress shielding after rTSA.

Methods: A total of 320 patients who underwent primary rTSA from October 2010 to May 2020 with at least 2 years of follow-up (mean follow-up: 32.6 months) were retrospectively reviewed. The participants were classified into three groups according to the humeral stem length of different prostheses types: group A (short stem, range: < 80 mm, n = 88), group B (medium stem, range: 80-100 mm, n = 155), and group C (standard stem, range: ≥ 100 mm, n = 77). The parameters, including stem alignment, stem distal tip decentering, and canal filling ratio (CFR) were determined and recorded on the radiographs at 4 weeks after surgery. Proximal humeral stress shielding and stem subsidence were evaluated using radiographs at 4 weeks after rTSA were compared with those at the final follow-up. Subgroup analyses were conducted according to the presence of stress shielding to determine correlations among stem length, malalignment, and stress shielding.

Results: Humeral stem malalignment was significantly higher in group A (21.6%) than in groups B (11.6%) and C (9.1%) (P = 0.018). However, stress shielding at the lateral metaphyses (36.4%) was more frequently observed in group C (P = 0.004). Longer stem, stem malalignment, and higher diaphyseal CFR were independent risk factors for stress shielding occurrence, with stem malalignment showing the highest odds ratio (14.82, P < .001).

Conclusion: Although shorter stems are beneficial for bone preservation, they could lead to stem malalignment, resulting in increased proximal humeral stress shielding.

Introduction: The humeral head is the second most common site for osteonecrosis but its epidemiology is poorly described. This study aimed to better understand its treatment in the United States by 1) evaluating total operative procedures with rates normalized to the annual surgical volume; 2) determining trends of non-joint preserving (shoulder arthroplasty) vs. joint preserving procedures; and 3) quantifying rates of operative techniques in different aged cohorts (<50 vs. ≥50 years old).

Methods: A nationwide database was queried for patients with humeral osteonecrosis who underwent surgery between January 1st, 2010 and April 30, 2021, yielding 9,307 cases. Patients classified under non-joint preserving procedures included those who underwent shoulder arthroplasty (total and reverse) (N = 5,752) and hemiarthroplasty (N = 2,086). Joint preserving procedures included humeral head core decompression and arthroscopic débridement (N = 1,469). The percentage of patients annually managed by each operative procedure was calculated and normalized to the overall annual surgical population from our sample. Linear regression modelling was performed to evaluate trends/differences in procedural volume over time based on the type of procedure (joint preserving vs. non-preserving) and age cohort (under versus over 50 years old). P-values < 0.05 were significant.

Results: Within this nationwide sample, the number of procedures to treat shoulder osteonecrosis relative to all shoulder procedures was 0.85% (9,307/1,092,726). Overall, shoulder arthroplasty (total and reverse) was the most commonly performed procedure (N = 5,752; 61.8%), followed by hemiarthroplasty (N = 2,086; 22.4%), and core decompression/arthroscopic débridement (N = 1,469; 15.8%). Non-joint preserving comprised 7,838 procedures (84.2%), while 1,469 (15.8%) were joint preserving. On age group subanalysis, there were significantly more joint preserving procedures in patients aged <50 years (25.8% vs. 14.1%, P < 0.001). Core decompression/arthroscopic débridement as a proportion of all procedures in patients younger than 50 increased over the study period (22.1% to 35.6%, P = 0.035).

Conclusion: Procedures used to manage humeral osteonecrosis comprise less than 1% of all shoulder surgeries. These procedures continue to be predominantly shoulder arthroplasty; however, the utilization of joint preserving procedures seem to be growing over time, notably in patients <50 years of age. Shoulder surgeons may use this data to better educate patients about treatment options during the decision-making process. Future studies should be aimed towards further characterizing patterns in the diagnosis and treatment of humeral osteonecrosis.

Background: Heterotopic ossification (HO) involves abnormal bone formation in soft tissues near joints, commonly occurring after elbow trauma or surgery, leading to pain and functional limitations. Previous studies have primarily characterized HO distribution based on bony landmarks, lacking a detailed investigation into the characteristics of its distribution in periarticular soft tissue in post-traumatic elbows. This study aimed to (1) develop a muscle-guided classification system using computed tomography (CT) to map HO relative to elbow muscle-tendon units and (2) investigate correlations between HO location and severity.

Methods: In a retrospective study, 56 patients with HO and elbow stiffness following trauma were analyzed. CT imaging was used to classify HO into seven categories: Posterior - olecranon tip - triceps brachii (P-O-T); Posteromedial - medial gutter - flexor carpi ulnaris (PM-MG-FCU); Posterolateral - lateral gutter - anconeus (PL-LG-AN); Medial - medial epicondylar - flexor muscles (M-ME-FLEX); Lateral - lateral epicondylar - extensor muscles (L-LE-EXT); Anterior - humeroulnar joint - brachialis (A-HU-B); and Anterior - humeroradial - supinator (A-HR-SP). HO severity was graded (1-3) based on CT morphology, and correlations between HO location and severity were assessed.

Results: PM-MG-FCU was the most common HO location (67.9%). Significant correlations were found between HO severity and location, with higher rates of HO in grades 2 and 3, characterized by extensive mature bone formation and bone bridge development occurring in the PL-LG-AN, P-O-T, and PM-MG-FCU.

Conclusion: The muscle-guided classification system effectively delineated HO distribution near elbow muscle-tendon units. HO locations surrounding the anconeus, triceps brachii, and FCU (flexor carpi ulnaris) correlate with higher radiographic severity, providing valuable insights for treatment strategies.

Background: Humeral capitellar osteochondritis dissecans (OCD) lesions can be challenging to treat. Past studies have demonstrated grafting with extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) to be a viable technique for treatment of talar dome OCD, though little literature exists regarding application of this technique to the capitellum. This study aimed to report patient-reported outcomes (PROs) and return to sport (RTS) of pediatric patients at ≥1-year postoperatively who underwent ECM-BMAC grafting for capitellar OCD lesions.

Methods: A consecutive, single surgeon series of patients aged <18 years with unstable, contained humeral capitellum OCD who underwent ECM-BMAC grafting and had ≥1-year of clinical follow-up were included. Elbow range of motion (ROM), RTS time, postoperative sport level, and complications were recorded at follow-up visits. PROs, including Hospital for Special Surgery (HSS) Pedi-FABS, QuickDASH, Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility, PROMIS Pain Interference, and PROMIS Upper Extremity, were obtained at baseline and ≥1-year postoperatively. Both PROs and ROM were compared pre- and postoperatively using Wilcoxon Signed-Rank tests based on normality testing with Shapiro-Wilk tests.

Results: Twenty patients were included (mean age 12.8 ± 1.4 years) with an average 22.2 ± 13.0 months follow-up. Fifteen (75%) patients were female. The most common primary sports were gymnastics, baseball/softball, and racquet sports. Flexion improved significantly at ≥1-year postoperative, while extension remained close to full pre- and postoperatively. PROs improved from pre- to postoperative for all assessed instruments except for the HSS Pedi-FABS. Eighteen patients returned to their primary sport at the same competitive level or higher at a mean 5.8 ± 1.2 months. The two patients who did not return to their primary sport changed sports due to preferences unrelated to their elbow. There were no complications (e.g. infection, stiffness, revision surgery).

Conclusions: This study demonstrated that ECM-BMAC grafting is a viable treatment strategy for pediatric patients with unstable, contained capitellar OCD lesions. We observed favorable PROs with a ∼90% RTS rate ≥1-year postoperatively, supporting the results of this technique that has demonstrated success in other anatomic regions and adult populations. These findings suggest ECM-BMAC grafting to be a viable treatment option for contained capitellar OCD lesions. Although these early results are promising, longer-term research studies are paramount in determining the outcomes of patients with capitellum OCD lesions treated with ECM-BMAC grafting.