Journal of Shoulder and Elbow Surgery最新文献

Background: Patients with massive irreparable rotator cuff tears sometimes experience significant functional impairment due to external rotation deficits, categorized as isolated loss of external rotation (ILER) or combined loss of elevation and external rotation (CLEER). Existing shoulder measurement tools primarily assess range of motion or power, overlooking specific deficits in activities of daily living (ADLs) related to external rotation. The ADLER (Activities of Daily Living in External Rotation) score was developed to address this gap, focusing on active external rotation disability.

Methods: The aim of the study was to validate the ADLER score using the Kirshner and Guyatt framework, encompassing item selection, scaling, reduction, reliability, validity, and responsiveness. The target population included patients with ILER or CLEER, identified with specific clinical signs (external rotation lag, dropping arm and Hornblower's sign) and CT-arthrogram or MRI-confirmed irreparable rotator cuff tears with Goutallier grade 3 or 4 fatty infiltration of infraspinatus and teres minor. Ten items were derived from patient-reported deficits, each scored from 0 to 3 (total 30 points). Interobserver reliability was assessed in 13 patients by two blinded orthopedic surgeons using Pearson's correlation coefficient and intraclass correlation coefficient (ICC). Validity was evaluated against the Constant-Murley Score and Subjective Shoulder Value (SSV), and responsiveness was measured by comparing pre and postoperative scores following L'Episcopo tendon transfer (seven tendon transfers alone and six with reverse shoulder arthroplasty).

Results: The ADLER score demonstrated excellent interobserver reliability (Pearson's r = 0.98, p < 0.001; ICC = 0.98, 95% CI: 0.948-0.993, p < 0.001) with a mean absolute difference of 1.23. Validity was confirmed through face and construct validity, with prior data showing a significant postoperative improvement (mean ADLER score from 4 to 27, p < 0.05) correlating with Constant-Murley and SSV outcomes. Responsiveness was evident, with a mean functional improvement of 23 points (p < 0.05) across three studies, reflecting enhanced ADLs post-intervention.

Conclusion: The ADLER score is a reliable, valid, and responsive surgical tool for assessing external rotation deficits in ADLs, applicable not only to patients undergoing reverse shoulder arthroplasty with L'Episcopo transfers but also to various procedures addressing external rotation deficits, such as latissimus dorsi or lower trapezius transfers.

Background: The purpose of this investigation was to evaluate the impact of scapular neck length (SNL) on outcomes following reverse total shoulder arthroplasty (rTSA) using a lateralized 135° implant (Univers Revers; Arthrex Inc.; Naples, FL). Our hypothesis was that increased postoperative SNL would be associated with improved range of motion (ROM) following rTSA.

Methods: A multicenter retrospective study was performed on a prospectively collected database. Inclusion criteria were patients undergoing primary rTSA with minimum 2-year follow-up. Preoperative radiographs were analyzed for SNL and glenoid height. Postoperative radiographs were analyzed for scapular notching, inferior glenosphere overhang, effective SNL defined as the distance from medial glenosphere to lateral column of scapula (MGLS), lateralization shoulder angle, and distalization angle. Patient reported outcomes, ROM, and strength at 2 years postoperatively were correlated with outcomes controlling for demographic variables. MGLS was stratified by 0-5 mm, 5-10 mm, and >10 mm for analysis.

Results: A total of 485 patients met inclusion criteria for this investigation. Preoperative SNL was negatively associated with external rotational strength at 2 years postoperatively (P = .039), but was not found to influence patient reported outcomes, ROM, or the incidence of scapular notching (P > .05). Increased postoperative MGLS was positively associated with active internal rotation to the highest spinal level (P = .024) and belly press strength (P < .001). Improved abduction strength was observed with MGLS >10 mm (P = .011) and improved belly press strength was observed with a postoperative MGLS of >5 mm (P < .001). Internal rotation was higher in the >10 mm group compared to the 0-5 mm (L3 vs. L4; P < .001). External rotation at 90° was higher in the >10 mm compared to the 5-10 mm group (73° vs. 57°; P = .013).

Conclusion: Increased effective postoperative SNL, or MGLS, is positively associated with rotational ROM and shoulder strength and following rTSA with the Arthrex Univers Revers. Postoperative MGLS of >10 mm is associated with increased Constant strength and belly press strength compared to an MGLS of 0 to 5 mm. The differences in external rotation at 90° in the >10 mm group compared to the 5-10 mm group and for the internal rotation in the 10 mm group compared to the 0-5 mm group met criteria for a substantial clinical benefit.

Background: Small, isolated coronoid fractures involving less than one-third of the coronoid height are often underestimated on plain radiographs due to minimal displacement and preserved joint congruity. However, these fractures can be associated with significant soft tissue injuries, leading to occult elbow instability. This study aimed to investigate the mechanisms and characteristics of isolated small coronoid fractures and to analyze their three-dimensional (3D) morphology using computed tomography (CT)-based modeling.

Methods: We retrospectively reviewed 27 cases of isolated, noncomminuted coronoid fractures involving less than one-third of the coronoid height. Fractures were classified using the O'Driscoll and Adams systems. Injury mechanisms, associated soft tissue injuries, and joint instability were evaluated using radiographs, CT, magnetic resonance imaging, and operative findings. 3D CT modeling was used to analyze fracture morphology, including fragment size, orientation, and anatomical involvement.

Results: Posteromedial rotatory instability (PMRI) was the most common diagnosis (66.7%). According to O'Driscoll's classification, anteromedial (AM) subtype 1 fractures predominated (44.4%). 3D CT revealed significant differences in fragment volume and orientation between PMRI, tip, and anterolateral subtypes. Soft tissue injuries such as lateral ulnar collateral ligament and medial collateral ligament tears were frequently observed across all subtypes, even in the absence of frank dislocation.

Conclusion: Small, isolated coronoid fractures often reflect underlying complex elbow instability, particularly PMRI, despite their benign radiographic appearance. Detailed evaluation using 3D CT and assessment of associated ligamentous injuries are essential for appropriate diagnosis and treatment planning. These findings highlight the limitations of current classification systems and suggest a need for a revised system incorporating injury mechanism and associated soft tissue damage.

Background: Proximal humerus fractures (PHFs) are increasingly prevalent in the aging population, with reverse shoulder arthroplasty (rTSA) emerging as a preferred surgical treatment for complex fracture patterns. Recent advancements have introduced shorter, metaphyseal-fixation humeral stems as alternatives to traditional modular diaphyseal stems. However, limited data exist comparing the clinical outcomes of these designs following rTSA for PHF.

Methods: A retrospective analysis of 99 patients undergoing rTSA for acute three- or four-part PHFs between 2014 and 2024 was conducted. Patients received either a modular diaphyseal stem (n = 66) or a nonmodular metaphyseal stem (n = 33). Demographics, perioperative variables, American Shoulder and Elbow Surgeons scores, visual analog scale scores, range of motion, complications, and revision rates were compared. Statistical analyses included t-tests for continuous variables and chi-squared tests for categorical data.

Results: No significant differences were observed between groups in terms of demographics, comorbidities, hospital stay, or overall postoperative complications. The modular diaphyseal cohort had a significantly longer operative time and follow-up duration. Postoperative American Shoulder and Elbow Surgeons scores were higher in the diaphyseal group (76.35 vs. 65.58, P = .015), while the metaphyseal group demonstrated superior abduction (74.55° vs. 57.93°, P = .0267) and external rotation (32.12° vs. 14.79°, P < .0001). No significant differences were found in postoperative visual analog scale scores (P = .117) or revision rates (P = 1.00).

Conclusion: Both modular diaphyseal and nonmodular metaphyseal stem designs offer safe and effective options for rTSA following PHF, with distinct advantages. Modular stems may provide improved functional scores over longer follow-up, whereas metaphyseal stems may enhance range of motion. These findings support individualized surgical planning based on patient anatomy, functional goals, and revision risk. Further long-term studies are warranted to optimize implant selection.

Background: Radial head replacement (RHR) is a well-established treatment for comminuted fractures (radial head fracture). In most cases, it provides satisfactory long-term functional results. However, some patients have pain and significant functional limitations. Our aim was to identify patients who underwent an RHR for acute trauma and had a clinical outcome that was considered an outlier. We assessed specific factors that contributed to an unfavorable result.

Materials and methods: From a cohort of 134 patients undergoing RHR for acute complex elbow instability, the Oxford Elbow Score (OES) was used to identify patients whose score was below the p25 (<35 points). Thirty-five patients (23 women and 12 men) with a mean age of 48 years (18-78) and a mean follow-up of 77 months (24-192) were below the p25. The univariate analysis included preoperative demographic characteristics, implant design, diagnosis, and postoperative clinical and radiographic outcomes. Results were compared to patients above the p75. An additional multivariate analysis was performed to identify predictive variables of a p25 OES.

Results: Patients belonging to p25 OES were significantly younger (48 vs. 58 years, P = .02), had a higher energy trauma (P = .01), and their diagnosis was more commonly a terrible triad (18 vs. 11, P = .004) or an Essex-Lopresti (5 vs. 0) injury. Twenty-two patients received a smooth-stem RHR and 13 an anatomic design, with no correlation between implant design and p25 OES (P = .83). The p25 OES showed significantly lower flexion-extension (P = .01), pronation (P = .01), Visual Analog Score (VAS) satisfaction (P < .001), and Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores (P < .001), with more pain (P < .001). All patients who required implant removal belonged to the p25 OES (10 vs. 0). On multivariate analysis, odds of belonging to p25 OES were greater only for younger (odds ratio = 0.94, 95% confidence interval: 0.88-0.99, P = .04) and female patients (odds ratio = 20.29, 95% confidence interval: 2.27-181.8, P = .007). A very strong correlation was observed for postoperative VAS for pain above 3 points, worse DASH and MEPS scores with a p25 OES. Lower flexion-extension arc of motion, lower levels of satisfaction, lateral ligament insufficency, and the overall presence of complications and implant removal showed moderate correlation with p25 OES.

Conclusion: RHR for traumatic complex elbow instability generally provides good long-term outcomes with few complications. Some preoperative characteristics, such as younger age, high-injury trauma, terrible triad, and longitudinal instability, are related to a lower OES with worse overall clinical outcomes. Female sex and younger age may be predictors of an unsatisfactory outcome after an RHR.