Journal of Shoulder and Elbow Surgery最新文献

Background: The efficacy of subscapularis (SSC) repair in reverse shoulder arthroplasty (RSA) remains controversial. Few studies have evaluated the postoperative integrity and effect on clinical outcomes of repaired SSC; however, conflicting results regarding whether the healing of the repaired SSC influences outcomes have also been reported. Therefore, this study aimed to address the controversy by evaluating clinical outcomes in SSC repair compared to non-repair after humeral lateralized RSA, and to evaluate the significance of the integrity of the repaired SSC.

Methods: This study included patients who underwent humeral lateralized RSA between 2015 and 2019 and categorized them into two groups: repaired (n=66) and non-repaired (n=36) SSCs. The clinical outcomes, such as the visual analog scale score, constant score, American Shoulder and Elbow Surgeons (ASES) score, active range of motion (aROM), activities of daily living scores consisting of active internal rotation and forward flexion (ADL score), and rotational strength, were compared. Ultrasonography was used to assess the integrity of the repaired SSC following the modified Sugaya classification and to evaluate the acromial fracture. Subgroup analysis was performed on patients with healed SSC versus non-healed SSC, versus non-repaired SSC.

Results: Overall, 102 patients were included, with a mean age of 73 ± 5 years. Both groups exhibited substantial postoperative improvements in clinical scores, active ROM, and rotational strength without significant differences. At the 2-year follow-up, 52% of patients showed healed tendons, while 44% exhibited retears in the repaired SSC group. Significant clinical improvements were noted in both groups, regardless of the SSC integrity. However, the healed SSC group exhibited significantly improved outcomes in ADL score, IR aROM, and IR strength compared to the non-healed SSC group (p=0.002, p=0.011, p<0.001). Meanwhile, compared to the non-repaired SSC group, the healed SSC group also showed significant improvements in IR aROM and IR strength (p=0.016, p=0.002), but the difference in ADL score was not statistically significant (p=0.133). Furthermore, while the SSC repair group showed a marginally higher rate of acromial fractures (9% vs. 6%, p=0.709) as evaluated through both radiography and ultrasonography, the overall rates of complications remained statistically comparable across the groups (13% vs. 11%, p=0.854).

Conclusions: Healed SSC groups showed significantly better IR aROM, and IR strength than both non-healed and non-repaired SSC groups, highlighting SSC healing's crucial role in enhancing IR functional outcomes even with humeral lateralized RSA; hence, SSC repair should be advocated whenever possible during RSA, though further research is needed to improve its low healing rate.

Background: Among emerging options, Middle Trapezius Tendon (MTT) transfer has shown promise, particularly in isolated supraspinatus irreparable rotator cuff tears (ISIRCTs) and nonarthritic shoulders unsuitable for reverse total shoulder arthroplasty. This study aims to assess clinical and radiological results of MTT transfer utilizing an Achilles tendon allograft for ISIRCTs.

Methods: We retrospectively reviewed patients who received MTT transfer using Achilles tendon allograft for ISIRCTs between May 2020 and August 2021. Clinical assessments using pain VAS, Constant, ASES, UCLA, and SANE score were assessed pre- and postoperatively. Active Range of Motion (aROM) were obtained, and radiologic assessments included AHD, Hamada grade, and MTT integrity.

Results: 18 patients were involved with mean age of 63.8 ± 7.1, followed for an average of 25.4 ± 4.4 months. Significant improvements were observed in pain relief (VAS:4.7±1.5 to 1.6±0.9, P<.001), shoulder function (Constant: 53.1±11.1 to 70.0±15.1, ASES: 57.7±13.5 to 78.2±17.0, UCLA: 13.6±4.5 to 22.0±6.4; all P<.001), and patient satisfaction (SANE: 51.3±14.1 to 73.7±15.0, P<.001). Active range of motion significantly improved in Forward elevation (FE) and abduction (ABD). Radiologic assessments showed no significant change in AHD and Hamada grade, with p-values of 0.503 and 0.260, respectively.

Conclusion: MTT transfer using Achilles tendon allograft showed improvement in pain relief, clinical scores, and active FE and ABD in patients with ISIRCTs. However, the validation of its effectiveness necessitates multicenter and long-term studies.

Background: Gabapentin is an anticonvulsant used for managing neuropathic pain. Its effectiveness and dosing strategies for postoperative pain, particularly in open shoulder rotator cuff repair, are still debated. This study assesses gabapentin 's impact on postoperative pain intensity in open rotator cuff repair.

Methods: Sixty eligible patients were randomly distributed into two groups: placebo and gabapentin. The gabapentin group received a daily dose of 600 mg, administered in two divided increments, beginning three days before the surgery and continuing for one week postoperatively. Pain intensity, assessed via the Visual Analog Scale (VAS), was the primary endpoint during the first postoperative week. Secondary aims conducted on both groups included quantifying opioid consumption, evaluation of side effects attributed to gabapentin and opioids, assessment of sleep quality, and patients' satisfaction levels with the employed approach.

Result: Postoperative pain in the gabapentin group significantly decreased from the first twenty-four hours until the fourth day post-surgery (p<0.002), accompanied by reduced opioid consumption (P=0.02). Following discharge, the prevalence of nocturnal sleep disruptions and oxycodone consumption in the gabapentin group notably decreased compared to the placebo group, alongside a significant improvement in sleep quality and duration until the fifth day, as well as overall satisfaction with the pain management approach seen within the gabapentin group (P=0.003).

Conclusion: Administering gabapentin perioperatively at 600 mg daily and divided over a minimum duration of four days postoperatively may significantly reduce postoperative pain intensity and opioid consumption in open shoulder rotator cuff repair surgery patients.

Introduction: Tranexamic acid (TXA) is increasingly utilized in total shoulder arthroplasty (TSA) to minimize blood loss. Despite its benefits, concerns persist regarding its use in patients at elevated risk of postoperative venous thromboembolism (VTE). This study evaluates trends in TXA use and assesses its safety in both general and high-risk patient populations.

Methods: Patients who underwent primary, elective anatomic TSA and reverse TSA from January 1st, 2016, to December 31st, 2020, were identified using the Premier database. TXA use trends and the proportion of patients requiring blood transfusions were reported. Patients were divided on the basis of having received TXA on the day of surgery or not. To account for confounding variables, a propensity score was generated for the probability of treatment with TXA. A sub analysis of high-risk patients, defined as those with a history of VTE, was performed using multivariable regression analyses. Endpoints included the 90-day risk of pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion.

Results: In total, 86,356 patients underwent TSA from 2016 to 2020. Of these, 41,380 (47.9%) received TXA, and 44,976 (52.1%) did not. After matching, 28,232 received TXA, and 28,232 did not. The use of TXA increased from 33.4% in 2016 to 60.3% in 2020. The rates of transfusion decreased from 1.05% to 0.47%. Following matching, the risk of all thromboembolic complications (odds ratio [OR]: 0.98, 95%-Confidence Interval [CI]: 0.72-1.33, p=0.874), DVT (OR: 1.11, 95%-CI: 0.71-1.71, p=0.655), and PE (OR: 0.87, 95%-CI: 0.56-1.33, p=0.513) were similar between cohorts. The high-risk cohort comprised 4,757 patients with a history of VTE, of which 1,850 (38.9%) received TXA, and 2,907 (61.1%) did not. The use of TXA for high-risk patients increased from 27.4% to 52.0% while rates of transfusion decreased from 1.76% to 0.70%. Following multivariable regression, there was similar risk of all thromboembolic complications (adjusted OR [aOR]: 0.77, 95%-CI: 0.47-1.28, p=0.316), DVT (aOR: 0.96, 95%-CI: 0.39-2.36, p=0.92), and PE (aOR: 0.54, 95%-CI: 0.23-1.28, p=0.163) between high-risk cohorts.

Discussion: TXA in shoulder arthroplasty usage has nearly doubled from 2016 to 2020 and is now administered to 60% of all patients. This rise in TXA use has been coupled with a significant decrease in the risk of blood transfusion. Patients receiving TXA were not at increased risk of thromboembolic, infectious, epileptogenic, surgical, and medical complications even if they had a history of VTE.

Introduction: Humeral loosening (HL) is an uncommon indication for revision shoulder arthroplasty. This systematic review describes patient characteristics (prosthetic type removed, reimplanted, and septic vs. aseptic loosening status), re-revision rate, and outcomes following revision surgery for a loose humeral stem.

Materials and methods: An electronic database search of PubMed, Scopus, Embase, and Cochrane was conducted accordant to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Studies that reported information on patients who had revision arthroplasty due to HL and reported their post-revision outcomes were included in this review.

Results: Our review included 13 studies, from which 119 revision cases due to HL were extracted. The prostheses subtypes revised for HL were 48.7% (58/119) Anatomic Total Shoulder Arthroplasties (TSAs), 46.2% (55/119) Reverse Shoulder Arthroplasties (RSAs), and 5.0% (6/119) Hemiarthroplasties (HAs). The implants used to revise patients with HL were 52.2% (59/113) RSAs, 35.4% (40/113) HAs, and 12.4% (14/113) TSAs. Septic loosening occurred in 11.7% (14/119) of the cases. Ninety-seven cases provided details regarding subsequent revisions, of which 28.9% (28/97) were re-revised. The following outcome scores were available: mean satisfaction rate was 71.4% (n = 49), the mean total ASES score was 52.5 (range 30-66) (n = 28), and the mean Constant score was 40.3 (range 34-41.3) (n = 14).

Conclusion: The most revised implants for HL were TSAs and RSAs. Reverse shoulder arthroplasties were the most common implants used for revision, followed by HAs. Aseptic loosening accounted for most cases, suggesting that infection is rarely the primary cause of HL. There is a pronounced risk of re-revision for recurrent HL. The irregular reporting of validated outcome scores makes it difficult to draw definitive conclusions regarding the treatments of these patients.

Background: The original Latarjet-Patte procedure is a reliable procedure to treat traumatic anterior shoulder instability. However, attempts to reduce possible complications have led to the emergence of modified techniques. More prominently are the arthroscopic approach and the use of cortical-buttons for coracoid fixation. To date, limited research is available directly comparing the simultaneous use of these two modifications to the original Latarjet-Patte technique. The purpose of this paper is to compare clinical and radiologic outcomes and complications between open Latarjet with screws and arthroscopic Latarjet with cortical-buttons for traumatic anterior shoulder instability.

Methods: A multicenter retrospective cohort study of medical records and imaging studies of two groups of patients, with two years of follow-up, who underwent either one of two variations of the Latarjet procedure: open approach with screws (open-screw group) or arthroscopic approach with cortical buttons (scope-button group). Group homogenization was assured by statistical comparison of 14 baseline independent variables as well as multiple regression analysis to assess confounding factors. The primary outcome was the Rowe scale at 24 months after surgery, for which the MCID value of 9.7 was used. Secondary outcomes were recurrence of instability; graft positioning; the Rowe scale at other points in time; and complications.

Results: Thirty-eight patients were evaluated in the open-screw group and 44 in the scope-button group, with a 24-month follow-up. All but one patient in each group achieved the MCID from pre- to postoperative Rowe score. The Rowe score did not differ between groups during any of the assessment times. There was no difference regarding graft vertical (p = 0.620) or horizontal (p = 0.280) positioning. There was one recurrence in each group: a dislocation in the open-screw group (p = 0.463) and a subluxation in the scope-button group (p > 0.999). Other complications happened exclusively in the scope-button group: neuropraxis (n = 1; p > 0.999), infection (n = 2; p > 0.999), graft fracture (n = 1; p > 0.999) and graft migration (n = 2; p > 0.999). Multiple regression analysis did not observe influence from any of the potential confounding factors on the final results.

Conclusion: At early follow-up, arthroscopic Latarjet with cortical-buttons yielded similarly good clinical and radiologic results as the conventional open Latarjet with screws.

Background: Surgeons disagree about whether patients should undertake home physical therapy (HPT) or formal physical therapy (FPT) after undergoing reverse total shoulder arthroplasty (RTSA). Recent studies suggest that HPT is as effective as FPT, but surgeons who perform RTSA may believe that FPT continues to have a role. Our primary purpose was to describe the opinions and self-reported practices of surgeons who perform RTSA regarding prescribing physical therapy (PT) after surgery. We also sought to identify factors associated with prescription of FPT.

Methods: A survey was distributed electronically from May to September 2023 to the 1076 members of the American Shoulder and Elbow Surgeons who were practicing in the United States at that time. Of these surgeons, 237 (22%) responded to the survey. Anonymous responses were collected via Qualtrics, including demographic data and information about the RTSA implant systems used. Descriptive statistics were used to analyze surgeon characteristics, implant types, and rehabilitation practices. Multivariate logistic regression was used to identify surgeon, procedure, and implant characteristics associated with the likelihood of FPT prescription. Because some respondents reported using multiple RTSA implant types and some did not answer implant-specific questions, a total of 225 RTSA implant types were included.

Results: Forty-six percent of respondents reported that they recommended FPT for every patient; 64% said they typically prescribe FPT. A smaller proportion of respondents who had completed a hand and upper-extremity fellowship said that they prescribed FPT compared with those who had not completed such a fellowship. However, PT prescription was not associated with any other studied characteristics, such as number of years in practice or whether the surgeon tended to repair the subscapularis. On average, respondents estimated that 92% of their patients received either FPT or HPT. Respondents also reported varying timeframes for starting PT activities after surgery. For example, 50% of respondents reported recommending passive shoulder range of motion below the shoulder level within the first postoperative week, whereas 73% recommended waiting 2-6 weeks for active shoulder range of motion below shoulder level.

Conclusion: Most surveyed surgeons prescribe FPT and/or HPT after primary RTSA, with a slight preference for FPT. Surgical factors did not influence rehabilitation preferences. Further randomized studies to investigate the impact of PT on clinical outcomes of RTSA are needed.

Introduction: Reverse total shoulder arthroplasty (rTSA) has become the operative treatment of choice for acute proximal humerus fractures in the elderly population, but little data exists on the long-term outcomes or how they compare to rTSA done for degenerative conditions. The purpose of this study is to compare the clinical and radiographic outcomes of patients undergoing rTSA for acute fracture versus degenerative conditions with a minimum 5-year follow-up.

Methods: Data was extracted from an international registry of patients with the Exactech Equinoxe rTSA implant from 2007-2018. Patients with a minimum follow-up of 5 years were then split into fracture and degenerative cohorts and matched 1:3 based on age, sex, and follow-up duration. Clinical and radiographic outcomes were compared between the cohorts including range of motion (ROM), patient-reported outcome measures (PROM), VAS pain score, complication and revision rates, implant characteristics, and scapular notching. This data was analyzed using Welch's t-test, Fisher's exact test, or Wilcoxon rank sum test.

Results: There were 384 total patients included in the study, with 96 fractures and 288 degenerative. At a mean follow-up of 6.4 years, the degenerative cohort had significant improvements in all PROMs and ROM, compared to their preoperative status. At the latest follow-up, the mean ASES score was 83 and the mean VAS pain score was 1.1 for both cohorts. Patients with degenerative indications had greater forward elevation which did not meet the minimally clinically important difference and greater internal rotation which did not meet the substantial clinical benefit threshold. Patient satisfaction was very high for both cohorts, with 97% in the degenerative cohort and 91% in the fracture cohort satisfied with the procedure (p=0.276). Complication and revision rates were similar between the two cohorts. Patients in the fracture cohort had a larger glenosphere diameter (p=0.045) and greater combined liner/tray offset (p=0.05). Patients in the elective cohort more frequently required an augmented baseplate (p<0.001). Scapular notching was 11% in the degenerative cohort and 9% in the fracture cohort (p=0.82).

Discussion: This study demonstrates no significant differences in the clinical or radiographic outcomes at a minimum of 5 years follow-up for patients undergoing rTSA for acute fracture versus degenerative conditions. Patients undergoing rTSA for either indication have similar rates of complications, revisions, and scapular notching, with high patient satisfaction. Patients undergoing rTSA for an acute fracture can expect similar results to those undergoing rTSA for degenerative conditions at minimum 5-year follow-up.