Journal of Shoulder and Elbow Surgery最新文献

Background: Lesser tuberosity osteotomy (LTO) repair in total stemless shoulder arthroplasty has a high nonunion rate and thus presents a challenge to shoulder surgeons. Improved repair techniques may mitigate nonunion from excessive fragment motion or inadequate compression. The purpose of this study was to evaluate the biomechanical properties of three LTO repair techniques in the setting of stemless shoulder arthroplasty. Tensionable cortical button (Button) and suture anchor (Anchor) constructs were compared to a reference suture with a lateral plate construct (Suture).

Methods: Forty human cadaveric shoulders from twenty matched pairs were dissected and the lesser tuberosity osteotomized. In each pair, the LTO was repaired with a Suture and lateral plate construct on one side and on the other side, either a tensionable cortical Button or suture Anchor construct was used. Sutures were passed through the humeral components of a stemless arthroplasty system during the procedures. All specimens were cycled 1000 times from 10-100 N at 1 Hz using a custom subscapularis cryoclamp. Cyclic construct gapping was recorded at regular intervals with a digital video system. All specimens were then loaded to failure, and failure load, displacement, mode, and construct stiffness were recorded. Statistical analyses compared the Suture constructs to their paired Button or Anchor constructs.

Results: Compared to their Suture pairs, the Button group displayed no differences in construct gapping (p≥0.138), but the Anchor group displayed up to 50% increased gapping from cycles 1-400 (p≤0.049). The Suture construct supported approximately 25% higher loads prior to failure when compared to their paired Button and Anchor group (p≤0.014). There were no differences in failure stiffness between the Sutures and their paired Buttons or Anchors.

Conclusion: In this controlled laboratory study, the decreased rate of initial construct gap formation and greater failure load of the suture construct suggests an environment for superior in vivo healing of the LTO as a result of decreased micromotion, with clinical implications still to be determined. Furthermore, the greater failure load in the suture construct could prevent catastrophic failure of the LTO in the delicate post-operative period. In the setting of total shoulder arthroplasty, an LTO subscapularis repair utilizing a suture with a lateral plate construct provides a biomechanically superior repair to either a tensionable cortical button or suture anchor repair.

Background: The advent of modern, precontoured locking plates has improved treatment of distal humerus fractures (DHFs) by providing an anatomic fit and a reliable locking mechanism with interdigitating screws. However, severe articular comminution may predispose surgical failure despite anatomic reduction and a biomechanically strong construct.

Methods: A retrospective review was performed to identify patients who underwent distal humerus open reduction internal fixation (ORIF) between 2015 and 2020. Fractures were classified using the AO/OTA classification and further categorized by anatomic location and number of fragments on preoperative imaging. Articular comminution was defined as the number of articular fracture fragments ≥1.5 cm and stratified as high (≥5 fragments) and low (<5 fragments) comminution. Outcomes included elbow range of motion, quick Disabilities of the Arm, Shoulder and Hand (qDASH), and Mayo Elbow Performance Score (MEPS). Complications were classified as major or minor based on the need for reconstructive reoperation. Outcomes and complications between high- and low-comminution DHFs were compared using Student t test and Fisher exact test.

Results: The study cohort consisted of 51 patients, 38 female (75%) and 13 male (25%), with a mean age of 63.3 years. Fracture types included 9 AO/OTA type A, 7 type B, and 35 type C. At a mean follow-up of 47 months, the mean arc of motion in the high-comminution group was 104° vs. 109° in the low-comminution group (P = .595). The mean MEPS was 79 vs. 88 (P = .376), and the mean qDASH score was 29 vs. 19 (P = .219) in the high-comminution and low-comminution groups, respectively. Among the intra-articular fractures, patients with high-comminution fractures experienced significantly more major complications (87.5% vs. 16.3%, P < .001) and overall complications (87.5% vs. 30.2%, P = .001) compared with those in the low-comminution group. Major complications in the high-comminution group included bone resorption with conversion to arthroplasty and radical contracture releases with heterotopic ossification excision. Major complications in the low-comminution group included nonunion, elbow contractures, deep infection, and bone resorption with implant failure. All highly comminuted fractures achieved satisfactory reduction with parallel-plate fixation. Final qDASH and MEPS scores were not affected by comminution severity, although a significantly higher proportion of patients required revision surgery in the high-comminution group.

Conclusion: Precontoured locking plates provide reliable fixation for intra-articular DHFs. However, severe articular comminution is associated with complications resulting in major reconstructive reoperations, even with satisfactory fixation. Despite this, conversion to total elbow arthroplasty remains low.

Hypothesis/background: Fatty infiltration (FI) and muscle atrophy following rotator cuff (RC) tears are largely irreversible and are major determinants of poor surgical outcomes, increased re-tear risk, and long-term functional disability. No pharmacologic therapies have been validated to prevent or reverse these degenerative changes. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), including liraglutide, have demonstrated antiadipogenic and tissue-preserving effects in other organ systems, suggesting potential application in RC-related muscle degeneration. We hypothesized that systemic liraglutide administration would attenuate FI, preserve muscle morphology, and improve functional outcomes in a rat model of chronic RC tear without tendon repair.

Purpose: To evaluate the effects of systemic liraglutide administration on FI, muscle morphology, and functional outcomes in a rat model of chronic RC tear without tendon repair.

Study design: A controlled laboratory study.

Methods: Adult male Sprague-Dawley rats underwent unilateral supraspinatus tendon transection with interposition of a silicone tube to prevent tendon-to-bone healing. Animals were randomly assigned to receive intraperitoneal liraglutide (250 ㎍/kg/d) or saline for 4 weeks, starting 2 weeks postinjury. At 6 weeks postsurgery, FI was assessed using Oil Red O staining, muscle morphology was examined via hematoxylin-eosin histology, and passive shoulder range of motion was measured with a goniometer. Neuromuscular function was evaluated through compound muscle action potential recordings, and FI was quantified as the percentage of red-stained FI area using ImageJ software with a uniform color-threshold algorithm.

Results: GLP-1RA significantly reduced FI compared with controls (Oil Red O-positive area: 1.11 ± 0.75% vs. 11.82 ± 3.89%, P < .001) and markedly decreased adipocyte deposition on H&E staining. Passive internal rotation was preserved (79 ± 38° vs. 70 ± 2°, P < .001), as was external rotation (55 ± 2° vs. 48 ± 3°, P < .001). Compound muscle action potential amplitudes were significantly greater in the liraglutide group (19.43 ± 8.77 mV vs. 7.61 ± 3.15 mV, P = .028).

Conclusion: Systemic liraglutide administration attenuated chronic muscle degeneration after RC tear by limiting FI, preserving muscle fiber morphology, maintaining joint mobility, and supporting neuromuscular function. These findings provide preclinical justification for therapeutic repositioning of GLP-1RAs in musculoskeletal disorders characterized by irreversible fatty degeneration.

Background: Hand-behind-back (HBB) motion is commonly used to assess shoulder internal rotation; however, it involves multiple joint movements, including scapulothoracic, glenohumeral, and elbow joint motions, thus complicating the interpretation of the HBB position. This study aimed to investigate three-dimensional joint alignment during HBB motion of the bilateral shoulders in patients with frozen shoulder and to identify which joint motions primarily contribute to motion limitation.

Methods: Seventeen patients with unilateral frozen shoulder underwent bilateral shoulder computed tomography (CT) scans in the neutral and HBB positions using an upright multidetector CT. Bone surface models of the thorax, scapula, humerus, and forearm were created to calculate the rotation of the scapulothoracic, glenohumeral, thoracohumeral, and elbow joints. The affected and unaffected sides were compared, and the correlation between the HBB reach level (vertebral level) and the thoracohumeral internal rotation angle was analyzed.

Results: No significant differences in joint rotation were observed between the sides in the neutral position. The affected side demonstrated significantly reduced glenohumeral internal rotation (31° vs. 66°, P < 0.001), abduction (10° vs. 22°, P < 0.001), and elbow flexion (74° vs. 115°, P < 0.001) during HBB motion. The scapulothoracic joint on the affected side had less internal rotation (18° vs. 21°; P = 0.045) and more anterior tilt (24° vs. 19°; P = 0.003). The HBB reach level was negatively correlated with the thoracohumeral internal rotation angle in the unaffected and affected sides (r = -0.518 and r = -0.675, respectively).

Conclusion: This study clarified that limited internal rotation of the glenohumeral joint is the main cause of restricted HBB motion in frozen shoulder, which supports the use of the thumb-to-spinous process as a valid measure of thoracohumeral internal rotation in patients with frozen shoulder.

Background: Olecranon fractures occur more commonly in older individuals. For patients ≥70 years of age, operative management is often considered standard of care, although recent evidence has supported non-operative treatment in frail and/or elderly patients. With evolving treatment indications, more granular evidence is beneficial to guide patient-specific decision making. The aim of this investigation was to explore patient and treatment factors associated with outcomes after displaced, closed olecranon fractures in older individuals.

Methods: This retrospective cohort study with prospective data collection included 113 patients (mean age 81; 81% female) ≥70 years of age with displaced, stable olecranon fractures (Mayo 2A/2B). Patients were treated operatively via precontoured olecranon locking plates (n=68) or tension band wiring (n=6) or non-operatively (n=39) with progressive mobilization. Frailty was quantified using the Clinical Frailty Scale. The primary outcome was Quick Disability of the Arm, Shoulder, Hand (QuickDASH) score. Secondary outcomes included range of motion, PROMIS global health, and complications. Mean time from injury to outcome collection was 16 ± 2 months.

Results: Mean QuickDASH was lower in the operative cohort (mean difference -8.3; 95% CI 0.4 to 16.2; p = 0.021) although the difference was not clinically meaningful (minimal clinically important difference = 15). Subgroup analysis by frailty revealed no differences between operative and non-operative management in the mildly frail and moderate to severely frail subgroups. Linear regression identified frailty was associated with limb-specific disability (β=4.86, p=0.001); age was not a significant predictor when controlling for frailty. In the plate fixation group, engaging the proximal fragment fixation with < 3 screws was associated with proximal fragment escape (β=3.13, SE=0.94, OR=22.9, 95% CI 3.63 to 144.8, p=0.001) independent of fragment size, comminution, and triceps reinforcement. In the non-operative group, increasing immobilization duration was associated with decreased arc of motion (β=-4.1, SE=1.3, R²=0.29, p=0.006).

Conclusion: This study reinforces recent Level I evidence suggesting that operative management of displaced olecranon fractures does not result in superior long-term functional outcomes for the average older patient. Frailty, rather than chronological age, is a primary driver of limb-related disability. Early mobilization is a low-risk alternative to operative management. When surgery is pursued to achieve faster recovery or improved early elbow extension, surgeons should ensure robust proximal fragment fixation with at least three screws to minimize the risk of failure.

Background: Rotator cuff repair (RCR) is increasingly performed due to advancements in surgical techniques and an aging population. While generally successful, complications like re-tear, stiffness, infection, and thromboembolic events remain concerns. The rising use of testosterone replacement therapy (TRT) in middle-aged and older men raises questions about its impact on surgical outcomes, as its effect on RCR complications remains unclear.

Methods: A retrospective cohort study was conducted using the PearlDiver Database. Patients who underwent arthroscopic RCR between January 2010 and April 2023 were identified using Current Procedural Terminology (CPT) code 29827. Those with at least two years of continuous follow-up were included, while patients under 21 or with unknown procedural laterality were excluded. Patients were categorized into two cohorts: those who received TRT within three months preoperatively and a control group who did not. Propensity score matching (1:1, caliper = 0.001) was performed to control for age, gender, Charlson Comorbidity Index, obesity, tobacco use, and hypogonadism. The primary outcomes included 2-year postoperative complications and reoperations. Secondary outcomes included 90-day major medical complications such as surgical site infection (SSI), pneumonia, pulmonary embolism, deep vein thrombosis, urinary tract infection, wound dehiscence, sepsis, acute kidney injury, and readmissions. Statistical analyses were performed using chi-square tests, and odds ratios with 95% confidence intervals were calculated.

Results: A total of 8,241 TRT users and 673,982 control patients were identified before matching. After propensity score matching, 5,109 patients remained in each cohort with no significant baseline differences. No significant differences were observed in 90-day postoperative complications, including SSI (0.5% vs. 0.4%, p = 0.64), pneumonia (0.6% vs. 0.5%, p = 0.79), sepsis (0.4% vs. 0.3%, p = 0.51), acute kidney injury (0.7% vs. 0.5%, p = 0.18), or readmissions (1.2% vs. 1.0%, p = 0.29). Similarly, no significant differences were found in pulmonary embolism or deep vein thrombosis. Over the two-year follow-up, TRT use was associated with a higher incidence of total shoulder arthroplasty (TSA) (0.7% vs. 0.4%, p = 0.037) but a lower incidence of lysis of adhesions (0.5% vs. 0.9%, p = 0.032). No significant differences were observed in revision RCR rates (2.6% vs. 2.3%, p = 0.41).

Conclusion: Preoperative TRT use was not linked to increased short-term complications after arthroscopic RCR. Over two years, TRT was associated with higher rates of TSA but lower rates of lysis of adhesions, with no difference in revision RCR.