Journal of Shoulder and Elbow Surgery最新文献

Background: Irreparable massive rotator cuff tears (IMRCTs) represent a formidable challenge in shoulder surgery, frequently leading to persistent pain, dysfunction, and progressive disability. Effective and durable treatment strategies remain an area of ongoing investigation.

Purpose: This study aimed to evaluate the short-term outcomes of a novel arthroscopic technique using a composite graft of autologous fascia lata and artificial ligament for dynamic reconstruction of the supraspinatus tendon in patients with IMRCTs.

Methods: We retrospectively analyzed 15 patients with IMRCTs who underwent this combined arthroscopic procedure at our institution between January 2022 and January 2023. Patients were followed for a mean of 24.3 ± 0.62 months (range: 24-26 months). Preoperative and postoperative assessments included shoulder range of motion (ROM), visual analog scale for pain, and functional scores such as the University of California, Los Angeles Shoulder Rating Scale, American Shoulder and Elbow Surgeons score, and Constant-Murley score. Rotator cuff integrity was assessed by magnetic resonance imaging at follow-up.

Results: Significant improvements were observed in all outcome measures at final follow-up (all P < .001): visual analog scale (4.6 ± 0.5 to 1.1 ± 0.3), American Shoulder and Elbow Surgeons (42.5 ± 3.9 to 87.5 ± 3.8), University of California, Los Angeles (11.5 ± 1.8 to 31.0 ± 2.3), and Constant-Murley (29.4 ± 5.4 to 84.1 ± 6.4) scores. ROM significantly improved: forward flexion (69° ± 9° to 148° ± 7°), abduction (61° ± 13° to 135° ± 11°), external rotation (22° ± 7° to 54° ± 4°) and internal rotation (19.7 ± 1.1° to 25.0 ± 0.8°). Postoperative magnetic resonance imaging demonstrated graft healing (Sugaya type I or II) in all cases. No complications occurred.

Conclusion: Arthroscopic dynamic reconstruction of the supraspinatus tendon using an autologous fascia lata and artificial ligament (Ligament Advanced Reinforcement System, LARS) composite graft yielded significant short-term improvements in pain, function, and ROM for patients with IMRCTs. This technique combines biological healing potential with mechanical reinforcement. However, these findings are preliminary due to the study's limitations, including its small sample size, retrospective design, and short follow-up. Larger, long-term studies are warranted to validate these results and assess the durability of the reconstruction.

Background: A subset of patients from "Part 1- The SHORT trial: Multicenter, Randomized, Controlled Trial of Surgeon-Directed Home Therapy vs. Outpatient Rehabilitation by Physical Therapists for Reverse Total Shoulder Arthroplasty" were analyzed for various personality, psychological, and health motivation scores to elucidate if these characteristics might influence success with either clinic-based physical therapy or surgeon-directed home therapy (HT).

Methods: Three of the original centers from the SHORT trial participated with the same patients and inclusion/exclusion criteria. Surveys designed to capture psychological traits, motivation, and gauge comprehensive patient health were administered to assess for moderating effects on American Shoulder and Elbow Surgeons score, pain intensity score, Single Assessment Numeric Evaluation score, and complications for both physical therapy and HT groups.

Results: A total of 89 patients across 3 sites were included for analysis. Moderator analysis demonstrated no association among the Short Grit Scale (P = .54, P = .48, P = .51, P = .61), the Short Health Anxiety Inventory (P = .34, P = .97, P = .37, P = .71), the Motivations and Attitudes Towards Changing Health score (P = .24, P = .41, P = .21, P = .95), the Shoulder Activity Scale (P = .97, P = .42, P = .08, P = .66), the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag assessment tool (OSPRO-YF) negative mood (P = .41, P = .95, P = .33, P = .87), OSPRO-YF fear (P = .38, P = .30, P = .75, P = .37), and OSPRO-YF coping (P = .50, P = .77, P = .75, P = .45) on American Shoulder and Elbow Surgeons scores, pain intensity scores, Single Assessment Numeric Evaluation scores, and complications respectively at final 2-year follow-up.

Conclusion: No personality, attitude, grit, psychological, or motivational characteristics were found to be associated with success or failure with surgeon-directed HT.

Background: Reverse total shoulder arthroplasty (rTSA) is increasingly performed in elderly patients with primary glenohumeral osteoarthritis (GHOA) and preserved rotator cuff function. Once reserved for cuff deficiency, it is now often selected based on age rather than cuff status, driving a rapid rise in its use among older adults. This meta-analysis compares rTSA and anatomic total shoulder arthroplasty (aTSA) in patients aged ≥70 years with a competent cuff, focusing on range of motion, functional outcomes, and risks of complications, revisions, and reoperations.

Methods: Following PRISMA 2020 guidelines, we systematically searched 5 databases from inception to March 2025 for comparative studies reporting on aTSA and rTSA in patients aged ≥70 years with primary GHOA and a competent rotator cuff. Inclusion was restricted to studies with ≥2 years' follow-up and validated outcome reporting. Continuous outcomes were pooled using inverse variance random-effects models, and dichotomous outcomes were assessed via Mantel-Haenszel risk ratios. Risk of bias was evaluated using ROBINS-I, and evidence certainty was appraised via GRADE.

Results: Eight studies encompassing 1716 patients met inclusion. Compared with rTSA, aTSA demonstrated significantly greater postoperative external rotation and internal rotation. There were no significant differences in forward elevation, abduction, and patient-reported outcomes (ASES, Constant, SST) between the groups. aTSA was associated with a nearly fourfold higher risk of revision and a higher overall complication rate while reoperation rates were comparable. Heterogeneity was low to moderate across most analyses, and no evidence of publication bias was detected.

Conclusion: In patients aged ≥70 years with primary GHOA and a competent rotator cuff, aTSA provides superior rotational mobility, exceeding the MCID and potentially supporting improvements in daily activities such as dressing or toileting. rTSA offers superior implant survivorship and lower complication rates without compromising patient-reported outcomes, though at the expense of reduced rotational range of motion. aTSA remains preferable in select active patients prioritizing rotation-dependent tasks, provided cuff integrity is preserved. These findings support a patient-tailored approach to implant selection.

Background: The indications for reverse total shoulder arthroplasty (rTSA) have progressively expanded, and it is now implanted for a wide range of clinical scenarios, including cases with an intact rotator cuff. The objective of this study was to use a validated computed tomography (CT) muscle segmentation software to evaluate the relationship of rotator cuff muscle volume and postoperative clinical outcomes.

Materials and methods: A retrospective study was conducted using an institutional database including all patients who underwent rTSA between 2016 and 2022, with a minimum of two years of follow-up. Patients were divided into 2 groups based on the indication: centered osteoarthritis (OA) and cuff tear arthropathy (CTA). Clinical outcomes were assessed preoperatively and postoperatively, including active range of motion (ROM), American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, and visual analog scale for pain. Preoperative CT scans were automatically segmented with a validated CT muscle segmentation software to isolate the scapula, humerus, deltoid, and the 4 rotator cuff muscles. Muscle volume and the percentage of intramuscular fat were measured and normalized to scapular volume. Statistical analyses were performed to investigate correlations between muscle volume, functional outcomes, and ROM.

Results: A total of 528 patients (460 OA, 68 CTA) with an average follow-up of 29.1 ± 8.6 months were included. Normalized muscle volume of the supraspinatus, infraspinatus, and subscapularis was significantly greater in OA patients than in CTA patients (P < .001). No significant differences were observed for the deltoid (P = .92) or teres minor (P = .81). The percentage of intramuscular fat was significantly higher in the supraspinatus, infraspinatus, teres minor, and subscapularis in CTA patients compared to OA patients (P < .001). No significant difference was observed for the deltoid (P = .97). No significant correlation was found between normalized muscle volume (cuff or deltoid) and functional scores or active ROM, either preoperatively or postoperatively following rTSA. In the CTA cohort, a moderate negative correlation was observed between deltoid intramuscular fat percentage and preoperative American Shoulder and Elbow Surgeons score (r = -0.43; P = .031) and preoperative visual analog scale (r = 0.43; P = .026). No correlation was found between intramuscular fat percentage (cuff and deltoid) and postoperative functional outcomes or active ROM.

Conclusion: rTSA for OA achieves better outcomes than rTSA for CTA. The difference in outcomes showed no correlation with muscle volumes, indicating that rotator cuff muscles may play a less critical role in functional outcomes after rTSA than previously thought.

Background: Osteosynthesis of proximal humeral fractures (PHFs) using locking plates (LPs) is associated with a high complication rate, and graft augmentation aims to reduce it. Our study compared clinical and radiographic outcomes as well as complications in older patients with 3- or 4-part PHFs operated with an LP with or without synthetic bone graft.

Methods: A prospective, randomized controlled trial included 70 patients with 3- or 4-part PHFs that were randomly assigned to osteosynthesis using an LP with calcium sulfate paste bone graft (Graft Group) or without graft (Control Group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the 3- and 6-month Constant-Murley score; the 3-, 6-, and 12-month University of California at Los Angeles score; American Shoulder and Elbow Surgeons score; visual analog scale for pain; Disabilities of the Arm, Shoulder, and Hand score; active range of motion; the 12-month Individual Relative Constant, patient satisfaction; abduction strength, head-shaft angle, and humeral height; and consolidation and complications on the first postoperative day and at 6 weeks, 3 months, 6 months, and 12 months.

Results: No differences were evidenced at 12 months between the Graft Group and Control Group, respectively, on the Constant-Murley score (67.7 ± 13.0 vs. 70.3 ± 9.4 points, P = .328), Individual Relative Constant (79.3 ± 9.7% and 81.6 ± 6.3%, P = .227), University of California at Los Angeles, American Shoulder and Elbow Surgeons, visual analog scale, Disabilities of the Arm, Shoulder, and Hand scores, active range of motion, and satisfaction rate (97.2% and 100%, P = .328). The abduction strength was significantly higher in the Graft Group (5.5 ± 1.8 vs. 3.7 ± 0.9 N, P < .001). No differences were shown between the mean head-shaft angle of healthy and operated shoulders in the groups on the first day (P = .455) and at 12 months (P = .671), likewise between the groups' mean humeral height on the first day (P = .298) and at 12 months (P = .354). There was a 100% consolidation with a mean of 7.7 and 8.3 weeks, respectively (P = .347) without any osteonecrosis in the Graft Group. There were no differences in patients with complications (13.9% vs. 29.4%, P = .111) or those who underwent reoperations (5.5% vs. 11.8%, P = .325). However, the total number of complications was significantly lower in the Graft Group (50.0% vs. 16.7%, P = .007).

Conclusion: Our study confirms that calcium sulfate synthetic bone substitute augmentation did not alter the Constant-Murley score or most secondary clinical and radiographic outcomes in older patients with 3- or 4-part PHFs. However, overall complications were reduced, and the abduction strength was higher in the Graft Group.

Background: Reverse total shoulder arthroplasty (rTSA) is widely recognized as an effective treatment for complex proximal humerus fractures (PHFs), providing reliable and predictable outcomes. However, whether glenoid lateralization confers tangible advantages in this setting remains unclear. This study aimed to evaluate the impact of different amounts of glenoid lateralization on clinical and functional outcomes following rTSA for PHFs. To our knowledge, this is the first study to specifically address this question.

Methods: A total of 132 patients with 3 or 4-part PHFs were treated with rTSA using the same humeral stem (Trabecular Metal Zimmer, TM, a cemented inlay stem, 150° neck-shaft angle), same 36-mm glenosphere, and same surgical team. Patients were allocated into 2 groups according to the glenoid baseplate: Group A received a medializing baseplate (TM Zimmer) and Group B a lateralizing baseplate (Comprehensive Zimmer). Minimum follow-up was 18 months. Functional outcomes were assessed using Constant-Murley Score (CS), range of motion (ROM), and muscle strength recovery with Medical Research Council (MRC) scale.

Results: Of the 132 patients initially enrolled (23 males, 109 females; mean age 74.3 years), 15 were excluded due to tuberosity healing failure or deep infection. The final cohort consisted of 117 patients (64 in Group A, 53 in Group B). At final follow-up, the overall cohort demonstrated very good results: mean forward flexion (FF) 157°, abduction 152°, external rotation (ER) 26°, and internal rotation to the L2 vertebral level; mean strength recovery with MRC scale were 4.7/5 for FF and abduction, and 4.3/5 for ER and internal rotation; mean CS was 67.4/100. Compared with Group A, Group B achieved significantly greater ROM in FF (153° vs. 161°) and ER (23° vs. 30°), higher muscle strength recovery (MRC scores), and superior CS (64.0 vs. 70.8), especially in subcategories of ROM (29.8/40 vs. 34.0/40), Pain relief (14.2/15 vs. 14.8/15), and Activities of daily living (14.8/20 vs. 16.1/20).

Conclusion: This is the first study to directly compare varying degrees of glenoid lateralization in rTSA for PHFs, with a significant sample size and rigorous selection of both patients and prosthetic components. While excellent mid-term outcomes were observed in all patients, the use of lateralized glenoid components was associated with superior ROM, pain relief, muscle strength, and overall clinical scores. In the context of PHFs managed with rTSA, glenoid lateralization with a humeral inlay stem with neck-shaft angle of 150° appears to provide significant functional advantages in functional outcomes.

Background: Elbow extension is crucial for daily activities but is often neglected in the context of brachial plexus injuries. Triceps palsy in children with brachial plexus birth injury (BPBI) can lead to significant functional impairments, including difficulty with overhead activities, stabilizing the arm, and performing tasks that require elbow extension.

Methods: This cohort study included 12 children with BPBI who underwent lower trapezius to triceps transfer for elbow extension. Patients were followed for 6 months to 2 years postoperatively. Manual muscle testing using Lovett and Sunderland's method was performed preoperatively and postoperatively. Statistical analysis, including the Wilcoxon signed-rank test, was used to compare muscle strength before and after surgery, with a significance level of P < .05.

Results: Muscle power increased significantly from 1.33 (1) to 4.41 (1) with P < .001. No one developed weakness in elbow flexion; in all cases, elbow flexion-extension motion could be actively done.

Conclusion: Lower trapezius-to-triceps transfer could be a promising surgical method for restoring elbow extension in children with BPBI.