Journal of Shoulder and Elbow Surgery最新文献

Purpose: To compare patient-reported outcomes, range of motion, and rates of revision surgery between male and female patients undergoing primary anatomic total shoulder arthroplasty (aTSA).

Methods: A systematic review was performed using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature search was performed on June 1^st, 2024, using the PubMed, Embase, and Scopus library databases for human clinical studies reporting postoperative outcomes and revision rates following aTSA between male and female patients. Preoperative and postoperative outcome scores and revision rates were stratified by patient sex and quantitatively compared. The quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

Results: Six studies met the inclusion criteria, totaling 4,525 patients. Males (n=2,288) had a mean age of 68.3 years and females (n=2,237) had a mean age of 67.4 years (mean difference, 2.02; p =0.43). Males demonstrated significantly greater improvement in postoperative American Shoulder and Elbow Surgeons (ASES) scores (mean difference 2.18, p <0.001) and Visual Analog Scale (VAS) pain scores (mean difference 0.40, p <0.001) compared to females. Females demonstrated higher rates of postoperative complications (10.1% vs. 7.3%, risk ratio 1.43, p<0.001) and revision surgeries (6.2% vs. 3.7%, risk ratio 1.87, p =0.03).

Conclusion: Males undergoing aTSA demonstrate significantly greater improvements in postoperative ASES and VAS scores than females. Females have higher rates of postoperative complications and revision surgery. These findings highlight the necessity for tailored preoperative counseling, perioperative management and postoperative care strategies. Further investigation is needed to determine the clinical significance of these difference and to identify modifiable biological and social risk factors to improve results in female patients.

Background: Given that shoulder instability mostly affects young patients, it is likely that return to active duty (RTAD) is an important factor in the military population. However, knowledge on factors associated with failure to RTAD in this patient group following arthroscopic Bankart repair (ABR) and Latarjet is limited.

Purpose: The aims were to (1) assess RTAD rates following ABR and Latarjet (2) determine prognostic factors that are associated with failure to RTAD and (3) assess the degree of limitation in work performance due to shoulder complaints.

Materials and methods: A retrospective cohort study was conducted including consecutive patients who underwent ABR or open Latarjet procedure to treat shoulder instability due to traumatic anterior shoulder dislocation(s) between 2014 and 2020. Failure to RTAD rates following ABR and Latarjet procedures were assessed presymptomatically, at six months and at final follow-up. A multivariate logistic regression analysis was used to identify factors associated with failure to RTAD. Covariates were selected based on univariate analyses. A heatmap was created to display the extent of limitations during work.

Results: One-hundred-seven patients in military service with an average follow-up of 63 ± 26 months were included. RTAD rates at final follow-up were 76% and 85% for ABR and Latarjet patients (p=0.33). There were no factors associated with failure to RTAD at 6 months and final follow-up. The percentage of patients working above shoulder height that were very/extremely limited decreased from 20% to 4% (ABR) and 33% to 0% (Latarjet) preoperatively to final follow-up.

Conclusion: The return to active duty rates at final follow-up were 76% for ABR and 85% for Latarjet (p = 0.33). No variables associated with failure to RTAD were found at 6 months and at final follow-up at 63 ± 26 months. The degree of limitation experienced during work decreased for both patient groups following surgery (16-33% to 0-4%), suggesting an overall improvement in work performance for both groups.

Background: Cutibacterium is the most common bacteria recovered from shoulder prosthetic joint infections (PJI). The correlation between Cutibacterium skin load at the time of primary shoulder arthroplasty and patient-reported outcomes and incidence of PJI has not been investigated. The purpose of this study was to evaluate the correlation of Cutibacterium load in (a) the unprepared skin surface and (b) the freshly incised dermal wound edge during primary shoulder arthroplasty with patient-reported outcomes and reoperation rate.

Methods: Cultures were obtained of the unprepared skin overlying the surgical incision and from the freshly incised dermal wound edge in patients undergoing primary shoulder arthroplasty (ream-and-run (RnR), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA)) with a minimum of two-year follow-up. A semiquantitative assessment of the load of bacteria in each culture was used, assigning a value based on the report from the microbiology lab: 0 for "no growth"; 0.1 for "growth of 1 colony only" or for "growth in broth only"; and 1, 2, 3 and 4 for 1+, 2+, 3+ and 4+ growth. Uni- and multivariate regression models and Kendall tau rank correlation were used to assess the relationship between Cutibacterium value with patient-reported outcomes and revision surgery. Data was analyzed for all TSAs (aTSA + rTSA) and RnRs separately.

Results: Two-hundred-fifty-six patients were included, consisting of 119 RnR and 137 TSAs (105 aTSA and 32 rTSA). The average follow-up was 3.9 ± 1.3 years. In TSA patients, higher skin surface Cutibacterium loads were weakly associated with higher preoperative SST scores (Tau=0.196, p=0.004) and postoperative SST scores (Tau=0.140, p=0.044). In RnR patients, skin surface Cutibacterium load was weakly associated with higher postoperative SST scores (Tau=0.155, p=0.048) and dermal wound edge load was weakly associated with higher percent mean perceived improvement (Tau=175, p=0.024) on univariate analysis. There were no other statistically significant associations between Cutibacterium load and PROs. Neither skin surface nor dermal wound edge bacterial load were significantly associated with reoperation rate. Only one enrolled patient was diagnosed with PJI.

Conclusion: The clinical significance of Cutibacterium load in the skin remains poorly understood. In this study, Cutibacterium skin load was not strongly associated with clinical outcomes and reoperation rate. Longer-term follow-up is necessary to better understand the clinical significance of Cutibacterium skin load and risk of PJI.

Background: The multidisciplinary health care model is integral for minimizing postoperative pain following shoulder surgery. Accordingly, the Australian and New Zealand College of Anaesthetists (ANZCA) stipulates that all health professionals involved in postoperative care require an adequate level of understanding in postoperative pain management¹⁴. However, no known peer-reviewed study investigates healthcare professionals' opinions regarding pain following shoulder surgery. This study aimed to assess the perception of patient postoperative pain and subsequent opioid use across medical practitioners, physiotherapists and nurses.

Methods: To address this aim, a 20-part questionnaire was developed to quantify the opinions of healthcare professionals regarding several shoulder surgery outcomes. The questionnaire utilized Visual Analogue Scales (VAS) to allow participants to quantify their subjective assessments of postoperative outcomes across five common types of shoulder procedures. Participants were recruited between 1 January 2021 and 31 December 2021 through contact with representatives from their affiliated organizations. Answers to pain-related questions were subsequently analyzed.

Results: The questionnaire netted 200 responses, of which 132 were complete, and 68 were partial completions. Responses from nursing (35%), allied health (40%) and medical (23%) were included for analysis. Nursing participants assigned higher immediate postoperative pain scores and longer opioid usage following all five types of shoulder surgery, when compared to the values assigned by either physiotherapists or doctors (p<0.05). There is no statistically significant difference in immediate postoperative pain scores, or duration of opioid use assigned between doctors and physiotherapists (p>0.05 for all five types of shoulder procedures).

Conclusion: When examined in the context of current peer-reviewed guidelines, the results of this study showed that all 3 study cohorts overestimated the duration of opioid requirement for all five types of shoulder surgeries assessed in this study - albeit to different degrees. These findings suggest the need for uniform education for doctors, nurses and physiotherapists regarding pain assessment and management immediately following shoulder surgery. While Australian guidelines are readily available online, the awareness of their existence may not be uniformed across all three professions - thus potentially accounting for the differences observed in this study.

Introduction: Preoperative opioid use is a risk factor for complications and diminished outcomes following rotator cuff repair (RCR). The purpose of this study was to evaluate the influence of preoperative opioid use on clinically relevant parameters of patient reported outcomes (PROs) following RCR.

Methods: A consecutive series of patients undergoing arthroscopic RCR from 2018 to 2020 were included. Preoperative opioid use within one year of surgery was determined and cumulative morphine milligram equivalents (MME) calculated. Preoperative and postoperative PROs at 3 and 6 months included visual analog scale (VAS) for pain, shoulder subjective value (SSV) and American Shoulder and Elbow Surgeons Shoulder Score (ASES). Proportion of patients achieving clinically relevant measures of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptoms state (PASS) was determined. Multivariate linear regression was used to identify factors associated with PROs.

Results: 760 patients (52% female) with mean age of 60 (range 49-73) years were included. 480 patients (63%) had no history of opioid prescriptions, while 280 (37%) had an opioid prescribed within one year prior to RCR. Preoperative, 3 month, and 6 month PROs were worse in the preoperative opioid cohort compared to opioid naïve (p<0.05). The rate of achieving PASS at 6 months was statistically greater in the opioid naïve cohort than the preoperative opioid used cohort for VAS for pain (58.7% vs 40.2%, p<0.001), and trended toward statistical significance for ASES (39.9% vs 26.7%, p=0.003) and SSV (55.5% vs 45.5%, p=0.031). There were no statistically significant differences in the proportion of patients achieving MCID or SCB at 3 or 6 months for any PRO between cohorts. Multivariate analysis demonstrated that preoperative opioid use was predictive of lower ASES (ß coefficient -7.47 [95% CI -5.2 to -9.7], p<0.001), lower SSV (ß coefficient -7.21 [95% CI -9.61 to -4.8), p<0.001), and higher VAS for pain (ß coefficient 1.07 [95% CI 0.81 to 1.33], p<0.001).

Conclusion: Patients with a history of preoperative opioid use had statistically significant lower rates of achieving PASS for VAS for pain and demonstrated similar trends for ASES and SSV compared to opioid naïve patients in the early postoperative period following arthroscopic RCR. However, there were no differences in the rate of achieving MCID and SCB for ASES, SSV, and VAS for pain between opioid use and opioid naïve cohorts. Preoperative opioid use was a consistent factor associated with inferior outcomes for ASES, SSV, and VAS.

Background: Preoperative intramuscular fat (IMF) is a strong predictor of tendon failure after a rotator cuff repair. Due to the contemporary labor intensive and time-dependent manual segmentation required for quantitative assessment of IMF, clinical implementation remains a challenge. The emergence of accurate three-dimensional evaluation of the rotator cuff may permit implementation with greater inter-rater reliability than common subjective scales (e.g., Goutallier classification (GC)). Here, we developed and validated convolutional neural network (CNN) model for auto-segmentation of the shoulder on Dixon MRI. Also, we aimed to assess the agreement between GC, two-dimensional (2D) and 3D IMF including their discriminatory ability for the identification of muscles above an IMF threshold shown to negatively impact surgical outcomes (i.e., GC ≥ 3).

Methods: This study retrospectively obtained fat-water Dixon shoulder MRIs between March 2023 and March 2024 to develop and validate a CNN model for the segmentation of individual rotator cuff muscles and surrounding tissues. The CNN model was trained using a modified U-Net architecture (n = 80) and tested on an external dataset (n = 25). Accuracy was primarily evaluated using the Dice Similarity Coefficient (DSC) compared to manual segmentation. Reliability was evaluated by the intraclass correlation coefficient (ICC_2,1) and discriminatory ability was evaluated by the area under the receiver operating characteristic curve (AUC).

Results: The model after training (37 male and 43 female, mean age = 55.8 ± 15.6 years) and testing (15 male and 10 female, mean age = 56.6 ± 19.7 years) produced DSCs of ≥ 0.89 except for teres minor (DSC = 0.86 ± 0.03). The model demonstrated excellent reliability for volume (ICC_2,1 ≥ 0.93) and good to excellent reliability for IMF (ICC_2,1 ≥ 0.80), with the exceptions of teres major volume (ICC_2,1 = 0.82, 95% CI: 0.63 - 0.92, p < 0.001) and subscapularis IMF (ICC_2,1 = 0.55, 95% CI: 0.22 - 0.77, p < 0.001). 3D IMF but not 2D IMF was associated with GC for the supraspinatus, subscapularis and infraspinatus (U ≥ 4.02, p < 0.045). The proposed CNN model's IMF outputs produced excellent discriminatory capability of muscles above the IMF threshold shown to negatively impact outcomes (AUC ≥ 0.93).

Conclusion: The development of a CNN model allows for efficient, accurate segmentation of muscle and bone, enabling reliable evaluation of muscle quality. The model demonstrates that 2D evaluation of IMF is insufficient for differentiating between rotator cuff muscles either side of a clinically meaningful IMF threshold on the GC scheme, whereas 3D IMF shows excellent discriminant validity across all rotator cuff muscles.

Background: The aim of this study was to develop a scoring system based on preoperative characteristics to predict clinical outcomes 2 years after revision rotator cuff repair.

Methods: This retrospective study included 195 patients (mean age, 55.1 years) who underwent revision rotator cuff repair between July 2001 and December 2020 in 12 treatment centers in France. All patients were evaluated preoperatively and at least 2 years after surgery in terms of Constant score, subjective shoulder value (SSV) and patient satisfaction. Variables associated with these clinical outcomes in a multivariable logistic regression model were included in the scoring system and weighted according to their association with 1, 2 or 3 of the considered clinical outcomes (Constant score, SSV, patient satisfaction). The ability of the scoring system to predict Constant scores > 70 points and SSVs > 70% 2 years after surgery was optimized using receiver operating characteristic (ROC) curves.

Results: In multivariate analysis, an isolated supraspinatus tear was associated with higher Constant scores (p = 0.019), SSVs (p < 0.001) and patient satisfaction (p = 0.004); work-related tendon tears were associated with lower Constant scores (p = 0.019) and SSVs (p = 0.005); female sex was associated with lower Constant scores (p = 0.002); manual work was associated with lower SSVs (p = 0.046); and smoking and a delay between primary and revision repair > 6 months were associated with lower patient satisfaction (p = 0.049 and p = 0.020). These variables were weighted in the scoring system from 0 to 9 points as follows: 3 points for an isolated supraspinatus tear, 2 points for a non-work-related tendon tear, and 1 point each for non-manual work, non-smoking status, male sex, and a delay to revision < 6 months. The AUCs of the scoring system to predict a Constant score > 70 points and an SSV > 70% two years after revision repair in these patients were 72% and 73%, respectively. The positive predictive value of a score ≥ 6/9 points was 80% for a Constant score > 70 points, 91% for an SSV > 70% and 91% for patient satisfaction, two years after revision repair.

Conclusion: A simple scoring system for patients with recurrent rotator cuff tear based on six preoperative characteristics was optimized to predict good clinical outcomes 2 years after revision rotator cuff repair. This revision rotator cuff repair prediction (RCRP) score could be used in patient counseling and to identify those most likely to benefit from revision repair.

Background: Scapular spine fractures occur in 1-11% of cases after reverse shoulder arthroplasty (RSA). While non-operative management has been recommended, poor clinical outcomes have been reported for Levy type II-III fractures. The literature on surgical management mostly includes open reduction and internal fixation (ORIF) for established non-unions with mixed results. Currently, little evidence exists on acute ORIF of displaced scapular spine fractures after RSA. Therefore, the purpose of this propensity score-matched study was to compare acute ORIF (<6 weeks) with non-operative management.

Methods: This retrospective case-control study included 74 Levy type II-III fractures from 3 surgical centers. Sixteen patients underwent acute ORIF within 6 weeks of symptom onset, and 58 patients non-operative management. In the operative group, 11 patients (69%) were treated with 90:90° double plating, 4 with hook plating (25%), and 1 (6%) with a hybrid double construct. Clinical (Subjective Shoulder Value (SSV), ASES score, VAS, patient satisfaction, and active forward elevation) and radiological outcomes were compared. Propensity score matching was performed using 5 criteria (age, sex, BMI, diagnosis, and Levy type) to balance the covariates and to reduce selection bias.

Results: Of the total group (74 fractures: 16 ORIF and 58 non-operative), 14 patients in each group were matched using the propensity score. At a mean follow-up of 3.7 years, the mean SSV was significantly better (p = 0.005) for the ORIF group (90%, IQR 76-90) compared to the non-operative group (57%, IQR, 42-70). The mean ASES score (82, IQR 74-90 versus 59, IQR 40-70), and mean active forward elevation (123°, IQR 95-137° versus 75°, IQR 50-100°) were significantly better in the ORIF group (p = 0.007 and p = 0.021, respectively) compared to the non-operative group. The union rate for the ORIF group was 93% (13/14), compared to 30% (4/13, 1 undetermined) for non-operative group (risk ratio 0.13, p = 0.001).

Conclusion: Acute ORIF for displaced Levy-type II and III scapular spine fractures after RSA is associated with significantly better clinical outcomes and union rates compared to non-operative treatment.

Background: One-third of patients who undergo open reduction and internal fixation (ORIF) of proximal humerus fractures require subsequent plate removal. It is currently unclear which patients will benefit most from this procedure. Therefore, to support preoperative decision-making we sought to identify predictive factors of the clinical benefits of plate removal.

Material and methods: All patients with ORIF for proximal humerus fractures from 2014-2020 were recorded prospectively in an institutional register. All those with a one-year follow-up were included in the study. The clinical and radiographic follow-ups after 12 months, and before and after plate removal were evaluated. The radiographic analysis included measuring known parameters (acromion tuberosity index, lateral acromion angle, critical shoulder angle) and coining a new measurement: the acromion plate angle (APA).

Results: We included 91 patients of whom 31 had undergone later plate removal. A significant difference between the group without (nPR) and with plate removal (PR) was only seen in the age (p=<0.001. Significant improvement in the absolute CS (+12.6), relative CS (+16.6), elevation (+29.5°), abduction (+32.6°) and external rotation (+18.1°) (p-values < 0.001) was observed following plate removal. The regression analysis revealed that older age and low APA were significant predictors of clinically relevant improvement of the absolute CS. Optimal cut-off points for age (>55 years) and APA (<36°), corresponding to a minimal increase of 10 points in the absolute CS, were also identified.

Conclusion: Significant improvements in absolute CS and range of motion were achieved in all patients after plate removal. Even though it was performed more frequently in younger patients, patients > 55 years profited the most. An APA of <36° was found to be a positive predictor for significant and relevant functional improvement after PR. Its easy use on ap radiographs allows uncomplicated integration into the clinical decision-making process and helps inform the patients in terms of what to expect after the intervention.

Background: Proximal humerus fractures (PHFs) are common in the elderly, with a rising incidence. Despite advances in surgical techniques, the optimal treatment for displaced PHFs remains controversial, as high-quality studies show no significant differences in functional outcomes between surgical and non-surgical treatments. This study aims to compare non-operative with surgical treatment using a locking plate for displaced PHFs in patients over 60 years old.

Methods: This prospective, randomized clinical trial compared non-operative and operative treatments using locking plates for displaced PHFs in patients over 60 years old. Patients were randomized 1:1 into two groups using a block randomization stratified by tuberosity involvement. The primary outcome was the Constant-Murley score at 24 months. Secondary outcomes included the Individual Relative Constant Score (IRCS), American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score at 3, 6, 12, and 24 months. The incidence of complications and the need for reoperations were evaluated.

Results: Eighty patients were randomized, with 71 completing 24 months of follow-up: 40 in the non-operative group and 31 in the operative group. At 24 months, the mean Constant-Murley scores were 68.7 ± 16.1 for the non-operative group and 66.5 ± 15.8 for the operative group (p=0.433). The ASES score at 24 months was 77.0 ± 23.1 for the non-operative group and 79.1 ± 20.0 for the operative group (p=0.871). The SANE scores at 24 months were 83.8 ± 19.3 for the non-operative group and 88.5 ± 17.2 for the operative group (p = 0.236). The IRCS at 24 months was 79.5 ± 25.2% for the non-operative group and 73.0 ± 29.2% for the operative group (p=0.244). Seventeen patients experienced complications, with six (15.0%) in the non-operative group and eleven (35.5%) in the operative group (p=0.070). The rate of a new surgical indication was 12.5% in the non-operative group and 22.6% in the operative group (p=0.421). Rotator cuff tears were 20.0% in the non-operative group versus 25.8% in the operative group (p=0.768).

Conclusion: The operative treatment of displaced proximal humeral fractures with locking plate osteosynthesis in patients over 60 years old shows no evidence of differences in clinical outcomes compared to non-operative treatment, as measured by the Constant-Murley Score, Individual Relative Constant Score, ASES, SANE, and complication rates.