Journal of Shoulder and Elbow Surgery最新文献

Introduction: Reverse total shoulder arthroplasty (rTSA) has surpassed anatomic total shoulder arthroplasty (aTSA) in popularity due to its superior outcomes in patients with rotator cuff deficiency and other complex shoulder pathologies. While primary rTSA demonstrates excellent functional improvements, revision rTSA remains challenging, with limited data available on outcomes. Previous studies on revision TSA have primarily focused on aTSA, with fewer studies evaluating revision rTSA outcomes. The purpose of this study is to compare the clinical and radiographic outcomes of a primary rTSA to a revision rTSA.

Methods: A prospective multicenter shoulder registry of a single manufacturer's implants (Equinoxe, Exactech, Inc., Gainesville, FL, USA) was used to conduct a retrospective review of patients that underwent revision of a rTSA to another rTSA and compare them to those who received a primary rTSA for osteoarthritis and rotator cuff disease between 2007 and 2023 with a minimum follow-up of two years. Cohorts were matched 3:1 (control: revision) by age, gender, body mass index and length of follow-up. Those that underwent revision for humeral fracture, infection, or an unknown reason were excluded. Preoperative and postoperative range of motion (ROM) and patient reported outcome measures (PROM) were compared. Other outcomes included scapular notching, complications, revisions, and patient satisfaction.

Results: There were 52 rTSA revised to a rTSA compared to 156 matched primary rTSA. The mean age was 69 years, 40% were female and the mean follow-up was 56 months. The revision group had significantly less postoperative abduction (108° vs 128°, adj. p=0.023), forward elevation (120° vs 145°, adj. p=0.003), and external rotation (28° vs 38°, adj. p=0.023) compared to the control group, with all exceeding the minimal clinically important difference (MCID). All PROM in the revision cohort were significantly worse than those in the primary rTSA cohort and exceeded the MCID. Patient satisfaction rate in the revision cohort was significantly lower than the primary cohort (80% vs 92%, adj. p=0.011). Complication (31% vs 6%, adj. p<0.001) and revision (12% vs 3%, adj. p=0.050) rates were significantly higher in the revision cohort, while humeral radiolucent line and scapular notching rates were similar between the two groups.

Discussion: Though patients undergoing revision rTSA demonstrated worse functional outcomes, including decreased range of motion, increased pain and lower patient satisfaction compared to those undergoing primary rTSA, both groups significantly improved from their preoperative conditions. Additionally, complication and revision rates were higher in the revision cohort. These findings highlight the challenges associated with revision rTSA.

Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care framework designed to reduce surgical stress, optimise physiological function, and accelerate postoperative recovery through standardised protocols. ERAS protocols have demonstrated clear benefits in hip and knee arthroplasty, yet their role in shoulder arthroplasty remains overlooked.

Aim: To assess the impact of ERAS protocols on perioperative outcomes in shoulder arthroplasty including pain control, opioid consumption, length of stay, and postoperative complications.

Methods: A systematic search of PubMed, Embase, Medline, Cochrane Library, and Global Health was performed from inception to February 14, 2025. The search yielded 29 studies encompassing 141,042 patients. Eligible studies included adult patients undergoing shoulder arthroplasty in which at least one ERAS-related perioperative intervention was compared with standard care and reported outcomes related to pain, opioid consumption, length of stay, or complications. Study selection followed PRISMA guidelines, and qualitative synthesis was conducted in accordance with SWiM recommendations.

Results: Opioid-free and multimodal analgesic strategies consistently reduced severity of pain and amount of opioid consumption, with opioid-free pathways additionally demonstrating effective pain control. Continuous interscalene blocks (C-ISB) provided superior pain relief over single-shot interscalene blocks (SS-ISB) within 24 hours. Liposomal bupivacaine (LB) showed significant pain reduction, although comparisons with other techniques were mixed. Opioid consumption was significantly lower in the LB, C-ISB, and multimodal groups. Length of stay was notably reduced with opioid-sparing regimens. Complication rates were generally low, with some studies reporting higher rates with C-ISB.

Conclusion: This review found evidence that multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty. Techniques such as C-ISB, LB and multi-modal anaglesia minimise opioid use, and reduce hospital stay without increasing complications. These findings support an evolving standard of care prioritising patient safety and recovery while addressing opioid overuse.

Introduction: Rotator cuff tears (RCTs) are commonly repaired after failure of conservative management. Prior literature has demonstrated that racial disparities exist in surgical management of RCTs. There is limited literature addressing whether certain patient populations are less likely to receive cortisone injection. Our hypothesis is that minority groups are less likely to undergo a cortisone injection for the non-operative treatment of RCTs. Additionally, we hypothesize that minority patients are less likely to undergo surgical management of RCTs compared to non-Hispanic white patients.

Methods: The TriNetX database was queried to identify all patients aged 18-90 years who were diagnosed with rotator cuff disease based on M75.1, S43.42, S46 ICD 10 codes between January 1, 2010, and December 31, 2024. Patients were then stratified based on ethnic/racial identity. Using CPT codes 29827, 23410, 23412, 23420 with appropriate ICD codes for common co-morbidities, the rates of cortisone injection and rotator cuff repair were characterized in a five-year post-diagnostic period. Categorical and continuous variables were assessed using a Chi-squared and student t-testing, respectively. Propensity score matched analysis were employed to control for non-racial/ethnic demographic variables and medical co-morbidities. Statistical significance for all analyses was set at p <0.005.

Results: 1,406,127 patients with rotator cuff disease were included. When assessing the matched odds ratio of receiving a cortisone injection compared to non-Hispanic white populations, minorities were 24% less likely to receive a cortisone injection (95% CI 0.75-0.77, p < 0.0001). African Americans were 19% less likely to receive an injection (95% CI 0.8-0.82, p < 0.0001) and Asian/Pacific Islanders had a 58% reduced chance (95% CI 0.41-0.44, p < 0.0001). These trends also extended to Hispanic patients, (10% reduced chance with 95% C.I 0.89-0.92, p < 0.0001). Minorities were 26% less likely to undergo surgical repair compared to their non-Hispanic white counterparts (95% CI 0.73-0.75, p < 0.0001), African Americans were 34% less likely (95% CI 0.64-0.67, p < 0.0001), and Asian/Pacific Islanders were 40% less likely (95% CI 0.58-0.62, p < 0.0001) to undergo surgical repair.

Discussion: Our findings suggest that minority patients are less likely to receive a cortisone injection or undergo surgical management for RCTs irrespective of underlying co-morbidities. Further research is necessary to assess the reasons for such disparities and potential methods for addressing these healthcare inequities.

Level of evidence: Level III, Retrospective Cohort Comparison using Large Database, Prognosis Study.

Background: Tension band wiring (TBW) is a widely used technique for displaced olecranon fractures but carries a substantial risk of complications, often due to technical errors. Despite being a designated core competency in orthopedic curricula, no standardized, procedure-specific tool exists to assess technical performance in TBW. This study aimed to establish international expert consensus on assessment parameters for evaluating surgical competence in TBW of simple transverse olecranon fractures.

Methods: A modified four-round Delphi process was conducted with 98 orthopedic trauma surgeons, primarily AO faculty. In Round 1, panelists proposed key performance parameters and typical errors. Responses were analyzed and processed by a steering committee. In Round 2, 46 parameters were rated for importance using a 5-point Likert-like scale; parameters with mean scores ≥3.0 were retained. In Round 3, specific score ranges were determined for each bone and fracture model; these results are not presented in this study. In the final round, experts assigned scores (1-10) to each retained parameter to reflect its impact on procedural quality. Descriptive statistics were used, and Pearson's correlation coefficient assessed the relationship between importance ratings and scores.

Results: A total of 43 parameters were retained, covering fracture reduction (8 items), K-wire placement (14), cerclage wire configuration (18), and end-of-procedure verification (3). The highest scoring parameter was "achieving anatomical fracture reduction" (mean score: 9.7), followed by "placement of the cerclage wire in a figure-of-8 configuration" (9.4). A very strong correlation was observed between importance and final scores (r = 0.91, p < 0.001), indicating internal consistency.

Conclusions: This international consensus study defines a comprehensive set of assessment parameters for TBW of olecranon fractures. The tool supports both structured evaluation and high-specificity feedback-key drivers of skill acquisition in competency-based surgical training. It may be used directly in feedback settings or adapted for simulation platforms and structured curricula.

Level of evidence: Level V, Treatment Study, Delphi Process.

Introduction: Scapulopexy can effectively treat symptomatic scapulothoracic dyskinesis. In patients with preserved serratus anterior function, restoring scapular positioning without rib-based fixation may reduce surgical risks and rib osteolysis. This study introduces a modified technique - Serratus Anterior Plication and PEctoralis minor Release (SAPPER) - and reports its outcomes in patients with refractory scapular dyskinesis associated with neurological symptoms.

Materials and methods: Patients referred for treatment of symptomatic scapular dyskinesis were included if EMG revealed lower brachial plexus dysfunction without peripheral nerve injury and shoulder MRI excluded rotator cuff tears or instability. Patients were clinically evaluated at a minimum of 6 months postoperatively by two independent investigators. Post- to preoperative differences were evaluated and subgroup analysis was performed to identify effect of preoperative medical treatment.

Results: Forty patients were included, with preoperative symptoms lasting a median of 4 [3-6] years. Intraoperatively, the following lesions were identified: SLAP lesions (77.5%), rotator interval lesions (27.5%), and medial pulley lesions (70%). Constant Score, Subjective Shoulder Value, Numeric Rating Scale, and shoulder flexion significantly improved from baseline to final follow-up (p < 0.0001). All patients reported recovery of neurological symptoms. Preoperative use of nerve pain medications or corticosteroids did not significantly influence outcomes.

Conclusions: The SAPPER technique is a safe and effective modification of traditional scapulopexy. It enhances scapular positioning and serratus function without the need for rib-based fixation, potentially minimizing complications. This approach significantly improves pain, function, and mobility in patients with refractory scapular dyskinesis and associated neurogenic thoracic outlet syndrome.

Background: Rotator cuff (RC) repair often fails due to poor healing at the tendon-to-bone interface (TBI) and irreversible fatty infiltration (FI) of the muscle. GATA6 has emerged as a potential transcriptional regulator of tissue regeneration, but no therapeutic agents currently target this pathway.

Purpose: To evaluate the therapeutic potential of isotretinoin, a known GATA6 modulator, in enhancing TBI healing and reducing FI following RC repair in a rat model.

Level of evidence: Level Ⅴ, Controlled laboratory study.

Methods: An RC repair rat model was established using 12-week-old male Sprague-Dawley rats. In the isotretinoin group, ten rats received an oral dose of 7 mg/kg isotretinoin daily for six weeks following RC tendon transection, while the control group of ten rats received only 0.9% saline. All rats were euthanized six weeks post-surgery. FI in the supraspinatus tendon was assessed qualitatively and quantitatively. TBI healing was histologically evaluated using the Bonar score after general tissue staining. Additionally, a biomechanical assessment of TBI healing was conducted utilizing a universal testing machine.

Results: Isotretinoin treatment significantly upregulated Gata6 expression while downregulating Caveolin-1 and PPAR-γ, with no significant change in C/EBP-α expression. Activation of the PKA/CREB signaling pathway was confirmed by increased phosphorylation of PKA and CREB. Histological analysis demonstrated improved collagen organization and cellularity at the TBI. Biomechanical testing revealed greater tensile strength and stiffness in the isotretinoin group compared to controls. Fatty infiltration in the supraspinatus muscle was markedly reduced.

Conclusions: Isotretinoin promotes TBI healing and suppresses muscle-FI following RC repair, which is associated with activation of the GATA6-Caveolin-1-PKA/CREB signaling axis.

Clinical relevance: This study identifies isotretinoin as a promising pharmacologic strategy to enhance RC repair outcomes by targeting a novel molecular axis. Drug repurposing of isotretinoin may offer a translatable solution for reducing RC repair failure in clinical settings.

Background: While two-dimensional methods quantify glenohumeral relationships, they are unable to capture three-dimensional anatomy and define the geometric relationship of the humeral head in the registry of the glenoid. We hypothesize that a geometric relationship of the humeral head and the glenoid exists in the three-dimensional space defined by the relationship of the best-fit sphere of the humeral head relative to the best-fit sphere of the glenoid such that relative measurements will define the normal shoulder and the pathologic shoulder.

Methods: A retrospective cohort study was conducted using CT scans from 90 shoulders including 30 normal, 30 with glenohumeral osteoarthritis (GHOA) with Walch type A1 glenoids, and 30 with cuff tear arthropathy [CTA]). Scans were then analyzed using surgical planning software. Angular measurements were calculated including Horizontal Displacement Angle (HDA) and Vertical Displacement Angle (VDA) in the coronal plane, and subluxation angle and Relative Subluxation Axial Angle (RSAA) in the axial plane.

Results: In the coronal plane, the mean HDA was significantly higher in GHOA (73.6°) compared to normal (66.9°, P=0.003) and CTA (62.7°, P<0.01). Mean VDA was significantly elevated in CTA (54.7°) compared to normal (42.2°, P<0.01) and GHOA (41.0°, P<0.01). In the axial plane, mean subluxation angle did not significantly differ between normal (95.6°), GHOA (94.1°), and CTA (98.3°) shoulders. Similarly, the mean Relative Subluxation Axial Angle (RSAA) did not differ significantly across normal (87.6°), GHOA (90.0°), and CTA (89.9°) cohorts. However, normal shoulders demonstrated significantly less variance in both axial parameters compared to pathologic shoulders. The variance in the subluxation angle was significantly lower in normal shoulders compared to both GHOA (P=0.034) and CTA (P=0.032). Likewise, the variance in the RSAA was significantly lower in normal shoulders compared to both GHOA and CTA (P < 0.01).

Conclusion: Defined geometric relationships exist between the humeral head in the reference of the glenoid sphere. This study establishes a reliable method of using best-fit spheres of the glenoid and humeral head. The HDA and VDA in the coronal plane differentiate the normal shoulder from those with GHOA and CTA. The subluxation angle and the RSAA in the axial plane describe the glenohumeral relationship in both subluxation and relative subluxation. This method quantifies the expected relationship of the humeral head in the glenoid registry in the normal shoulder and characterizes predictable disruptions in disease, supporting improved understanding of premorbid anatomy and potential restoration of optimal shoulder function.

Background: Preoperative three-dimensional (3D) templating can improve surgical accuracy in anatomic-press-fit radial head arthroplasty (RHA). However, current imaging segmentation methods used for templating are time-consuming and prone to variability. This study aimed to train and validate an nnU-Net deep learning model to automate multiclass bone segmentation for RHA templating. We hypothesized that the nnU-Net model would achieve high accuracy in segmenting the upper extremity bones thereby supporting 3D bone templating in RHA.

Methods: A total of 93 upper extremity computed tomography (CT) scans met the eligibility criteria. Ground-truth segmentation was performed by a trained orthopedic surgeon and reviewed by a radiologist and an engineer to ensure accuracy. The nnU-Net model was trained and evaluated using the Dice Similarity Coefficient (DSC) and Hausdorff Distance to measure overlap and segmentation accuracy against manual segmentations. The 3D bone models derived from the nnU-Net model and manual segmentation were compared through Mean Surface Distance (MSD) and Root Mean Squared Error (RMSE) were determined to assess the surface variation between the bone models. The average time on segmenting each CT was compared.

Results: The nnU-Net achieved high segmentation accuracy with DSC values of 0.99 for the humerus, 0.98 for the ulna, and 0.96 and 0.95 for the cortical and non-cortical radii, respectively. The MSD remained below 0.2 mm for all bone classes. The mean RMSE values were consistent at 0.2 mm across all bones. Segmentation time averaged 3 min per scan compared to 78 min for manual segmentation, with consistent performance across gender, arm side, and CT slice thickness.

Discussion and conclusion: This deep learning model provides a fast and reliable solution for multiclass bone segmentation and demonstrates high accuracy in segmenting cortical and non-cortical regions, which are essential for RHA templating. The accuracy was consistent with clinical needs and fits below the sizing intervals of commercially available prostheses. This supports its potential utility for 3D preoperative planning in RHA, despite its inability to capture cartilage. This approach demonstrates clinical feasibility for improving efficiency and precision in templating radial head replacement surgery.

Background: Sleep disturbance is common among patients undergoing rotator cuff repair (RCR), yet the perioperative course of pain-related sleep disruption and the influence of behavioral factors are not well defined. Patients frequently ask perioperative sleep-related questions that lack evidence-based answers. This study aimed to characterize changes in sleep quality and sleeping patterns before and after RCR.

Methods: Adults undergoing primary elective RCR at a single academic center (November 2021-October 2024) were prospectively enrolled. Surveys were completed preoperatively and at 2, 6, 12, and 24 weeks postoperatively. The primary outcome was the Pain and Sleep Questionnaire 3-item index (PSQ-3; 0-300). Secondary measures included the Sleep Hygiene Index (SHI), sleep position, sling use, and 24-hour visual analog scale (VAS) for pain. Analyses used Chi-square/Fisher's tests, Kruskal-Wallis/ANOVA, and Spearman correlations, all with Bonferroni correction to evaluate sleep position changes and candidate predictors. Primary mixed-effects models used 2 weeks as the reference time and preoperative PSQ-3 and VAS scores as a covariate to identify predictors of postoperative PSQ-3 and VAS pain. Secondary models used preoperative scores as the reference to determine when outcomes improved beyond baseline.

Results: Sixty-three patients were enrolled; 50 (51 shoulders) completed final follow-up. Mean age was 59.9 ± 9.7 years, BMI 31.4 ± 6.0 kg/m², baseline SHI 10.2 ± 5.9. and PSQ-3 of 130.6 ± 99.1. At 2 weeks, back sleeping increased (85% from 39.2%, p < 0.001) and side sleeping declined (27.5% from 64.7%, p = 0.011). By 6 weeks, side sleeping partially recovered; by 24 weeks, sleep positions resembled baseline. Mixed-effects modeling demonstrated worse PSQ-3 at 2 weeks (β = +30.98, p = 0.039), followed by significant improvement below baseline by 6 weeks (β = -32.64, p = 0.030), 12 weeks (β = -56.20, p < 0.001), and 24 weeks (β = -92.55, p < 0.001). By 24 weeks, 55% of patients reported no nighttime sleep disturbance (PSQ-3 = 0). Nicotine use and preoperative side sleeping were independently associated with worse postoperative PSQ-3 and VAS scores. Additionally, Workers' Compensation status and higher preoperative pain predicted higher postoperative VAS.

Conclusions: Sleep after RCR worsens transiently but improves by 6 weeks, with continued improvement by 12 weeks and 24 weeks. Most patients resume preoperative sleep positions by 6 months. Nicotine use and preoperative side sleeping are predictors of increased pain-related awakenings during RCR recovery.

Background: Adhesive capsulitis, commonly known as frozen shoulder, is a fibro-inflammatory condition characterized by the gradual onset of pain and progressive restriction of shoulder motion, with evidence suggesting that endocrine factors may play a role in its pathogenesis. Despite biologic plausibility linking testosterone to capsular fibrosis, the relationship between endogenous androgen levels and adhesive capsulitis has not been thoroughly investigated. The purpose of this study is to assess the risk of developing adhesive capsulitis within 1 year, 2 years, and 5 years after their serum testosterone level lab draw.

Methods: A retrospective cohort study was conducted using the TriNetX research database to identify male patients aged 35 years and older who had testosterone lab levels between 2005 and 2025 and never had any surgical procedures on the shoulder. Patients were stratified into two cohorts based on serum testosterone levels: a low testosterone group (serum testosterone levels <300 ng/dL) and a normal to high-range group (serum testosterone levels 300-1000 ng/dL). Sub-analyses were performed based on excluding and including patients receiving testosterone replacement therapy. Risk ratios (RR), confidence intervals (CI), and p-values were calculated using Student's t-tests and chi-square tests, as appropriate.

Results: After propensity score matching, 301,219 patients were included in each testosterone cohort. Patients with normal-high testosterone levels had a significantly greater risk of adhesive capsulitis compared with those with low testosterone at 1 year (0.17% vs 0.14%, RR = 1.23, 95% CI 1.08-1.39, p = 0.002), 2 years (0.29% vs 0.25%, RR = 1.17, 95% CI 1.06-1.29, p = 0.002), and 5 years (0.54% vs 0.48%, RR = 1.12, 95% CI 1.05-1.21, p = 0.001) from their lab draw. When excluding men on testosterone replacement therapy (TRT), results remained consistent across all time points-1 year (0.15% vs 0.12%, RR = 1.23, 95% CI 1.03-1.47, p = 0.022), 2 years (0.26% vs 0.22%, RR = 1.17, 95% CI 1.03-1.34, p = 0.019), and 5 years (0.47% vs 0.42%, RR = 1.13, 95% CI 1.03-1.25, p = 0.013). Among patients on TRT, no significant differences were observed at 1 year (0.19% vs 0.16%, RR = 1.18, 95% CI 0.97-1.45, p = 0.106) or 2 years (0.35% vs 0.30%, RR = 1.15, 95% CI 0.99-1.34, p = 0.061), although risk was significantly elevated at 5 years (0.67% vs 0.59%, RR = 1.15, 95% CI 1.03-1.28, p = 0.010).

Conclusions: Normal-high endogenous testosterone levels (300-1000 ng/dl) were associated with an increased risk of adhesive capsulitis. These findings highlight the importance of considering hormonal status in adhesive capsulitis risk assessment, and prospective studies with direct hormone measurements are warranted to validate these associations.