Journal of Shoulder and Elbow Surgery最新文献

Background: This study aimed to investigate the biomechanical effect of subacromial spacer (physically depressing the humeral head) and magnets (concavity compression restoration) in massive rotator cuff tear (MRCT). We assessed the influence on superior stability by employing the subacromial spacer (the spacer effect) and magnets (concavity compression effect) separately or in combination in MRCT.

Methods: A customized shoulder testing system tested seven fresh-frozen cadaveric shoulders. The prosthesis implantation was performed prior to all experimental conditions. Each specimen underwent the following conditions: (1) intact rotator cuff without magnets, (2) MRCT without magnets; (3) MRCT with magnets, (4) MRCT with a spacer, (5) MRCT with magnets and a spacer. For each condition, superior migration and subacromial contact pressure were measured at 0°, 30°, and 60° abduction angles.

Results: Condition 2 resulted in a significant increase in both superior migration and subacromial contact pressure compared to condition 1. Condition 3 exhibited no significant differences in both parameters compared to condition 2 (p > 0.05). In condition 4, both parameters significantly decreased (p < 0.05), and in condition 5, levels were restored to those of the intact condition with no significant difference. Neither parameter between conditions 4 and 5 differed significantly (p > 0.05).

Conclusion: The combination of the static (spacer) and dynamic (concavity compression) effect demonstrated restoration of superior migration and subacromial contact pressure after MRCT to levels comparable to the intact condition. However, the subacromial spacer alone also showed positive results, and the influence of concavity compression was minimal. To achieve superior stability in MRCT, the static role (spacer) as superior restraint is more critical for rotator cuff function than the dynamic role (concavity compression).

Background: Simultaneous rotator interval release is not classically performed during arthroscopic rotator cuff repair (RCR). However, concurrent rotator interval release has been anecdotally reported to facilitate less propensity for postoperative shoulder stiffness. The purpose of our investigation was to compare outcomes of pain and stiffness among patients who underwent arthroscopic rotator cuff repair with and without concomitant rotator interval release.

Methods: A single-blinded, randomized controlled trial was conducted between September 2018 and April 2021. Outcomes including Visual Analog Scale (VAS), narcotic usage, American Shoulder and Elbow Surgeons (ASES) Shoulder Score, active forward flexion (aFF), and active external rotation (aER) range of motion measurements were collected at 4-6 weeks, 3 months, 6 months, and at most recent follow-up postoperatively.

Results: 83 patients were prospectively enrolled and randomized into RCR with rotator interval versus without interval release. Postoperative temporal association between VAS score, ASES score, and average narcotic pain tablet use did not depend on group assignment (P = 0.990, P = 0.760, and P = 0.700, respectively). Similarly, the association between time point and aFF and aER range of motion did not depend on group assignment (P = 0.300 and P = 0.630, respectively).

Conclusion: Arthroscopic rotator interval release during rotator cuff repair showed no statistically significant difference in short-term or long-term postoperative pain or range of motion outcomes compared to control.

Background: The purpose of this study was to evaluate the short-term functional outcomes, structural healing and neuromuscular activity after arthroscopic assisted lower trapezius transfer for irreparable posterior superior rotator cuff tears.

Methods: All patients who underwent arthroscopic assisted lower trapezius tendon transfer for an irreparable posterior superior rotator cuff tear between 2017-2021 by two surgeons with a minimum of 2 year follow-up were identified. Functional outcome scores (American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) for pain), range of motion, shoulder strength, magnetic resonance imaging (MRI) to assess transfer healing and needle electromyographic (EMG) examination to assess lower trapezius muscle activity were performed at a minimum of two-years postoperatively. Contralateral nonoperative lower trapezius muscle activity was assessed by EMG. Grafts were defined as completely healed if anatomic graft healing occurred, partial healing if some graft was healed to the proximal humerus and unhealed if no graft was attached to the proximal humerus on postoperative MRI.

Results: Twenty-four eligible patients (25 shoulders) were identified through chart review. Mean age and follow-up were 54.9±9.5 and 2.9±1.7 years, respectively. Overall, 72% (18/25) clinical follow-up was obtained. All functional outcomes including ASES (preoperative, 48.8±19.6; postoperative, 80.9±15.4; p<0.001), VAS pain (4.9±2.3; 1.4±1.5; p<0.001), and active forward flexion (110°±53.2; 141.7±40.4°; p=0.024) statistically significantly improved. Twelve shoulders (48%) presented for EMG follow-up. All twelve patients demonstrated EMG activity of the lower trapezius in forward elevation, external rotation at the side, and external rotation at 90° of abduction, which was symmetric to the contralateral shoulder. Fifteen shoulders (60%) were available for MRI follow-up. Thirteen (87%) patients demonstrated complete or partial healing of the allograft to the greater tuberosity, while 2 (13%) demonstrated a complete tear of the graft.

Conclusions: Arthroscopic assisted lower trapezius transfer demonstrates improved functional outcomes two-years postoperatively. Complete re-tear of the transfer is relatively uncommon (13%). The lower trapezius fired in phase in forward flexion, external rotation at the side, and external rotation in 90° of abduction in all patients that underwent EMG testing, which was consistent with the firing pattern of the contralateral normal lower trapezius muscle. These results may support the theory that active function of the muscle transfer itself, as opposed to a tenodesis effect, is a potential mechanism by which this procedure improves shoulder function as it consistently fires in phase.

Background: There is no evidence on which functional levels have to be recovered to return to the preinjury sport at preinjury level, i.e. successful RTS, after open Latarjet procedure. Therefore, this study aimed to identify whether RTS criteria assessed at 4.5 months postoperatively predict successful RTS at 1 year after open Latarjet procedure.

Methods: All patients who underwent an open Latarjet procedure between August 2018 and July 2021 were eligible. At 4.5 months postoperatively, patients completed the Shoulder Instability-Return to Sport after Injury questionnaire, and performed unilaterally with each side maximal isometric strength in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test. They answered RTS inquiry at 12 months postoperatively. Logistic regressions were applied to assess the ability of ratios based on operated-nonoperated ratios, or on dominant-nondominant ratios, to predict successful RTS.

Results: Among 126 eligible patients, 110 answered the RTS inquiry; 21 were excluded, 49 patients were included in the successful RTS group, and 40 in the unsuccessful RTS. No ratios based on operated-nonoperated ratios were prognostic factors for successful RTS. Despite a low precision of the model (area under the ROC curve = 0.64), dominant-nondominant ratios in internal rotation strength (Odd-Ratio = 0.98; p=0.02), balance between external and internal rotator strength at the operated shoulder (OR = 1.03; p=0.02) and muscular endurance ability (OR = 1.03; p=0.04) were found prognostic factors for successful RTS.

Conclusion: The findings challenge the ability of criteria expressing operated shoulder functions with reference to those of the contralateral one in predicting a successful return to sport. They suggest that, when assessed 4.5 months postoperatively, the balance of function between dominant and nondominant shoulders in reference to those of healthy athletes would be better predictors of returning to preinjury sport at the preinjury level. This study highlights that clinicians and sport supervisors may place particular care on recovery in dominant-nondominant balance in maximal internal rotation strength and in upper extremities strength endurance to enhance the likelihood to return to sport successfully for their athletes who underwent anterior shoulder stabilization surgery by open Latarjet procedure.

Background: The constraint of the polyethylene liner in reverse total shoulder arthroplasty (rTSA) can affect glenohumeral joint stability. However, its influence on glenohumeral range of motion (ROM) remains unclear. Therefore, it was the objective of this study to determine the effect of sequentially increasing polyethylene liner constraint on impingement-free ROM following rTSA. Additionally, these sequentially increasing constraint designs were evaluated with various humeral neck shaft angles (NSAs), glenosphere diameters, and a new variable termed the polyethylene rim width.

Methods: Twenty upper extremity cadavers were computed tomography scanned and manually segmented to developed three-dimensional models of the scapula and humerus. Each model was then virtually implanted with a generic rTSA implant. Nine different polyethylene constraint ratios (defined as the ratio between the polyethylene depth and polyethylene radius; with values ranging from 0.35-0.75 in 0.05 increments) were assessed, along with three NSAs (135°, 145°, and 155°), three glenosphere diameters (36mm, 39mm, and 42mm), and four polyethylene rim widths (1mm, 2mm, 3mm, and 4mm). This resulted in 108 different polyethylene designs and 324 different rTSA designs. All virtually implanted bone models were imported as rigid bodies into a custom motion software, in which six standard motions (abduction, adduction, forward elevation, extension, internal rotation, and external rotation) were conducted, followed by the assessment of global circumduction ROM. Impingement during each motion was automatically detected. The maximum impingement-free ROM for each implant configuration and motion pathway were then quantified and statistically assessed.

Results: Polyethylene constraint, polyethylene rim width, NSA, and glenosphere diameter were all found to significantly affect impingement-free ROM for all motions simulated (P<0.001). Increases in polyethylene constraint and rim width were found to significantly reduce impingement-free ROM (P<0.001). A 135° NSA with a 42mm glenosphere combination were found to maximize ROM during extension, adduction, internal rotation, external rotation, and global circumduction motion, while a 155° NSA with a 36mm glenosphere combination resulted in optimized abduction and forward elevation ROM.

Discussion: Increases in polyethylene constraint were found to significantly reduce impingement-free ROM for all motions evaluated. However, polyethylene constraint had the greatest impact on glenohumeral extension, adduction, internal rotation, external rotation, and global circumduction. Polyethylene rim width was also found to significantly affect impingement-free ROM for all motions. Further study is needed to determine the optimal value of polyethylene liner constraint in rTSA due to its impact on rTSA biomechanics, joint stability and ROM.

Introduction: Randomized controlled trials (RCTs) have assessed a range of treatments for shoulder adhesive capsulitis (AC), with conflicting results over the most clinically beneficial options. This study used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate statistical fragility of the outcomes reported in RCTs assessing the efficacy of shoulder AC treatments.

Methods: PubMed and Embase were systematically searched for RCTs from January 1, 2004, to May 1, 2024 that assessed shoulder AC treatments. We quantified FI and rFI, which represent the amount of outcome event reversals necessary to change statistical significance for significant and non-significant findings, respectively. Subanalyses were performed for outcomes relating to clinical efficacy, patient satisfaction, pain, and adverse events. The FQ was determined by dividing the FI by the study sample size.

Results: Of 468 articles screened, there were a total of 38 RCTs analyzed that yielded 67 outcomes of interest. Across the 67 outcomes, the median FI was 3 (IQR [Interquartile Range] 2-6) and the median FQ was 0.075 (IQR 0.034-0.100). The 17 statistically significant outcomes had a median FI of 2 (IQR 1-4) and a median FQ of 0.050 (IQR 0.018-0.091). The remaining 50 outcomes were statistically nonsignificant, with a median FI of 4 (IQR 2-6) and a median FQ of 0.079 (IQR 0.037-0.102). Notably, in 40.3% of all outcomes, loss-to-follow-up was greater or equal to the outcome's respective FI or rFI. The most fragile outcomes were related to patient satisfaction (FI 2) and adverse events (FI 2.5).

Conclusion: The outcomes of interest regarding treatments for adhesive capsulitis from RCTs are statistically fragile, most notably significant outcomes and those pertaining to patient satisfaction. RCT results surrounding adhesive capsulitis treatments remain inconclusive; thus, combining p-values with both FI and FQ metrics may improve the interpretation of clinical findings regarding treatment modalities for adhesive capsulitis. Future clinical RCTs may reduce outcome fragility by improving follow-up rates and increasing patient sample sizes.

Background: Sternoclavicular joint (SCJ) osteoarthritis is rarely treated surgically, and the available published manuscripts are limited to small patient series. The aims of this systematic review were to identify the surgical treatment options for osteoarthritis of the SCJ, describe the quality of the available literature, analyze the outcome and complications and compare open versus arthroscopic surgery.

Methods: Literature was searched in PubMed, MEDLINE and Embase. Single case reports and studies that did not include surgical management were excluded. Data of interest included study year, sample size, diagnosis, sex, age, demographics, clinical data, type of surgical management, follow-up periods, outcomes and complications related to the surgical treatment.

Results: Eight articles on series of patients met the inclusion criteria and included 107 patients. Mean patient age was 48.2 years (range 17-72). 68% of patients were female and 32% male. The most commonly described treatment option was arthroscopic resection of the medial clavicle end (56%). Revision surgery was performed in 3 cases; 2 following trauma and 1 for persistent pain. The mean follow-up period was 45.4 months (range 28-80). Scores from patient reported outcome measures (Rockwood-, Constant- and DASH-questionnaires) and VAS pain scores all improved significantly from pre- to postoperatively. Four studies with 32 patients reported the overall subjective patient outcome with 84 % reaching excellent or good. There were no randomized controlled trials and no comparative cohorts. Arthroscopic surgery was only reported by one center, and this may induce risk of bias. It was not possible to compare outcomes following open and arthroscopic surgery.

Conclusion: Based on this systematic review, surgical treatment of SCJ osteoarthritis is a safe procedure which offers good pain reduction and a high rate of satisfaction. It is not possible from literature to conclude whether open or arthroscopic surgery is preferable.

Introduction: Subacromial balloon spacers are implants used for the treatment of irreparable rotator cuff tears. Many studies on subacromial balloon spacers use industry funding and existing literature has shown that industry funding can impact reported outcomes in research. This study aims to evaluate the outcomes of industry-funded balloon spacer studies. We hypothesized that industry-funded studies are more likely to report positive results than studies without funding.

Methods: PubMed, Scopus, and Embase were searched using the term "balloon spacer" from January 1, 2000, to the present. Inclusion criteria were (1) a study on subacromial balloon spacers with (2) funding or conflict of interest (COI) explicitly documented. Outcomes of studies were categorized into "positive" if the null hypothesis was rejected or the outcomes favored the implant, "neutral" if the null hypothesis was confirmed, or "negative" if the result did not favor the implant. Funding type was grouped by "no funding" or "industry funding", studies with other funding types such as specialty society or National Institute of Health. Agreement between two reviewers in categorization of study outcome was analyzed using Cohen's kappa. Statistical analyses were conducted using Fisher exact tests. The level of significance was set at α = 0.05 with a Bonferroni correction of p < 0.0125.

Results: Twenty studies were included for analysis; 9 (45 %) were industry-funded, 8 (40%) received no funding, and 3 (15%) received other funding. Of the 9 industry-funded studies, 8 (88.9%) reported "positive" outcomes and 1 (11.1%) reported a "neutral" outcome. Of the 8 non-funded studies, 4 (50%) reported "positive" outcomes, 2 (25%) reported "negative" outcomes, and 2 (25%) reported "neutral" outcomes. For studies with other funding, 1 (33.3%) was "positive", 1 (33.3%) was "negative", and 1 (33.3%) was "neutral." Cohen's kappa of 0.806 indicated substantial agreement. By Fisher exact test, industry-funded studies were significantly more likely to report "positive" outcomes than non-funded studies (p=0.0105) but not more than studies with other funding (p=0.6000).

Conclusion: Industry funding in studies on subacromial balloon spacers significantly increases the chance of the study reporting a "positive" outcome compared with non-funded studies. Clinicians using published literature to direct the use of subacromial balloon spacers in their practice should be wary of how study funding might impact their reported outcomes.

Background: While anatomic total shoulder arthroplasty (aTSA) is standard of care in older patients with an intact rotator cuff undergoing shoulder arthroplasty for osteoarthritis (OA), rheumatoid arthritis (RA), late post-traumatic sequelae (LPTS) or avascular necrosis (AVN), superiority of aTSA versus shoulder hemiarthroplasty (HA) remains controversial in younger patients. This study aimed to compare these two procedures in patients under 60 years regarding 1) overall and diagnosis specific revision rates, and 2) overall one-year change in pain and function.

Methods: A retrospective cohort study was performed with data from the Dutch Arthroplasty Register (LROI) from 2014-2022. All patients with OA, RA, LPTS or AVN under 60 years undergoing HA or aTSA were included. Cox proportional hazards regression analysis was performed to compare the incidence of revision in these nine years, adjusting for diagnosis, Walch classification and year of surgery. Also, the one-year postoperative change on the numeric rating scale for pain during activity (NRS, range 0-10) and the Oxford Shoulder Score (OSS, range 0-48) were compared between these two procedures using multivariate linear regression analysis. Multiple testing was adjusted for as proposed by Benjamini and Hochberg.

Results: In total, 521 HAs and 1056 aTSAs were included (median age 54.0 years, 73.6% OA, 4.4% RA, 12.0% LPTS and 10.0% AVN). The overall unadjusted 8-year revision rates were 21.1% (95% CI 16.9-26.4%) and 11.3% (95% CI 8.8-14.5%) in the HA and aTSA group, respectively. In the total study population, HAs had a 1.77 (95% CI 1.24-2.53) times higher hazard on revision after adjustment for potential confounders. In the subgroup of OA or RA, the hazard ratio was 2.21 (95% CI 1.47-3.34) in favor of aTSA, and in the subgroup of LPTS or AVN, this ratio was 1.13 (95% CI 0.59-2.18). In the whole study population, 16.5% of patients provided PROM data, and while there was no statistically significant difference for the adjusted one-year change on the NRS between the groups, the OSS showed a 5.0 (95% CI 0.5-9.5) points greater improvement in the aTSA group.

Conclusion: In younger patients with an intact rotator cuff, aTSA is superior to HA regarding medium-term revision rates when performed for OA or RA, whereas revision rates are comparable in case of LPTS or AVN. Also, while the survey response rate was limited, overall patient-reported shoulder function may undergo a relatively greater one-year improvement after aTSA than after HA.

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.