Journal of Shoulder and Elbow Surgery最新文献

Background: Scapular dyskinesis is an alteration in scapular position and movement that disrupts glenohumeral kinematics. Among its causes, pectoralis minor retraction induces scapular protraction and internal rotation, altering shoulder biomechanics. Often asymptomatic, scapular dyskinesis may also cause pain and reduced joint mobility, compromising function. Initial management relies on targeted rehabilitation, which generally ensures recovery. However, when conservative treatment fails, surgery may be considered. This study evaluates the clinical outcomes of arthroscopic pectoralis minor tenotomy in patients with painful shoulder and scapular dyskinesis due to pectoralis minor retraction.

Methods: A retrospective monocentric study included patients operated on between 2020 and 2024 for painful shoulder syndrome associated with scapular dyskinesis secondary to excessive pectoralis minor tension. Patients undergoing concomitant or subsequent surgery on the same shoulder were excluded. We conducted a longitudinal intra-subject study comparing pre- and postoperative outcomes. Patients were assessed preoperatively and at their last follow-up for active range of motion, pain (VAS), Constant score, and Simple Shoulder Value (SSV). Complications were recorded.

Results: Thirty-seven patients met the entry criteria and were enrolled in the study with a mean follow-up 19.9 months (range, 6 to 44). All patients were women (mean age 43.8), with 49% reporting trauma and 57% practicing sports. Among the 37 patients, information on preoperative corticosteroid injections was missing for 2 patients. Of the remaining 35, 34 (97%) received at least one injection. Functional scores and pain improved significantly postoperatively. The Constant score increased from 55.3 to 73.27 (p < 0.001), the VAS decreased from 7.51 to 2.62 (p < 0.001), and the SSV rose from 46.75 to 74.73 (p < 0.001). Active elevation improved significantly from 128.38 degrees to 143.9 degrees (p = 0.013), while external and internal rotations showed no significant difference. Four cases of adhesive capsulitis were reported; three resolved with rehabilitation, while one patient retained stiffness in elevation at last follow-up.

Conclusion: When conservative treatment fails, arthroscopic tenotomy is an effective surgical option for patients with painful shoulder and scapular dyskinesis due to pectoralis minor contracture. This study demonstrates significant improvement in functional scores, pain, and anterior elevation range, while external and internal rotations remain unchanged. However, randomized studies with longer follow-up are needed to confirm result durability.

Background: Online physician review websites are being increasingly utilized by patients when choosing their surgeon. Although most reviews are positive, extremely negative reviews can significantly compromise a physician's online reputation. The purpose of this study was to analyze factors that contribute to negative reviews for orthopedic shoulder surgeons.

Methods: One hundred orthopedic shoulder surgeons were randomly selected from the "find a doctor" tool on the American Shoulder and Elbow Surgeons (ASES) website. A search was performed for all reviews listed under the selected surgeons on the following sources: Google Reviews, Healthgrades, Vitals, and Yelp. For each website, a surgeon's average rating, total number of reviews, and number of 1-star reviews was recorded. One-star reviews with comments were then reviewed to categorize the complaint(s), determine whether they referenced a clinical or non-clinical issue, and determine whether the complaint referenced a surgical or non-surgical episode of care. Categorical variables were analyzed using a chi-square test.

Results: A total of 7616 reviews were analyzed and 722 (9.5%) were identified as one-star. After application or exclusion criteria, 329 single-star reviews with 837 total complaints were included for analysis. Of the 329 single-star reviews, 237 (72.0%) were from non-surgical patients and 92 (28.0%) were from surgically treated patients. Non-surgical patients had a significantly higher rate of total complaints per each review than surgical patients (1.76 vs. 0.78, p=0.034). The most common complaints were regarding bedside manner (160 complaints), insufficient time with the provider (82 complaints), uncontrolled pain (73 complaints), and rude staff (72 complaints). Poor surgical outcomes were noted in terms of complication (66 complaints), reoperation (26 complaints) and readmissions (2 complaints).

Conclusion: For orthopedic shoulder surgeons, the most common complaints are non-clinical and include poor bedside manner, wait time, and insufficient time with the provider. Relatively few negative reviews referenced objective measures of healthcare quality such as complications or surgical outcomes. These results provide a deeper understanding of the reasons for patient dissatisfaction in shoulder surgery, which can be considered when striving to maintain a favorable online reputation.

Background: Dislocation of the sternoclavicular joint (SCJ) is the most common SCJ condition reported to be managed surgically. However, primary SCJ osteoarthritis (OA) is substantially more common. There are few reports in the literature on the outcome of surgical management of primary SCJ OA. We have successfully adopted sternal docking allograft reconstruction for SCJ instability and have now expanded the technique to patients with primary SCJ OA. This is our first report on the outcome of the sternal docking technique specifically for patients with primary SCJ OA.

Methods: Between 2012 and 2023, one fellowship trained shoulder surgeon consecutively performed surgical resection of the medial end of the clavicle and semitendinosus allograft ligament reconstruction using the sternal docking technique in 29 patients with SCJ OA. Seven patients were lost to follow-up (one declined participation, and 6 could not be contacted). The remaining 22 patients form the study cohort. There were 17 females and 5 males with a mean age of 49 ± 11 years at the time of surgery (range, 32-71 years). Their electronic medical records were reviewed to collect demographics, pain using a visual analog scale (VAS), complications and reoperations. Patients were also contacted at most recent follow-up to record VAS for pain, subjective shoulder value and American Shoulder and Elbow Surgeons shoulder score. The procedure was considered successful when patients experienced pain relief and did not develop any complications or required reoperation. The mean length of follow-up was 4 ± 3 (range, 1-12) years.

Results: SCJ reconstruction was associated with significantly improved pain relief and overall shoulder function. Preoperatively, the mean VAS was 6 ± 1.5 (range, 4-9) points. At the most recent follow-up, the mean pain score was 0.5 ± 1.5 (range, 0-6) points, with median scores of 90 (interquartile range: 60-98) for subjective shoulder value and 80 (interquartile range: 70-81) points for American Shoulder and Elbow Surgeons. Twenty-one of 22 patients reported high satisfaction rates with their postoperative outcomes, with one patient endorsing partial satisfaction due to limited shoulder range of motion. Persistent peri-incisional numbness was reported by one patient. There were no re-operations at the time of the most recent follow-up.

Conclusion: Medial clavicle resection and ligament reconstruction seems to be associated with good overall outcomes, a high degree of patient satisfaction, and a low reoperation rate in patients with primary SCJ OA.

Background: Frozen shoulder (FS) is a common fibroinflammatory disorder of the glenohumeral joint capsule, characterized by persistent pain and progressive restriction of range of motion. The fibroblast-to-myofibroblast transition is a central pathological event driving capsular fibrosis, yet the molecular regulators underlying this process remain poorly defined. Protein tyrosine phosphatase 1B (PTP1B) has emerged as a key regulator of fibrosis in multiple organs, but its role in musculoskeletal fibrosis, particularly in FS, has not been investigated.

Methods: In this prospective case-control study, glenohumeral capsular tissues were collected from 21 patients with idiopathic FS and 21 matched controls with rotator cuff tears during arthroscopic surgery. Tissue samples were evaluated using histology, immunofluorescence, and Western blotting. Clinical function was assessed preoperatively using the American Shoulder and Elbow Surgeons and Constant-Murley scores.

Results: FS patients exhibited significantly worse functional outcomes across all domains, including pain, range of motion, and activities of daily living. Histopathological analysis revealed pronounced fibroblast proliferation, dense collagen deposition, hypervascularity, and perivascular adipocyte accumulation in FS capsules compared to controls. Critically, PTP1B expression was significantly upregulated in FS tissues. PTP1B immunoreactivity was prominently localized to α-SMA⁺ myofibroblasts. Co-localization studies confirmed an enrichment of PTP1B within activated myofibroblasts, indicating its specific involvement in fibrotic transdifferentiation.

Conclusion: This study identified PTP1B as a novel biomarker that was upregulated in FS and was specifically associated with myofibroblast activation and capsular fibrosis. These findings position PTP1B as a promising therapeutic target for mitigating fibrosis and functional impairment in FS.

Background: Glenohumeral internal rotation deficit (GIRD) has been associated to shoulder injuries in overhead athletes. The glenohumeral posterior capsule stretching techniques, such as the sleeper stretch and cross-body stretch, are used to improve range of motion (ROM) and reduce pain. However, there are no studies comparing these techniques in symptomatic overhead athletes with GIRD. This study aimed to compare the effects of sleeper stretch and cross-body stretch on shoulder pain and shoulder ROM in overhead athletes with GIRD and shoulder pain.

Methods: This is a randomized, double-blind, controlled clinical trial. Overhead athletes aged 18 to 40 years who were actively engaged in their sport at a competitive level, with shoulder pain and GIRD were randomly allocated into 2 groups: the Cross-body Stretch Group (CBG), and the Sleeper Stretch Group (SSG). Both groups received interventions 3 times a week for four weeks. The primary outcomes were shoulder pain intensity and glenohumeral internal rotation range of motion. Secondary outcomes included affective response to interventions, adherence, and reported co-interventions.

Results: Thirty-five athletes participated in the study, with 17 allocated to the CBG and 18 to the SSG. No significant differences were observed between groups for shoulder pain and GIRD. SSG showed a decrease of -2.17 in pain intensity (95% CI = -3.13 to -1.21), while CBG reduced pain by -1.54 (95% CI = -2.53 to -0.55). Additionally, GIRD was attenuated in both treatment groups, with the SSG showing a reduction of -14.69 (95% CI = -19.48 to -9.89) and the CBG showing a reduction of -14.77 (95% CI = -19.70 to -9.84).

Discussion: The results of this study suggest that both the sleeper stretch and the cross-body stretch significantly reduced pain and improved glenohumeral internal rotation in overhead athletes with shoulder pain and GIRD after four weeks, with no significant difference between them. Affective responses, adherence, and the occurrence of co-interventions were similar, indicating good tolerance and safety of both techniques. These findings provide clinical support for the use of either strategy in the conservative management of these athletes. Future research should focus on the long-term effects and the investigation of multimodal treatment strategies.

Conclusion: Both sleeper stretch and cross-body stretch showed similar effects in reducing pain and glenohumeral internal rotation deficit.

Background: Stemless anatomic total shoulder arthroplasty (aTSA) has gained considerable traction as an alternative to traditional stemmed implants for the management of glenohumeral arthritis, particularly for patients where bone preservation is a priority. However, some surgeons remain cautious employing a lesser tuberosity osteotomy (LTO) when using stemless implants due to concerns of metaphyseal fixation and implant stability. This study evaluates clinical, radiographic, and functional outcomes of a novel transosseous suture-cable repair for LTO in stemless aTSA.

Methods: A retrospective review identified 55 stemless aTSAs performed in fifty-two patients by a single surgeon from September 2022 to September 2024. Patients ≥18 years old who underwent stemless aTSA with LTO were included, while revisions or patients with prior metal hardware were excluded. All patients underwent a transosseous suture-cable LTO repair anchored to the bicipital groove. Patient charts were reviewed to assess clinical, radiographic, and patient-reported outcomes. Radiographic LTO healing was classified as fully healed, partially healed, or not healed, and reoperation and implant-related complications were assessed. Functional outcomes included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Pain was evaluated using the visual analog scale (VAS). Range of motion (ROM) was measured for abduction, forward flexion, external rotation, and internal rotation (IR) preoperatively and at final follow-up.

Results: At the latest follow-up, 87.3% (n=48) of LTOs demonstrated full bony healing, 10.9% (n=6) were partially healed, and 1.8% (n=1) did not heal. Follow-up time for this study was 26.7 ± 8.3 months. No implant loosening or malposition was observed. There were no reoperations. Postoperatively, glenohumeral abduction improved from 58.6° ± 28.7° to 104.5° ± 49.8° (p<0.001), forward flexion from 110.0° ± 27.0° to 149.3° ± 33.6° (p<0.001), and external rotation from 17.8° ± 18.3° to 50.4° ± 16.4° (p<0.001). Of the patients with "poor" IR, approximately 22% (7/32) improved to "acceptable" or "normal" IR (p=0.027). Mean postoperative ASES and SANE scores were 94.0 ± 7.4 and 88.2 ± 9.2, respectively, with a mean VAS pain score of 0.1 ± 0.6.

Conclusion: Transosseous suture-cable fixation for LTO in stemless aTSA achieves high healing rates, excellent functional outcomes, and minimal complications. Patients showed significant improvements in pain, motion, and internal rotation, supporting the role of LTO in preserving subscapularis function.

Background: Lower trapezius transfer has been demonstrated to restore external rotation in patients with brachial plexus palsies. In certain cases of cuff tear arthropathy, patients exhibit preserved forward elevation but lack active external rotation. This study evaluates the clinical outcomes of lower trapezius transfer, augmented with a semitendinosus tendon autograft and anchored to the infraspinatus insertion using an arthroscopically assisted technique and, to determine whether pain relief and functional improvement are maintained at minimum 7.5-year follow-up compared to the 11-month follow-up.

Methods: Between March 2014 and February 2024, 23 patients (15 men, 8 women; mean age 55 years, range 32-75) underwent surgical reconstruction of irreparable posterosuperior rotator cuff tears involving the supraspinatus, infraspinatus, and non-functional teres minor. A 6 cm horizontal incision was made just inferior to the scapular spine to harvest the lower trapezius tendon, which was augmented with the semitendinosus tendon. The extended tendon was fixed laterally to the greater tuberosity at the infraspinatus insertion via arthroscopy. The proximal stump was fixed medially into the lower trapezius muscle belly with the arm in maximum external rotation. Clinical outcomes were assessed using the Constant-Murley score, Visual Analog Scale (VAS), active Range of Motion and, Subjective Shoulder Value (SSV).

Results: Twenty-three patients were included, with a first mean follow-up of 11 months (range: 5-19 months). Twelve patients had a second mean follow-up of nine years and four months (range: 92-128 months). At the first follow-up, the average increase in external rotation in adduction was 40°, and 70° at ninety degrees of abduction (p<.001). The Constant-Murley score improved from 46 to 82 points (p<.001), the SSV increased from 40% to 67% (p<.001), and VAS pain decreased from 5 to 1 (p<.001). Both the lag sign and Hornblower sign were negative post-transfer. The subgroup with a follow-up of at least 7.5 years showed slight improvements in functional outcomes, including active range of motion (aROM), Constant score, VAS, and SSV, but no statistically significant differences compared to the 11-month follow-up. Complications included two hematomas, only one requiring revision due to infection.

Conclusion: Lower trapezius transfer is an effective treatment for irreparable posterosuperior rotator cuff tears with external rotation deficiency. This procedure results in significant improvement in pain and active external rotation in adduction and at 90° of abduction. Functional results remain stable over a long-term follow-up of minimum 7.5 years.

Background: Reverse shoulder arthroplasty (rTSA) and anatomic total shoulder arthroplasty (aTSA) treat glenohumeral osteoarthritis (GHOA) with comparable early outcomes. Given increasing utilization of rTSA for GHOA, we sought to evaluate outcomes of rTSA and aTSA for GHOA at early and midterm follow-up.

Methods: A retrospective propensity-matched cohort study of patients undergoing aTSA and rTSA for GHOA with early and midterm follow-up was performed. Matching included age, sex, body mass index, preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative forward elevation, and Walch glenoid morphology. Baseline patient characteristics, range of motion, ASES, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain scores, complications and revision rTSAs/aTSAs were assessed at early and midterm follow-up.

Results: One hundred twenty-two patients (61 per group) were included with early and midterm follow-up. Baseline characteristics, comorbidities, preoperative ASES, SANE, VAS pain scores, and range of motion were similar (P > .05). Both groups showed significant improvements in ASES, SANE, and VAS scores at both time points (P < .001); >96% achieved minimal clinically important difference for ASES. While more aTSA patients met substantial clinical benefit early (95.1% vs. 80.3%, P = .027); there was no statistically significant difference at midterm follow-up (P = .074). aTSA patients had better early internal (5.0 vs. 3.3, P < .001) and external rotation (63.0° vs. 57.0°, P = .036), with no difference at midterm follow-up. Complication rates were similar; however, aTSA had more revisions and radiolucencies.

Conclusion: aTSA and rTSA yield similar clinical outcomes for GHOA at early and midterm follow-up. Early differences in substantial clinical benefit, internal, and external rotation with aTSA diminished by midterm follow-up. Complication rates were similar between the cohorts. One patient in the aTSA group was revised to rTSA and no patients with primary rTSA required revision. While rTSA and aTSA result in excellent clinical outcomes, longer follow-up is needed to determine durability.

Background: Intra-articular corticosteroids are widely used for adhesive capsulitis, but alternatives are needed for patients with contraindications. Hyaluronic acid (HA) and ketorolac have demonstrated individual benefits; however, evidence regarding their combined use remains limited. This study aimed to evaluate and compare the clinical outcomes of intra-articular injection of combined moderate -molecular-weight HA and ketorolac versus ketorolac alone in patients with adhesive capsulitis, focusing on shoulder function, pain reduction, and improvement in range of motion (ROM). We hypothesized that the HA + ketorolac combination would provide superior improvement in function, pain, and ROM compared with ketorolac alone.

Methods: In this randomized, double-blind controlled trial, 56 patients were allocated to HA + ketorolac (n = 28) or ketorolac alone (n = 28). Each received a single intra-articular injection followed by standardized rehabilitation. Outcomes included the Thai Shoulder Pain and Disability Index (Thai SPADI), visual analog scale (VAS), passive ROM, and analgesic use, assessed at baseline and at 2, 6, 12, and 24 weeks.

Results: Both groups improved significantly in SPADI and VAS over time, with no between-group differences at any visit (24-week SPADI: 9.8 ± 12.5 vs 12.1 ± 17.8; P = .932; VAS: 0.8 ± 1.1 vs 1.4 ± 2.2; P = .501). The HA + ketorolac group demonstrated greater recovery in specific ROM planes, including significantly better external rotation at 24 weeks (mean difference 9°, 95% confidence interval [CI] 0 -18; P = .039) and greater improvement in adduction at both 2 weeks (mean difference 5°, 95% CI 0 -10; P = .039) and 24 weeks (mean difference 8°, 95% CI 2 -14; P = .012). Analgesic consumption was comparable between groups, and no serious adverse events were reported.

Conclusion: Both HA + ketorolac and ketorolac alone significantly improved pain and function in adhesive capsulitis. Combination therapy provided small but statistically significant advantages in recovery of external rotation and adduction. Both treatments represent reasonable options, particularly for patients in whom corticosteroids are contraindicated.