Journal of Shoulder and Elbow Surgery最新文献

Background: Small, isolated coronoid fractures involving less than one-third of the coronoid height are often underestimated on plain radiographs due to minimal displacement and preserved joint congruity. However, these fractures can be associated with significant soft tissue injuries, leading to occult elbow instability. This study aimed to investigate the mechanisms and characteristics of isolated small coronoid fractures and to analyze their three-dimensional (3D) morphology using computed tomography (CT)-based modeling.

Methods: We retrospectively reviewed 27 cases of isolated, noncomminuted coronoid fractures involving less than one-third of the coronoid height. Fractures were classified using the O'Driscoll and Adams systems. Injury mechanisms, associated soft tissue injuries, and joint instability were evaluated using radiographs, CT, magnetic resonance imaging, and operative findings. 3D CT modeling was used to analyze fracture morphology, including fragment size, orientation, and anatomical involvement.

Results: Posteromedial rotatory instability (PMRI) was the most common diagnosis (66.7%). According to O'Driscoll's classification, anteromedial (AM) subtype 1 fractures predominated (44.4%). 3D CT revealed significant differences in fragment volume and orientation between PMRI, tip, and anterolateral subtypes. Soft tissue injuries such as lateral ulnar collateral ligament and medial collateral ligament tears were frequently observed across all subtypes, even in the absence of frank dislocation.

Conclusion: Small, isolated coronoid fractures often reflect underlying complex elbow instability, particularly PMRI, despite their benign radiographic appearance. Detailed evaluation using 3D CT and assessment of associated ligamentous injuries are essential for appropriate diagnosis and treatment planning. These findings highlight the limitations of current classification systems and suggest a need for a revised system incorporating injury mechanism and associated soft tissue damage.

Background: Proximal humerus fractures (PHFs) are increasingly prevalent in the aging population, with reverse shoulder arthroplasty (rTSA) emerging as a preferred surgical treatment for complex fracture patterns. Recent advancements have introduced shorter, metaphyseal-fixation humeral stems as alternatives to traditional modular diaphyseal stems. However, limited data exist comparing the clinical outcomes of these designs following rTSA for PHF.

Methods: A retrospective analysis of 99 patients undergoing rTSA for acute three- or four-part PHFs between 2014 and 2024 was conducted. Patients received either a modular diaphyseal stem (n = 66) or a nonmodular metaphyseal stem (n = 33). Demographics, perioperative variables, American Shoulder and Elbow Surgeons scores, visual analog scale scores, range of motion, complications, and revision rates were compared. Statistical analyses included t-tests for continuous variables and chi-squared tests for categorical data.

Results: No significant differences were observed between groups in terms of demographics, comorbidities, hospital stay, or overall postoperative complications. The modular diaphyseal cohort had a significantly longer operative time and follow-up duration. Postoperative American Shoulder and Elbow Surgeons scores were higher in the diaphyseal group (76.35 vs. 65.58, P = .015), while the metaphyseal group demonstrated superior abduction (74.55° vs. 57.93°, P = .0267) and external rotation (32.12° vs. 14.79°, P < .0001). No significant differences were found in postoperative visual analog scale scores (P = .117) or revision rates (P = 1.00).

Conclusion: Both modular diaphyseal and nonmodular metaphyseal stem designs offer safe and effective options for rTSA following PHF, with distinct advantages. Modular stems may provide improved functional scores over longer follow-up, whereas metaphyseal stems may enhance range of motion. These findings support individualized surgical planning based on patient anatomy, functional goals, and revision risk. Further long-term studies are warranted to optimize implant selection.

Background: Radial head replacement (RHR) is a well-established treatment for comminuted fractures (radial head fracture). In most cases, it provides satisfactory long-term functional results. However, some patients have pain and significant functional limitations. Our aim was to identify patients who underwent an RHR for acute trauma and had a clinical outcome that was considered an outlier. We assessed specific factors that contributed to an unfavorable result.

Materials and methods: From a cohort of 134 patients undergoing RHR for acute complex elbow instability, the Oxford Elbow Score (OES) was used to identify patients whose score was below the p25 (<35 points). Thirty-five patients (23 women and 12 men) with a mean age of 48 years (18-78) and a mean follow-up of 77 months (24-192) were below the p25. The univariate analysis included preoperative demographic characteristics, implant design, diagnosis, and postoperative clinical and radiographic outcomes. Results were compared to patients above the p75. An additional multivariate analysis was performed to identify predictive variables of a p25 OES.

Results: Patients belonging to p25 OES were significantly younger (48 vs. 58 years, P = .02), had a higher energy trauma (P = .01), and their diagnosis was more commonly a terrible triad (18 vs. 11, P = .004) or an Essex-Lopresti (5 vs. 0) injury. Twenty-two patients received a smooth-stem RHR and 13 an anatomic design, with no correlation between implant design and p25 OES (P = .83). The p25 OES showed significantly lower flexion-extension (P = .01), pronation (P = .01), Visual Analog Score (VAS) satisfaction (P < .001), and Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores (P < .001), with more pain (P < .001). All patients who required implant removal belonged to the p25 OES (10 vs. 0). On multivariate analysis, odds of belonging to p25 OES were greater only for younger (odds ratio = 0.94, 95% confidence interval: 0.88-0.99, P = .04) and female patients (odds ratio = 20.29, 95% confidence interval: 2.27-181.8, P = .007). A very strong correlation was observed for postoperative VAS for pain above 3 points, worse DASH and MEPS scores with a p25 OES. Lower flexion-extension arc of motion, lower levels of satisfaction, lateral ligament insufficency, and the overall presence of complications and implant removal showed moderate correlation with p25 OES.

Conclusion: RHR for traumatic complex elbow instability generally provides good long-term outcomes with few complications. Some preoperative characteristics, such as younger age, high-injury trauma, terrible triad, and longitudinal instability, are related to a lower OES with worse overall clinical outcomes. Female sex and younger age may be predictors of an unsatisfactory outcome after an RHR.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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