Journal of Shoulder and Elbow Surgery最新文献

Background: The Nexel total elbow arthroplasty (TEA) was introduced as an enhancement of the Coonrad-Morrey TEA, which through design modifications aimed to improve patient outcomes. However, high revision rates due to loosening have been reported for this implant.

Methods: A review of 101 consecutive primary Nexel TEAs performed between 2015 and 2021 at a single institution was conducted using data from the Norwegian Arthroplasty Register (NAR), electronic medical records, and radiographic evaluations. Implant revision, other secondary surgery and complications were investigated. Serial radiographs were examined for implant loosening using established criteria. Clinical outcomes, including Mayo Elbow Performance Score (MEPS), range of motion (ROM), and pain, were assessed.

Results: After an average of 44 (range 13-84) months from surgery to case review, five implant revisions were performed among the 101 cases, with two revisions related to aseptic loosening. Radiographic evaluation of non-revised cases revealed an additional four cases of suspected aseptic looseningproportionLLY. There were 38 secondary surgeries performed in 18 of 101 elbows, and 27 complications in 22 of the elbows. Clinical outcomes were good or excellent in 81% of cases, including revised elbows, according to MEPS classification. The mean flexion-extension arc was 113° at last follow-up vs 87° preoperatively. Mean pain at rest (NRS) improved from 4.0 to 0.8 at last follow-up and pain during activity from 7.9 to 1.7.

Conclusion: There were five implant revisions performed among the 101 cases, two due to aseptic loosening. An additional four suspected aseptic loosenings were identified in serial radiographs. Reoperations and complications were frequent but within the expected range for TEA in a mixed population. Most of the patients showed a marked clinical improvement from the procedure, with the best results found among those with acute fractures and the least favorable in those with fracture sequelae.

Background: Revision shoulder arthroplasty in the setting of severe glenoid bone loss presents significant reconstructive challenges. The use of femoral head allograft has emerged as a potential solution to restore glenoid bone stock and provide a stable foundation for component fixation. This study evaluates the outcomes and viability of femoral head allograft in managing severe glenoid defects during revision procedures.

Methods: A retrospective review of data collected from 2008 to 2023 from a single surgeon at a single institution utilizing a single reverse total shoulder implant system with a monoblock central screw baseplate. There were 29 patients with a minimum 2 year clinical and radiographic follow-up. All included patients underwent revision reverse shoulder arthroplasty with the use of bulk femoral head allograft to fill large glenoid defects. Indications for revision included failure of reverse total shoulder arthroplasty (n=3), failure of shoulder hemiarthroplasty (n=5), and failure of anatomic total shoulder arthroplasty (n=21). Patient-specific variables, radiographic parameters, and both pre- and post-operative patient outcomes (American Shoulder and Elbow Surgeons (ASES) Score, Simple Shoulder Test (SST), Visual Analog Scale (VAS) - Pain, VAS - Function, and Single Assessment Numeric Evaluation (SANE) were collected. Descriptive statistics were utilized to analyzes significant differences in the data based upon rate of secondary procedure for glenoid sided failure as the primary outcome. Secondary outcomes included changes in patient reported outcome measures.

Results: 29 patients met inclusion criteria with a mean follow-up of 5.57 years. The average baseplate contact to native bone was 47.3% (10% - 80%) There were 3 patients (10.3%) who observed with glenoid-sided complications. One patient had early radiographic detection of glenoid sided loosening without mechanical symptoms (13.5 months), while the other two patients had baseplate failures (15.0 and 24.7 months) requiring a subsequent revision surgery. All-cause two-year implant survival was 93.1% (27/29), five-year implant survival was 90.9% (20/22), and ten-year implant survival was 87.5% (14/16). There were significant improvements in all patient-reported outcome measures between pre-operative and post-operative states (p <.001). There were significant increases in patient forward elevation (p<.001) and abduction (p<.001).

Conclusion: Use of femoral head allograft in management of severe glenoid defects during revision reverse shoulder arthroplasty results in significant increases in patient-reported outcomes and range of motion with a low percentage (10.3%) of glenoid-sided complications. All-cause two- and five-year implant survival is greater than 90% with most failures occurring within 15 months of the initial surgery.

Background: Reverse shoulder arthroplasty (rTSA) has become increasingly common for inflammatory arthritis (IA) due to concerns regarding rotator cuff failure and glenoid loosening in anatomic total shoulder arthroplasty (aTSA). Comparative data between these procedures in IA, however, remain limited. This study aims to compare functional outcomes and revision-free survival between aTSA and rTSA in IA using data from the New Zealand Joint Registry (NZJR).

Methods: All primary aTSA and rTSA procedures performed for IA between 2000 and 2022 were identified in the NZJR. Demographic data, revision events, causes of revision, and Oxford Shoulder Scores (OSS) were analysed. Revision rates were expressed per 100 component-years. Cox regression models estimated the hazard of revision, adjusted for age, sex, and ASA.

Results: A total of 714 arthroplasties were included (433 rTSA, 281 aTSA) with mean follow-up of 6.0 years for rTSA and 9.8 years for aTSA. aTSA patients were younger (65.7 vs 70.3 years, p<0.001) and had higher BMI (30.3 vs 28.2, p=0.018). aTSA demonstrated significantly higher OSS at all time points: 38.7 vs 36.4 at 6 months (p=0.012), 41.9 vs 38.0 at 5 years (p=0.002), and 41.9 vs 35.4 at 10 years (p=0.021), however this did not exceed reported minimal clinically important difference. Revision rates were equivalent: 0.92 per 100 component-years for rTSA and 0.99 for aTSA (p=0.529). Ten-year revision-free survival was 92.0% for rTSA and 90.8% for aTSA. Causes of revision differed, with infection more frequent in rTSA (33.3% vs 7.4%, p=0.02), while aTSA was more often revised for glenoid loosening and cuff failure.

Conclusion: Compared with rTSA, aTSA was associated with statistically higher functional outcomes and equivalent revision-free survival. Inflammatory arthritis is not a contraindication to aTSA with it being a viable option for appropriately selected patients, rTSA should be consider for those with rotator cuff deficiency or severe glenoid pathology.

Objective: To investigate the application value of a custom 3D-printed hemi-elbow prosthesis in the repair and reconstruction of bone defects following distal humeral tumor resection, and to analyze and evaluate the shorterm and midterm prognosis of patients who received this treatment.

Methods: This is a retrospective study of 5 patients with aggressive or malignant tumors of the distal humerus treated at our center between September 2021 and August 2023.

Results: The surgical procedures for all 5 patients were completed successfully. All cases achieved either marginal or wide resection, and the prostheses were successfully implanted in each case without any intraoperative complications. The mean follow-up period was 33.4±10.8months (range: 24-46 months). Four patients remained alive without evidence of tumor recurrence, while one patient ultimately died due to lung metastasis progression. At the final follow-up, there were no signs of degenerative joint disease, aseptic loosening, or postoperative prosthetic infections. However, complications included 1 case of early ulnar nerve palsy and 1 case of ulnar nerve injury with concomitant elbow joint stiffness. At final follow-up, the mean elbow flexion was 126° ± 15° (range, 100°-140°), the mean extension deficit was 15° ± 9° (range, 5°-30°), and the mean arc of elbow motion was 111° ± 22° (range, 70°-135°). Mean forearm rotation was 161° ± 16° (range, 130°-175°). The average Musculoskeletal Tumor Society 93 score was 27.2 points, and the average Mayo Elbow Performance score was 97points.

Conclusion: The application of a custom 3D-printed hemi-elbow prosthesis for the repair and reconstruction of bone defects following distal humeral tumor resection results in good elbow joint mobility and postoperative function. Subsequent follow-up showed no occurrence of degenerative joint disease, loosening, or infection-related complications. Additionally, the use of mesh grafts facilitates improved joint capsule reconstruction and promotes early postoperative mobilization. To reduce the risk of postoperative elbow stiffness, careful attention must be paid to the placement of mesh grafts, minimizing their contact with muscle bellies to lower the risk of adhesions. Further improvements in prosthetic design and an emphasis on postoperative elbow rehabilitation are necessary to enhance clinical outcomes.

Background: Corticosteroid injections (CSIs) are widely used for symptomatic relief in shoulder arthritis, yet concerns persist regarding their impact on postoperative outcomes following shoulder arthroplasty. This study evaluates the dose-dependent relationship between preoperative CSIs and postoperative complications in patients undergoing anatomic or reverse total shoulder arthroplasty (TSA).

Methods: Using the PearlDiver insurance claims database (2010-2022), we identified patients undergoing TSA with at least one CSI in the preceding 5 years compared to those without any prior history of CSI. Patients were stratified by the number of preoperative CSIs (no CSI, 1-2, 3-4, 5+) and matched by baseline demographics. Surgical and medical complications were assessed at 90 days, 1 year, and 5 years postoperatively, with 5 year surgical complications being the primary outcome of interest.

Results: Of 124,144 patients, increased CSIs were associated with progressively higher rates of surgical complications. At 1 year, rates of revision, postoperative stiffness, cuff disease, and nerve injury showed a stepwise increase in complications with each additional CSI given. Receiving 5 or more CSIs before shoulder arthroplasty was associated with higher rates of revision at 5 years (OR 1.60, CI 1.10-2.34, NNH 71.4) and postoperative stiffness at 1 year (OR 1.24, CI 1.03-1.48) and 5 years (OR 1.27, CI 1.07-1.51) compared with matched patients receiving no CSIs. For every additional CSI given preoperatively, there was a statistically significant compounding 2.03% increased risk of revision surgery within 5 years in the unmatched cohort and a statistically significant compounding 2.67% increased risk of new onset rotator cuff disease within 5 years in the matched cohort.

Conclusion: A dose-dependent relationship exists between preoperative CSIs and postoperative complications following TSA. Increasing number of injections were correlated with higher risks of prosthetic loosening, stiffness, revision surgery, and new rotator cuff disease, suggesting reason for cautious use of CSIs. Additional work would be required to see if this relationship is causal.

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.

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.