Journal of Shoulder and Elbow Surgery最新文献

Background: Biomechanical studies suggest that the triceps brachii muscle generates resistive force against valgus stress on the elbow during baseball pitching. However, given the parallel fiber orientation in the distal tendinous structure of the triceps brachii, the mechanism behind this anti-valgus force remains unclear. In the present study, we aimed to examine the anatomy of the distal tendinous structure of the triceps brachii using bony morphological, macroscopic, and histological methods.

Methods: We analyzed 25 elbow specimens from 18 cadavers, all of Japanese ethnicity, using micro-computed tomography (micro-CT). Four specimens were excluded due to severe osteophytes, leaving 21 specimens randomly allocated to three groups: 13, 4, and 4 specimens to the macroscopic examination group, the histological examination group, and the chemically débrided bone examination group, respectively. In 6 of the 13 specimens analyzed macroscopically, we quantitatively measured the local thickness of the triceps tendon using micro-CT.

Results: The distal tendinous portion of the triceps brachii was comprised of an intramuscular tendon and a superficial aponeurosis. The intramuscular tendon, located between the long and medial heads of the triceps, curved medially to laterally and inserted broadly onto the proximal and lateral facets via fibrocartilage. The superficial aponeurosis, attached to the lateral and medial heads, had fibers that ran straight and merged distally with the aponeurosis of the anconeus. The intramuscular tendon (2.2 ± 0.4 mm) was significantly thicker than the superficial aponeurosis (0.9 ± 0.2 mm, P < 0.001).

Conclusion: The current study revealed a nonuniform distal tendinous structure of the triceps brachii, with a thick intramuscular tendon and a thin superficial aponeurosis. In particular, the intramuscular tendon was curved from the medial-to-lateral direction and had a firm insertion. These findings suggest that the intramuscular tendon can contribute force to prevent valgus stress on the elbow as a dynamic stabilizer during the pitching motion.

Background: Painful degeneration of the sternoclavicular joint refractory to nonoperative treatment has historically been managed with resection of the degenerative segment of the medial clavicle. Although this has produced good results with improvement in symptoms, recurrent pain necessitating revision surgery is not an infrequently encountered outcome. To reduce the occurrence of recurrent postoperative pain, a novel technique to reconstruct the intra-articular disc at the time of medial clavicle resection was developed.

Methods: 10 patients whom underwent medial clavicle excision and interposition arthroplasty with a lateral meniscus allograft were retrospectively reviewed. Functional results were based on VAS pain scores and subjective shoulder scores.

Results: VAS pain score improved from 7.5 (5-10) preoperatively to 1.2 (0-2; p = .005, W-value = 0) postoperatively, with an average improvement of 6.3. The mean preoperative SSV score improved from 54.5 (25-70) preoperatively to 88.5% (80-95%; p = .005; W-value = 0) postoperatively, with a mean increase of 34 percentage points. No patients experienced a complication and or recurrence of pain at most recent follow-up.

Conclusion: Minimal excision of the medial clavicle and interposition arthroplasty with lateral meniscal allograft successfully reduces pain and restores stability and function for the treatment of painful degeneration of the SC joint.

Background: Among rugby players, anterior shoulder dislocation is challenging to treat during the in-season period. It often leads to recurrent shoulder instability and requires prolonged rest post-surgery. No studies have determined the effectiveness of immobilization, early muscle strength training, or both in preventing reinjury in this population. Thus, the present study aimed to determine the impact of treatment outcomes between different immobilization methods and early muscle strength training in the conservative treatment of first-time anterior shoulder dislocation among young rugby players.

Methods: Rugby players under 23 years of age who chose conservative treatment for first-time anterior shoulder dislocation were included. The recurrence rate and recurrence-free period in a season and 2 years after return to sport (RTS) were retrospectively investigated for each immobilization method. The subjects were classified into three groups based on the immobilization method used: IIR group (incomplete immobilization in internal rotation was advised), iER group (strength training was started after 3-4 weeks of immobilization in external rotation [ER]), and iER+T group (early muscle strength training was combined immediately after the start of ER immobilization). All groups were allowed to RTS 8 weeks after injury or later. The endpoint was defined as a dislocation episode or the subjective feeling of shoulder subluxation, to a degree where the player could no longer continue to play the rest of the season.

Results: Thirty-four shoulders of 34 patients (31 males and three females; median age at injury: 17 [range: 15-22] years) were included (IIR group, 8 shoulders; iER group, 8 shoulders; and iER+T group 18 shoulders). The recurrence rates during the first season after RTS were 100%, 87.5%, and 55.6% in the IIR, iER, and iER+T groups, respectively, with statistically significant difference between groups (p = .037). Compared with the IIR and iER groups, the iER+T group showed a longer survival curve with significant difference in the transition of each curve for the treatment success rate (p = .045). In the IIR, iER, and iER+T groups, approximately 0%, 11.7%, and 50.0% of patients were able to continue to play for more than half of the remaining season without any recurrence of instability, and the overall probability of recurrence in 2 years was estimated to be 100%, 100%, and 81.7%, respectively.

Conclusion: The combination of immobilization in ER and early muscle strength training may be an effective treatment for anterior shoulder dislocation during the in-season period.

Background: Mobilization of the subscapularis muscle (SSC) is crucial for optimal access to the glenohumeral joint during anatomical total shoulder arthroplasty (ATSA). However, the ideal mobilization technique remains controversial. This study aimed to assess the impact of the lesser tuberosity C-block osteotomy, a modified lesser tuberosity osteotomy, on the postoperative subscapularis (SSC) volume following anatomical shoulder arthroplasty and compare it to the volume of the infraspinatus/teres minor.

Materials and methods: All patients between 2006-2022 who received an anatomical total shoulder arthroplasty with the lesser tuberosity C-block osteotomy for primary shoulder osteoarthritis or avascular necrosis of the humeral head with a minimum follow-up of one year and received full scapulae CT scans postop were included in the study. Utilizing imaging software and a validated method established for healthy shoulders, we assessed the postoperative volume of the transversal force couple.

Results: 56 patients (59 shoulders) with an average follow-up of 5 years were included in the study. A strong correlation (rₛ=0.954) was observed between the volumes of the anterior and posterior parts of the transverse force couple, with no statistically significant difference (P=0.207) noted in muscle volumes. The mean transverse force couple ratio was 1.01±0.06, with similar values found across all age groups. Intraobserver and interobserver correlation coefficients were excellent.

Conclusion: Using the lesser tuberosity C-block osteotomy during anatomical total shoulder arthroplasty does not disrupt the essential volumetric balance between the subscapularis and infraspinatus/teres minor, as observed in a well-functioning transverse force couple.

Background: While stress shielding and adaptive bone changes around the humeral component are often observed after shoulder arthroplasty, the potential causative factors and clinical significance of these findings at mid-term follow-up have not been well elucidated. The purpose of this study was to investigate the frequency, patterns and clinical significance of radiographic findings around the humeral component of total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) at minimum 4-year follow-up.

Methods: The 6-week and minimum 4-year radiographs of patients who underwent HA and TSA were evaluated for filling ratios, changes in the humeral bone surrounding the component, and component shift or subsidence. All procedures were performed using a traditional-length, smooth stem fixed by impaction autografting with the goal of secure fixation with a relatively low filling ratio. Radiographs after TSA were evaluated for high-grade radiolucencies around the glenoid component. The clinical outcomes of interest were revision for humeral fixation failure and Simple Shoulder Test (SST) score.

Results: 170 patients met the study criteria (91 TSA and 79 HA). The mean radiographic and clinical follow-up was 7.0 years [interquartile range (IQR), 5.3 to 8.6 years]. No patients were revised for loose humeral components during the study period. For both HA and TSA, the most common zones of cortical thinning or resorption involved the medial calcar, greater tuberosity and lateral humerus diaphysis. The mean metaphyseal filling ratio (MFR) was higher in patients with bone changes in ≥3 zones (p < 0.001) and resorption of the calcar (p = 0.051). The frequency and degree of bone changes around the humeral component were higher in TSA patients with high-grade radiolucencies around the glenoid component. These findings in TSA patients with high-grade radiolucencies around the glenoid component had a stronger correlation with inferior SST scores than in patients who did not have a high-grade radiolucencies around the glenoid component.

Conclusions: At minimum 4-year and mean 7-year follow-up, greater bone changes around the humeral component were associated with higher metaphyseal filling ratios. The association of glenoid component radiolucency with the degree and clinical impact of these bone changes should be considered when interpreting mid-term radiographs after TSA and may represent the effects of other processes - such as osteolytic reaction to particulate debris - in addition to stress shielding.

Level of evidence: Level IV; Case Series; Treatment Study.

Background: Anatomic total shoulder arthroplasty are highly successful procedures for treatment of glenohumeral arthritis to reduce pain, improve range of motion, and overall quality of life. However, the long-term survivorship of the implant systems is less widely documented in the existing literature. The purpose of this study was to establish the long-term patient outcomes and identify factors influencing the postoperative implant survivorship of total anatomic shoulder arthroplasty devices/procedures utilizing the short-stemmed prosthesis and hybrid glenoid components of the Comprehensive Shoulder System (Zimmer Biomet, Warsaw, IN, USA) at an average of ten years.

Methods: Between 2007 and 2015, 159 shoulders in 128 unique patients were sequentially enrolled in the prospective, observational study following their anatomic total shoulder arthroplasty utilizing the Zimmer Biomet Comprehensive Shoulder System with the Mini Stem component and Modular Hybrid Glenoid component variation. Enrolled patients were clinically evaluated on an annual basis following their operation for up to ten years including a physical exam, radiographic evaluation, and patient outcomes via a modified Constant Score and satisfaction.

Results: The implant survival rate was 98.1% at ten years. The mean patient age was 70.4± 8.3 years (Range: 50.7-90.3 years) at the time of surgery. Average Constant Scores improved from preoperative to 6 months postoperative with an average of 81.55 ± 16.10 and 84.09 ± 15.12, respectively however there was a statistically significant longitudinal decline in Constant Score with increasing age for an average loss of 0.5 points per year. The overall revision rate for this cohort was 1.26% for a total of two revision cases secondary to external trauma and not implant system related.

Conclusion: Anatomic total shoulder arthroplasty with the Comprehensive Shoulder System had a high survivorship rate at the ten-year follow-up with improved clinical results postoperative. Patients had comparable long-term clinical results to the current longitudinal literature regarding survivorship of other implant systems.

Background: Acromioclavicular (AC) joint injury management has historically been guided by the severity and grade of the injury. However, recent debates have emerged regarding the role of surgical intervention for these injuries. Insurance-based disparities in surgical treatment have been well-documented across various orthopedic conditions. This study seeks to determine whether insurance coverage influences the likelihood of undergoing surgical fixation for AC joint dislocation.

Methods: We conducted a retrospective analysis of the National Readmissions Database (NRD) spanning from 2016 to 2021. Using International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified patients with isolated AC joint dislocation and determined whether they received surgical intervention based on ICD-10 procedural codes. A total of 5,654 cases of AC joint dislocation were identified, of which 219 (3.9%) underwent operative management. Statistical analysis was conducted via univariate analysis using Pearson's chi-square test, followed by multivariable logistic regression to assess the significance of demographic and socioeconomic factors on likelihood of operative intervention. Results were presented as odds ratios (ORs) and 95% confidence intervals.

Results: After adjusting for demographic and socioeconomic variables including age, sex, income quartile, and medical comorbidities, patients with Medicaid insurance were significantly less likely to receive surgical intervention for AC joint dislocation compared to those with private insurance (OR 0.51; 95% CI 0.34-0.76; p < 0.01). Furthermore, individuals residing in areas with the highest income quartile by ZIP code exhibited the greatest likelihood of undergoing surgery (OR 1.91; 95% CI 1.27-2.89; p < 0.01), in contrast to those in lower-income areas.

Conclusions: This study suggests that patients insured by Medicaid are less likely to undergo surgery for acromioclavicular joint injury compared to those with private insurance. Additionally, patients from higher-income areas were more likely to receive operative treatment. These findings emphasize the need for more standardized treatment guidelines, particularly as the controversy surrounding operative versus nonoperative management of these injuries persists, and no definitive gold standard surgical technique exists. Surgeons must remain vigilant of these biases that may influence clinical decision-making.

Introduction: Shoulder and elbow surgery fellowships in the United States are recognized for their academic emphasis, yet the correlation between an applicant's research productivity and fellowship match results remains unclear. This study (1) analyzed temporal trends in research productivity among matched fellowship applicants, (2) evaluated the influence of quantity of publications and first authorships on match positions, and (3) investigated program variations in research productivity.

Methods: This is a retrospective analysis of data from the San Francisco (SF) Match Database for shoulder and elbow surgery applicants matched between 2017 and 2024. Allopathic (MD), osteopathic (DO), and international medical graduates (IMGs) were included. PubMed was queried to quantify publications and first authorship before and during residency, analyzing their association with applicant and fellowship rank. Publication volumes per fellowship program were also calculated for institutions with at least five years of match data.

Results: 290 matched applicants were evaluated across 34 fellowship programs, comprising 229 MDs, 29 DOs, and 32 IMGs. There was almost a five-fold increase in the average number of publications per applicant, from 2.72 ± 3.54 in 2017 to 12.80 ± 15.88 in 2024 (B 1.30; p = 0.001). Similarly, first authorship publication counts increased almost three-fold, from 1.31 ± 2.12 in 2017 to 3.66 ± 5.01 in 2024 (B = 0.29, p = 0.02). Fellowship program analysis revealed wide variation in mean publication counts of matched applicants (p = 0.008), with Rush University Medical Center (27.88 ± 33.86), Massachusetts General Hospital (13.65 ± 26.62), Mayo Clinic (13.06 ± 14.77), Thomas Jefferson University Hospital (12.19 ± 10.64) exhibiting the highest averages. Candidates with more publications (p = 0.04), first authorships(p = 0.02), and total first authorships (p = 0.04) during residency were ranked higher by fellowship programs. There was a significant correlation between greater publication count during residency and more favorable fellowship rank (-0.15, p = 0.02) and applicant match position (-0.12, p = 0.049). No significant associations were found between pre-residency publications (p = 0.38), total publications (p = 0.13), and pre-residency first authorships (p = 0.20) with fellowship rank positions.

Conclusion: Research productivity has increased substantially among matched applicants. The more academically productive residents tend to be ranked more favorably by fellowship programs and match higher on their list. However, these associations were relatively weak, highlighting the complexity of the fellowship selection process and the notion that research productivity alone does not guarantee placement in preferred programs.

Background: Surgical techniques for biceps tenodesis vary in approach, fixation strategy, and anatomic location without clear superior technique for this common procedure.

Hypothesis/purpose: The purpose of this study was to prospectively evaluate a randomized cohort of patients undergoing arthroscopic suprapectoral (ASBT) with interference screw fixation using an inlay technique versus mini-open subpectoral (MOBT) with a unicortical button implant using an onlay technique with regards to 1) clinical outcome measures and 2) structural healing as evaluated by ultrasound.

Methods: From May 2017 to April 2021, patients undergoing biceps tenodesis were preoperatively randomized to either ASBT or MOBT. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) scores were recorded at baseline, three months, and two years postoperatively. The integrity of the biceps tendon at the tenodesis site was independently examined via ultrasound by a musculoskeletal trained radiologist at three months and two years postoperatively. T-tests were performed for continuous variables, while Chi squared tests were performed for categorical variables.

Results: A total of 52 patients (24 ASBT, 28 MOBT) were randomized and completed follow-up. At baseline, three months, and two years postoperatively, the mean ASES, SANE and VAS scores were not statistically different between ASBT and MOBT. At the three-month postoperative ultrasound, 23/24 (96%) of the ASBT patients and 26/28 (93%) of the MOBT patients were noted to have a clearly intact biceps tenodesis. At two years, all biceps tenodesis regardless of group were noted to be intact and healed, including all three shoulders whose ultrasound noted a questionably intact repair without significant retraction of the tendon at prior three-month ultrasound evaluation.

Conclusion: This study demonstrates similar clinical outcomes at two year follow-up between ASBT and MOBT. Both groups demonstrated improvement that exceeded the reported patient acceptable symptom state (PASS) and minimal clinically important difference (MCID). Ultrasound showed excellent structural healing rates for both inlay and onlay biceps tenodesis techniques.

Level of evidence: Level II; Randomized Controlled Trial; Treatment Study.

Background: Heterotopic ossification (HO) of the elbow resulting in limited motion is a relatively uncommon condition often caused by burns, trauma, and central nervous system injuries. This retrospective study presents the long-term outcomes of 51 cases of elbow HO treated with surgical excision and regimented postoperative rehabilitation protocol.

Methods: A retrospective case series was conducted on 48 patients (51 elbows) who underwent surgical excision of elbow heterotopic ossification. All procedures were performed in the inpatient setting at an Academic Level I Trauma Center between September 1999 and August 2022 by fellowship-trained upper extremity surgeons. Patient demographics and case characteristics such as age, gender, mechanism of injury, and comorbidities were collected for comparison. Long-term follow-up examinations were elbow flexion-extension arcs, pronosupination arcs, Visual Analog Scale (VAS) pain scores, and Mayo Elbow Performance Scores (MEPS).

Results: Patients were followed for a minimum of 2 years with an average follow-up of 8 years (range, 2-24 years). The median flexion-extension arc at final follow-up was 110° (95°-130°), which was maintained at 85% of the intraoperative arc achieved. Pronosupination arc at final follow-up was 170° (105°-180°), which was maintained at 97% of intraoperative levels. The median reported MEPS and VAS scores were 80 (70-93) and 2 (0-4), respectively. Although it wasn't statistically significant, patients diagnosed with type II diabetes had the worst flexion-extension arcs at final follow-up and highest complication rates compared to other risk factors.

Conclusion: Surgical excision coupled with HO prophylaxis and a regimented rehabilitation program resulted in a lasting improvement in functional outcomes for patients with elbow dysfunction secondary to heterotopic ossification at long term follow-up. Overall, patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function.