Journal of Shoulder and Elbow Surgery最新文献

Background: Proximal humerus fractures (PHFs) are common in the elderly, with a rising incidence. Despite advances in surgical techniques, the optimal treatment for displaced PHFs remains controversial, as high-quality studies show no significant differences in functional outcomes between surgical and non-surgical treatments. This study aims to compare non-operative with surgical treatment using a locking plate for displaced PHFs in patients over 60 years old.

Methods: This prospective, randomized clinical trial compared non-operative and operative treatments using locking plates for displaced PHFs in patients over 60 years old. Patients were randomized 1:1 into two groups using a block randomization stratified by tuberosity involvement. The primary outcome was the Constant-Murley score at 24 months. Secondary outcomes included the Individual Relative Constant Score (IRCS), American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score at 3, 6, 12, and 24 months. The incidence of complications and the need for reoperations were evaluated.

Results: Eighty patients were randomized, with 71 completing 24 months of follow-up: 40 in the non-operative group and 31 in the operative group. At 24 months, the mean Constant-Murley scores were 68.7 ± 16.1 for the non-operative group and 66.5 ± 15.8 for the operative group (p=0.433). The ASES score at 24 months was 77.0 ± 23.1 for the non-operative group and 79.1 ± 20.0 for the operative group (p=0.871). The SANE scores at 24 months were 83.8 ± 19.3 for the non-operative group and 88.5 ± 17.2 for the operative group (p = 0.236). The IRCS at 24 months was 79.5 ± 25.2% for the non-operative group and 73.0 ± 29.2% for the operative group (p=0.244). Seventeen patients experienced complications, with six (15.0%) in the non-operative group and eleven (35.5%) in the operative group (p=0.070). The rate of a new surgical indication was 12.5% in the non-operative group and 22.6% in the operative group (p=0.421). Rotator cuff tears were 20.0% in the non-operative group versus 25.8% in the operative group (p=0.768).

Conclusion: The operative treatment of displaced proximal humeral fractures with locking plate osteosynthesis in patients over 60 years old shows no evidence of differences in clinical outcomes compared to non-operative treatment, as measured by the Constant-Murley Score, Individual Relative Constant Score, ASES, SANE, and complication rates.

Background: Anatomic total shoulder arthroplasty (aTSA) is a well described technique for addressing glenohumeral osteoarthritis. Little has been written on outcomes for newer stemless humeral implants in older patients, with none looking specifically at an implant relying on screw fixation. The purpose of this study is to evaluate the clinical and radiographic outcomes for patients over 70 years of age undergoing aTSA with the Eclipse (Arthrex Inc., Naples, FL, USA) stemless humeral component.

Methods: A retrospective review utilizing a multicenter shoulder arthroplasty registry was performed evaluating all patients over 70 who underwent aTSA with a stemless humeral implant for a diagnosis of glenohumeral osteoarthritis and had a minimum follow-up of 2 years. Thirty-seven patients met the study criteria and were matched for comparative analysis to 37 patients 65 years of age and younger. Outcome scores were obtained preoperatively and at 2 years postoperatively using the VAS (Visual Analog Scale), Constant-Murley, American Shoulder and Elbow Surgeons (ASES) and Western Ontario Osteoarthritis Index (WOOS) scores. The percentage of patients in each group who exceeded the MCID for the ASES and WOOS was reported. When available, postoperative radiographs were evaluated for the presence of radiolucent lines and calcar resorption.

Results: There was a statistically significantly higher preoperative WOOS score in the older patient group, otherwise there was not statistical difference between the two groups in regards to baseline scores or range of motion. At two-year follow-up, older patients were noted to have significantly better VAS, ASES, WOOS, and Constant-Murley scores when compared to younger patients (p < .05). All patients over the age of 70 achieved MCID for the ASES compared to 84% of those 65 and younger (p=0.011), while for the WOOS 100% of older patients achieved MCID compared to 86% of those in the control group (p=0.022). Postoperative range of motion was not significantly different between the two groups, although older patients had better active internal rotation at 90 degrees of abduction (p=.002). Partial calcar resorption was noted in one patient in each age group. Radiolucent lines were noted in two patients over the age of 70 and one patient in under 65.

Discussion: Patients over the age of 70 with glenohumeral osteoarthritis undergoing aTSA with a stemless humeral component have equivalent, if not better, outcomes when compared to younger patients. Age alone does not appear a limitation for stemless aTSA.

Background: Rheumatoid arthritis (RA) poses unique challenges in total elbow arthroplasty (TEA) due to systemic inflammation. Previous studies suggest higher revision rates in RA patients after TEA, yet comprehensive investigations have not been conducted. We theorized that RA patients undergoing TEA would demonstrate a greater likelihood and risk of requiring revision procedures compared to those without RA. We aimed to assess revision incidence and complications in an RA compared to a non-RA cohort.

Methods: A retrospective cohort study was conducted using data from the PearlDiver database to analyze patients who underwent TEA between from January 2010 to October 2022. The study population was divided into RA and non-RA cohorts. The primary outcome was 5-year all-cause revision incidence. Secondary outcomes were elbow fracture, infection, instability, and triceps and nerve injury. Potential contributing factors such as immunosuppressive drug use and perioperative flares were assessed. Demographic characteristics including age, sex, and Charlson Comorbidity Index were noted for each cohort. Propensity-score matching aligned RA TEA patients with a general TEA (non-RA) population. Matching used a 1:4 ratio; after matching, cumulative incidence was assessed via Kaplan-Meier analysis.

Results: Following matching, 499 RA patients were compared with 1,949 general matched control (non-RA) patients. The RA group had a higher 5-year cumulative incidence of revision after TEA compared to the non-RA cohort (4.3% vs. 1.4%, hazard ratio [HR] 2.95, 95% confidence interval [CI] 1.63-5.34, P <.001). However, there were no significant differences in complication rates between the two groups within 5 years after the initial procedure. No significant difference in elbow instability after TEA was observed between the RA and non-RA cohorts.

Conclusions: Our study provides evidence supporting the notion that RA patients undergoing TEA are at a higher risk of revision procedures. Despite comparable complication rates between RA and non-RA cohorts, further investigation into the underlying mechanisms of increased revision rates in RA patients is warranted.

Background: Reverse shoulder arthroplasty (rTSA) is increasingly being used to treat complex proximal humerus fractures, especially in the senior population. The question of whether it is worthwhile to repair the greater tuberosity (GT) after rTSA for proximal humerus fractures still needs to be answered.

Methods: A systematic review was performed on PubMed, Scopus, Cochrane library and EMBASE, for studies available up to February 2024 focused on tuberosity repair following rTSA for proximal humerus fracture and reporting clinical outcomes and range of motion (ROM) between patients with anatomic GT healing and patients with malunion or nonunion of GT. The primary outcome was the rate of anatomical healed GTs. Patients with GT malunion or non-union were collectively categorized as non-healed. The secondary outcomes were active ROM and functional scores. A random-effects proportion meta-analysis (weighted for individual study size) was generated for calculation of the pooled rate of GT non-healing. The plausible predictive factors for GT non-healing (gender distribution, mean age, mean time from injury to surgery, dominant side distribution, humeral inclination of the implanted prostheses) were analyzed by performing a meta-regression. Any statistically significant difference in terms of ROM (active anterior elevation, abduction and external rotation) between healed and non-healed GT groups was detected by constructing individual forest plots.

Results: A total of 21 studies was selected and included in the meta-analysis, with a sample of 1616 rTSAs in 1614 patients. The rate of GT non-healing ranged from 15.0% to 63.2%, with a pooled rate of 31.9% (95% CI, 25.6%-38.2%; I² = 86.8%). The meta-regression failed to individuate any plausible predictive factor among the evaluated elements. Anatomic GT healing provided improved ROM in active abduction (p=0.002), anterior elevation (p<0.00001) as well as external rotation (p<0.0001). With regard to internal rotation, a statistically significant difference in favor of GT healed group was reported in only 3 out of 13 studies. Similarly, the random-effect meta-analysis demonstrated better functional scores in patients with healed GT according to 3 out of 5 functional scores.

Conclusion: GT healing following rTSA for proximal humerus fracture provides increased ROM and better functional outcomes. Moreover, this does not result in higher level of pain for patients. Future prospective studies with more rigorous selection criteria are welcome to increase the level of evidence on this topic.

Background: Rotator cuff tear (RCT) is the most common tendon injury. Currently, arthroscopic rotator cuff repair (ARCR) is the primary method for diagnosing and treating RCT. One of the major complications following ARCR is retear. This study aims to evaluate the correlation between systemic lipid metabolism and retear occurrence after ARCR through a retrospective analysis of postoperative patients.

Methods: This retrospective study reviewed consecutive patients of a single surgeon who underwent ARCR from January 2021 to January 2022. Eligibility for inclusion required complete sequential follow-up data, encompassing preoperative laboratory tests and a series of postoperative MRI evaluations at 1, 2, 3, and 6 months. Exclusion criteria included patients with incomplete laboratory tests, a history of tumors, prior shoulder surgeries, isolated subscapularis tendon tears, the rotator cuff related muscles are not clearly or completely displayed in MRI, absence of follow-up MRI, or those under treatment with lipid-lowering medications. Logistic regression analysis was employed to identify preoperative factors associated with retear, with statistical significance adjudged at P < 0.05.

Results: From the initial cohort of 400 patients who underwent ARCR during the study period, 202 met both inclusion and exclusion criteria. These patients were subsequently divided into a training group (n=122) and a test group (n=80), maintaining a ratio of 6:4. Statistical analysis revealed significant risk factors for post-ARCR retear including high BMI (>27.1; Odds Ratio (OR): 5.994, 95% Confidential Interval (CI): 1.762-13.980; P=.042), subscapularis muscle fatty infiltration of Grades 3 and 4 (OR: 8.509, 95%CI: 3.811-17.702; P=.009), serum ApoB levels exceeding 1.4 g/L (OR: 9.658, 95%CI: 3.520-21.753; P=.028), and an ApoB/A1 ratio greater than 1.8 (OR: 5.098, 95%CI: 1.787-10.496; P=.016). Conversely, the serum HDL level above 1.2 mmol/L (OR: -3.342, 95%CI: -7.466-0.659; P=.039) served as a protective factor. The model incorporating these five factors predicted retear with a sensitivity of 78.3% and specificity of 98.0% (AUC = 0.924, accuracy = 90.3%). Moreover, a new model comprising three lipid metabolism-related factors including HDL, ApoB and the ApoB/A1 ratio showed a sensitivity of 80.5% and specificity of 83.2% (AUC = 0.866, accuracy = 85.8%) for predicting retear after ARCR.

Conclusions: A predictive model utilizing key systemic lipid metabolism markers including HDL, ApoB, and the ApoB/A1 ratio, demonstrates effective forecasting of retear incidence following ARCR.

Background: Primary treatment for supracondylar humerus fractures SCHF involves a closed reduction and fixation with K-wires. The aim of this study is to investigate whether a target marking of the humerus is effective in reducing operation duration and radiation exposure in surgically treated pediatric supracondylar humerus fractures.

Methods: Patients treated with a closed reduction and percutaneous pinning (CRPP) for a SCHF between 2019 and 2023 were included. The study data was evaluated into two groups; Group 1 with patients who underwent closed reduction followed by outlining the boundaries of the humerus on the skin and subsequent fixation with K-wires (target marking group), while Group 2 patients underwent closed reduction without outlining (unmarked group). The same K-wire configuration, consisting of 2 lateral and 1 medial crossed pinning, was utilized. Operation duration and the radiation dose received (millisievert) were recorded for each patient and compared in-between.

Results: Overall surgical duration was significantly shorter in Group 1 (p < 0.001). A significantly lower radiation dose was required in patients of Group 1 to achieve a satisfactory reduction for both fracture types and for the overall patient cohort (p < 0.001).

Conclusions: Enhancing the three-dimensional perception of the surgeon in pediatric supracondylar humerus fractures treated with closed reduction and percutaneous pinning resulted in a reduction of both the operative duration and the radiation dose. A novel method of 'target marking' showed a significant reduction in surgical duration and the amount of radiation exposure.

Background: The contraction of the flexor pronator muscles (FPMs) plays an important role in stabilizing the elbow joint in baseball players. However, the influence of different types of contractions on the medial joint space (MJS) in high school baseball players is not well understood. This study aimed to elucidate the effects of individual or combined contractions of the FPMs, specifically the flexor carpi ulnaris (FCU), flexor digitorum superficialis (FDS), pronator teres (PT), palmaris longus, and flexor carpi radialis, on the MJS in high school baseball players.

Hypothesis: We hypothesized that contractions, particularly of the FDS, PT, and FCR, would lead to a narrowing of the MJS.

Methods: The study included 36 high school baseball players who executed nine different contraction tasks related to the FPMs (including a resting state) in a randomized order. The MJS was measured using ultrasound equipment and compared with the resting state. The Friedman test, as a repeated-measures one-way ANOVA, was performed, followed by Steel's test for multiple comparisons. All analyses were conducted using EZR software, with a significance level set at 5%.

Results: The repeated-measures one-way ANOVA and the Friedman test revealed a significant difference among the nine contraction tasks (p < 0.001). Using Steel's test, a significant reduction in the MJS (mean ± SD) was observed compared with the resting state (4.8 ± 1.2 mm), particularly in contraction tasks involving the PT (4.0 ± 1.0 mm, p = 0.017), FDS and PT (4.0 ± 1.1 mm, p = 0.007), and FCU, FDS, and PT (4.0 ± 1.1 mm, p = 0.008).

Conclusions: Incorporating the PT into contraction tasks significantly reduced the MJS, emphasizing the important role of the PT in elbow joint stability. More work is required to see if the results of this study can be used to develop injury prevention and rehabilitation strategies.

Introduction: Total shoulder arthroplasty has been used for over 50 years to treat glenohumeral arthritis. In recent years, one area of innovation has been the use of ceramic-bearing surfaces. The advantages of ceramic bearing surfaces include utility in stemless implants and hemiarthroplasty, where their use in hip arthroplasty has been shown to decrease wear rates compared to metal implants and potentially reduced revision rates. With interest in utilizing ceramics for other arthroplasty indications continuing to grow, the purpose of this systematic review is to consolidate recent clinical findings involving ceramic-bearing surfaces to determine their suitability for anatomic shoulder replacement.

Methods: Medline, Embase, and Cochrane Library were searched up to April 2024 according to PRISMA guidelines. Metrics analyzed include patient-reported outcome measures (PROMs), postoperative complications, and radiographic findings. Secondary outcomes included forward flexion, external rotation, and abduction.

Results: Eight studies comparing 716 patients were included with an average follow-up of 57.3 months (range 24-70.7). The mean age for the study population was 67.7 years old. All eight studies included cohorts that had undergone shoulder arthroplasty with an implant with a ceramic humeral head component. All studies showed significant improvement in range of motion and patient outcome scores both postoperatively and up to 2 years after the patient's initial operation. Patient satisfaction was similarly positive, with 97% of patients reporting satisfactory results. Radiographically, six studies reported Lazarus grades with 71.9% (213/296) were grade 0, 23.3% (69/296) were grade 1, 3.7% (11/296) were grade 2, and 0.67% (2/296) demonstrated a grade 3 Lazarus score. One study presented a patient with a grade 5 Lazarus, making up only 0.34% (1/296) of the observed population.

Conclusion: Anatomic shoulder replacements using ceramic-bearing surfaces show safety and efficacy at numerous follow-up intervals, with complication rates approaching those of historical controls with metal implants. Future randomized controlled trials should be performed to investigate potential advantages compared to titanium and cobalt-chromium alloy humeral heads.