Journal of Shoulder and Elbow Surgery最新文献

Background: Lateral collateral ligament (LCL) insufficiency of the elbow can be diagnosed using various clinical examinations. Among them, the posterolateral rotatory drawer (PLRD) test has been reported to have high sensitivity and specificity. Magnetic resonance imaging (MRI) is also frequently used to assess the LCL complex but studies show variable efficacy, raising doubt about its reliability as a gold standard diagnostic tool. Currently, no comparative studies exist between clinical testing and advanced imaging for LCL insufficiency. Hence, the aim of this study is to directly compare the PLRD test and MRI in terms of sensitivity and specificity for diagnosing LCL insufficiency.

Methods: We conducted a retrospective study using data from a single surgeon's database, including patients who underwent elbow arthroscopy (gold standard), MRI, and preoperative PLRD test between April 2017 and April 2025. All patients had MRI reviewed by consultant specialist musculoskeletal radiologists. Sensitivity and specificity of the PLRD test and MRI was calculated using arthroscopy as the reference standard for LCL insufficiency.

Results: Eighty-one patients were eligible for inclusion. Of these, 14 had a positive PLRD test, 9 had positive MRI findings, and 14 had positive arthroscopic findings. The PLRD test demonstrated a sensitivity of 85.7% (95% CI 57.2%-98.2%) and specificity of 97.0% (95% CI 89.6%-99.6%). In contrast, MRI had a sensitivity of 42.9% (95% CI 17.7%-71.1%) and a specificity of 95.5% (95% CI 87.5%-99.1%).

Conclusion: In our cohort, the PLRD test outperformed MRI in diagnosing LCL insufficiency. It is important for clinicians to be aware that a negative MRI does not preclude the presence of LCL insufficiency, and we recommend the PLRD test be used as the primary preoperative clinical assessment tool.

Background: Stemless reverse shoulder arthroplasty (rTSA) has been used in Europe for over 15 years with promising clinical outcomes and low complication rates. However, concerns persist regarding humeral component subsidence due to the metaphyseal fixation. Limited data exist on this potential complication. The primary aim of this study was to identify factors associated with humeral implant subsidence in stemless rTSA. The secondary objective was to evaluate the functional impact of such subsidence.

Methods: This retrospective, single-center study included a consecutive series of patients who underwent primary stemless rTSA for indications including primary osteoarthritis, cuff tear arthropathy, post-traumatic arthritis, or massive irreparable rotator cuff tears. All patients had a minimum 2-year follow-up with clinical (Constant score and simple shoulder value) and radiographic evaluation. Implant subsidence was assessed by comparing immediate postoperative and final follow-up X-rays and categorized as none, mild (<5°), or significant (>5°). Radiographs were reviewed independently by 2 observers. Associations between subsidence and demographic, surgical, and implant positioning factors were analyzed, along with clinical outcomes and complication rates.

Results: Seventy-two shoulders were analyzed (48.6% male; mean age 66.9 ± 8.7 years; mean follow-up 43.3 ± 9.0 months). Mild and significant humeral subsidence were observed in 12.5% (9/72) of cases each. In 94% (17/18), subsidence occurred in varus. Univariate analysis identified several factors significantly associated with humeral component subsidence: male gender (P = .006), greater patient height (P = .007), lower preoperative external rotation (P = .036), a humeral cut angle <140° (P = .009), nonparallel implant alignment relative to the humeral cut (P = .014), and superior positioning of the glenosphere (P < .001). Subsidence was associated with greater strength (P = .017), higher subjective shoulder value (P = .025), and higher activity scores (P = .022) at the last follow-up. There was no significant association between subsidence and overall Constant score (P = .097), patient satisfaction (P = .327), implant loosening (P = .26), occurrence of complications (P = .17), or revision surgery (P = .45).

Conclusion: At a mean follow-up of 43 months, humeral implant subsidence was observed in 25% of cases, predominantly in varus. Subsidence was linked to implant positioning and patient activity level but was not associated with poorer clinical outcomes. These findings support the importance of optimal surgical technique in stemless rTSA.

Background: Anteromedial facet (AMF) fractures of the coronoid process are typically accompanied by tears of the lateral collateral ligament (LCL) and the posterior bundle of the medial collateral ligament (pMCL). Addressing the bone defect and repairing the LCL is essential in the acute setting to prevent persistent varus posteromedial rotatory instability (VPMRI) and subsequent progression to osteoarthritis. However, pMCL repair is not typically performed. Therefore, the present biomechanical study investigates the amount of stress experienced by the pMCL in cases of anteromedial facet defects and its role in contributing to VPMRI of the elbow.

Methods: Nine fresh-frozen cadaveric elbows were tested under varus loading (3 Nm) with elbow flexion at 30°, 60°, and 90° in 3 distinct bone defect scenarios: (A) non-fractured coronoid; (B) anteromedial facet fracture, subtype II; and (C) anteromedial facet fracture, subtype III. The strain of the LCL and the ulnar collateral ligament (UCL) with its anterior (aMCL) and posterior bundles (pMCL) were measured quantitively via strain gauges (μm/m), as an estimate for their involvement in the instability pattern.

Results: Across all scenarios, the highest strain of the pMCL under varus force was observed with elbow flexion at 30° with a supinated forearm (mean = 171.72 μm/m, min 22.79 μm/m, max 348.9 μm/m, SD = 110.5 μm/m), while the aMCL remained relaxed. The degree of elbow flexion significantly influenced the strain on the pMCL under varus force (P = .01). Strain on the pMCL increased in scenario B (162.45 μm/m, SD 122.2 μm/m) and scenario C (185.1 μm/m, SD 117.8 μm/m). There was no statistically significant difference between both scenarios (P = .96).

Conclusion: The pMCL is notably influenced by varus force, particularly with elbow flexion at 30°. AMF coronoid fractures resulted in a higher strain of the pMCL. Repairing the pMCL in cases of AMF defects could enhance elbow stability.

Background: Although prior studies have raised concern regarding the longevity of anatomic total shoulder arthroplasty (aTSA) in young and active patients, it remains an effective treatment option for this population commonly presenting with multifactorial etiologies of shoulder arthritis. The purpose of this study was to perform a systematic review evaluating aTSA indications, outcomes, and implant survivorship in young and active patients aged 50 years or less.

Methods: A systematic review of the literature from 1980 to 2024 evaluating outcomes following aTSA in patients less than 50 years of age was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient demographics, indications for aTSA, and the number of prior shoulder surgeries were recorded when available. Outcomes included implant survivorship, revision and complication rates, indications for revision, preoperative and postoperative range of motion, as well as patient-reported outcome scores.

Results: The literature search identified 814 articles, and 9 studies met the final inclusion criteria following full-text review. A total of 173 patients (184 shoulders) were assessed across the included studies, and the mean age ranged from 33.3 to 44.2 years old. Average duration of clinical and radiographic follow-up ranged from 2.3 to 22.0 years. The most common indications for aTSA were glenohumeral osteoarthritis (37.5%) and rheumatoid arthritis (35.8%), followed by post-traumatic arthritis (8.5%), chondrolysis (7.4%), avascular necrosis (6.3%), and other (4.5%). Revision rate ranged from 3.8% (1/26 at 2.3 years) to 41.2% (7/17 at 14.5 years). Implant survivorship ranged from 80 to 100%, 95 to 100% at 0-10 years, 71% to 84% at 11-15 years, and 61% to 64% at >15 years. The most commonly reported outcome scores were the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and the visual analog scale for pain. Forward flexion increased by a mean 32° (range, 12° to 51°), abduction increased by 41° (range, 26° to 64°), and external rotation increased by 22° (range, 14° to 26°) at the final follow-up CONCLUSION: In young patients under the age of 50 years, aTSA is a reliable option for restoring shoulder function and range of motion with low revision rates and high implant survivorship at short- to mid-term follow-up. The most common indications for aTSA were glenohumeral osteoarthritis and rheumatoid arthritis. Compared to older patients, those under 50 may expect moderately inferior functional outcomes and long-term.

Background: There is evidence that patients who experience more pain and restricted motion prior to and/or after arthroscopic rotator cuff repair are more likely to heal their repairs. The mechanisms underlying this "pain and gain" phenomenon are undetermined. The aim of this study was to determine if the signaling molecules interleukin (IL)-6, IL-1β, and IL-8, which are involved in tendon healing, were associated with this "pain and gain" process postrotator cuff repair.

Methods: Tendon samples from 19 consecutive patients were collected intraoperatively from the torn edge of the supraspinatus tendon closest to the biceps tendon during arthroscopic rotator cuff repair. IL-6, IL-1β, and IL-8 cytokine staining in the tendon samples were evaluated using immunohistochemistry and quantified with QuPath software. Patient outcomes were assessed preoperatively and at 6-week, 12-week, and 24-week follow-ups. Tendon repair integrity was assessed with ultrasound. The stiffness (kPa) of the healing supraspinatus tendon preoperatively and at 6-week, 12-week, and 24-week follow-ups was quantified with shear wave elastography using an ACUSON S3000 ultrasound system (Siemens, California, USA) with a Linear 9L4 transducer.

Results: The torn tendon edges of patients with restricted preoperative range of motion (<120° forward flexion or <30° external rotation) had 1.4-fold increased expression of IL-1β (P = .03) and IL-6 (P = .01) positive cells compared to patients without range of motion restriction. Patients with increased IL-6, IL-1β, and IL-8 expression measured in the intraoperative tendon were also more likely to have increased patient-rated pain scores both preoperatively and at 6-, 12-, and 24-week follow-up. Patients who had torn tendons with increased IL-1β (r = 0.58, P = .02) and IL-8 (r = 0.69, P = .01) expression had higher tendon elastography values at 6 weeks postrotator cuff repair.

Conclusion: This data support the hypothesis that increased expression of IL-6, IL-1β, and IL-8 at the edge of the torn supraspinatus tendon is associated with a stronger healing response and stiffer, more robust tendons postrepair. Elevated cytokine levels in the intraoperative torn tendon were associated with increased pain and restricted passive range of motion and with improved tendon mechanical strength as indicated by higher elastography values in the healing tendon. In other words, IL-6, IL-1β, and IL-8 are key players in the "pain and gain" phenomenon following rotator cuff repair.

Background: Physician reimbursement for orthopedic procedures, such as total shoulder arthroplasty (TSA) and related revision surgeries, has been subject to economic pressures over the past 2 decades. Understanding trends in reimbursement, especially when adjusted for inflation, provides insight into health care economics and informs policy decisions.

Methods: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried to extract reimbursement data from 2000 to 2025 for various TSA procedures, including primary and revision surgeries. Current Procedural Terminology (CPT) codes 23470; 23472; 23473; 23474; 23334; and 23335 were included. All monetary values were converted to 2025 United States dollars using the Consumer Price Index to adjust for inflation. For each procedure, we calculated the mean annual reimbursement and trends in inflation-adjusted reimbursement through 2025.

Results: Across all procedures, there was a consistent decline in inflation-adjusted reimbursement. For instance, CPT code 23470 (hemiarthroplasty) decreased from $2,419.81 in 2000 to $1,192.43 in 2025. CPT code 23472 (TSA) showed a similar trend, declining from $2,467.96 in 2000 to $1,433.64 in 2025. Revision procedures, such as CPT code 23474 (humeral and glenoid component), experienced notable reductions, with a peak of $2,515.25 in 2015 falling to $1,718.62 in 2025. All linear regression models showed statistically significant downward trends (P < .001), with R² values ranging from 0.885 to 0.915.

Conclusion: Inflation-adjusted physician reimbursement for TSA procedures has declined substantially from 2000 to 2025. These findings highlight a continued decline in reimbursement despite stable or increasing procedural complexity, which may impact provider sustainability and access to care.

Background: Opioid overdose is a leading cause of injury-related death in the United States, prompting calls for reform in surgical prescription practices. Cold therapy units (CTUs) have been widely accepted as an adjunct to pharmacologic therapy for pain management, but these devices are not consistently reimbursed by insurance companies and have not been extensively studied in arthroscopic shoulder surgery. The purpose of our study is to assess the impact of a standardized CTU protocol on postoperative pain and opioid consumption following arthroscopic rotator cuff repair (ARCR), along with its effects on early postoperative shoulder functional outcomes.

Methods: A prospective cohort trial was conducted on adult patients undergoing primary ARCR between June 2023 and November 2024. Patients were instructed to use a commercial CTU at least 4 times daily in 30-minute sessions for a minimum of 2 weeks. Patients documented pain levels and opioid use during their first postoperative week. Patient-reported outcome measures, including the visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, were collected preoperatively and at 6 weeks, 3 months, and 6 months postoperatively. A historical cohort that followed the same multimodal pain management protocol but without use of CTU served as a control group for comparison.

Results: Fifty patients in the CTU group and 51 patients in the control group were included with no significant differences in demographics between groups. Intraoperatively, there was no difference in distribution of constructs used or number of tendons repaired. VAS scores were lower in the CTU group throughout the first postoperative week, which was statistically significant on postoperative day 2 (3.1 vs. 4.0, P = .03) but below the threshold for clinical significance. The amount of mean total morphine milligram equivalents (MME) used in the first postoperative week was significantly lower in the CTU group (115.2 ± 83.1 MME vs. 168.3 ± 96 MME, P = .02). In multivariable regression, CTU use was significantly associated with decreased postoperative opioid consumption (P = .05). There were significant improvements in ASES and DASH scores in both groups by 3 months and 6 months, respectively, but no difference between groups.

Conclusion: A standardized postoperative CTU regimen reduced opioid consumption following ARCR. Patients who used CTUs reported statistically lower but clinically equivocal VAS scores during the first postoperative week. Patient-reported functional outcomes were not affected by CTU use.

Background: Posterolateral rotatory instability (PLRI) is an instability pattern due to injury of the radial ulnohumeral ligament (RUHL) or lateral ulnar collateral ligament complex of the elbow. Recent literature has demonstrated that females may be more predisposed to this condition due to elevated levels of estrogen and progesterone. The purpose of this study was to analyze patient-reported outcome measures and return to a preinjury level of function for females who underwent operative management for PLRI.

Methods: All females who underwent surgical management of the elbow at a single academic institution between 2011 and 2021 were retrospectively reviewed. Patients were included if they underwent arthroscopic or open repair/reconstruction of their RUHL. At final postoperative follow-up, patient-reported outcome measures including Single Assessment Numeric Evaluation (SANE) and Mayo Elbow Performance Score (MEPS) were obtained. Patients were asked whether their elbow had returned to a preinjury level of function, and athletes were asked whether they returned to sport postoperatively. Subsequent complications and surgeries were also recorded.

Results: A total of 37 patients (41 elbows) were analyzed, with 90.2% (37 of 41) having undergone RUHL repair and 9.8% (4 of 41) reconstruction. Sixty-one percent (25 of 41) had acute symptoms affecting their dominant elbow. Thirty-four percent (14 of 27) of patients underwent prior surgery to their affected elbow. At a mean follow-up of 6.1 ± 2.7 years, the mean SANE and MEPS of the entire cohort at final follow-up were 95.9 ± 8.5 and 86.3 ± 14.3, respectively. Based on the MEPS, 32 elbows had excellent or good outcomes, whereas 9 had fair or poor outcomes. Eighty-three percent (34 of 41) of patients stated that their elbow returned to a preinjury level of function, whereas 92.9% (13 of 14) of athletes were able to return to sport postoperatively. There was no significant difference in outcomes between those who were treated arthroscopically vs. with an open approach (P ≥ .331), acutely vs. chronically (P ≥ .538), and those who underwent primary vs. revision surgery (P ≥ .061).

Conclusions: Females demonstrated favorable clinical outcomes at a mean follow-up of 6 years, with a majority of elbows returning to a preinjury level of function and sport, regardless of whether they underwent primary or revision surgery. In addition, there was no significant difference in outcomes for elbows treated arthroscopically or through an open approach. These findings support the efficacy of RUHL repair in females with PLRI and suggest that favorable outcomes can be achieved even in revision settings.