Journal of Shoulder and Elbow Surgery最新文献

Background: Rotator cuff (RC) repair often fails due to poor healing at the tendon-to-bone interface (TBI) and irreversible fatty infiltration (FI) of the muscle. GATA6 has emerged as a potential transcriptional regulator of tissue regeneration, but no therapeutic agents currently target this pathway.

Purpose: To evaluate the therapeutic potential of isotretinoin, a known GATA6 modulator, in enhancing TBI healing and reducing FI following RC repair in a rat model.

Level of evidence: Level Ⅴ, Controlled laboratory study.

Methods: An RC repair rat model was established using 12-week-old male Sprague-Dawley rats. In the isotretinoin group, ten rats received an oral dose of 7 mg/kg isotretinoin daily for six weeks following RC tendon transection, while the control group of ten rats received only 0.9% saline. All rats were euthanized six weeks post-surgery. FI in the supraspinatus tendon was assessed qualitatively and quantitatively. TBI healing was histologically evaluated using the Bonar score after general tissue staining. Additionally, a biomechanical assessment of TBI healing was conducted utilizing a universal testing machine.

Results: Isotretinoin treatment significantly upregulated Gata6 expression while downregulating Caveolin-1 and PPAR-γ, with no significant change in C/EBP-α expression. Activation of the PKA/CREB signaling pathway was confirmed by increased phosphorylation of PKA and CREB. Histological analysis demonstrated improved collagen organization and cellularity at the TBI. Biomechanical testing revealed greater tensile strength and stiffness in the isotretinoin group compared to controls. Fatty infiltration in the supraspinatus muscle was markedly reduced.

Conclusions: Isotretinoin promotes TBI healing and suppresses muscle-FI following RC repair, which is associated with activation of the GATA6-Caveolin-1-PKA/CREB signaling axis.

Clinical relevance: This study identifies isotretinoin as a promising pharmacologic strategy to enhance RC repair outcomes by targeting a novel molecular axis. Drug repurposing of isotretinoin may offer a translatable solution for reducing RC repair failure in clinical settings.

Background: While two-dimensional methods quantify glenohumeral relationships, they are unable to capture three-dimensional anatomy and define the geometric relationship of the humeral head in the registry of the glenoid. We hypothesize that a geometric relationship of the humeral head and the glenoid exists in the three-dimensional space defined by the relationship of the best-fit sphere of the humeral head relative to the best-fit sphere of the glenoid such that relative measurements will define the normal shoulder and the pathologic shoulder.

Methods: A retrospective cohort study was conducted using CT scans from 90 shoulders including 30 normal, 30 with glenohumeral osteoarthritis (GHOA) with Walch type A1 glenoids, and 30 with cuff tear arthropathy [CTA]). Scans were then analyzed using surgical planning software. Angular measurements were calculated including Horizontal Displacement Angle (HDA) and Vertical Displacement Angle (VDA) in the coronal plane, and subluxation angle and Relative Subluxation Axial Angle (RSAA) in the axial plane.

Results: In the coronal plane, the mean HDA was significantly higher in GHOA (73.6°) compared to normal (66.9°, P=0.003) and CTA (62.7°, P<0.01). Mean VDA was significantly elevated in CTA (54.7°) compared to normal (42.2°, P<0.01) and GHOA (41.0°, P<0.01). In the axial plane, mean subluxation angle did not significantly differ between normal (95.6°), GHOA (94.1°), and CTA (98.3°) shoulders. Similarly, the mean Relative Subluxation Axial Angle (RSAA) did not differ significantly across normal (87.6°), GHOA (90.0°), and CTA (89.9°) cohorts. However, normal shoulders demonstrated significantly less variance in both axial parameters compared to pathologic shoulders. The variance in the subluxation angle was significantly lower in normal shoulders compared to both GHOA (P=0.034) and CTA (P=0.032). Likewise, the variance in the RSAA was significantly lower in normal shoulders compared to both GHOA and CTA (P < 0.01).

Conclusion: Defined geometric relationships exist between the humeral head in the reference of the glenoid sphere. This study establishes a reliable method of using best-fit spheres of the glenoid and humeral head. The HDA and VDA in the coronal plane differentiate the normal shoulder from those with GHOA and CTA. The subluxation angle and the RSAA in the axial plane describe the glenohumeral relationship in both subluxation and relative subluxation. This method quantifies the expected relationship of the humeral head in the glenoid registry in the normal shoulder and characterizes predictable disruptions in disease, supporting improved understanding of premorbid anatomy and potential restoration of optimal shoulder function.

Background: Preoperative three-dimensional (3D) templating can improve surgical accuracy in anatomic-press-fit radial head arthroplasty (RHA). However, current imaging segmentation methods used for templating are time-consuming and prone to variability. This study aimed to train and validate an nnU-Net deep learning model to automate multiclass bone segmentation for RHA templating. We hypothesized that the nnU-Net model would achieve high accuracy in segmenting the upper extremity bones thereby supporting 3D bone templating in RHA.

Methods: A total of 93 upper extremity computed tomography (CT) scans met the eligibility criteria. Ground-truth segmentation was performed by a trained orthopedic surgeon and reviewed by a radiologist and an engineer to ensure accuracy. The nnU-Net model was trained and evaluated using the Dice Similarity Coefficient (DSC) and Hausdorff Distance to measure overlap and segmentation accuracy against manual segmentations. The 3D bone models derived from the nnU-Net model and manual segmentation were compared through Mean Surface Distance (MSD) and Root Mean Squared Error (RMSE) were determined to assess the surface variation between the bone models. The average time on segmenting each CT was compared.

Results: The nnU-Net achieved high segmentation accuracy with DSC values of 0.99 for the humerus, 0.98 for the ulna, and 0.96 and 0.95 for the cortical and non-cortical radii, respectively. The MSD remained below 0.2 mm for all bone classes. The mean RMSE values were consistent at 0.2 mm across all bones. Segmentation time averaged 3 min per scan compared to 78 min for manual segmentation, with consistent performance across gender, arm side, and CT slice thickness.

Discussion and conclusion: This deep learning model provides a fast and reliable solution for multiclass bone segmentation and demonstrates high accuracy in segmenting cortical and non-cortical regions, which are essential for RHA templating. The accuracy was consistent with clinical needs and fits below the sizing intervals of commercially available prostheses. This supports its potential utility for 3D preoperative planning in RHA, despite its inability to capture cartilage. This approach demonstrates clinical feasibility for improving efficiency and precision in templating radial head replacement surgery.

Background: Sleep disturbance is common among patients undergoing rotator cuff repair (RCR), yet the perioperative course of pain-related sleep disruption and the influence of behavioral factors are not well defined. Patients frequently ask perioperative sleep-related questions that lack evidence-based answers. This study aimed to characterize changes in sleep quality and sleeping patterns before and after RCR.

Methods: Adults undergoing primary elective RCR at a single academic center (November 2021-October 2024) were prospectively enrolled. Surveys were completed preoperatively and at 2, 6, 12, and 24 weeks postoperatively. The primary outcome was the Pain and Sleep Questionnaire 3-item index (PSQ-3; 0-300). Secondary measures included the Sleep Hygiene Index (SHI), sleep position, sling use, and 24-hour visual analog scale (VAS) for pain. Analyses used Chi-square/Fisher's tests, Kruskal-Wallis/ANOVA, and Spearman correlations, all with Bonferroni correction to evaluate sleep position changes and candidate predictors. Primary mixed-effects models used 2 weeks as the reference time and preoperative PSQ-3 and VAS scores as a covariate to identify predictors of postoperative PSQ-3 and VAS pain. Secondary models used preoperative scores as the reference to determine when outcomes improved beyond baseline.

Results: Sixty-three patients were enrolled; 50 (51 shoulders) completed final follow-up. Mean age was 59.9 ± 9.7 years, BMI 31.4 ± 6.0 kg/m², baseline SHI 10.2 ± 5.9. and PSQ-3 of 130.6 ± 99.1. At 2 weeks, back sleeping increased (85% from 39.2%, p < 0.001) and side sleeping declined (27.5% from 64.7%, p = 0.011). By 6 weeks, side sleeping partially recovered; by 24 weeks, sleep positions resembled baseline. Mixed-effects modeling demonstrated worse PSQ-3 at 2 weeks (β = +30.98, p = 0.039), followed by significant improvement below baseline by 6 weeks (β = -32.64, p = 0.030), 12 weeks (β = -56.20, p < 0.001), and 24 weeks (β = -92.55, p < 0.001). By 24 weeks, 55% of patients reported no nighttime sleep disturbance (PSQ-3 = 0). Nicotine use and preoperative side sleeping were independently associated with worse postoperative PSQ-3 and VAS scores. Additionally, Workers' Compensation status and higher preoperative pain predicted higher postoperative VAS.

Conclusions: Sleep after RCR worsens transiently but improves by 6 weeks, with continued improvement by 12 weeks and 24 weeks. Most patients resume preoperative sleep positions by 6 months. Nicotine use and preoperative side sleeping are predictors of increased pain-related awakenings during RCR recovery.

Background: Adhesive capsulitis, commonly known as frozen shoulder, is a fibro-inflammatory condition characterized by the gradual onset of pain and progressive restriction of shoulder motion, with evidence suggesting that endocrine factors may play a role in its pathogenesis. Despite biologic plausibility linking testosterone to capsular fibrosis, the relationship between endogenous androgen levels and adhesive capsulitis has not been thoroughly investigated. The purpose of this study is to assess the risk of developing adhesive capsulitis within 1 year, 2 years, and 5 years after their serum testosterone level lab draw.

Methods: A retrospective cohort study was conducted using the TriNetX research database to identify male patients aged 35 years and older who had testosterone lab levels between 2005 and 2025 and never had any surgical procedures on the shoulder. Patients were stratified into two cohorts based on serum testosterone levels: a low testosterone group (serum testosterone levels <300 ng/dL) and a normal to high-range group (serum testosterone levels 300-1000 ng/dL). Sub-analyses were performed based on excluding and including patients receiving testosterone replacement therapy. Risk ratios (RR), confidence intervals (CI), and p-values were calculated using Student's t-tests and chi-square tests, as appropriate.

Results: After propensity score matching, 301,219 patients were included in each testosterone cohort. Patients with normal-high testosterone levels had a significantly greater risk of adhesive capsulitis compared with those with low testosterone at 1 year (0.17% vs 0.14%, RR = 1.23, 95% CI 1.08-1.39, p = 0.002), 2 years (0.29% vs 0.25%, RR = 1.17, 95% CI 1.06-1.29, p = 0.002), and 5 years (0.54% vs 0.48%, RR = 1.12, 95% CI 1.05-1.21, p = 0.001) from their lab draw. When excluding men on testosterone replacement therapy (TRT), results remained consistent across all time points-1 year (0.15% vs 0.12%, RR = 1.23, 95% CI 1.03-1.47, p = 0.022), 2 years (0.26% vs 0.22%, RR = 1.17, 95% CI 1.03-1.34, p = 0.019), and 5 years (0.47% vs 0.42%, RR = 1.13, 95% CI 1.03-1.25, p = 0.013). Among patients on TRT, no significant differences were observed at 1 year (0.19% vs 0.16%, RR = 1.18, 95% CI 0.97-1.45, p = 0.106) or 2 years (0.35% vs 0.30%, RR = 1.15, 95% CI 0.99-1.34, p = 0.061), although risk was significantly elevated at 5 years (0.67% vs 0.59%, RR = 1.15, 95% CI 1.03-1.28, p = 0.010).

Conclusions: Normal-high endogenous testosterone levels (300-1000 ng/dl) were associated with an increased risk of adhesive capsulitis. These findings highlight the importance of considering hormonal status in adhesive capsulitis risk assessment, and prospective studies with direct hormone measurements are warranted to validate these associations.

Introduction: Weightlifting is a common form of recreational activity that can place higher levels of stress on the shoulder joint and is of particular interest to many patients undergoing shoulder arthroplasty. Despite the growing number of individuals receiving anatomic and reverse total shoulder arthroplasty (rTSA), recommendations regarding return to weightlifting remain unclear. The purpose of this study was to report the rate of return to weightlifting following primary shoulder arthroplasty and to evaluate postoperative function and performance outcomes.

Methods: A retrospective review of a single institution's shoulder and elbow surgery repository identified patients who underwent anatomic total shoulder arthroplasty (aTSA), hemiarthroplasty (HA), or rTSA by a single fellowship-trained shoulder and elbow surgeon between February 2009 and August 2023. Patients who self-identified "weights" or "weight training" as a usual sport on the American Shoulder and Elbow Surgeons (ASES) questionnaire at a minimum two-year follow-up were included. Demographics, surgical indications, range of motion (ROM), patient-reported outcome measures (ASES, SANE, SST, VAS pain/function), and return to weightlifting status were analyzed and compared between anatomic (aTSA/HA) and reverse (rTSA) cohorts.

Results: Of the 200 shoulder arthroplasty patients self-identified as weightlifters, 184 patients (92%) met inclusion criteria with a mean follow-up of 66.6 ± 34.7 months. The mean age was 64.8 ± 8.1 years, and 76.6% were male. Overall, 70.1% of patients reported no difficulty performing their usual weightlifting activities, 21.7% reported some difficulty, 7.6% reported great difficulty, and only one patient (0.5%) was unable to participate. There was no statistically significant difference in rates of full return to weightlifting between patients treated with aTSA or HA and those treated with rTSA (74.3% vs 56.8%, p = 0.10). Postoperative range of motion only differed for internal rotation (8 vs 4, p=0.001). Both cohorts achieved substantial postoperative improvements in ASES (mean 86.1 ± 16.8), SANE (83.4 ± 21.6), SST (10.3 ± 2.0), and VAS pain (1.3 ± 2.2) scores.

Conclusion: Shoulder arthroplasty patients can expect a high likelihood of returning to weightlifting without difficulty, with excellent pain relief and functional improvement.

Level of evidence: Level III, Retrospective Cohort Comparison, Prognosis Study.

Background: Shoulder arthroplasty effectively treats various degenerative and traumatic shoulder conditions, but outcomes can be compromised by complications, limited mobility, and persistent pain. The impact of previous non-arthroplasty surgery on functional outcomes remains unclear. Therefore, the purpose of this study is to determine if a history of prior non-arthroplasty shoulder surgery is associated with worse functional outcomes after primary shoulder arthroplasty.

Methods: This registry study with data sourced from the Dutch Arthroplasty Register (LROI) includes adult patients who underwent primary arthroplasty between 2014 and 2022, with or without a history of prior non-arthroplasty shoulder surgery. Prior surgeries were divided in the following categories: osteosynthesis, stabilization, rotator cuff, subacromial decompression, and other shoulder surgeries. The outcomes of the study include revision rate, shoulder function and shoulder pain.

Results: 25,188 shoulder arthroplasty procedures were recorded in the registry between 2014 and 2022. Of the procedures, 18,160 (72.1%) were reverse total shoulder arthroplasty, 4,772 (18.9%) anatomic total shoulder arthroplasty, and 2,256 (9.0%) hemi shoulder arthroplasty. A total of 4,203 patients (16.7%) underwent prior shoulder surgery, while 20,985 (83.3%) did not. From 2017 onwards, completion rates of PROMs ranged from 21.2% to 30.0%. Prior shoulder surgery was associated with higher chance of revision surgery (HR (95%CI) = 1.48 (1.31 to 1.68), n=25,188). Prior surgery was associated with less improvement in shoulder function (regression coefficient (95%CI) = -2.84 (-3.83 to -1.84), n=3,206), less improvement in pain score at rest (regression coefficient (95%CI) = -0.57 (-0.77 to -0.37), n=3,325) and less improvement in pain during activity (regression coefficient (95%CI) = -0.64 (-0.88 to -0.41), n=3,318) after 12 months. Patients with a history of osteosynthesis (HR (95%CI) = 1.58 (1.31 to 1.91)) or rotator cuff repair (HR (95%CI) = 1.47 (1.18 to 1.83)) had lower prosthesis survival compared to those without such interventions.

Conclusions: A history of non-arthroplasty shoulder surgery is associated with higher revision rates and poorer patient-reported outcomes after primary shoulder arthroplasty. These findings highlight the importance of surgical history in preoperative counseling and risk stratification.

Background: Fragment displacement is a key determinant of treatment strategy and functional outcomes in isolated greater tuberosity (GT) fractures. However, the relative contributions of fracture morphology and shoulder dislocation to displacement remain unclear. This study aimed to identify factors associated with fragment displacement, with a particular focus on facet involvement, fracture type, and the presence of shoulder dislocation using three-dimensional (3D) computed tomography (CT). Secondary displacement during nonoperative management was also explored.

Methods: We retrospectively analyzed 102 shoulders (mean age 64.5 ± 14.5 years) with isolated greater tuberosity fractures, including shoulders with and without anterior dislocation. Using 3D CT images obtained at the time of injury, fracture morphology was evaluated based on the number of rotator cuff attachment facets (superior, middle, inferior) and fracture type, classified as Avulsion, Split, or Depression. Fragment displacement was defined as ≥5 mm translation in any direction and was assessed on post-reduction CT in dislocation cases. Associations between fragment displacement, fracture morphology, and the presence of dislocation were analyzed using chi-square tests and multivariate logistic regression. Secondary displacement during follow-up was evaluated in nonoperatively managed shoulders using standard radiographs.

Results: Overall, 65 shoulders (63.7%) exhibited ≥5 mm displacement. Displacement correlated significantly with the number of involved facets (p < .001), fracture type (p = .008), and dislocation (p = .011). In the displaced group, 3 facets were involved in 49 shoulders, compared with only 8 in the non-displaced group. Multivariate logistic regression identified facet count as the strongest independent factor (odds ratio [OR] 7.72; 95% confidence interval [CI] 3.06-19.44; p < .001). Compared with Depression-type fractures, Split-type fractures showed a significantly higher risk of displacement (OR 14.9; 95% CI 1.78-125.0; p = .013). Dislocation was associated with displacement on univariate analysis but did not remain an independent predictor after adjustment (OR 3.01; p = .071). Among 34 nonoperatively managed shoulders, secondary displacement occurred in 4 cases and was more frequently observed in fractures involving three facets and in Split-type fractures.

Conclusion: Fragment displacement in GT fractures is most strongly associated with the number of involved facets, suggesting that the extent of rotator cuff attachment has a major influence on fragment stability. Although dislocation was associated with an increased risk of displacement, facet morphology was the decisive determinant. CT-based assessment of facet involvement provides valuable information for understanding displacement risk in GT fractures.