Journal of Shoulder and Elbow Surgery最新文献

Hypothesis and background: As the incidence of reverse total shoulder arthroplasty (RTSA) continues to rise, better understanding of the long-term risks and complications is necessary to determine the best choice of implant. The majority (75%) of RTSA performed in New Zealand use either SMR (Systema Multiplana Randelli, Lima-LTO, Italy) or Delta Xtend (DePuy Synthes, USA). The aim of this registry-based study was to compare implant survival, risk of revision and reasons for revision between the two most frequently used RTSA prostheses: SMR and Delta Xtend.

Methods: Using data from the New Zealand Joint Registry between 1999 and 2022, we identified 5,891 patients who underwent RTSA using either SMR cementless (62.8%) or Delta Xtend prostheses (37.2%). Delta Xtend was sub-divided into cementless (31.4% of total) and cemented humeral stem (5.8% of total) sub-groups for analysis. Revision-free implant survival and functional outcomes (Oxford Shoulder Score [OSS] at 6-months, 5-years, and 10-years were adjusted by age, American Society of Anesthesiologists (ASA) grade, indication, sex, and surgeon volum for between-group comparisons.

Results: Ten-year revision-free implant survival was 93.0%, 92.5%, and 95.8% for Delta Xtend cemented, Delta Xtend cementless and SMR, respectively. The Delta Xtend cemented implant had a two-fold higher adjusted revision risk compared to both the Delta Xtend cementless and the SMR cementless implants (Hazard Ratio [HR]=2.04, p=0.011; and HR=2.59, p<0.001, respectively). There was no significant difference between the Delta Xtend cementless and SMR cementless groups (HR=1.28, p=0.129). The Delta Xtend cemented group was significantly (p≤0.01) older, more co-morbid (ASA 3-4), female and indicated for fracture compared to other groups. The most common reason(s) for revision was aseptic loosening and infection for Delta Xtend cementless; aseptic loosening, instability/dislocation and infection for Delta Xtend cemented; and aseptic loosening alone for SMR cementless. Average OSS was significantly lower in Delta Xtend cemented compared to Delta Xtend cementless and SMR cementless at 6 months (30.8, 35.9 vs. 35.6, respectively, p<0.01) and 5 years (37.4, 40.7 vs. 39.5, respectively, p<0.01).

Conclusions: Overall, we found Delta Xtend cemented group had over two-fold the risk of revision compared to Delta Xtend cementless and SMR cementless groups, while there was no difference in revision risk between the Delta Xtend and SMR cementless prostheses. As the incidence of reverse total shoulder arthroplasty (RTSA) continues to rise, better understanding of the long-term risks and complications is necessary to determine the best choice of implant.

Background: Arthroscopic repair is recommended for patients with bony Bankart lesions to restore anterior shoulder stability and avoid recurrent glenohumeral instability. The aim of this study was to investigate the clinical and radiological outcomes of patients following arthroscopic bony Bankart repair using a single suture anchor fixation technique named the "door-locking" technique.

Methods: From January 2017 to February 2024, a consecutive series of 22 patients with acute bony Bankart lesions underwent shoulder arthroscopy. The size of the fragment was measured using computed tomography (CT). The range of motion (ROM) and functional scores including the American Shoulder and Elbow Surgeons (ASES) score, the University of California, Los Angeles (UCLA) score, and Rowe score were assessed preoperatively, immediately after the surgery, and at the final follow-up. The adequacy of reduction and union of the bony fragment were evaluated by CT postoperatively. Intra- and postoperative complications and patient satisfaction were evaluated.

Results: Four women and 18 men were included in the study, with an average age of 39.4 years (range, 21-68 years). The mean time from the initial injury to surgery was 16.5 days (range, 3-45 days). The average glenoid bone defect was 21.1% (range, 9%-45%). The operation time ranged from 45-150 minutes, with an average of 80.4 minutes. The mean duration of follow-up was 28.0 months (range, 4-54 months). The mean ASES score, UCLA score, and Rowe score improved from 42.1, 11.6, and 56.0 preoperatively to 91.8, 31.1, and 93.2 at the last follow-up, respectively (all P < 0.05). At the final follow-up, the ROM in terms of forward elevation, external rotation, and internal rotation was significantly improved compared with that before surgery. There was no recurrence of instability. No serious complications (e.g., infection, thrombosis, and re-dislocation) occurred. The postoperative CT scan showed adequate reduction and complete union of the bony fragment in 20 cases. However, the bony fragments were not anatomically reduced in two patients due to a large fragment size. All patients were satisfied or very satisfied with the outcome.

Conclusion: The arthroscopic "door-locking" technique is a valid method for treating acute bony Bankart lesions with an intact capsular-labrum-ligament complex. This method has a low complication rate and is associated with high levels of patient satisfaction.

Introduction: Patient Reported Outcome Measurement Information Systems (PROMIS) is increasingly being utilized across the United States as a patient reported outcome evaluation tool for a wide variety of musculoskeletal conditions. However, PROMIS Upper Extremity physical function (P-UE) has demonstrated limited responsiveness in the early postoperative period after total shoulder arthroplasty (TSA). The aim of this study is to determine if addition of PROMIS Pain Interference (P-Interference) or Pain Intensity (P-Intensity) scores improve the ability to detect postoperative changes in the one-year postoperative period following TSA.

Methods: Patients who were indicated for and elected to undergo TSA between 2020-2022 were prospectively enrolled. Prospective data was collected for patient surveys (ASES, SST, WOOS, P-UE, P-Interference and P-Intensity) at the 2-week, 6-week, 3-month, 6-month and 12-month timepoints. Instrument responsiveness for each PROM was evaluated using the effect size (ES; Cohen d). Responsiveness was defined by the absolute values of each measurement, previously reported as small (0.2), medium (0.5), or large (0.8). Statistical analysis (two sample t-tests and Fisher's tests) was performed using R studio version 4.2.3 (Boston, MA, USA).

Results: A total of 127 subjects were enrolled in this study. All survey instruments demonstrated large responsiveness (>0.8) at 3, 6 and 12-months. P-Intensity was the only instrument to demonstrate large responsiveness at 2-weeks with its addition to P-UE showing an improved responsiveness at all time points. Moreover, the addition of P-Intensity had a lower response burden at all time points when compared to the legacy measures (ASES, SST and OSS) at all time points albeit no difference to ASES (p=0.55) at 12-months after surgery. P-Interference, and other legacy scores demonstrated large responsiveness starting at 6-weeks postoperatively.

Conclusion: The responsiveness of PROMIS UE can be improved by coupling the outcome measure to P-Intensity scores with a significantly lower response burden when compared to the legacy measures evaluated at nearly all time points.

Background: There is conflicting evidence on the impact of mental health on postoperative outcomes following total joint arthroplasty. Specific to shoulder arthroplasty there is a lack of data investigating the correlation between mental health and surgical outcomes. Most studies have focused on patient-reported outcome measures, while few have explored objective clinical outcomes. Additionally, studies that do explore clinical outcomes often fail to control for comorbidities. The purpose of this study is to determine if the presence of a mental health condition is associated with poorer outcomes after shoulder arthroplasty when accounting for covariates.

Methods: A retrospective chart review was performed on patients who underwent primary shoulder arthroplasty between 2007 and 2022 at a single institution. Mental health diagnoses assessed included disorders associated with depression, anxiety, trauma, alcohol-use disorder, bipolar disorder, and schizoid disorders. Multivariable regression modeling was used to control for confounding variables and assess the likelihood of adverse clinical outcomes for patients with mental health disorders. Patient-reported outcome measures were also collected and compared.

Results: 1169 patients underwent shoulder arthroplasty between January 2007 and September 2023 at our institution. After controlling for covariates, all-cause readmission within 90 days was found to be significantly associated with alcohol-related disorders (OR = 3.22 [95% CI, 1.30-7.23], p = .007) and bipolar disorders (OR = 4.21 [95% CI, .88-15.58], p = .043).

Conclusion: After adjusting for covariates, alcohol-related and bipolar disorders may be associated with increased risk of 90-day readmission after shoulder arthroplasty, but further investigation is necessary in order to better assess these effects. No associations were found between any mental health disorders and 90-day reoperation of the same joint, 365-day mortality, or patient-reported outcomes.

Background: Subscapularis tendon (SSC) tears have recently become an area of current research focus. However, the risk factors for atraumatic isolated SSC tears, particularly anatomical factors, remain poorly determined. Therefore, the purpose of this study was to identify the associated factors contributing to isolated SSC tears.

Methods: This study involved single shoulders of 605 subjects drawn from a cohort of rural residents. The inclusion criteria required each subject to sign an informed consent document and to have a complete clinical evaluation. The exclusion criteria comprised the absence of a complete magnetic resonance imaging study, current medication use that might have affected serum lipid levels, a history of shoulder trauma or surgery, and the presence of osteoarthritis, calcific tendinitis, frozen shoulder, or superior or posterosuperior rotator cuff tear. Diagnoses of isolated SSC tear were based on magnetic resonance imaging findings. Logistic regression analysis was conducted using demographic, physical, social, anatomical, comorbidities, and serological parameters. Anatomical variables included the supraspinatus fossa glenoid angle on axial (SGAX), a method to measure glenoid version, coracohumeral distance on axial and sagittal plans, and coracoid index. When multicollinearity among studied variables was detected, separate multivariable analyses were performed to address this issue, with each analysis including only one of those multicollinear variables along with the other significant variables obtained from univariate analyses.

Results: Among anatomical variables, coracohumeral distance on axial and sagittal planes, as well as the coracoid index, did not show significant associations. However, SGAX, an index of glenoid version, was found to be significantly associated with atraumatic isolated SSC tears. Greater glenoid retroversion is significantly associated with atraumatic isolated SSC tears, along with age, waist circumference, dominant side involvement, manual labor, diabetes, metabolic syndrome, and biceps tendon injury (P ≤ .013).

Conclusions: The SGAX, serving as an index for glenoid version, is an independently associated factor for atraumatic isolated subscapularis tendon tears, with greater glenoid retroversion being an anatomical risk factor for these tears, along with overuse-related factors such as dominant-side involvement and manual labor, as well as metabolic factors such as obesity, diabetes, metabolic syndrome, and biceps tendon injury.

Background: The Latarjet procedure is considered the gold standard for treating patients with anterior shoulder instability in the presence of critical glenoid bone loss. Proponents of the Latarjet contend that its efficacy is in-part attributable to the "sling effect" of the conjoint tendon; however, recent studies have demonstrated similar restoration of anterior stability in patients undergoing free bone block (FBB) procedures. The purpose of this systematic review was to evaluate the biomechanical and clinical evidence for the sling effect.

Methods: A systematic review was performed per PRISMA guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried separately for (1) controlled laboratory studies comparing the restoration of anterior stability with and without an intact, tensioned conjoint tendon and (2) comparative clinical studies comparing patient outcomes after Latarjet versus a FBB procedure. A descriptive synthesis of the controlled laboratory studies and a quantitative meta-analysis of comparative clinical studies was performed.

Results: Six controlled laboratory studies and four comparative clinical studies were included. Four of the laboratory studies supported the presence of a sling effect, whereas two studies concluded there was no added effect; however, their data trended in favor of improved anterior stability with the sling effect. Meta-analysis of the four comparative clinical studies demonstrated no difference between Latarjet and FBB for any range of motion measure, outcome score, or the odds of recurrent instability (Odds ratio: 0.83, 95% confidence interval: 0.20-3.52), which is concordant with the findings of each individual study.

Conclusion: While both Latarjet and FBB procedures are efficacious in restoring stability, our critical review of the literature suggests that the reduction in anterior translation attributed to the "sling effect" in biomechanical cadaveric studies is not clinically relevant when sufficient anterior glenoid bone has been restored.

Background: Radiographs are frequently obtained after total shoulder arthroplasty (TSA) to confirm implant placement and follow the status of the bone and prostheses; however, standardization of their use is lacking. There are concerns regarding frequent use of radiographs due to their cost and patient radiation exposure. The aim of this study is to assess the postoperative radiograph frequency and efficacy in primary anatomic and reverse total shoulder arthroplasty. We hypothesize that multiple radiographs taken beyond the initial 2-week postoperative interval are of uncertain benefit for both primary anatomic and reverse total shoulder arthroplasties, regardless of the presence of symptoms.

Methods: A retrospective chart and imaging review was conducted on all patients who underwent primary TSA between 2014 and 2021, with documentation of at least 2 years of follow-up. All available postoperative radiographs, radiologist interpretations, and clinic notes were followed up for 2 years after the date of surgery, or until another surgery was performed within the 2-year timeframe. Radiographs were assessed for component positioning, fractures, loosening, and dislocation. Clinic notes were also checked for changes in patient management. Patients were grouped by surgery type (anatomic/reverse).

Results: A total of 213 patients (234 surgeries) were identified (55 anatomic TSA, 179 reverse TSA). The mean number of radiographs within the first 2 years of surgery was 3.6 for anatomic TSA and 4.0 for reverse TSA. 166 patients were asymptomatic and had only 3 positive X-rays and zero revision rate in the first 2 years. No changes in management were implemented based on these routine radiographs. 68 surgeries were symptomatic, of which 21 had positive X-rays. Of this subgroup, 19 (90.5%) underwent revision.

Conclusion: Routine radiographs are overused and typically do not lead to any changes in asymptomatic patients in the first 2 years after TSA. For patients experiencing pain or limited range of motion, ongoing assessment using additional X-rays, CT scans, or other diagnostic tests is recommended for effective monitoring.

Background: Clinically important improvement after total shoulder arthroplasty is often assessed with shoulder-specific patient-reported outcome measures (PROMs) quantifying reduction in pain and restoration in function. It is unclear if commonly utilized threshold such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), or patient acceptable symptom state (PASS), represent optimal improvement from the patients' perspective. The objectives of this study were to utilize the Simple Shoulder Test to: 1) compare commonly utilized thresholds for change in score and final score to thresholds optimized to patient satisfaction using receiver operative characteristic (ROC) curve analysis, and 2) determine the impact of using different thresholds on reporting of independent predictors of successful outcome in terms of patient satisfaction.

Methods: This study included 406 anatomic total shoulder arthroplasty (aTSA) patients from a longitudinally maintained database with two-year follow-up. Surveys included the Simple Shoulder Test (SST) and a satisfaction questionnaire. SST thresholds were calculated by commonly described techniques for MCID, SCB, %MPI (percentage of maximal possible improvement), and PASS. ROC curves were constructed to determine the optimal threshold of SST change in score (Change-ROC), final SST score (Final-ROC), and %MPI (%MPI-ROC) based on patient satisfaction. Youden's index (J) was calculated to determine each threshold's performance in maximizing sensitivity and specificity. Multivariable analysis was performed to determine predictors of surpassing selected threshold values.

Results: The thresholds with the highest Youden's index correlating best with patient satisfaction were %MPI-ROC (aTSA 61%, J=0.49; RnR 63% J=0.64) and Final-ROC (aTSA 9.5, J=0.48; RnR 9.5 J=0.60). Commonly utilized thresholds including MCID of 2.0 (J=0.21) and SCB of 2.7 (2.7) had the lowest Youden's index of the thresholds studied. Characteristics predictive of success varied substantially based on selected threshold.

Conclusions: Current thresholds commonly utilized to gauge success after aTSA have limited ability to predict success based on patient satisfaction using the Simple Shoulder Test. Given that focus in healthcare value is shifting towards patient satisfaction, optimal thresholds utilized to measure success after shoulder arthroplasty may require reconsideration.

Prosthetic arthroplasty has emerged as a major contributor to the management of shoulder disorders. This paper outlines the situation in Australia regarding the process by which shoulder replacement devices are made available. Although entry of joint replacement devices to the Australian market is relatively unrestricted, they must be first approved by the Therapeutic Goods Administration-based on safety and efficacy-to be legally used. In addition, to obtain a private insurance rebate (Prescribed List) and thus be commercially viable, the Federal Department of Health and Aged Care requires a more stringent benchmark of comparative clinical effectiveness and value for money. The AOANJRR (Australian Orthopaedic Associate National Joint Replacement Registry) records the implantation and possible revision of virtually all (>98%) major joint arthroplasties in Australia and plays an important role in informing surgeons about their implant selection, but also in identifying and highlighting devices with a higher than anticipated rate of revision. Although the increased cost of health care is placing pressure on health care systems around the world, in Australia, access to shoulder arthroplasty remains relatively unrestricted-but carefully controlled and monitored.

Background: The debate surrounding the influence of the open Latarjet procedure on postoperative scapular motions persists, and there is no evidence regarding its effects on periscapular muscle activation. This study aimed to assess the short-term influence of the open Latarjet procedure on scapular kinematics and periscapular muscle activity during arm raising and lowering based on comparisons between patients and healthy athletes.

Methods: 22 healthy male athletes and 22 male athletes scheduled for glenohumeral stabilization surgery by the open Latarjet procedure were included. Scapular kinematics, periscapular muscle activities, and shoulder-related quality of life were recorded before surgery and 3 months postoperatively for the Latarjet group. For the healthy group, same assessments were performed 3 months apart. Bilateral differences in both scapular kinematics and periscapular muscle activation ratios and the Western Ontario Shoulder Instability (WOSI) index were defined as dependent variables.

Results: Scapular kinematics of the operated shoulder, namely scapular upward/downward rotation, internal/external rotation, and anterior/posterior tilt recorded between 20° and 120° of humerothoracic elevation, showed no alterations 3 months after surgery (P > .05) and did not differ from those observed in healthy athletes (P > .05). Similarly, all periscapular muscle activations were not different within time and between groups (P > .05). The WOSI index of the operated shoulder was significantly improved postoperatively (871.9 ± 443.7 vs. 1346.3 ± 552.3) but remained higher than the WOSI indices of the nonoperated shoulder or those of the healthy group (52.7 ± 75.6).

Conclusions: This study emphasizes the short-term effects of the open Latarjet procedure, demonstrating an improvement in the shoulder-related quality of life 3 months after surgery. Notably, during this period, both kinematics and periscapular muscle activity remained consistent and similar to the patterns observed for healthy athletes.