Journal of Shoulder and Elbow Surgery最新文献

Background: Surgical technique has been shown to influence risk of surgical site infection following rotator cuff repair (RCR). Few studies have reported the rate of infection associated with mini-open RCR. The goal of this study was to report the postoperative infection rate and risk factors for infection among patients undergoing RCR performed by a single surgeon using a modified mini-open technique. Our hypothesis was that the rate of infection after mini-open RCR would be lower than previously reported for this surgical approach.

Methods: We retrospectively reviewed an institutional shoulder surgery database to identify patients who underwent mini-open RCR performed by one surgeon at an academic tertiary care institution between 2003 and 2020. Patient records were reviewed to determine which individuals returned within 3 months postoperatively with a superficial or deep surgical site infection requiring operative management. Patient demographics, preoperative clinical characteristics, intraoperative variables, microbiological findings, infection management, and clinical course after infection were recorded. Backward elimination multivariate regression was used to assess for significant risk factors for infection.

Results: Of the 925 patients identified, 823 (89%) had at least 3 months of follow-up and were included for further analysis. A majority of the patients undergoing RCR were men (57%). The mean age was 58.4 ± 9.9 years, and the mean body mass index was 29.3 ± 5.9 kg/m². Fourteen cases (1.7%) of postoperative surgical site infection were identified in 13 patients. Ten infections (1.2%) were superficial and 4 (0.49%) were deep. The most commonly identified organisms were Staphylococcus aureus and Cutibacterium acnes. Male sex (odds ratio [OR] 4.3, 95% CI 1.2-15.3) and diabetes mellitus (OR 3.9, 95% CI 1.2-12.6) were found to be associated with greater risk of infection. The RCR construct was found to be intact in all 10 patients with superficial infections and 2 of the 4 patients with deep infections. All infections were successfully treated with 1 round of surgical débridement and wound irrigation, and with 6 or fewer weeks of intravenous antibiotic therapy. All patients with postoperative infections recovered with no sequelae at a median final follow-up of 63.5 months (range, 3-215 months).

Conclusions: This single-surgeon series of a large patient cohort undergoing mini-open RCR over an 18-year period demonstrated a low overall infection rate of 1.7%. Only 4 infections were deep, which suggests that deep infection after mini-open RCR is uncommon and approximates infection rates seen with arthroscopic techniques.

Background: As the average age of patients undergoing shoulder arthroplasty (SA) increases, the frequency of SA patients with osteoporosis is expected to rise. While the effects of osteoporosis have been described in the broader orthopedic literature, it is presently unclear how osteoporosis affects SA postoperative medical and implant-related outcomes.

Methods: A multicenter database TriNetX was queried for patients between 2011-2021 who underwent SA with and without osteoporosis. Patients with less than 2-years of follow-up and those with a prior shoulder hemiarthroplasty were excluded. Primary outcomes included 2-year periprosthetic joint infection (PJI), prosthesis dislocation, periprosthetic fracture, and revision surgery. Secondary outcomes included 90-day medical complications and readmissions. Osteoporotic and control patient cohorts were propensity matched in a 1:1 ratio.

Results: 7,842 patients were included after matching in each cohort. Baseline demographic variables were similar between groups, except osteoporotic patients had a lower BMI (28.6 vs 31.0 kg/m²; p < 0.001). Osteoporotic patients undergoing SA were more likely to experience wound disruptions, stroke, pulmonary embolism, deep vein thrombosis, myocardial infarction, anemia, pneumonia, renal failure, transfusion, and readmission within 90 days after surgery. At 2 years postoperative, osteoporotic SA patients experienced an elevated risk of mechanical loosening, PJI, dislocation, periprosthetic fracture, and required revision surgery at a higher rate than control patients.

Conclusions: Osteoporotic patients undergoing shoulder arthroplasty are at greater risk for medical complications within the 90-day peri-operative period as well as implant-related complications within 2 years of surgery. Patients and surgeons should be aware of the potential higher risk of complications in osteoporotic patients following SA, and further investigation into benefits of preoperative management and treatment of osteoporosis is necessary.

Hypothesis: Delivery of soluble allogeneic type I telocollagen (allo-telocollagen) will accelerate and improve the healing of damaged tendons. Our hypothesis draws from known mechanochemical properties of type I collagen that direct its incorporation into damaged connective tissue. We further suggest that allo-telocollagen will raise a minimal immunogenic reaction due to homology within species.

Methods: Seventy-eight shoulders (39 Sprague-Dawley rats) had their supraspinatus tendon surgically detached from its footprint on the humerus and repaired (72 shoulders) or left uninjured (6 shoulders). The repaired tissue was treated with an injection of 100 μl of saline, 10 mg/ml allogeneic atelocollagen (allo-atelocollagen), or 10 mg/ml allo-telocollagen at 0-, 1-, and 2-weeks post-surgery. At 30- and 60-days post-surgery, the tendons were assessed by mechanical testing (failure load, failure stress, stiffness, and relaxation) and by semiquantitative histological scoring.

Results: At 30-days post-surgery, the mechanical and histological outcomes were not statistically different. However, at day 60, allo-telocollagen improved the failure strength of the supraspinatus (29.9 ± 4.7 N) relative to saline (20.0 ± 3.5 N; P value <= 0.001) or allo-atelocollagen (23.2 ± 1.5 N; P value = 0.025) treated tendons, and it approached that of uninjured controls (36.9 ± 5.0 N; P value = 0.021). Allo-telocollagen improved the failure stress of the supraspinatus (34.1 ± 9.3 MPa) relative to the saline treated tendons (21.4 ± 6.0 MPa; P value = 0.031; 160% improvement) and was no different than uninjured controls (33.4 ± 9.9 MPa; P value = 0.999) or allo-atelocollagen (32.3 ± 7.4 MPa; P value = 0.977). The stiffness of uninjured controls was far greater than any of injured/treated tendons (>200% stiffer). Histological scoring showed that the allo-telocollagen treated tendons produced better collagen fiber arrangement (1.55 ± 0.17) than saline (2.50 ± 0.29; P value = 0.001) or allo-atelocollagen (2.23 ± 0.28; P value = 0.042) treated tendons and that it did not increase markers of immunogenesis (1.10 ± 0.42) relative to either saline (1.44 ± 0.20; P value = 0.369) or allo-atelocollagen (0.68 ± 0.41; P value = 0.1058).

Conclusions: While all three treatments produced similar results at 30 days, by 60 days, soluble allo-telocollagen clearly separated from the other interventions, yielding better mechanical and histological outcomes in a torn/repaired rotator cuff rat model. Allo-telocollagen treated tendons also approached the failure strength and matched the failure stresses of uninjured control tendons. The data suggest a new use for allo-telocollagen as a deliverable direct protein mechanotherapeutic that can improve both healing quality and speed.

Background: Humeral distalization is inherent to reverse total shoulder arthroplasty (rTSA) and is often produced with concomitant humeral lateralization via the level of the humeral head cut, implant positioning, implant neck shaft angle, and polymer insert thickness. Biomechanical data on the isolated effects of humeral distalization remain limited but could be important to consider when optimizing postoperative rTSA shoulder function. This study investigated the effects of isolated humeral distalization on shoulder biomechanics using a biorobotic shoulder simulator.

Methods: Eight fresh-frozen cadaveric shoulders were tested using custom polymer inserts that translated the bearing surface 0, +5, +10, and +15 mm along the humeral stem axis, producing isolated distalization without lateralization. Specimens underwent passive elevation in the scapular plane with a static scapula to assess glenohumeral range of motion. Scapular plane abduction motion trajectories were then performed, driven by previously collected scapulothoracic and glenohumeral kinematics from rTSA patients. The effect of isolated distalization on passive elevation was tested using mixed-effects linear regression and the effect on muscle force, joint reaction force, and muscle excursion during active scapular-plane abduction was tested using statistical parametric mapping random effects analysis.

Results: Maximum passive scapular plane elevation increased with humeral distalization (4° per 5 mm distalization). During active elevation, deltoid and rotator cuff muscle forces, and joint reaction forces, increased up to 37% per 5 mm of distalization. Simulated deltoid muscle excursion was altered with increasing distalization but amounted to no more than 0.8 mm change from baseline per 5 mm of distalization. Rotator cuff muscles were consistently lengthened throughout abduction, up to 1.6 mm per 5 mm of distalization. These trends were observed across various patient motions.

Conclusions: Isolated humeral distalization caused dramatic increases in the muscle forces required to perform scapular-plane abduction. Joint reaction forces increased correspondingly. These results suggest that implant and surgical strategies to generate deltoid muscle tension without humeral distalization may promote better active range of motion and more durable long-term outcomes over approaches that rely on distalization.

Background: Nontraumatic shoulder pain is a prevalent issue among male high school volleyball players, but its comprehensive assessment has been lacking in prior research, which often isolated specific aspects of shoulder function. This study aimed to identify contributing factors to shoulder pain in this population.

Hypothesis: The hypothesis posited that limited shoulder internal rotation (IR) range of motion (ROM), imbalance in rotator cuff muscle strength, intrinsic sensory disturbance, and joint stability are associated with shoulder pain in male high school volleyball players. Additionally, there was an anticipation that a substantial proportion of players would experience shoulder pain but refrain from reporting it to coaches.

Methods: Forty-nine male volleyball players aged 15-17 years were evaluated between February and June 2023. Questionnaires assessed the prevalence of shoulder pain during spiking and/or serving, as well as the frequency of reporting this pain to coaches. Various factors, including acromio-humeral distance, shoulder ROM, isometric strength, proprioception, joint stability (Upper Quarter Y-Balance Test), joint position sense, and upper extremity power (Seated Medicine Ball Throw Test; SMBT), were quantified. Logistic regression analyses was conducted to explore potential connections between these variables and shoulder pain.

Results: Shoulder pain was reported by 39% of participants, but it was rarely communicated to coaches (95%). Jump serves (odds ratio 1.84, p=0.02) and reduced shoulder IR ROM (odds ratio 0.94, p=0.03) were associated with shoulder pain.

Conclusion: This study provides crucial insights into the prevalence, severity, and associated factors of shoulder pain among male high school volleyball players. The findings underscore the importance of improving athlete-coach communication to facilitate early intervention and preventive measures. Significant associations were observed between the use of jump serves, reduced shoulder internal rotation range of motion, and shoulder pain, highlighting the relevance of specific volleyball techniques in injury prevention. These findings offer valuable guidance to coaches and trainers in developing interventions aimed at mitigating the risk of shoulder pain and enhancing player performance.

Background: Patients undergoing reverse shoulder arthroplasty (RTSA) have been noted on postoperative radiographs to have a curved bony overgrowth on the inferior glenoid neck. This study aims to investigate potential risk factors for and postoperative effects of these ossifications, here called glenoid hyperostosis (GHOST) lesions due to their location.

Methods: A retrospective review of patients undergoing reverse total shoulder arthroplasty between 2007 and 2020 at a single institution was performed. Predictors including gender, age, implant sizing, and preoperative diagnosis were examined using logistic regression analysis. Outcomes including readmission rate, revision rate, preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and American Shoulder and Elbow Surgeons (ASES) functional outcome scores were also analyzed using two-sample t-tests.

Results: Preoperative and postoperative radiographs of 170 primary reverse shoulder arthroplasty patients were assessed. 25.9% of RTSAs were identified to have a GHOST lesion. When adjusting for race, age, BMI, preoperative diagnosis, male patients were still associated with 2.28 odds of developing a GHOST lesion compared to female patients (95% CI: 1.08 - 4.86). Other elements such as age, race, BMI, laterality, preoperative diagnosis, implant manufacturer, and implant sizing demonstrated no statistically significant association to GHOST lesion presence. Postoperatively, GHOST lesion development was not associated with range of motion or ASES score. However, presence of GHOST lesions on radiographs was associated with increased pain scores for patients at 2 months (p = 0.034) and 12 months (p = 0.029) postoperatively.

Discussion: Inferior glenoid hyperostosis (GHOST) lesions is a common and potentially benign finding following reverse shoulder arthroplasty, with unclear etiology. Risk factors for GHOST lesions included male gender, while patient demographics, implant type or size, shoulder lateralization and distalization were not associated with lesion formation. Clinically, greater short-term VAS scores were seen in patients with GHOST lesions. However, there were no differences observed between the two groups in ASES scores or postoperative range of motion at later time points. Further research is needed to identify risk factors and assess the clinical implications of GHOST lesions.

Background: Orthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021.

Methods: The Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch's t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021.

Results: Between 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon's patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228).

Conclusion: Female representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Background: Focused extracorporeal shock wave therapy (FSWT) is effective for treating calcific tendinitis of the shoulder. However, only a few reports exist on the factors related to calcium resorption after FSWT. Thus, this study aimed to investigate the factors associated with calcium resorption.

Methods: In 117 shoulders with chronic calcific rotator cuff tendinitis, FSWT was administered nine times once every 2 weeks (a total of 16 weeks). After nine sessions of FSWT, the shoulders were radiographed and categorized into complete resorption (CR) and incomplete resorption (ICR) groups. Evaluated parameters included age, duration of disease, Gärtner classification, size of calcium deposits, presence of blood flow around calcium deposits using the Doppler function of the ultrasound imaging system, Japanese Orthopaedic Association (JOA) score, University of California at Los Angeles score, disability of the arm, shoulder, and hand (UCLA) score, and tenderness.

Results: The CR group included 93 shoulders (79.4%) and the ICR group included 24 shoulders (20.6%). In the two-arm comparison, CR showed significantly longer disease duration (P=.012) and high tenderness (P=.0013). Blood flow around calcium deposits was observed in 79.5% of shoulders in the CR group (P<.0001) and 29.1% in the ICR group. Type 1 Gärtner classification (P=.0009) was observed in 28 shoulders (30.1%) in the CR group and 17 shoulders (70.8%) in the ICR group. The two groups had no significant differences in age, size of calcium deposits, JOA score, or UCLA score. Multiple logistic regression analysis was performed using the following items that showed significant differences: absence of blood flow (odds ratio [OR], 8.51, 95% confidence interval [CI]: 2.24-22.8), Gärtner classification (OR, 5.60, 95%CI: 1.73-13.3), and duration of disease (OR, 1.06, 95%CI: 0.97-1.26). Longer disease duration, Gärtner type 1, and absence of blood flow around calcium deposits resulted in difficulty in calcium resorption.

Conclusion: Patients with Gärtner type 1 with prolonged disease duration and absence of blood flow around calcium deposits may have difficulty in achieving complete resorption.