Journal of Shoulder and Elbow Surgery最新文献

Introduction: Shoulder and elbow surgery fellowships in the United States are recognized for their academic emphasis, yet the correlation between an applicant's research productivity and fellowship match results remains unclear. This study (1) analyzed temporal trends in research productivity among matched fellowship applicants, (2) evaluated the influence of quantity of publications and first authorships on match positions, and (3) investigated program variations in research productivity.

Methods: This is a retrospective analysis of data from the San Francisco (SF) Match Database for shoulder and elbow surgery applicants matched between 2017 and 2024. Allopathic (MD), osteopathic (DO), and international medical graduates (IMGs) were included. PubMed was queried to quantify publications and first authorship before and during residency, analyzing their association with applicant and fellowship rank. Publication volumes per fellowship program were also calculated for institutions with at least five years of match data.

Results: 290 matched applicants were evaluated across 34 fellowship programs, comprising 229 MDs, 29 DOs, and 32 IMGs. There was almost a five-fold increase in the average number of publications per applicant, from 2.72 ± 3.54 in 2017 to 12.80 ± 15.88 in 2024 (B 1.30; p = 0.001). Similarly, first authorship publication counts increased almost three-fold, from 1.31 ± 2.12 in 2017 to 3.66 ± 5.01 in 2024 (B = 0.29, p = 0.02). Fellowship program analysis revealed wide variation in mean publication counts of matched applicants (p = 0.008), with Rush University Medical Center (27.88 ± 33.86), Massachusetts General Hospital (13.65 ± 26.62), Mayo Clinic (13.06 ± 14.77), Thomas Jefferson University Hospital (12.19 ± 10.64) exhibiting the highest averages. Candidates with more publications (p = 0.04), first authorships(p = 0.02), and total first authorships (p = 0.04) during residency were ranked higher by fellowship programs. There was a significant correlation between greater publication count during residency and more favorable fellowship rank (-0.15, p = 0.02) and applicant match position (-0.12, p = 0.049). No significant associations were found between pre-residency publications (p = 0.38), total publications (p = 0.13), and pre-residency first authorships (p = 0.20) with fellowship rank positions.

Conclusion: Research productivity has increased substantially among matched applicants. The more academically productive residents tend to be ranked more favorably by fellowship programs and match higher on their list. However, these associations were relatively weak, highlighting the complexity of the fellowship selection process and the notion that research productivity alone does not guarantee placement in preferred programs.

Background: Surgical techniques for biceps tenodesis vary in approach, fixation strategy, and anatomic location without clear superior technique for this common procedure.

Hypothesis/purpose: The purpose of this study was to prospectively evaluate a randomized cohort of patients undergoing arthroscopic suprapectoral (ASBT) with interference screw fixation using an inlay technique versus mini-open subpectoral (MOBT) with a unicortical button implant using an onlay technique with regards to 1) clinical outcome measures and 2) structural healing as evaluated by ultrasound.

Methods: From May 2017 to April 2021, patients undergoing biceps tenodesis were preoperatively randomized to either ASBT or MOBT. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) scores were recorded at baseline, three months, and two years postoperatively. The integrity of the biceps tendon at the tenodesis site was independently examined via ultrasound by a musculoskeletal trained radiologist at three months and two years postoperatively. T-tests were performed for continuous variables, while Chi squared tests were performed for categorical variables.

Results: A total of 52 patients (24 ASBT, 28 MOBT) were randomized and completed follow-up. At baseline, three months, and two years postoperatively, the mean ASES, SANE and VAS scores were not statistically different between ASBT and MOBT. At the three-month postoperative ultrasound, 23/24 (96%) of the ASBT patients and 26/28 (93%) of the MOBT patients were noted to have a clearly intact biceps tenodesis. At two years, all biceps tenodesis regardless of group were noted to be intact and healed, including all three shoulders whose ultrasound noted a questionably intact repair without significant retraction of the tendon at prior three-month ultrasound evaluation.

Conclusion: This study demonstrates similar clinical outcomes at two year follow-up between ASBT and MOBT. Both groups demonstrated improvement that exceeded the reported patient acceptable symptom state (PASS) and minimal clinically important difference (MCID). Ultrasound showed excellent structural healing rates for both inlay and onlay biceps tenodesis techniques.

Level of evidence: Level II; Randomized Controlled Trial; Treatment Study.

Background: Heterotopic ossification (HO) of the elbow resulting in limited motion is a relatively uncommon condition often caused by burns, trauma, and central nervous system injuries. This retrospective study presents the long-term outcomes of 51 cases of elbow HO treated with surgical excision and regimented postoperative rehabilitation protocol.

Methods: A retrospective case series was conducted on 48 patients (51 elbows) who underwent surgical excision of elbow heterotopic ossification. All procedures were performed in the inpatient setting at an Academic Level I Trauma Center between September 1999 and August 2022 by fellowship-trained upper extremity surgeons. Patient demographics and case characteristics such as age, gender, mechanism of injury, and comorbidities were collected for comparison. Long-term follow-up examinations were elbow flexion-extension arcs, pronosupination arcs, Visual Analog Scale (VAS) pain scores, and Mayo Elbow Performance Scores (MEPS).

Results: Patients were followed for a minimum of 2 years with an average follow-up of 8 years (range, 2-24 years). The median flexion-extension arc at final follow-up was 110° (95°-130°), which was maintained at 85% of the intraoperative arc achieved. Pronosupination arc at final follow-up was 170° (105°-180°), which was maintained at 97% of intraoperative levels. The median reported MEPS and VAS scores were 80 (70-93) and 2 (0-4), respectively. Although it wasn't statistically significant, patients diagnosed with type II diabetes had the worst flexion-extension arcs at final follow-up and highest complication rates compared to other risk factors.

Conclusion: Surgical excision coupled with HO prophylaxis and a regimented rehabilitation program resulted in a lasting improvement in functional outcomes for patients with elbow dysfunction secondary to heterotopic ossification at long term follow-up. Overall, patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function.

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.