Journal of Shoulder and Elbow Surgery最新文献

Background: Revision reverse total shoulder arthroplasty (rTSA) is performed as a salvage procedure after failed shoulder arthroplasty. However, it presents substantial challenges compared to primary rTSA due to altered anatomy and compromised bone quality. This study aimed to compare clinical outcomes of revision rTSA based on the revision humeral stem fixation methods (cemented vs. cementless) and stem length (short vs. standard vs. long).

Methods: We conducted a retrospective analysis using a prospectively maintained shoulder arthroplasty database from a single institution. All revision rTSAs performed between 2005 and 2023 with a minimum 2-year follow-up were included. Patients were excluded for revision from a primary antibiotic spacer placed in the native shoulder or a history of multiple arthroplasty procedures. The final cohort consisted of 113 revision rTSAs (45 cemented vs. 68 cementless; 16 short vs. 79 standard vs. 18 long). Demographic data, surgical characteristics, outcome scores, active range of motion (ROM), complications, and re-revision rates were compared across cohorts.

Results: Revision rTSA showed no significant differences in active ROM or outcome scores between the cemented and cementless humeral fixation cohorts. The short and standard stem cohorts demonstrated greater improvement in active abduction compared to the long stem cohort (34 ± 32 vs. 0 ± 18; P = .045; 37 ± 41 vs. 0 ± 18; P = .001). Similarly, they exhibited greater improvement in the Constant score (23.5 ± 17.7 vs. 3.5 ± 10.5; P = .018; 19.1 ± 19.5 vs. 3.5 ± 10.5; P = .012). Overall re-revision rates in the cemented and cementless cohorts were 7.2% and 14.9%, respectively, and humeral stem re-revision rates were 7.2% and 9.9%, respectively. (P = .204 and P = .746). Overall re-revision rates in the short, standard, and long stem cohorts were 3.7%, 13.7%, and 11.5%, respectively, and humeral stem re-revision rates were 0%, 10.3%, and 11.5%, respectively. (P = .361 and P = .199).

Conclusion: The use of a short stem in revision rTSA demonstrated clinical outcomes comparable to other stem lengths. Complications and re-revision rates did not significantly differ by cement use or stem length.

Background: Hemiarthroplasty with concentric glenoid reaming (ream-and-run arthroplasty) using a metal humeral head can be considered in young, active patients who want to remain active and avoid the risks and limitations associated with a prosthetic glenoid component. However, there are concerns with glenoid bone wear over time. This study sought to better characterize the amount and rate of glenoid wear and associations with glenoid wear with patient-reported outcomes.

Materials and methods: Patients enrolled into shoulder arthroplasty database with comparable radiographs and minimum 4-year radiographic follow-up were included. Medialization was determined by measuring the position of the humeral head center of rotation relative to a line drawn through the lateral edge of the acromion and parallel with the glenoid face. The amount of medialization was calculated between interval radiographs. Glenoid wear was categorized into minimal/mild (≤5 mm), moderate (>5 mm but below ≤10 mm), or substantial (>10 mm). Simple Shoulder Test were collected preoperatively and annually for each patient.

Results: Comparable radiographs of 113 shoulders with a mean radiographic follow-up of 6.7 ± 2.3 years were analyzed. Minimal/mild glenoid wear was noted in 92 (81%) patients, moderate wear in 15 (13%), and severe wear in 6 (5%). The mean total glenoid wear was 2.9 ± 4.3 mm. Based on linear modeling, the glenoid wear rate was calculated at 0.3 mm per year, but medialization rates were best predicted by a quadratic function (R² = 0.821; P = .001) rather than a linear function. The majority of glenoid wear occurred in the first 4 years after ream-and-run arthroplasty and plateaued thereafter. On multivariable analysis, younger patients (P = .004) and patients without prior shoulder surgery (P = .015) were at risk for moderate or severe glenoid wear. Change in Simple Shoulder Test and pain scores were not different in those with minimal/mild wear compared to those with moderate or severe medialization, but open revision rates were higher in those with moderate or severe medialization.

Conclusion: Glenoid wear after hemiarthroplasty with concentric glenoid reaming using a metallic humeral head occurs at a rate of approximately 0.3 mm/year but may not be linear over time. Improvement in clinical outcomes demonstrated no differences between minimal/mild wear and moderate/severe wear cohorts.

Background: Baseplate failure is a rare but serious complication following reverse shoulder arthroplasty (rTSA), often leading to poor outcomes and revision surgery. Existing studies are limited by small samples or single-center designs. This multicenter study aimed to identify surgical, implant, and patient-related risk factors for baseplate failure after rTSA.

Methods: A multicenter, retrospective study was conducted across 15 U S. institutions involving 24 ASES surgeons. Patients who underwent rTSA from June 2013 to May 2019 with a minimum 3-month follow-up were included. Study parameters were established using the Delphi method. Patients with confirmed baseplate failure were compared to those without using univariate and multivariable logistic regression analyses. Failure was defined radiographically as gross baseplate shift or hardware breakage.

Results: Among 5,049 cases, 83 (1.6%) experienced baseplate failure at a median of 72 weeks post-surgery. Most failures (76%) were atraumatic; 12% were traumatic, and 12% had an unknown mechanism. Radiographs showed hardware breakage in 68.7% of the failures-33.3% involved central screw/post fractures and 86.0% involved peripheral screw fractures. Baseplate shift occurred in 78.3% of cases. Independent predictors of failure included revision arthroplasty (OR = 4.57; P < .001), use of bone graft (OR = 2.81; P < .001), and total glenoid-sided lateral offset (OR = 1.08; P = .002). Central screw fixation reduced failure risk (OR = 0.55; P = .014). In primary rTSA, bone grafting (OR = 4.42; P < .001) and lateral offset (OR = 1.07; P = .046) were significant predictors. In revision rTSA, only bone grafting remained significant (OR = 3.75; P < .001). Allograft use led to higher failure rates than autograft (14.7% vs 3.9%; P = .001).

Conclusion: Revision surgery, bone grafting (especially allografts), and increased lateral offset were significantly associated with higher odds of baseplate failure after rTSA. Central screw fixation appears protective. Most failures were atraumatic, underscoring the importance of achieving stable bone ingrowth. These findings may inform surgical planning and patient counseling regarding factors associated with increased failure risk.

Background: Scapulohumeral rhythm (SHR) describes the relative contributions of the humerus and scapula to total shoulder motion and is defined as the ratio of glenohumeral (GH) elevation to scapulothoracic (ST) upward rotation. The impact of reverse total shoulder arthroplasty (rTSA) on scapular kinematics and SHR has not been fully elucidated. The purpose of the present study was to perform a systematic review and meta-analysis of the literature to compare SHR among patients following rTSA and asymptomatic controls.

Methods: A literature search was performed by querying PubMed, EMBASE, and the Cochrane computerized databases to identify studies that assess SHR, or the relationship of GH elevation to ST upward rotation, in patients after rTSA. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Quantitative review was performed for studies that reported either SHR directly, or reported GH and ST rotation. Differences in SHR were compared between different ranges of humeral elevation including rest-30°, 30-60°, 60-90°, and the total arc of elevation.

Results: Twenty-seven studies comprised of 464 patients who underwent rTSA were included in the final analysis for review. Among the studies included, 19 (70%) directly assessed SHR. The average SHR across all elevation ranges in the scapular plane was 1.6 (range: 0.8-2.7). The average SHR in the rest-30°, 30-60°, and 60-90° elevation arc ranges were 4.3 (range: 0.8-34), 2.0 (range: 0.7-4), and 1.8 (range: 0.8-3), respectively. Compared to controls, patients who underwent rTSA had greater ST upward rotation, quantified as a significantly lower SHR (1.9 vs. 3.2, P = .0238).

Conclusion: There is an increased contribution of ST rotation relative to GH motion throughout arm elevation following rTSA compared to asymptomatic shoulders. The average SHR was lowest between 60° and 90° of arm elevation compared to the other measured ranges of arm elevation, indicating a greater contribution of ST rotation required at higher angles of arm elevation. Further investigations are needed to determine the clinical implications of greater ST motion in patients following rTSA, as well as the biomechanical causes and consequences of this alteration in scapular kinematics.

Background: The ream-and-run arthroplasty (RnR) has shown to be a viable treatment option for young, active patients with shoulder osteoarthritis. However, there are notable concerns with the generalizability of these findings as much of the literature on the RnR is published by the originating surgeon. Additionally, a high proportion of RnR patients represented in the studies are self-selecting the procedure, which may introduce biased outcomes. Therefore, our purpose was to compare the clinical outcome improvement and satisfaction of patients who self-selected the RnR procedure as their preferred treatment method and those who did not.

Methods: We used a retrospective, cross-sectional comparative study design and included patients who had undergone an RnR performed by one fellowship-trained orthopedic surgeon with a minimum of 1-year follow-up. Patients who deliberately sought out the surgeon and RnR procedure made up the self-selecting group (RnR_SS), and all other patients who underwent the RnR procedure and met inclusionary criteria were our control group (RnR_CON). Clinical improvement at the most recent follow-up visit on the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and daily and worst pain outcomes were compared between groups. Satisfaction at their latest follow-up postarthroplasty was also compared.

Results: A total of 78 shoulders (47 = RnR_SS, 31 = RnR_CON) belonging to 70 patients were included. Both groups reported significant improvements at the latest follow-up compared to their preoperative condition (P < .001), and no differences were found between groups in MOI% (P > .05) or proportion of patients reaching Minimal Clinically Important Difference (MCID) on any patient-reported outcome. Groups also reported similar subjective satisfaction ratings (P > .05).

Conclusions: RnR patients self-selecting the RnR arthroplasty were found to report similar pain and functional improvements and satisfaction ratings as those who were not specifically seeking out the procedure. This finding provides evidence to support generalizability of previous RnR results because patients self-selecting the RnR likely make up a bulk of those represented in existing literature.

Background: Subcoracoid impingement co-occurs with subacromial impingement in 19% of the patients with rotator cuff tears. The influence of subcoracoid impingement in patients with full-thickness rotator cuff tear (FT-RCT) remains unknown. Therefore, it is worthwhile to investigate potential differences between FT-RCT patients with and without subcoracoid impingement.

Methods: Twenty-two participants were categorized as having an FT-RCT combined with subcoracoid impingement, while 25 others were diagnosed with an FT-RCT without subcoracoid impingement. Characteristics and tear sizes were recorded using ultrasonography (USG). Humeral head migration was assessed by calculating the acromiohumeral distance using USG at 0°, 60°, and 90° of shoulder abduction. Shoulder range of motion, pain levels, and self-reported shoulder function were evaluated. Scapular kinematics (upward/downward rotation, anterior/posterior tilt, and external/internal rotation) and associated muscle activities (upper trapezius, lower trapezius, serratus anterior [SA], and teres major [TM]) were recorded during arm raising and lowering using motion tracing and surface electromyography systems, respectively.

Results: The FT-RCT combined with subcoracoid impingement group experienced slightly higher pain levels (1.7 ± 0.6, 95% CI = 0.5-2.9, P = .008) and marginally more humeral head superior migration from 0°-60° shoulder abduction (0.14 ± 0.05 cm, 95% CI = 0.03-0.25 cm, P = .017) compared to the FT-RCT without subcoracoid impingement group. Regarding scapular biomechanics, the FT-RCT combined with subcoracoid impingement group demonstrated decreased upward rotation during arm lowering (4.0 ± 1.3°, 95% CI = 1.4-6.5°, P = .003) as well as decreased SA muscle activation during arm lowering (18.8% ± 8.5%, 95% CI = 1.7%-36.0%, P = .032) and decreased TM muscle activation during arm raising (11.4 ± 6.0%, 95% CI = 0.6%-23.5%, P = .018).

Conclusion: Patients with FT-RCT combined with subcoracoid impingement report a slightly higher pain score. Greater superior humeral head migration, coupled with reduced scapular upward rotation, may exacerbate impingement and worsen symptoms. Additionally, these patients exhibit decreased recruitment of the SA and TM muscles. Despite reaching statistical significance, the magnitude of difference may limit its clinical applicability and warrants cautious interpretation.

Background: Isolated arthroscopic Bankart repair (IABR) and open Bankart repair plus inferior capsular shift (OBICS) have not been previously compared in the context of a first episode of anterior shoulder dislocation (FEAD). This study aimed to compare the recurrence rate, functional outcomes, range of motion (ROM), and return to preinjury sport (RTS) level between IABR and OBICS in collision athletes with FEAD. We hypothesized that OBICS would yield clinical outcomes comparable to those of IABR.

Methods: A prospective cohort study involving 80 collision athletes, divided into 2 groups of 40 patients each, was conducted. The inclusion criteria were age ≤ 30 years, with or without a glenoid bone defect ≤ 13%, and on-track Hill-Sachs lesions, all of which presented with first-time anterior shoulder dislocation. The mean follow-up was 68.9 months (range, 60-85) for the OBICS group and 70.5 months (range, 60-87) for the IABR group. The recurrence rate was considered the primary outcome, whereas the Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES) score, ROM, and RTS were secondary outcomes. All assessments were conducted at baseline, 6 months, 12 months, and a minimum of 60 months postoperatively. All outcomes were compared between the 2 groups.

Results: The OBICS group demonstrated a significantly lower recurrence rate (2.5%) than did the IABR group (17.5%) (P = .031). Both groups showed significant improvements in WOSI and ASES scores from baseline to the final follow-up (P = .001); however, no significant differences were found between the groups at the 5-year follow-up (WOSI: P = .38; ASES: P = .72). There were no significant differences in ROM within or between groups. The degree of external rotation was similar in both groups (rotation at the side: OBICS P = .82, IABR P = .91; at 90° abduction: OBICS P = .68, IABR P = .43). RTS rates were also comparable, with 80% of OBICS patients and 82.5% of IABR patients returning to their preinjury level (P = .69) and 17.5% (OBICS) and 15% (IABR) returning to a lower level (P = .47).

Conclusions: Compared with IABR, OBICS resulted in a significantly lower recurrence rate. The functional scores and the ROM and RTS outcomes were comparable between the groups. We highly recommend OBICS for collision athletes with FEADs.

Background: Lesser tuberosity osteotomy (LTO) is one method that can be used for subscapularis mobilization during anatomic total shoulder arthroplasty (aTSA) and has reported union rates of 83%-97%. However, LTO nonunion remains a cause of aTSA failure, and the factors influencing LTO healing are not well understood. The goal of this study is to identify patient-specific and technique-specific factors affecting the incidence of LTO union following aTSA.

Methods: We conducted a retrospective review of all patients who underwent aTSA with LTO between February 2019 and December 2021. Patients with at least 3 months of radiographic follow-up were included. LTO union was assessed using radiographs and classified as healed, nondisplaced nonunion, or displaced nonunion (DN). Patients who underwent revision surgery for LTO failure prior to the 3-month time point were categorized in the DN group. Patient demographics, surgical characteristics, and radiographic variables were analyzed to determine their influence on radiographic union.

Results: Of the 449 included patients, 66.6% achieved LTO union, 26.7% were nondisplaced nonunion, and 6.7% were DN. Younger age was identified as a predictor of nonunion (odds ratio = 0.98; P = .037). No significant differences in union rates were observed based on implant type or size, LTO thickness, change in the humeral head center of rotation, or any additional demographic variables. Despite a 33.4% nonunion rate, only 2.7% of patients with nonunion required revision surgery due to subscapularis-related complications.

Discussion: Younger age is a positive predictor of radiographic LTO nonunion following aTSA, while additional demographic, surgical, and radiographic factors do not significantly influence union rates. Despite the reported radiographic nonunion rate, the need for revision surgery remains low.

Background: Arthroscopy-assisted lower trapezius tendon transfer (aLTT) has emerged as a reasonable treatment option for posterosuperior irreparable rotator cuff tears (PSIRCTs) due to its biomechanical advantages and favorable clinical outcomes. Although there are various surgical techniques for aLTT, the optimal positioning of the graft on the humeral head footprint is unknown in aLTT. This study aimed to evaluate clinical and radiological outcomes based on the interpositional graft position of aLTT graft in PSIRCTs.

Methods: Patients who underwent aLTT for PSIRCTs from 2017 to 2022 were retrospectively analyzed, with a minimum follow-up period of 2 years. Patients were classified into anterior group (n = 44) if the interpositional graft was in the anterior position (supraspinatus footprint) or posterior group (n = 68) if it was in the posterior position (infraspinatus footprint) on postoperative magnetic resonance image. Clinical outcomes were evaluated with the visual analog scale score, patient-reported outcome measurements, active range of motion (aROM), and aROM strength. Radiological outcomes were evaluated by the acromiohumeral distance (AHD), Hamada grade, progression of osteoarthritis, and acromial wear.

Results: Although both groups showed significant postoperative improvements in clinical outcomes, the postoperative forward elevation (160.2˚ ± 28.3˚ vs. 150.4˚ ± 22.0˚; P = .037) of the anterior group were significantly higher than that of the posterior group. Moreover, the postoperative forward elevation strength (27.4 ± 4.5 vs. 24.4 ± 4.4; P = .037) of the anterior group were significantly higher than that of the posterior group. Postoperatively, AHD significantly increased in the anterior group, whereas no significant change was observed in the posterior group. The achievement of minimal clinical importance difference for AHD (68.2% vs. 45.6%; P = .021) were significantly better in the anterior group. Although the posterior group demonstrated a numerically higher rate of progression of osteoarthritis and acromial wear, the difference was not statistically significant.

Conclusion: ALTT showed significant postoperative clinical improvement regardless of the interpositional graft position in patients with PSIRCTs. However, attaching the interpositional graft to the supraspinatus footprint is thought to provide dynamic stability and static stability in subacromial space, leading to favorable outcomes. Therefore, unless the posterior remnant cuff is insufficient for posterior side-to-side suturing, it is recommended to place the graft as anteriorly as possible.