Journal of Shoulder and Elbow Surgery最新文献

Background: Total shoulder arthroplasty (TSA) has been removed from the Center for Medicare and Medicaid Services "in-patient only" list. Thus, the onus of TSA outpatient versus inpatient classification has become more complex, leading to failed outpatient TSA and unintended extended hospital stays. While most patients can be safely treated with outpatient TSA, a select vulnerable population may benefit from inpatient designation. This study aims to identify the rate of failure to discharge after two midnights, perioperative reasons for failure to discharge, and independent risk factors associated with failure to discharge.

Methods: This study retrospectively identified elective, outpatient designated, unilateral primary anatomic and reverse TSA procedures performed at a single institution between 2017 and 2023. Operative indications included osteoarthritis, rheumatoid arthritis, dislocation and fracture. Demographics, medical comorbidities, surgical characteristics and social factors were compared using univariate analysis. A multivariable regression model was built to determine independent risk factors associated with conversion to inpatient stay.

Results: A total of 648 patients met inclusion criteria, with a total of 122 patients (19%) staying over two midnights. The most common reason for late discharge was inpatient medical management (63%), followed by physical therapy recommendation/rehab placement (30%), and patient/family readiness (7%). Multivariable regression found living alone to be the strongest predictor of conversion to inpatient stay (OR 4.2, 95% CI 2.6-7.1), followed by female sex (OR 2.6, 95% CI 1.5-4.6) and CCI (OR 1.6, 95% CI 1.3-1.9).

Conclusion: Nearly 1 in 5 patients failed to discharge before two midnights, most commonly due to postoperative medical needs or rehabilitation barriers. Above patient comorbidities, living alone was the strongest predictor of prolonged stay. These findings support the need for more nuanced, patient-centered, risk stratification models for predicting feasibility of outpatient discharge in patients undergoing TSA.

Study design: Retrospective Case-Control.

Background: With the introduction of reverse total shoulder arthroplasty (rTSA) in the USA in 2004, the indications for TSA have expanded significantly, leading to a dramatic rise in primary and revision TSA procedures. Despite these increases in utilization, the epidemiology of revision TSA has not been studied on a large scale. The purpose of this study is to determine the epidemiology of revision TSA over the past 10 years and forecast the incidence over the next five years.

Methods: In this retrospective cohort study, the TriNetX US Collaborative Network database was queried from 2015-2024 using Current Procedural Terminology (CPT) codes 23473, 23474, and 1021145 to identify patients undergoing revision TSA. This database includes deidentified electronic health record data from 67 U.S. healthcare organizations; therefore, findings reflect patients treated within the US only. This query resulted in 70,349 patients who underwent revision during the study period. The data were analyzed using linear regression modelling to determine if there was a significant trend in the incidence of revision TSA. Poisson analysis was performed to calculate incidence rate ratios between years during the study period. An Auto-Regressive Integrated Moving Average (ARIMA) model was used to project future trends in the incidence of revision TSA through the year 2030.

Results: The incidence of revision TSA increased from 223 to 1247 cases per 100,000 person-years 2015 to 2024, a 5.6-fold increase. Poisson analysis shows a significant and steady upward trend, with notable acceleration in the recent years (p < 0.001). The Poisson-based ARIMA model of revision TSA volume projects growth to 1,929 cases per 100,000 patients per year by 2030 (R² = 0.88, mean absolute percentage error = 16%.) CONCLUSIONS: The incidence of revision TSA has steadily increased from 2015 to 2024, with a greater than five-fold increase over the study period and a marked acceleration in recent years. Time series forecasting projects a continued upward trend with an over 50% increase in cases from 2025-2030, indicating a growing burden on healthcare systems. Sustained increases in revision procedures will require expanded healthcare resources and specialized training to meet the growing surgical demand.

Background: In subacromial pain syndrome (SAPS), a common cause of shoulder pain, thoracic spine targeted interventions have been associated with improvements in shoulder outcomes. This study aimed to investigate the effects of adding thoracic extension exercises (TEE) or thoracic kinesio taping (KT) to shoulder exercises (SE) on shoulder pain, disability, active range of motion (AROM), and strength in adults with SAPS.

Methods: Seventy-five adults with SAPS were randomized into three groups. Group A and Group B received TEE and KT in addition to SE, respectively, while Group C received only SE. All exercises were performed five days a week for three weeks. KT was applied every three days, for a total of five applications. Assessments included shoulder pain intensity (Visual Analog Scale, VAS), pressure pain threshold (PPT) of the upper trapezius and pectoralis major (algometer), self-reported disability (Disabilities of the Arm, Shoulder, and Hand, DASH) and health status (Short Form-36), AROM (universal goniometer), isometric strength of the shoulder (hand-held dynamometer), and thoracic kyphosis (inclinometer).

Results: Pain decreased by approximately 3.1-4.4 cm on the VAS, DASH scores improved by 20-23 points, and shoulder AROM increased by 7-50° across groups (p<0.05). PPT increased by 2.7-7.2 kg/cm² in measures showing statistically significant improvement (p<0.05). Isometric shoulder strength increased in Groups A and B (p<0.05), whereas no significant strength changes were observed in Group C (p>0.05). Between-group comparisons demonstrated greater improvements in PPT of the pectoralis major and shoulder abductor and adductor strength in the groups receiving thoracic interventions compared with SE alone (p<0.05).

Conclusion: Although all interventions improved most outcomes, adding TEE or KT to SE resulted in greater improvements in pain sensitivity and shoulder muscle strength, with no superiority between TEE and KT. Longer-term studies are warranted.

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

Background: Despite the clinical importance of rehabilitation after arthroscopic rotator cuff repair (ARCR), standardized postoperative rehabilitation protocols are yet to be established. Therefore, this study aimed to investigate the current consensus on rehabilitation protocols after ARCR among active members of the Korean Shoulder and Elbow Society (KSES). We hypothesized that rehabilitation protocols would vary and that there might be a tendency to adjust rehabilitation based on the preoperative tear size and level of physical demand of the individual patient.

Methods: Between November 2023 and February 2024, an anonymous electronic survey questionnaire was distributed to 140 active members of the KSES under the auspices of the KSES Public Relations Committee. It assessed the surgeon's level of experience, rehabilitation protocols, and whether adjustments were made to the immobilization period based on tear size. Additionally, the clinical scenario of a medium-sized rotator cuff tear (RCT) was used to analyze the consensus on detailed rehabilitation protocols, including immobilization, postoperative pain management, and timing of return to daily activities.

Results: A total of 113 expert shoulder surgeons, with a mean clinical experience of 14.5 ± 7.6 years, responded to the survey (response rate 80.7%). All respondents reported using an abduction brace, and 92.9% adjusted the immobilization duration based on the tear size (r = 0.648, p < 0.001). In a medium-sized RCT scenario, 43.4% initiated rehabilitation during immobilization. Range of motion exercise was started after brace removal by 96.5% and strengthening by 80.5% at postoperative 3.1 ± 0.9 months. Patient-performed self-exercise was preferred over supervised physiotherapy or continuous passive motion machine. Analgesic use declined over time, with more pronounced reductions in opioids and acetaminophen than in non-steroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors. Injection therapy was considered by 76.1% of surgeons to manage pain that was not adequately controlled by oral analgesics. Return to work (85.8%) and sports activities (77.0%) were adjusted based on labor (r = 0.702, p < 0.001) and sports intensity (r = 0.367, p < 0.001), respectively.

Conclusions: Despite variations in detailed protocols, the structured framework based on tear size and physical demands observed among the active members of the KSES, coupled with the preference for patient-directed rehabilitation and multimodal pain control, may suggest future efforts toward developing evidence-based and culturally adaptable rehabilitation guidelines. Further studies with higher levels of evidence are required to establish standardized and effective rehabilitation protocols.

Level of evidence: V, Expert opinion.

Background: Diagnosing simple valgus instability of the elbow currently involves time and cost-intensive imaging modalities such as MRI or MRA. Previous studies have demonstrated that stress radiography represents an alternative diagnostic tool for such conditions. The aim of this study was to investigate if standardized valgus stress radiography can identify soft-tissue lesions of the medial elbow.

Methods: A telos stress device (telos GAIII/E; telos Arzt- und Krankenhausbedarf GmbH; Woelfersheim-Bernstadt; Germany) was used to apply 50 N of valgus stress to six cadaveric elbows during static radiographic imaging. Forearm flexor and extensor tendons were loaded with 25 N and 20 N respectively. Ulnohumeral joint spaces [mm] were measured with the joint in the intact state (M1), after transection of the medial collateral ligament (M2) and after release of the common flexor tendon (M3). Imaging was repeated in 0°, 30° and 60° flexion with the forearm in neutral rotation, supination and pronation in each position.

Results: Mean joint gapping was increased in all groups representing ligament- and/or tendon-deficient joint conditions compared to the intact (stressed) state (group M1). The absolute difference in ulnohumeral joint gapping after common flexor tendon transection compared to the uninjured state was statistically significant (p<0.05) in all positions but not in 30° flexion and supination. Medial joint laxity was greater in 60° than 0° or 30° flexion. Joint spaces were greater in pronation and neutral rotation compared to supination.

Conclusion: Telos stress radiographic imaging can be used to detect large ligamentous injuries at the medial elbow. Dynamic joint stabilization might affect the detection of MCL injuries. Stress radiographic imaging at the elbow should involve examination of the joint at flexion angles of 60°.

Level of evidence: 5:

Background: Shoulder arthroplasty is indicated to treat pain and dysfunction associated with advanced glenohumeral osteoarthritis (GHOA). However, the relationship between preoperative pathoanatomy and clinical presentation remains unclear. The purpose of this study was to evaluate associations between radiographic pathoanatomy, physical examination findings, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) in patients with advanced GHOA who elect to undergo shoulder arthroplasty.

Methods: This retrospective study included 280 patients with primary GHOA (148 males, 52.9%; mean age 68.5 ± 8.6 years) who were treated with anatomic total shoulder arthroplasty (aTSA, n = 147), reverse total shoulder arthroplasty (RSA, n = 81), or ream and run arthroplasty (RNR, n = 52). Preoperative pathoanatomy was characterized using plain radiographs and CT scans and classified according to the Samilson-Prieto (SP), Kellgren-Lawrence (KL) and Walch classifications. Additional radiographic parameters were evaluated. Associations between pathoanatomy and clinical presentation were analyzed using multivariable regression. The minimal clinically important difference (MCID) was used to evaluate the clinical significance of associations.

Results: Greater humeral head flattening was associated with significantly and clinically relevant less active forward elevation (AFE) (B = -0.56, P = .048), active external rotation (AER) (B = -0.38, P = .048), and internal rotation (IR) (B = -0.06, P = .027). Larger humeral neck spur size was associated with significant and clinically relevant less AER (B = -0.40, P = .01). There were no clinically significant associations between SP grade, KL grade, Walch classification, critical shoulder angle, humeral medialization, glenoid version, or glenoid inclination and ROM or PROMs. There were no significant associations between pathoanatomy and HRQoL.

Discussion: There were limited associations between the severity of pathoanatomy in advanced GHOA and clinical presentations. The only significant associations between pathoanatomy and the clinical presentation related to the humerus, correlating with reduced ROM, but not with PROMs or HRQoL. These findings suggest that existing classification systems for GHOA may not fully capture the variability in clinical symptoms. Further research with larger cohorts, including patients with earlier stage GHOA, is needed to clarify the relationship between pathoanatomy and clinical manifestations of GHOA.

Background: Reconstruction after proximal humerus tumor resection poses challenges in restoring stability and function due to loss of rotator cuff attachments and soft-tissue integrity. Hemiarthroplasty (HA) with synthetic mesh augmentation has traditionally been used, whereas reverse total shoulder arthroplasty (rTSA) has emerged as an alternative. Comparative data between these techniques in oncologic settings remain limited. This study compared functional outcomes and complication profiles between HA with aortograft mesh (HA-aortograft) and rTSA endoprosthetic reconstructions following proximal humeral oncologic resection.

Methods: A single-center retrospective cohort study was performed on 68 patients who underwent oncologic proximal humerus resection and reconstruction with HA-aortograft (n = 58) or rTSA (n = 10) from 2000 to 2025. Functional outcomes, including forward elevation (FE), external rotation lag, and internal rotation to the hip or less, were assessed preoperatively, 6 and 12 months postoperatively, and at final follow-up. Complication, recurrence, and revision rates were recorded. Between-group comparisons used t-tests or Fisher's exact tests; within-group changes used paired tests.

Results: rTSA had shorter mean final follow-up (21.9 vs. 43.5 months, P = .001) and shorter resection lengths (7 vs. 12.7 cm, P < .001). rTSA demonstrated superior FE at 6 months (76° vs. 34°, P = .004) and final follow-up (87° vs. 41°, P = .018); this superiority persisted when restricting analysis to those with preserved deltoid insertions. Longitudinally, HA-aortograft lost significant FE function from baseline at 6 months (-36°, P = .003) and 12 months (-25°, P = .042). In contrast, rTSA achieved significant gains at 6 months (+50°, P = .015) and final follow-up (+60°, P = .023). A greater proportion of rTSA patients achieved the minimal clinically important difference for FE (≥12°) at 6 months (80% vs. 20.6%, P = .001) and final follow-up (77.8% vs. 26.5%, P = .008). Rotational outcomes were largely comparable cross-sectionally, though rTSA showed a trend toward greater improvement in external rotation lag and internal rotation limitation. Rates of implant-related complication (rTSA 10% vs. HA-aortograft 12.1%) and revision (rTSA 10% vs. HA-aortograft 5.2%) were similar between groups.

Conclusion: rTSA endoprosthetic reconstruction provided superior restoration of FE and overall functional recovery compared with HA-aortograft following proximal humeral oncologic resection, without increased complication or revision rates.

Background: Scapular dyskinesis is frequently observed with various types of shoulder instability, but whether scapular dyskinesis could contribute to shoulder instability is still unclear. The purpose of this study was to determine the effects of scapular orientation on anterior and posterior glenohumeral translation using a cadaveric model of anterior and posterior labral tears.

Methods: Twenty fresh-frozen cadaveric shoulders were divided into 2 groups: the anterior lesion (n = 10) and posterior lesion (n = 10) groups. The humeral head was translated anteriorly or posteriorly with a constant 30 N force in the anterior or posterior tear groups, respectively. Humeral head displacement was measured at neutral scapula orientation for the intact labrum and following anterior or posterior labral tears. Following a labral tear, humeral head displacement was also measured at 6 additional scapular orientations (±10° increments from neutral), including downward rotation, upward rotation, posterior tilt, anterior tilt, internal rotation, and external rotation. The humerus was held at 0° of horizontal abduction and 40° of horizontal abduction (the apprehension test position) or 40° of horizontal adduction (the jerk test position) in the anterior lesion or posterior lesion groups, respectively.

Results: The presence of isolated labral tears generally increased anterior and posterior translations on the order of 1-2 mm in the neutral scapular orientation (P ≤ .021). Anterior humeral head translation in 0° humeral abduction further increased by approximately 1 mm in the mean upward scapular rotation orientation (P ≤ .021). In the apprehension test, anterior translation increased from posterior to anterior scapular tilt (1.3 mm, P = .017), and from internal to external scapular rotation (1.8 mm, P ≤ .006). Posterior humeral translation in 0° humeral abduction showed trends increasing from downward to upward scapular rotation (1.2 mm, P ≤ .027) and posterior to anterior scapular tilt (2.8 mm, P ≤ .007), while slightly decreasing from internal to external scapular rotation (0.6 mm, P = .014). Posterior translation in the jerk test increased from downward to upward scapular rotation (0.8 mm, P ≤ .012) and posterior to anterior scapular tilt (0.9 mm, P ≤ .043), but slightly decreased from internal to external scapular rotation (0.6 mm, P = .001).

Conclusion: Increased scapular upward rotation, anterior tilt, and external rotation were associated with increased anterior translation of the humeral head in shoulders with anterior labral lesions. In shoulders with posterior labral lesions, increased scapular upward rotation, anterior tilt, and internal rotation were associated with increased posterior translation of the humeral head. These findings suggest that scapular dyskinesis could contribute to instability recurrence.

Background: Frailty is a well-established predictor of poor outcomes after orthopedic surgery. The 6-item modified Frailty Index (mFI) 6, which includes hypoalbuminemia, may provide enhanced risk stratification compared to the widely used 5-item mFI-5. The predictive value of the mFI-6 vs. the mFI-5 for short-term complications after surgical management of proximal humerus fractures (PHFs) remains unclear.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was conducted to identify patients who underwent open reduction and internal fixation, hemiarthroplasty, or total shoulder arthroplasty for PHFs from 2011 to 2023. Patients were stratified by mFI-6 score (< 3 vs. ≥ 3). Thirty-day outcomes, including readmission, mortality, complications, hospital length of stay, and discharge disposition, were measured. Receiver operating characteristic analysis compared the predictive performance of the mFI-6 and mFI-5 for these outcomes.

Results: A total of 30,070 patients met inclusion criteria. 5.4% were classified as highly frail (mFI-6 ≥ 3). Patients with high mFI-6 scores had significantly increased rates of readmission (9.9% vs. 2.9%), mortality (1.6% vs. 0.2%), overall complications (15.2% vs. 4.7%), nonhome discharge (29.1% vs. 8.6%), and longer hospital stays (4 ± 5 days vs. 2 ± 4 days) (all P values < .001). After multivariate regression, these outcomes remained independently associated with high mFI-6 scores. The area under the receiver operating characteristic curve for the mFI-6 was highest for mortality (area under the curve: 0.751), showing consistently superior performance compared to the mFI-5 for readmission, mortality, complications, and nonhome discharge. After stratifying by procedure, such differences remained across most outcomes.

Discussion: In patients undergoing operative management of PHFs, higher mFI-6 scores are strongly associated with adverse 30-day outcomes. The mFI-6 demonstrates improved predictive ability over the mFI-5, supporting its adoption for preoperative risk stratification in patients undergoing surgery for PHFs.