Shoulder & Elbow

With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes.

A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means.

Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies.

Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.

To systematically review the literature assessing glenoid bone loss restoration by different bone block options and compare their dimensions.

Systematic examination of articles in PubMed and EMBASE databases was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies of bone grafts for treating anterior glenohumeral instability. Statistical analyses were conducted via Review Manager, and a p-value of <0.05 was statistically significant.

Our review included 25 studies evaluating 870 shoulders. Traditional arc Latarjet (TL) had more depth than congruent arc Latarjet (CAL; p = 0.003). The coronal radii of curvature of TL, CAL, distal tibia, and iliac crest bone blocks were similar to native glenoid (p = 0.400, 0.817, 0.467, 0.216, respectively). CAL coracoid bone blocks restored significantly more glenoid surface area (30.3%) than TL bone blocks (p = 0.012). The glenoid width and surface area restoration by distal clavicle bone blocks were equivalent to TL (p = 0.058 and p = 0.103, respectively).

The CAL technique restored higher percentages of glenoid surface area than TL but has less depth, which may increase fracture risk during screw insertion. The distal clavicle bone block is a suitable substitute to TL as it was equivalent regarding glenoid width and surface area restoration.

Given its complexity, there is no consensus regarding the assessment of non-traumatic shoulder instability (NTSI) to this day. We, therefore, conducted a scoping review to map the existing white and grey literature regarding diagnostic and assessment tools for the NTSI population.

We followed the Arksey and O'Malley five-stage guideline for the conduct of scoping reviews and searched through 12 electronic databases for English-language articles and reviews from 2000 to 2024 related to NTSI's diagnosis and assessment tools.

Among the 3426 identified studies, 58 were included (describing 59 different interventions). Case–control studies (43.1%, 25/58) and narrative reviews (34.5%, 20/58) were the most prevalent. Diagnostic imaging was the most studied intervention (35.6%, 21/59). Twenty-seven studies specified a direction of instability, of which 59% (16/27) were multidirectional instability. Non-traumatic shoulder instability often affects young individuals, with complex symptoms, including neuromotor deficits, muscular imbalances and kinematic alterations, involving psycho-behavioural and somatosensory components.

Non-traumatic shoulder instability's aetiologies and clinical manifestations are multifactorial. The prevalence and incidence of this dysfunction are probably underestimated. Clinical history is crucial to retrace a complex and chronic dysfunction. The use of orthopaedic shoulder tests and the routine use of imaging currently appear to have limited relevance as a first-line approach.

The purpose of this study is to quantify the difference in biomechanical stability of suture button (SB) and suture tape cerclage (STC) constructs with hand tensioning versus device tensioning of anterior glenoid augmentation bone grafts in an anterior glenoid bone loss model.

Artificial bone blocks with a density of 15 lb/ft³ (240.3 kg/m³) were used as models for glenoid fixation with bone graft. The biomechanical stability of SB and STC tensioned by hand was compared to those tensioned by a device. Average displacement (mm) following application of various forces (50, 100, 150, and 200 N) during a 7-phase, 100-cycle, stairstep cyclic loading protocol was recorded.

Both SB and STC fixation displayed significantly lower construct displacement at all tested forces when tensioned with a device versus hand (p < 0.001). Device-tensioned SB and STC were comparable in construct stability at forces below 100N. However, at forces above 100 N, device-tensioned SB exhibited significantly less displacement than device-tensioned STC.

Using a tensioning device for SB or STC fixation of a coracoid graft model results in less displacement and improved stability compared to hand tensioning. Biomechanically, a tensioning device enhances the stability of suture fixation in glenoid bone graft constructs.

This study aims to evaluate long-term survivorship of arthroscopic Bankart repair (ABR).

About 101 patients under a single surgeon were followed up for ≥2 years post-ABR. Primary outcome was survivorship, defined as re-dislocation post-surgery. Secondary outcomes included a range of motion, strength, pain, University of California-Los-Angeles shoulder score, Oxford shoulder score (OSS), Oxford Shoulder Instability Score (OSIS), Constant Murley Score, and satisfaction. Clinical factors were correlated.

Eight patients experienced postoperative dislocation (5 high-energy trauma, 2 low-energy trauma, 1 atraumatic), with 2 patients requiring revision. The mean time to post-operative dislocation was 1.5 years (range 0.3–3.8). Competitive athletes demonstrated worse survivorship (p = 0.027) but greater isometric strength at 6 months (p = 0.041) compared to recreational players. Patients ≥25 years old experienced slower recovery of internal rotation at 3 months (p = 0.006). Patients with surgery >1 year after injury had slower recovery of external rotation (p = 0.006), worse Constant scores at 3 months (p = 0.036) and lesser improvements in isometric strength at 3 months (p = 0.032). Patients with single pre-operative dislocations (p = 0.036 OSS; p = 0.039 OSIS) and patients ≥25 years old (p = 0.044 OSS) had worse Oxford scores at 3 months.

ABR demonstrates good outcomes with low recurrence. This study prognosticates long-term outcomes across various subgroups.

There is wide variability in the conclusions of studies examining the effects of diabetes mellitus (DM) on outcomes of shoulder arthroplasty (SA). The objective of this study was to determine if there are differences in complication profiles between patients with DM and those without undergoing anatomic and reverse total SA.

A retrospective review of patients undergoing SA in a single center from January 2014 to December 2019 was performed. Patients were then stratified into two cohorts, patients with controlled DM (mean hemoglobin A1C < 7%) and those without. Outcomes analyzed included intraoperative complications, postoperative complications, and revision surgery rates. Emergency department (ED) visits and hospital readmissions within 30 days were also recorded.

A total of 595 patients underwent SA. No significant difference was found between the diabetes (n = 151) and control group (n = 444) with regard to length of stay (P = .168), complications (P = .286), infection rate (P = .977), 30-day ED visits (P = .789), and readmissions (P = .230). The average time to revision was 26.8 months in the diabetes group and 26.6 months in the control group (P = .989).

Following SA patients with controlled DM showed no increased risk of postoperative infection, ED visitation,hospital readmission, and revision surgery rate when compared to non-diabetics.

Level III—retrospective cohort.

Scapula alata (SA) is a condition characterized by medial winging and reduced upward rotation of the scapula during arm elevation, leading to impaired shoulder function. This study aimed to assess diagnostic and treatment approaches for SA in public hospitals in Denmark.

A cross-sectional survey was undertaken using a self-administered questionnaire to healthcare professionals across departments in public hospitals in Denmark. The survey investigated diagnostic practices, including referral to electroneurography (ENG), ICD-10 coding and local treatment practices.

A total of 20 hospital departments completed the questionnaire. Six hospitals use ENG as part of their diagnostic practice. Six different ICD-10 codes were reported for SA. Annual patient numbers ranged from 0 to 20, with four hospitals accounting for most of the patients. Doctors and physiotherapists are the primary healthcare providers involved in the diagnostic and treatment process. Only four hospitals reported written local guidelines for SA treatment. Treatment approaches included exercise therapy, brace treatment, surgery, and in some cases, a waiting approach.

The survey revealed significant variations in diagnostic and treatment practices for SA across Denmark. This emphasizes the need for further research and national and international consensus, including standardized guidelines for diagnostics and treatment practices.

Differences in implant positioning between anatomical and reverse shoulder arthroplasties have raised concerns about the adequacy of assessing the global glenoid inclination (GGI) using the method described by Maurer to define the position of the metallic base in reverse shoulder arthroplasty. The reverse shoulder angle (RSA) has been proposed to measure the inclination of the lower half of the glenoid. This study aims to evaluate the interobserver agreement of manual measurements of the RSA using two-dimensional (2D) computed tomography (CT) images and its relationship with the automated measurement of the GGI.

This cross-sectional study evaluated 2D CT images of 38 CT scans of patients with degenerative shoulder diseases. Manual measurements of the RSA were conducted by five independent shoulder surgeons. GGI measured by automated software was determined.

The interclass correlation coefficient was 0.72 for RSA. Mean RSA was 25.7° ± 7.1°, significantly higher than automated GGI measurements (11.2 ± 9.0; p < .0001). On average, RSA was 14.6 ± 6.3 greater than GGI, irrespective, diagnosis, Favard's glenoid subtype, and version angle.

Our study demonstrated that the RSA angle can be reproducibly used to assess glenoid inclination on 2D CT images presenting high interobserver agreement. RSA differs significantly from the GGI, indicating that measuring glenoid inclination for reverse or anatomical arthroplasty requires distinct methodologies that account for the inherent differences in these angles.

Impaired sleep quality often drives patients with rotator cuff tears (RCT) to seek surgical intervention. This meta-analysis reviews the impact of arthroscopic rotator cuff repair (ARCR) on sleep quality beyond six months and identifies influencing factors, primarily narcotics, on sleep quality.

The search spanned PubMed, Google Scholar, Embase, and the Cochrane Central Register, targeting articles evaluating rotator cuff injury and sleep quality. Information gathered included study features, bias risk assessment, evaluation of sleep quality using sleep-specific patient-reported outcomes, and the effects of opiates on sleep outcomes.

Ten studies, including 445 patients who underwent ARCR were included. The preoperative mean Pittsburgh Sleep Quality Index (PSQI) varied from 6.6 to 15. Eight studies presented a mean PSQI score of 3.6–7.1 at 6 months postoperatively; two studies reported mean score of 4.2 and 5.4 at 12 months. Both were found to be statistically significant by this meta-analysis compared to preoperative scores. Three studies found narcotic use, RCT size, alcohol consumption, diabetes, and hypertension to negatively affect PSQI scores.

Arthroscopic rotator cuff repair significantly improves sleep quality at 6 and 12 months following surgery. Perioperative narcotic use, RCT size, alcohol consumption, diabetes, and hypertension may negatively impact sleep quality.

ChatGPT is rapidly becoming a source of medical knowledge for patients. This study aims to assess the completeness and accuracy of ChatGPT's answers to the most frequently asked patients’ questions about shoulder pathology.

ChatGPT (version 3.5) was queried to produce the five most common shoulder pathologies: biceps tendonitis, rotator cuff tears, shoulder arthritis, shoulder dislocation and adhesive capsulitis. Subsequently, it generated the five most common patient questions regarding these pathologies and was queried to respond. Responses were evaluated by three shoulder and elbow fellowship-trained orthopedic surgeons with a mean of 9 years of independent practice, on Likert scales for accuracy (1–6) and completeness (rated 1–3).

For all questions, responses were deemed acceptable, rated at least “nearly all correct,” indicated by a score of 5 or greater for accuracy, and “adequately complete,” indicated by a minimum of 2 for completeness. The mean scores for accuracy and completeness, respectively, were 5.5 and 2.6 for rotator cuff tears, 5.8 and 2.7 for shoulder arthritis, 5.5 and 2.3 for shoulder dislocations, 5.1 and 2.4 for adhesive capsulitis, 5.8 and 2.9 for biceps tendonitis.

ChatGPT provides both accurate and complete responses to the most common patients’ questions about shoulder pathology. These findings suggest that Large Language Models might play a role as a patient resource; however, patients should always verify online information with their physician.

Level V Expert Opinion.

Revision total elbow arthroplasty (TEA) is indicated for component loosening, periprosthetic joint infection, and fractures. Previous investigations into revision TEA complications have small sample sizes and limited exploration of acute complications. This study aims to characterize the 30-day complications and associated demographics of patients undergoing revision TEA using a large national database.

The 2015–2020 American College of Surgeons National Surgical Quality Improvement Program database was used to identify all revision TEA patients.

The analysis included 158 patients (average age 62.6 years). The overall complication rate was 13.9% (n = 22). The most common 30-day complications were organ/space surgical site infection (3.8%, n = 6), unplanned readmission (3.2%, n = 5), intraoperative or postoperative transfusion (3.2%, n = 5), and unplanned reoperation (1.9%, n = 3). Patients with a history of dyspnea or steroid/immunosuppressant use for a chronic condition had significantly higher rates of bleeding requiring transfusion (p = .029 and p = .021, respectively). Additionally, patients aged 80 years or older had a significantly higher rate of unplanned readmission (p = .032).

Revision TEA has a 13.9% rate of complications within 30-days of surgery, with most involving surgical site infection, unplanned readmission, and blood transfusion.

IV.

To compare outcomes between open reduction internal fixation (ORIF), total elbow replacement (TER) and distal humerus hemiarthroplasty (DHH) for AO type-C (AOC) fractures of the distal humerus in patients aged 50 years or older.

A retrospective analysis of acute AOC distal humerus fractures in patients aged 50 years or older between 2016 and 2022. Outcomes measured: Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), complication rate, re-operation rate and range of movement (ROM).

Sixty-five patients met the inclusion criteria (20 males, 45 females). Mean age was 64.4, 77.1 and 61.3 years old for ORIF, TER and DHH respectively. Logistic model analysis revealed a statistically significant increased complication rate in the ORIF group compared to the TER and DHH groups (ORIF vs TER p = 0.01; ORIF vs DHH p = 0.048). There was a higher re-operation rate in the ORIF group compared to the DHH group (p = 0.03). There were no differences in OES, MEPS or ROM between groups.

This supports the use of TER in elderly patients with AOC distal humerus fractures. In the younger patient, DHH may have lower rates of complications and re-operations compared to ORIF, but function remains similar. We propose a prospective randomised control trial.

This study aimed to assess reachable workspace (RWS) in patients post-osteosynthesis of shoulder, elbow, or wrist fractures and explore correlations with self-reported function and kinesiophobia.

An observational case-control study compared patients with fractures to a control group, utilizing questionnaires and 3D kinematic data.

The sample included 66 individuals who had undergone osteosynthesis: 21 with shoulder fractures, 10 with elbow fractures, and 22 with wrist fractures. A control group of 23 participants without upper limb pathologies was also established. Inclusion criteria were ages 18–80 and recent surgery; exclusions were previous upper limb surgeries, cervical pathologies, systemic diseases or nerve injuries.

RWS, the three-dimensional volume the hand can reach, was measured with participants standing. Kinesiophobia was assessed using the Tampa Scale of Kinesiophobia (TKS), and physical disability and pain were measured using the DASH questionnaire and the Numeric Pain Rating Scale (NPRS).

Fracture groups exhibited significant RWS reductions (62–85%) compared to the control group, with no significant differences among the fracture types. RWS showed a high correlation with TKS (R = 0.77) and a moderate correlation with DASH (R = 0.52).

RWS is a promising biomechanical parameter for assessing upper limb function post-fracture, aiding in refining rehabilitation protocols.

Arthroscopic rotator cuff repair (ARCR) surgery is often recommended to reduce pain, restore function, and improve quality of life in patients with rotator cuff tears. Several factors can influence how effectively patients manage their pain, follow rehabilitation guidelines, and perceive their overall recovery, including patient perspectives, socioeconomic status, and beliefs on rehabilitation. Understanding these characteristics is crucial to optimizing patient outcomes and modifying rehabilitation approaches to meet specific patient requirements.

To obtain an in-depth understanding of patient perspectives, socioeconomic status, and beliefs on rehabilitation after ARCR.

This qualitative study consisted of face-to-face semi-structured interviews with 13 participants who underwent ARCR. Interviews were recorded, transcribed, and analysed using a six-step approach as proposed by Braun and Clarke.

The mean age of the included participants was 53 ± 8.07 years, with 76% being male with most of the participants belonging to lower middle and upper lower socioeconomic status. Three major themes emerged from the interview: 1) Role of healthcare provider, 2) Socio-environmental factors, and 3) Cognitive-behavioural response.

Our findings imply that rehabilitation strategies should incorporate a more comprehensive patient-centred approach that considers a wider range of factors influencing compliance with therapy and overall rehabilitation.