| 1. |
- Aagaard, Knut E., et al.
(author)
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Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears
- 2023
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In: Journal of Shoulder and Elbow Surgery. - : MOSBY-ELSEVIER. - 1058-2746 .- 1532-6500. ; 32:10, s. 2074-2081
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Journal article (peer-reviewed)abstract
- Background: Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair. Methods: This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging–verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed. Results: Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63). Conclusion: Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.
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| 2. |
- Björnsson Hallgren, Hanna, et al.
(author)
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Good outcome after repair of trauma-related anterosuperior rotator cuff tearsda prospective cohort study
- 2021
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In: Journal of shoulder and elbow surgery. - : MOSBY-ELSEVIER. - 1058-2746 .- 1532-6500. ; 30:7, s. 1636-1646
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Journal article (peer-reviewed)abstract
- Background: Anterosuperior rotator cuff tears with a displaced long head of the biceps tendon are most often trauma-related, and patients with these conditions often present with severe pain and shoulder dysfunction. Repair of the subscapularis and supraspinatus and a biceps tenodesis or a tenotomy are the recommended treatments based on retrospective studies. The aim of this study was to prospectively evaluate clinical and structural treatment outcome in a cohort of trauma-related anterosuperior injuries in patients with previously healthy shoulders. Materials and methods: Patients seeking care for a suspected rotator cuff injury after shoulder trauma were screened according to a protocol including clinical examination, baseline scoring with Western Ontario Rotator Cuff Index (WORC) and numeric rating scale of pain, ultrasound, and magnetic resonance imaging (MRI). Those with anterosuperior injuries were offered surgical treatment, structured postoperative physiotherapy, and inclusion in the present study with 1-year follow-up, including MRI, baseline scores, Constant-Murley score, and Patient Global Impression of Change. Thirty-three patients (78% men) with a mean age of 59 (40-76) years were included. Results: All patients had a biceps pulley lesion, a displaced biceps tendon, and incomplete full-thickness subscapularis and supraspinatus tears. Six patients declined surgery. At follow-up, the operated patients reached a median WORC score of 86% and a median change from baseline to follow-up of 50% (P = .0001). Pain decreased (P = .0001) at rest, at night, and during activity. The median Constant-Murley score was 86% of the contralateral nonoperated shoulder, 58% of the contralateral abduction strength recovered after surgery, and 86% reported that they were recovered or much improved. All repairs and tenodeses healed except for 2 supraspinatus tendons. The 6 nonoperated patients reached a median WORC score of 90, a change in the median value from baseline to follow-up of 31, but reported more pain, and a smaller proportion considered themselves as recovered or much improved. In all patients, the 1-year MRIs had signal changes in the upper muscular portion of subscapularis, consistent with fatty infiltration, regardless of operative or nonoperative treatment. Conclusion: Anterosuperior rotator cuff injury with an associated pulley lesion and displaced long head of the biceps tendon may be treated successfully with surgery as the majority of patients in our cohort clinically recovered or were much improved without pain after a year. With a 1-year perspective, nonoperatively treated patients may also reach a reasonable clinical outcome. Independently of treatment or tendon healing, residual subscapularis muscle injury was seen, which may have long-term implications. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
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| 3. |
- Jonsson, Eythor, 1982, et al.
(author)
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Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial
- 2024
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In: Journal of Shoulder and Elbow Surgery. - : Elsevier. - 1058-2746 .- 1532-6500. ; 33:2, s. 343-355
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Journal article (peer-reviewed)abstract
- Background: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. Material and methods: This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. Results: Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of −5.6 points (95% CI: −18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. Conclusion: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.
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| 4. |
- Jonsson, Eythor, 1982, et al.
(author)
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Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients over 70 years of age: a multicenter randomized controlled trial.
- 2021
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In: Journal of shoulder and elbow surgery. - : Elsevier BV. - 1532-6500 .- 1058-2746. ; 30:5, s. 994-1006
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Journal article (peer-reviewed)abstract
- The most appropriate treatment for displaced multifragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty (rTSA) is a promising treatment option that is being used increasingly. The purpose of this study was to compare the outcome of rTSA with hemiarthroplasty (HA) for the treatment of displaced 3- and 4-part fractures in elderly patients.This is a multicenter, randomized controlled trial. We included patients over 70 years of age with displaced 3- or 4-part proximal humeral fractures between September 2013 and May 2016. The minimum follow-up was 2 years with outcome measures including the Constant score (primary outcome), the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the EQ-5D, range of motion, as well as pain and shoulder satisfaction assessed on a visual analog scale (VAS).We randomized 99 patients to rTSA (48 patients) and HA (51 patients). Fifteen patients were lost to follow-up, leaving 41 rTSA and 43 HA patients for analysis. Their mean age was 79.5 years and there were 76 females (90%). The rTSA group had a mean Constant score of 58.7, compared with 47.7 in the HA group, a mean difference of 11.1 points (95% CI, 3.0-18.9, P =0.007). Compared with HA, rTSA patients had greater mean satisfaction with their shoulder (79 vs 63mm, P = 0.011); flexion (125° vs 90°; P < 0.001) and abduction (112° vs 83°, P < 0.001), but there was no difference for WOOS, pain or the EQ-5D. We identified three and four adverse events in the rTSA and HA groups, respectively. For patients 80 years or older (n = 38), there was no difference between treatment with rTSA and HA for pain (17 vs 9mm, P = 0.17) or shoulder satisfaction (77 vs 74mm, P = 0.73).We found that rTSA provides better shoulder function than HA as measured with the Constant score, further emphasized by rTSA patients being more satisfied with their shoulder function. The difference appears to be mainly due to a better range of motion (abduction and flexion) in the rTSA group. The results also indicate that patients over 80 years of age benefit less from an rTSA than patients between 70 and 79 years of age.Level I; Randomized Controlled Trial; Treatment Study.
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| 5. |
- Livesey, Michael G., et al.
(author)
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Acromion morphology is associated with glenoid bone loss in posterior glenohumeral instability
- 2023
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In: JOURNAL OF SHOULDER AND ELBOW SURGERY. - : Elsevier BV. - 1058-2746 .- 1532-6500. ; 32:9, s. 1850-1856
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Journal article (peer-reviewed)abstract
- Background: The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability. Methods: This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL > 13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage. Results: Patients without GBL had a steeper acromial tilt (58.5 degrees +/- 1.4 degrees) compared with those with 0%-13.5% GBL (64.3 degrees +/- 1.5 degrees) or GBL >= 13.5% (67.7 degrees +/- 1.8 degrees) (P =.004). Patients without GBL also had greater posterior coverage (65.4 degrees +/- 1.7 degrees) compared with those with GBL (60.3 degrees +/- 1.4 degrees) (P =.015). Posterior acromion height was not significantly different among groups. Conclusion: The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue-stabilizing procedures. Level of evidence: Anatomy Study; Imaging (c) 2023 Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.
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| 6. |
- Lluch-Girbés, Enrique, et al.
(author)
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Kinetic chain revisited : Consensus expert opinion on terminology, clinical reasoning, examination and treatment in people with shoulder pain
- 2023
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In: Journal of shoulder and elbow surgery. - : Elsevier BV. - 1058-2746 .- 1532-6500. ; 32:8, s. e415-e428
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Journal article (peer-reviewed)abstract
- OBJECTIVES: To determine the most appropriate terminology and issues related to clinical reasoning, examination and treatment of the kinetic chain (KC) in people with shoulder pain by an international experts panel.DESIGN: Delphi study METHODS: A three-round Delphi study that involved an international panel of experts with extensive clinical, teaching and research experience in the study topic was conducted. A search equation of terms related to KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across five different domains (terminology, clinical reasoning, subjective examination, physical examination and treatment) using a 5-point Likert-type scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.RESULTS: Participation rate was 30.2% (n=16) while retention rate was high throughout the 3 rounds (100%, 93.8%, 100%). A total of 15 experts from different fields and countries completed the study. After the three rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain, 17 items in the "rationale and clinical reasoning" domain, 11 items in the "subjective examination" domain, 44 items in the "physical examination" domain and 27 items in the "treatment" domain. "Terminology" was the domain with the highest level of more agreement with two items achieving an Aiken's V of 0.93, whereas "physical examination" and "treatment" of the KC where the two areas with less consensus. Together with "terminology" items, one item from the "treatment" and two items from the "rationale and clinical reasoning" domains reached the highest level of agreement (v=0.93 and 0.92, respectively).CONCLUSION: This study defined a list of 102 items across five different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination and treatment) regarding to KC in people with shoulder pain. The term KC was preferred and a definition for this concept agreed. Dysfunction of a segment in the chain (i.e., weak link) was agreed to result in altered performance or injury to distal segments. Experts considered important to assess and treat the KC in particular in throwing/overhead athletes and agreed that no one size fits all approach exist when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.
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| 7. |
- Midtgaard, Kaare S., et al.
(author)
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Biomechanical significance of the collateral ligaments in transolecranon fracture-dislocations
- 2021
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In: Journal of shoulder and elbow surgery. - : MOSBY-ELSEVIER. - 1058-2746 .- 1532-6500. ; 30:6, s. 1245-1250
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Journal article (peer-reviewed)abstract
- Background: It is widely accepted that transolecranon fracture-dislocations are not associated with collateral ligament disruption. The aim of the present study was to investigate the significance of the collateral ligaments in transolecranon fractures. Methods: Twenty cadaveric elbows with a mean age of 46.3 years were used. All soft tissue was dissected to the level of the capsule, leaving the anterior band of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) intact. A standardized, oblique osteotomy starting from the distal margin of the cartilage bare area of the ulna was made. The elbows were loaded with an inferiorly directed force of 5 and 10 N in the intact, MCL cut, LCL cut, and both ligaments cut states. All measurements were recorded on lateral calibrated radiographs. Results: The mean inferior translation with intact ligaments (n 20) when the humerus was loaded with 5 and 10 N was 1.52 mm (95% confidence interval [CI], 1.02-2.02) and 2.23 mm (95% CI, 1.61-2.85), respectively. When the LCL was cut first (n = 10), the inferior translation with 5 and 10 N load was 4.11 mm (95% CI, 0.95-7.26) and 4.82 mm (95% CI, 1.91-7.72), respectively. When the MCL was cut first (n - 10), the inferior translation when loaded with 5 and 10 N was 3.94 mm (95% CI, 0.796-7.08) and 5.68 mm (95% CI, 3.03-8.33), respectively. The inferior translation when loaded with 5 and 10 N and both ligaments cut was 15.65 mm (95% CI, 12.59-18.79) and 17.50 mm (95% CI, 14.86-20.13), respectively. There was a statistical difference between the intact and MCL cut first at 10 N and when both ligaments were cut at 5 and 10 N. Conclusions: The findings suggest that collateral ligament disruption is a prerequisite for a transolecranon fracture-dislocation. An inferior translation of more than 3 mm suggests that at least one of the collateral ligaments is disrupted, and more than 7.5 mm indicates that both collateral ligaments are disrupted. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
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| 8. |
- Ranebo, Mats, et al.
(author)
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Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial
- 2020
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In: Journal of shoulder and elbow surgery. - : MOSBY-ELSEVIER. - 1058-2746 .- 1532-6500. ; 29:3, s. 459-470
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Journal article (peer-reviewed)abstract
- Background: Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears. Methods: We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy. Results: The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 421 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR)) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P- .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 63% of repaired patients and tear progression amp;gt;5 mm in 29.2% of unrepaired patients. Conclusions: We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
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| 9. |
- Scheer, Vendela, et al.
(author)
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Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure
- 2021
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In: Journal of shoulder and elbow surgery. - : MOSBY-ELSEVIER. - 1058-2746 .- 1532-6500. ; 30:6, s. 1316-1323
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Journal article (peer-reviewed)abstract
- Introduction: Most surgical site infections after shoulder surgery are caused by Cutibacterium acnes. Topically applied benzoyl peroxide (BPO) has for years been used to decrease the skin load of C acnes in treatment of acne vulgaris. The purpose of this study was to examine this effect on bacterial colonization in patients subjected to elective shoulder surgery at different stages of the procedure. Methods: A total of 100 patients scheduled for primary elective open shoulder surgery were randomized to prepare either with BPO or according to local guidelines-with soap (control group). Four skin swabs were taken in a standardized manner at different times, before and after surgical skin preparation, 1 in dermis, and finally after the skin was sutured. Before skin incision, 5 punch biopsies (3 mm in diameter and maximum 4 mm deep) were retrieved spaced 2 cm apart in the planned skin incision. On culturing, quantification of C acnes was made by serial dilutions. Results: Men had a 5-fold higher amount of C acnes on untreated skin. Treatment with BPO considerably lowered this count (P = .0001 both before and after skin disinfection compared to the control group. This positive effect of BPO persisted until skin closure, the point at which some recolonization of C acnes had occurred, but to a higher degree in the control group (P = .040). Conclusion: Preoperative BPO treatment of the shoulder may be an effective method to decrease bacterial skin load of C acnes from skin incision until wound closure. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
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| 10. |
- Schmidt, Viktor, et al.
(author)
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Epidemiology, treatment, and mortality of 3,983 scapula fractures from the Swedish fracture register
- 2024
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In: Journal of shoulder and elbow surgery. - : Elsevier. - 1058-2746 .- 1532-6500.
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Journal article (peer-reviewed)abstract
- BACKGROUND: Scapula fractures are relatively uncommon, accounting for <1% of all fractures and approximately 3-5% of shoulder girdle fractures. This study comprehensively describes the epidemiology, fracture classification, treatment, and mortality associated with scapula fractures within a large adult Swedish population.METHODS: This observational study included all patients ≥18 years old at the time of injury with a scapula fracture (ICD S42.1) registered in the Swedish Fracture Register between March 2011 and June 2020. Variables studied were age, sex, and injury mechanism, including energy level, fracture classification, associated fractures, treatment, and mortality.RESULTS: We included 3,930 patients (mean age 58 years, SD 18, 64% men) with 3,973 scapula fractures. Some 22% of the fractures were caused by high-energy trauma and 21% had at least one associated fracture. High energy-injuries were most common in glenoid neck (44%) and scapular body (35%) fractures. However, same-level falls were the most common cause of glenoid rim (62%) and intra-articular glenoid (55%) fractures. Clavicle fractures (9%) and proximal humerus fractures (5%) were the most commonly associated fractures. The most common fracture types were the glenoid rim (n=1,289, 32%) and scapular body (n=1,098, 28%) fractures. Nonoperative treatment was performed in 81% of patients. Glenoid rim and intra-articular glenoid fractures were treated operatively in over 30% of cases. The mortality rate for the whole cohort was 4% at 1 year.CONCLUSIONS: Scapula fractures are predominately sustained by men. High energetic injuries and associated fractures are present in one in five patients. Nonoperative treatment is chosen in four of five patients, but for some fracture types one in three undergo surgery.
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