Constant-Murley Score: systematic review and standardized evaluation in different shoulder pathologies

Improved healing and functional outcome is seen at 12 months after injecting leukocyte rich-PRP in arthroscopically repaired labrum: A case-control study

Introduction

A study with the hypothesis: platelet-rich plasma (PRP) injection into labrum repair will produce better healing response and improved functional outcome in patients of recurrent shoulder dislocation treated with arthroscopic Bankart repair.

Methods

Arthroscopically repaired recurrent shoulder dislocation patients. Group 1 (cases): administered LR-PRP injection. Group 2 (controls): not received PRP injection. The injection was given arthroscopically at the labrum-bone interface after repair was completed.

Results

A total of 40 patients: 20 in group I (cases) and 20 in group II (controls). The mean age was 26 ± 6 years; 36 patients (90%) were male and 4 patients (10%) were female. All three scores showed improvement at follow-up evaluation inside the groups (P < .001). Individual score improvement was more in group I, the difference was statistically significant for the American Shoulder and Elbow Surgeon (ASES) and Disabilities of the Arm, Shoulder and Hand (DASH) scores (P < .05). The CSS was also higher in group I (93.2 ± 2.8) at follow-up as compared to group II (91.5 ± 2.7, P = .063). Follow-up magnetic resonance imaging (MRI) evaluation showed improvement in labral height (P < .05), Labrum height glenoid index (P > .05), and Labral slope (P < .05) in both the groups, the increase was more in group I as compared to group II.

Conclusion

PRP injection at the labrum-bone interface provides a better healing response in the labrum and better functional outcomes at 12 months after arthroscopic bankart repair.

Level of evidence

Level III, case-control study.

Persian Version of the Modified Constant Score in Overhead Athletes: A Reliability and Validation Study

CONTEXT

Shoulder impingement syndrome (SIS) is the most common shoulder injury among overhead athletes. The Constant score (CS) is a combined scoring system to evaluate functional status of the shoulder in patients with shoulder pain.

DESIGN

Cross-sectional study.

METHODS

Cultural adaptation of the Persian version of CS was conducted using Beaton's guideline. Sixty-three overhead athletes (23.57 [7.50] y old) with SIS completed the final version for psychometric assessment. After 5 to 7 days, a group of 33 patients completed the Persian CS again to assess test-retest reliability. Internal consistency, floor/ceiling effects, and item-total correlation were evaluated in patients with SIS. Concurrent validity was assessed through comparison with the disability of the arm, shoulder, and hand questionnaire scores. Twenty-five healthy athletes (31.80 [7.32] y old) participated for determining discriminant validity.

RESULTS

The Persian CS demonstrated good test-retest reliability, with subjective and objective intraclass correlation coefficients of .79 and .80, respectively. The internal consistency was satisfactory (Cronbach alpha = .74). No ceiling or floor effects were noted. The Pearson correlation coefficient between CS and disability questionnaire was -.68. The mean total score for patients was 67.02, while for the healthy group was 96.99 (P = .000). The standard error of measurement was 1.51 for patients and 0.7 for healthy group. The smallest detectable change was 16.95 for patients and 5.71 for healthy group.

CONCLUSION

The translation and cross-cultural adaptation of CS into Persian were successful. The Persian version demonstrates sufficient reliability and validity to evaluate shoulder function in overhead athletes with SIS.

Pain, Function, and Elastosonographic Assessment After Shockwave Therapy in Non-Calcific Supraspinatus Tendinopathy: A Retrospective Observational Study

Background: Non-calcific supraspinatus tendinopathy (SNCCT) is a frequent cause of shoulder pain, often associated with functional impairment and reduced quality of life. Recent advancements in diagnostic imaging, including shear wave elastography (SWE), provide quantitative data on tendon stiffness and thickness, facilitating more precise evaluations. Extracorporeal shockwave therapy (ESWT) has emerged as a minimally invasive and effective treatment for SNCCT, but its effects on tendon properties measured through SWE require further investigation. Objective: This retrospective observational study aimed to evaluate the impact of ESWT on supraspinatus tendon characteristics in patients with SNCCT by assessing tendon thickness, SWE velocity, and clinical outcomes. Methods: This observational study enrolled 39 patients with SNCCT, aged 30-75 years, who received three ESWT sessions over 3 weeks. The intervention was delivered using a Modulith SLK system at an energy level of 0.20 mJ/mm2 with 2400 pulses per session. SWE and conventional ultrasound were used to measure tendon thickness and SWEv at baseline (T0) and 6 months post-treatment (T1). Clinical outcomes were assessed using the Visual Analog Scale (VAS), Constant and Murley Score (CMS), and modified Roles and Maudsley scale. Data were analyzed using paired t-tests and correlation analyses. Results: At baseline, affected tendons exhibited increased thickness (7.5 ± 0.9 mm) and reduced SWEv (3.1 ± 0.7 m/s) compared to healthy tendons (4.5 ± 0.7 mm and 6.9 ± 1 m/s, respectively; p < 0.05). Six months after ESWT, tendon thickness decreased significantly (6.2 ± 0.9 mm, p < 0.05), and SWEv increased (5.7 ± 1.8 m/s, p < 0.05), indicating improved elasticity. Clinical outcomes improved significantly, with the VAS scores decreasing from 6.5 ± 1.4 to 3.2 ± 2.1, the CMS score rising from 59.1 ± 17.3 to 78.2 ± 17.7, and the modified Roles and Maudsley scale improving from 2.3 ± 0.6 to 1.5 ± 0.8 (p < 0.05 for all). SWEv positively correlated with the CMS (r = 0.4) and negatively with the VAS and the modified Roles and Maudsley scale (r = -0.6 and r = -0.5, respectively). Conclusions: ESWT significantly reduces tendon thickness and enhances elasticity, correlating with improvements in pain and functional scores. SWE proved to be a reliable method for monitoring structural and clinical changes in SNCCT. Further research, including randomized controlled trials, is recommended to confirm these findings and explore longer-term outcomes.

Therapeutic effect of titanium locking plate combined with suture anchor repair in proximal humeral fractures

Objective

To explore the therapeutic effect of titanium locking plate combined with suture anchor (SA) repair in the treatment of proximal humeral fractures (PHF).

Methods

This retrospective study was conducted by analyzing the clinical data of 113 patients with PHF admitted to Wuhan Fourth Hospital from March 2021 to October 2023. Among them, 55 patients underwent open reduction and internal fixation (OR/IF) using titanium locking plate (OR/IF group), and 58 patients underwent surgery with titanium locking plate combined with SA (SA group). Perioperative condition, treatment success rate, shoulder joint function before and after the surgery, shoulder joint range of motion, and incidence of complications were compared between the groups.

Results

Surgery duration and the length of hospital stay of patients in the SA group were significantly shorter than those in the OR/IF group, and the intraoperative blood loss was significantly lower in the SA group than in the OR/IF group (P<0.05). In terms of treatment effect, the SA group was significantly higher than the OR/IF (P<0.05). After the surgery, muscle strength, pain levels, daily living activities, and shoulder joint range of motion scores of both groups improved, and the improvement was more significant in the SA group compared to the OR/IF group (P<0.05). After the surgery, the degrees of internal rotation, forward flexion, backward extension, and external rotation of the shoulder joints in both groups increased compared to pre- surgery levels, and were greater in the SA group compared to the OR/IF group (P<0.05). The incidence of complications in the SA group was lower than that in the OR/IF group (P<0.05).

Conclusions

In patients with PHF, the combination of titanium locking plate and SA has a more significant therapeutic effect than that of titanium locking plate alone, which is associated with improved shoulder joint function and range of motion, and reduced incidence of complications.

Medialized vs. Lateralized Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design.

RESULTS

Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery.

CONCLUSION

Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Optimizing post-surgical outcomes: unveiling the importance of patient-reported outcomes with insights from the schulthess local shoulder arthroplasty registry

OBJECTIVE

The establishment of clinical registries is essential for the comprehensive evaluation of surgical outcomes. In 2006, the Schulthess Shoulder Arthroplasty Registry (SAR) was launched to systematically assess safety, implant longevity, functional outcomes, pain levels, quality of life, and patient satisfaction in individuals undergoing shoulder arthroplasty. This paper aims to outline the registry data and demonstrate how it is leveraged to improve clinical outcomes. Additionally, we provide guidance for organizations currently collecting or planning to collect similar data.

PARTICIPANTS

Our SAR systematically records adult patients' data undergoing either anatomic or reverse shoulder joint replacement at the Schulthess Clinic. Both primary and revision surgeries are comprehensively documented within the registry.

CURRENT OUTCOMES

From March 2006 to December 2023, the SAR included 98% of eligible operations. A total of 2301 patients were recruited, accounting for 3576 operations and 14,487 person-years of follow-up. At baseline, the mean age was 71 (range: 20-95), with 65% being female patients. The most prevalent indication was cuff tear arthropathy (46%), and the mean preoperative Constant Score was (31 ± 15). Notably, functional recovery peaked at 12 months postoperatively, displaying no clinically significant deterioration during the initial ten follow-up years in the overall cohort (including both primary arthroplasty and revisions). The registry has been instrumental in addressing various clinical and methodological inquiries, focusing particularly on comparing different implant configurations and surgical techniques to optimize functional recovery. Additionally, SAR data played a pivotal role in substantiating the clinical significance and reliability of radiological monitoring for cortical bone resorption, scapular notching, and glenoid component loosening.

Gender-based differences in mid-term clinical outcomes and patient acceptable symptomatic state attainment after arthroscopic rotator cuff repair: Minimum 2-year follow up

OBJECTIVE

There is paucity of literature on the impact of patients' gender on recovery and treatment success after arthroscopic rotator cuff repair. This study investigates the effect of gender on patient-reported outcomes preoperatively and postoperatively (minimum 2 years), and to determine if gender affects the attainment of patient-acceptable symptomatic state (PASS) thresholds.

METHODS

266 patients (117 males, 149 females), who underwent primary arthroscopic rotator cuff repair for atraumatic, full-thickness tears, were included. Functional outcomes and pain scores were collected preoperatively and postoperatively. Percentage of attainment of PASS for the various outcome scores was calculated and compared between males and females.

RESULTS

Women had statistically significantly poorer functional outcome and pain scores preoperatively and at 1 and 2 years postoperatively (P ​< ​0.01). They also experienced less improvement in outcome scores throughout the postoperative period. Women had statistically significantly lower rates of PASS attainment at 2 years postoperatively.

CONCLUSION

Women experience greater pain and poorer shoulder function compared with men preoperatively, and up to 2 years postoperatively. Women are less likely to achieve PASS thresholds postoperatively, compared to their male counterparts.

STUDY DESIGN

Retrospective Cohort Study.

LEVEL OF EVIDENCE

III.

Diagnostic Ultrasound in the Evaluation of Stiff Shoulder: Association of Axillary Recess Thickness With Standard Clinical Measures

OBJECTIVES

Stiff shoulder, including primary and secondary types, poses diagnostic challenges due to vague definitions and criteria. This study evaluates the diagnostic potential of ultrasound-measured axillary recess thickness in shoulder stiffness.

DESIGNS

In this cross-sectional study, 35 patients with unilateral shoulder stiffness were assessed. Axillary recess thickness was measured using high-resolution ultrasound. Parameters like passive range of motion, Numerical Rating Scale, and Constant-Murley score were evaluated to find correlations with axillary recess thickness.

RESULTS

The average age was 50.7 yrs, and mean body mass index was 22.7. Axillary recess thickness in stiff shoulders (average 3.19 mm) was significantly higher than in unaffected shoulders (average 1.93 mm, P < 0.001). A cutoff of 3.0 mm for axillary recess thickness yielded 73.3% sensitivity and 84.6% specificity for primary stiffness; 2.6 mm cutoff resulted in 57.9% sensitivity and 88.2% specificity for secondary stiffness. Significant correlations were found between axillary recess thickness and passive range of motion, especially in shoulder external rotation and extension.

CONCLUSIONS

Axillary recess thickness measured by ultrasound might serve as a valuable diagnostic and evaluation parameter in shoulder stiffness.

Ultrasonography-guided corticosteroid injection in the coracohumeral ligament in patients with adhesive capsulitis of the shoulder: a double-blinded, sham-controlled randomized study

BACKGROUND

Contracture and thickening of the coracohumeral ligament (CHL) occur in patients with adhesive capsulitis. This adversely affects the movement and function of the shoulder joint. There is limited evidence that explores the effectiveness of an isolated steroid injection into the CHL in combination with physical therapy. This prospective randomized control trial aimed to evaluate the clinical effects of ultrasonography-guided corticosteroid injection compared to a sham injection into the CHL in subjects with adhesive capsulitis.

METHODS

Forty patients (23 males, 52.2 ± 8 years of age) with unilateral adhesive capsulitis (with 5.4 ± 2 months' mean duration of symptoms) were randomly assigned to either the experimental or control group. Both groups received ultrasonography-guided injections into the CHL. The experimental group (n = 20) received corticosteroids and the control group (n = 20) received a sham lidocaine injection. All subjects underwent supervised conventional physical therapy 3 times a week for 3 months. Subjects were evaluated for improvements in pain, range of motion, and disability at 6 and 12 weeks compared with preinjection baseline measurements. Data were compared statistically across groups and times at P < .05. The CHL thickness was compared at baseline across sides using paired t tests.

RESULTS

The experimental group showed statistically greater improvements in pain, functional scores, flexion, abduction, and internal and external rotation range of motion at 12 weeks compared with the control group. Pain reduction was observed in both groups at 6 and 12 weeks, but the experimental group exhibited significantly greater reductions. The CHL was significantly thicker on the affected side than on the unaffected side (P < .001).

DISCUSSION AND CONCLUSION

This study partially supported the hypothesis. Notably, significant improvements in pain, range of motion, and functional scores were observed at 12 weeks in the experimental group. The greater improvements in pain and external rotation may have resulted in lower disability scores in the experimental group. The results emphasize the importance of targeted intervention into the CHL.

Clinical outcomes validate the RAND/UCLA appropriateness criteria algorithm for anatomical total shoulder arthroplasty for streamlining the clinical decision-making process

Aims

A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness.

Methods

Clinical data from a multicentre database identified patients who underwent primary aTSA from November 2004 to January 2023. A total of 390 patients (mean follow-up 48.1 months (SD 42.0)) were included: 97 (24.9%) were classified as appropriate, 218 (55.9%) inconclusive, and 75 (19.2%) inappropriate. Patients were classified as "appropriate", "inconclusive", or "inappropriate", using a modified version of an appropriateness algorithm, which accounted for age, rotator cuff status, mobility, symptomatology, and Walch classification. Multiple pre- and postoperative scores were analyzed using Pearson's chi-squared test and one-way analysis of variance (ANOVA). Postoperative complications were also analyzed.

Results

All groups achieved significant improvement in mean PROM scores postoperatively. "Appropriate" patients experienced significantly greater improvement in visual analogue scale (VAS) and American Shoulder and Elbow Surgeons (ASES) score compared to "inconclusive" and "inappropriate". The appropriate group had a significantly greater proportion of patients who achieved minimal clinically important difference (MCID) (95.8%; n = 93) and substantial clinical benefit (SCB) (92.6%; n = 89). Overall, 13 patients had postoperative complications. No significant differences in postoperative complications among classifications were found.

Conclusion

Our data clinically validate the RAND/UCLA aTSA appropriateness criteria algorithm, allowing for more rapid and reliable determination of aTSA candidacy. "Appropriate" patients were more likely to achieve MCID and SCB for ASES scores compared to "inappropriate" patients. Among "appropriate" patients who did not achieve SCB, 50% (n = 4) had a postoperative complication. There was a significantly higher proportion of postoperative complications among those who did not achieve SCB across all three groups. Only 7.1% (n = 1) of patients who did not achieve SCB in the inappropriate group had a postoperative complication. Thus, it can be inferred that the failure to reach SCB in the appropriate group was likely to be due to a postoperative complication, whereas for patients deemed "inappropriate", failure to reach SCB may be secondary to factors accounted for within our algorithm.

Is it necessary to use a sling or abduction pillow sling after superior rotator cuff repair? A preliminary report

Objectives

The study aimed to evaluate the effects of the use of a shoulder sling, shoulder sling with a pillow, or not using a sling on the shoulder functional score and pain levels following arthroscopic rotator cuff tear repair.

Patients and methods

This randomized prospective study was performed with 90 patients (49 males, 41 females; mean age: 56.2±12.2 year; range, 33 to 77 years) with a small-to-mid, full-thickness rotator cuff tear between July 2020 and October 2022. All patients underwent arthroscopic double-row repair. The nonsling group wore no sling, the sling group wore a sling, and the abduction pillow sling group wore a sling with an abduction pillow. The same rehabilitation program was performed. The Visual Analog Scale (VAS) score, Constant-Murley scores, and degrees of flexion and abduction were recorded preoperatively, on the 15th and 45th days, and at three months, six months, and one year.

Results

On the 15th postoperative day, the VAS score was found to be significantly lower in the nonsling group. On the 45th day, the Constant-Murley score was found to be significantly higher in the abduction pillow sling group. There was no significant difference between the groups regarding the Constant-Murley scores at three weeks, six months, and one year. The shoulder forward flexion angle was significantly lower in the nonsling group on the 45th day. There was no significant difference between the three groups in respect of the shoulder forward flexion at three months, six months, and one year.

Conclusion

No difference was determined between the groups at the six-month and one-year functional results. Not using a sling bandage can be recommended by reducing pain in the early postoperative period.

Which patient level factors predict persistent pain after reverse total shoulder arthroplasty?

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is commonly performed to reduce pain and restore shoulder function in patients with severe shoulder conditions. While most patients experience significant pain relief and functional improvement following surgery, a subset of patients continue to report persistent pain even two years postoperatively. The aim of this study was to identify both modifiable and non-modifiable preoperative factors that contribute to the risk of persistent postsurgical pain after RTSA. By understanding these factors, clinicians can better anticipate which patients are at higher risk and develop tailored preoperative and postoperative pain management strategies to improve overall outcomes.

METHODS

In this retrospective cohort study, 703 patients with complete data undergoing primary RTSA performed between 2011 and 2022 were analyzed. Persistent postsurgical pain was defined as a pain score ≥ 3 on a numeric rating scale. Multivariable regression models were used to identify patient-related and disease-related predictors of persistent postsurgical pain.

RESULTS

The cohort comprised 445 women (63%) and 258 men (37%) with a mean age of 74 ± 8 years at the time of surgery. Persistent postsurgical pain was reported by 18% of patients. Preoperative pain scores averaged 6.0 ± 2.5 on the NRS scale, which decreased to 1.2 ± 1.8 postoperatively. Key predictors included higher preoperative pain levels (β = 0.10, p < 0.001), worse preoperative QuickDASH scores (β = 0.09, p = 0.002), mild symptoms of anxiety or depression (β = 0.52, p = 0.001), prior contralateral TSA surgery (β = 0.34, p = 0.018) and greater number of previous ipsilateral shoulder surgeries (β = 0.44, p < 0.001). In contrast, patients with rheumatoid arthritis (β = - 0.85, p < 0.001) or primary osteoarthritis (β = - 0.82, p < 0.001) experienced lower pain levels.

CONCLUSION

Our study offers important insights into the predictors of persistent postsurgical pain two years after RTSA. Key factors, including higher preoperative pain scores, poor mental health, elevated QuickDASH scores, prior contralateral TSA surgery and a history of prior ipsilateral shoulder surgeries, were identified as significant risk indicators for persistent postsurgical pain.

Types of Injuries and the Severity of Shoulder Dysfunction Associated with Diabetes Mellitus in Patients with Functional Impairment: A Case-Control Study

BACKGROUND/OBJECTIVES

Patients with diabetes have been reported to experience a higher prevalence of shoulder disorders compared to those without diabetes or with other medical conditions. However, the specific types of shoulder injuries and the extent of functional impairment associated with diabetes mellitus remain unclear. This study aimed to assess the association between diabetes and specific shoulder injuries, as well as the degree of functional impairment in affected patients.

METHODS

A case-control study was conducted involving 136 patients with shoulder functional impairment (UCLA Shoulder Scale ≤ 27). The study included 38 patients with diabetes and 98 non-diabetic controls. Shoulder injuries were diagnosed using ultrasonography, focusing on the supraspinatus tendon, long head of the biceps tendon, subscapularis tendon, and the presence of adhesive capsulitis or rotator cuff tears.

RESULTS

Diabetic patients had significantly higher rates of poor shoulder function compared to non-diabetic controls (89.47% vs. 63.26%, adjusted OR [adOR] 5.22, 95% CI 1.57-17.32, p = 0.007). While both groups had high rates of supraspinatus and long head of the biceps tendon injuries (~80%), no significant differences were found between them (p > 0.300). However, diabetic patients were more than three times as likely to have subscapularis tendon injuries (adOR 3.15, 95% CI 1.26-7.90, p = 0.014) and massive rotator cuff tears (adOR 3.76, 95% CI 1.16-12.15, p = 0.027). Additionally, diabetes was associated with a fourfold increased risk of adhesive capsulitis (adOR 4.16, 95% CI 1.20-14.47, p = 0.025).

CONCLUSIONS

Diabetes mellitus is linked to greater functional and structural deterioration of the shoulder, highlighting the importance of considering diabetes as a risk factor for specific shoulder injuries. Early diagnosis and treatment may improve outcomes for diabetic patients with shoulder disorders.

Survivorship and outcomes of arthroscopic bankart repair for anterior shoulder dislocations: A minimum of 2 year follow-up

Background

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

Methods

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.

Results

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.

Discussion

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

AAOS 2024 best paper in the shoulder and elbow classification: watchful waiting provides higher value with similar functional outcomes to physical therapy for frozen shoulder: a prospective randomized controlled trial

BACKGROUND

Physical therapy remains a ubiquitous treatment modality for the management of frozen shoulder (adhesive capsulitis) despite limited high-level evidence supporting its use. Leveraging patient-reported outcome measures (PROMs) and healthcare costs, this study compared patient outcomes and value achieved through watchful waiting (WW) vs. physical therapy (PT) for conservative management of frozen shoulder.

METHODS

Patients in this prospective, parallel randomized controlled trial who were diagnosed with frozen shoulder were randomized 1:1 to WW or PT. All patients were offered therapeutic, intra-articular corticosteroid injections (CSIs). The primary outcome was the American Shoulder and Elbow Surgeons Score. Secondary outcomes included patient value (ie, 12-month American Shoulder and Elbow Surgeons score divided by healthcare costs), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and Visual Analog Scale pain. Due to the confidentiality of internal hospital data, all economic outcomes were divided by an undisclosed constant to set the normalized study mean for direct costs to 1000; similarly, patient value was normalized to set the study mean to 100. Outcomes were assessed at baseline, 6 weeks, 3 months, 6 months, and 12 months using mixed-effects models, with sensitivity analyses adjusting for nonlinear improvement trajectories and CSIs.

RESULTS

Between November 2014 and November 2022, 175 patients were screened, 61 of whom (34.9%) were randomized to WW (31 patients) or PT (30 patients). Forty-seven patients (96%) received at least one CSI, with no significant difference in CSI administration between cohorts (P = .29). Relative to baseline scores, patients from both cohorts improved significantly at each time point for all PROMs (P < .05 for all), with no significant differences in PROMs between groups at any time point (P > .05 for all). However, compared to those assigned WW, patients randomized to PT incurred 10.0× higher costs (normalized mean difference: 1636; 95% CI: 967, 2304; P < .001) and achieved only 16.9% of the patient value (normalized mean difference: -147.0; 95% CI: -207.5, -86.5; P < .001). These results held across all sensitivity analyses.

CONCLUSION

Relative to WW, patients randomized to PT reported similar PROMs but incurred significantly higher direct costs (10.0×) and imposed a greater economic burden on the healthcare system (3.4-6.0×). Accordingly, WW resulted in significantly higher (5.9×) patient value than PT. Although additional high-level, multicenter studies are needed to corroborate these findings, the present study may support physicians and patients in pursuing the most appropriate treatment plan for each patient based on their individualized needs and preferences.

High-energy injuries, combined ligamentous injuries, and joint incongruity as predictors of postoperative shoulder dysfunction in AC joint dislocation surgery

OBJECTIVE

To identify risk factors associated with postoperative shoulder joint dysfunction in patients who underwent surgical intervention for acromioclavicular (AC) joint dislocation, with the aim of enhancing preoperative counselling, surgical planning, and postoperative management to optimize functional outcomes.

METHODS

Patients who underwent surgery for AC joint dislocation between January 2018 and January 2023 at a hospital orthopaedic centre were enrolled into this retrospective study. Inclusion criteria were patients aged ≥18 years with a documented AC joint dislocation who underwent surgical treatment and had a minimum follow-up period >1 year. Patients with pre-existing shoulder conditions, prior shoulder surgeries, or incomplete medical records were excluded. Visual Analog Scale pain score ≥5 and Constant-Murley Score ≤70 was considered indicative of shoulder joint dysfunction. Statistical analyses included univariate and multivariate logistic regression to identify independent risk factors for postoperative shoulder joint dysfunction.

RESULTS

Among 208 included patients, 56 (27%) exhibited shoulder joint dysfunction at the final follow-up. High-energy injury mechanisms, combined coracoclavicular ligament injuries, and lack of coronal plane congruity were identified as significant predictors of postoperative dysfunction. Specifically, high-energy injuries (odds ratio [OR] 5.493, 95% confidence interval [CI] 2.068, 14.590), combined coracoclavicular ligament injuries (OR 0.118, 95% CI 0.032, 0.432), and lack of coronal plane congruity (OR 2.540, 95% CI 1.197, 5.387) were associated with an increased risk of poor shoulder function postoperatively. Other factors, such as age, injury mechanism, and postoperative exercise compliance also contributed to the outcomes. Level of evidence: iv.

CONCLUSIONS

Injury mechanism, ligamentous injuries, and joint congruity are important in determining postoperative shoulder function. Accurate joint reduction and diligent postoperative rehabilitation are crucial for optimal recovery. These findings provide valuable insights for improving patient care and surgical outcomes in AC joint dislocation treatment. Further research is needed to validate these findings and explore additional factors that may influence postoperative shoulder function.

The clinical course and outcomes following arthroscopic frozen shoulder 360° release

Background

Frozen shoulder (FS) is a debilitating inflammatory condition affecting the shoulder capsule that causes significant pain and stiffness. Its etiology, pathophysiology, and treatment remain poorly understood. Although regarded as self-limiting, FS can have profound implications on the activities of daily living and usually takes 1-4 years to resolve on its own accord. In recalcitrant or severe cases where active range of motion (AROM) is extensively restricted, an arthroscopic 360° release may be performed. The aim of this study is to evaluate the clinical outcomes following the FS 360° arthroscopic release.

Methods

An observational prospective cohort study was conducted assessing patient-reported outcome measures (PROMs) in patients who underwent the 360° arthroscopic release between July 2013 and January 2019. Various questionnaires were used to evaluate their shoulder preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months postoperatively. Relevant PROMs included the Oxford Shoulder Score; Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder, and Hand; Constant-Murley Score; American Shoulder and Elbow Surgeons score; and general measures of pain intensity (visual analog scale) and well-being (EQ-5D-3L). AROM movements included forward flexion, abduction, external rotation, internal rotation, as well as external and internal rotation at 90° of abduction.

Results

Fifty consented patients underwent the arthroscopic FS 360° release. The mean age was 52.1 ± 7.7 years (range 35-72), and mean body mass index was 27.1 ± 4.7 kg/m2 (range 19.5-37.5). All PROMs, AROM movements, patient satisfaction, and EQ-5D-3L scores improved significantly between preoperative and 24-month time points (P < .001). Within-participant analysis demonstrated that there was no significant difference between the pathological shoulder AROM and the contralateral (healthy) shoulder AROM (collected preoperatively) for any movement at 24 months postoperatively (all P > .05). No complications or reoperations were reported.

Conclusion

The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant FS. Statistically and clinically significant improvements in AROM and PROMs (Oxford Shoulder Score; Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder, and Hand; Constant-Murley Score; and American Shoulder and Elbow Surgeons score) occurred shortly after the surgery and progressively improved from 2 weeks to 24 months postoperatively, with the operative shoulder achieving similar range of motion as the nonpathological contralateral shoulder at 24 months.

Understanding the Multifactorial Influences on Postsurgical Pain After Rotator Cuff Repair: A Retrospective Cohort Study

Background

The experience of chronic postsurgical pain (CPSP) can vary widely among patients after rotator cuff repair (RCR).

Purpose

To determine the prevalence and predictive factors of CPSP at 6 months after RCR.

Study Design

Cohort study; Level of evidence, 3.

Methods

The following assessments were conducted preoperatively and 6 months postoperatively in adult patients with RCR who had undergone primary arthroscopic RCR (N = 1987): Constant score, pain assessed on the numeric rating scale (0-10), the Subjective Shoulder Value, the Oxford Shoulder Score, and quality of life as measured by the EuroQol-5 Dimensions-5 Level (EQ-5D-5L). Patient characteristics-including age, sex, body mass index, and smoking status-and surgical factors-including the duration of surgery and the American Society of Anesthesiologists (ASA) classification-were also reported. Multivariate logistic regression analysis was performed to determine which variables were predictors for CPSP.

Results

The prevalence of moderate to severe preoperative pain in the patients was 30.4% for CPSP. After adjusting for age, surgery duration, ASA classification, sex, and body mass index, results revealed that unique predictors for CPSP were as follows: (1) the presence of preoperative negative affect-assessed using the anxiety/depression dimension of the EQ-5D-5L (odds ratio [OR], 1.46 (P < .001); (2) preoperative pain (OR, 1.17; P < .001); and (3) shoulder function (OR, 0.96; P < .001). None of the surgical factors appeared to predict CPSP.

Conclusion

Patients predisposed to CPSP can be identified during the preoperative phase. Collectively, there is a call for a more in-depth assessment of biopsychosocial risk factors that could substantially influence the postoperative pain experience.

Displaced proximal humeral fractures in skeletally immature patients: functional outcomes of surgical treatment

PURPOSE

To report the functional results of our experience and to describe intraoperative findings and complications due to the techniques used in our service.

METHODS

From January 2018 to December 2022, 27 Pediatric patients aged from 8 to 16 years underwent surgery to treat proximal humerus fractures. Their demographic characteristics were evaluated, as well as their clinical characteristics on admission, type of reduction (closed/open), presence of interposition in open reductions, type of implant, complications, and functional range of movement according to two shoulder functional scores.

RESULTS

Mean age was 11.2 years (8-15), there was a predominance of males, who accounted for 70% of the cases, and sports accidents were the cause of injury in 44% of the cases. Anatomical location was balanced between patients, including 55% of physeal fractures and 45% of metaphyseal ones. Overall, 81.5% of patients required open reduction to achieve axis correction, and that 55.5% of fractures were fixed with Kirschner wires, and 44, 4% with elastic titanium nails. Mean QuickDASH score was 0.58 (0-1.7), and Constant score was 9 (3-24). There were no major complications, but 27% of cases subjected to open reduction presented a hypertrophic scar.

CONCLUSION

Surgical treatment of severely displaced proximal humerus fractures is successful, both with closed and open reduction; type of implant does not play a key role and should be selected based on the characteristics of each case. Surgical training should prevail at the time of decision-making. When these recommendations are followed, results can be excellent and sequelae are infrequent.

The reliability and concurrent validity of goniometric and visual estimation in participants with unilateral shoulder pain

INTRODUCTION

The Constant-Murley Score (CMS) uses universal goniometry (UG), and the Shoulder Functional Reach Score (SFRS) uses visual estimation (VE). The CMS has validity challenges, and the SFRS has been critiqued for using VE. This study sought to determine the reliability and concurrent validity of VE when compared to the UG for shoulder flexion and abduction. Differences between symptomatic and asymptomatic shoulder and expert and novice raters were also explored.

METHODS

Participants were included if they were at least 18 years old with unilateral, symptomatic shoulder pain, with no post-surgical contraindications. All conditions were randomized, and raters were blinded.

RESULTS

The intertester reliability for UG had Intraclass Correlation Coefficient (ICC) values of 0.76-0.91 at visit one. VE had ICC values that ranged from 0.87 to 0.92 at visit one. VE test-retest reliability had ICC values from 0.81 to 0.94. At visit one, concurrent validity was demonstrated by rho values from 0.84 to 0.89. There were statistically significant differences between the shoulders (P ≤ 0.0448), and there were no differences between the raters (P ≥ 0.0960).

DISCUSSION

UG and VE of active shoulder flexion and abduction are reliable and concurrently valid. Additionally, there were differences between symptomatic and asymptomatic shoulders, and there were no differences between novice and expert raters.

CONCLUSION

The SFRS may be reliable and valid for measuring shoulder motion using VE within and between treatment sessions. Future research should examine this in larger, more diverse participant populations.

Effect of extracorporeal shock wave combined with autologous platelet-rich plasma injection on rotator cuff calcific tendinitis: study protocol for a randomized controlled trial

BACKGROUND

Rotator cuff calcific tendinitis (RCCT) is a common shoulder disease whose main symptoms include shoulder pain, limited mobility, and calcification deposits in the shoulder. Traditional treatment methods have certain limitations, so finding new treatment methods has become the focus of research. Extracorporeal shock wave (ESW) and platelet-rich plasma (PRP) treatments have attracted much attention due to their non-invasive and tissue repair-promoting properties; however, the efficacy of their combined treatment in RCCT remains unclear.

METHODS

This study is designed as a single-center, assessment-blind, randomized controlled clinical trial with three parallel groups. Sixty subjects will be recruited and randomly divided into the ESW group, PRP group, and ESW combined with PRP group, in a 1:1:1 ratio. The entire intervention period is 4 weeks, and the follow-up period is 4 weeks. Outcomes will be measured at baseline (T0), after 1 week of intervention (T1), after 2 weeks of intervention (T2), after 4 weeks of intervention (T3), and after an additional 4 weeks of follow-up period (T4). The primary endpoint is the VAS score. Secondary endpoints are ASES, CMS, UCLA, and the location and size of calcified areas.

DISCUSSION

This study aims to evaluate the efficacy of ESW therapy combined with PRP in treating RCCT. We compare the effects of single and combined treatments to explore their impact on disease symptoms, functional improvement, and calcification regression. This provides a scientific basis for identifying more effective treatment options.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06372600. Registered on April 17, 2024; version 1.

Impact of needle warming moxibustion combined with trigger point massage on shoulder function and stress responses in elderly patients with frozen shoulder

OBJECTIVE

To explore the therapeutic effects of needle warming moxibustion (NWM) combined with trigger point massage on shoulder function and stress responses in elderly patients with frozen shoulder (FS), providing clinical guidance.

METHODS

A retrospective analysis was conducted on 116 patients with FS treated at the Guangdong Work Injury Rehabilitation Hospital from October 2022 to October 2023. The study included 61 patients who received NWM combined with trigger point massage (research group) and 55 patients who received conventional treatment (control group). Shoulder function and pain were assessed using the Constant-Murley Score (CMS) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Additionally, the time to resume normal daily activities, time to achieve no self-perceived pain, and adverse reactions were documented. Post-treatment stress response indicators and inflammatory factors; adrenaline (ADR), cortisol (Cor), adrenocorticotropic hormone (ACTH), C-reactive protein (CRP), nitric oxide (NO), and prostaglandin E2 (PGE2), were measured. A 3-month follow-up was conducted to record prognostic recurrence.

RESULTS

After treatment, the research group showed significantly better shoulder function, reduced pain, and shorter times to resume daily activities and to achieve no self-perceived pain compared to the control group (all P<0.05). Post-treatment levels of ADR, Cor, ACTH, CRP, NO, and PGE2 were also lower in the research group (all P<0.05). The incidence of adverse reactions did not significantly differ between groups (P>0.05); however, the recurrence rate was lower in the research group compared with the control group (P<0.05).

CONCLUSIONS

NWM combined with trigger point massage effectively improves shoulder function and reduces inflammation and stress responses in elderly patients with FS, supporting its clinical application.

Tendon transfers for the management of irreparable subscapularis tears

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Efficacy of Targeted Scapular Stabilization Exercise Versus Conventional Exercise for Patients With Shoulder Pain: A Randomized Clinical Trial

OBJECTIVE

The aim of the study is to investigate the efficacy of targeted scapular stabilization exercise in shoulder pain.

DESIGN

This is an evaluator-blinded, multicenter, randomized controlled trial. The scapular stabilization exercise group ( n = 45) received scapular stabilization exercise based on the type of scapular dyskinesis for 6 wks; the conventional exercise group ( n = 45) received pendulum, wall climbing and stick exercises for 6 wks. Constant-Murley score, numerical rating scale, range of motion, type of scapular dyskinesis, lateral scapular sliding test, pectoralis minor index, scapular index, and satisfaction were assessed at baseline, 2-, 4-, and 6-wk treatment as well as a 6-wk follow-up.

RESULTS

After a 6-wk intervention, the improvement of Constant-Murley score was greater in the scapular stabilization exercise group than in the conventional exercise group, and improvement continued at the 6-wk follow-up ( F = 15.39, P < 0.001, partial η 2 = 0.17). The results were also significant for numerical rating scale during activity, lateral scapular sliding test, pectoralis minor index, type of scapular dyskinesis, and satisfaction in favor of the scapular stabilization exercise group ( P < 0.05).

CONCLUSIONS

Targeted scapular stabilization exercise is an effective intervention program that might be applied to the rehabilitation of shoulder pain.

The effects of telemedicine on Rotator cuff-related shoulder function and pain symptoms: a meta-analysis of randomized clinical trials

BACKGROUND

The effectiveness of telemedicine in aiding rehabilitation exercises among patients with rotator cuff (RC) disorders remains unknown. Therefore, this meta-analysis aimed to assess the effectiveness of telemedicine in patients with RC disorders.

METHODS

Randomized clinical trials (RCTs) on the effectiveness of telemedicine in patients with RC disorders were summarized through a meta-analysis. A systematic search for these RCTs was conducted in PubMed, Cochrane, Embase, and Web of Science databases up to July 2024. Statistical analysis was performed using Stata 16. Publication bias was estimated with the funnel plot and Egger's test.

RESULTS

Ten studies involving 497 participants (telemedicine group = 248 and conventional group = 249) were enrolled, with follow-up durations ranging from 8 weeks to 48 weeks. Functional outcomes measured by the Constant-Murley score were markedly improved after treatment in the telemedicine group compared to the conventional group. Moreover, compared to conventional treatment, telemedicine significantly improved shoulder function evaluated by Quick Disabilities of the Arm, Shoulder, and Hand Score, relieved pain assessed by visual analog scale pain score, and improved range of motion after treatment and in the final follow-up period.

CONCLUSION

Telemedicine has demonstrated potential in alleviating pain and enhancing shoulder function and motion in patients with RC injuries. It may be a feasible intervention for rehabilitation exercises. Further research with a large sample size and standardized treatment is warranted to validate these findings.

Surgical approaches of shoulder calcific tendonitis: a systematic review and meta-analysis

Background

Calcific tendonitis is a painful shoulder disorder characterized by calcium deposits (CDs) in the rotator cuff tendon. This systematic review and meta-analysis examined the most efficient surgical procedure for calcific tendonitis. This includes the comparison between the three main surgical techniques: CD removal, CD removal with subacromial decompression (SAD) and CD removal with tendon repair with respect to functional outcomes and pain control scores.

Methods

Four electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) were searched in February 2023. Studies were eligible for inclusion if they were peer-reviewed, and participants were patients diagnosed with calcific tendonitis of one or more rotator cuff tendon based on diagnostic imaging who underwent shoulder calcific tendonitis surgery. Other shoulder pathology diagnoses were excluded. Meta-analyses were conducted for results that were sufficiently homogeneous in terms of statistical, clinical, and methodological characteristics. Subgroup analyses were performed to determine if effect sizes differed based on the patient's position during the surgery, physiotherapy, and follow-up time.

Results

All surgical interventions resulted in significant improvements in shoulder function and pain control. There were no significant differences between CD removal vs. CD removal with SAD or CD removal vs. CD removal with tendon repair. However, there was a trend in favor of CD removal alone or CD removal with SAD approaches, as they provided better outcome scores than CD removal with tendon repair in terms of shoulder function and pain control.

Conclusions

All surgical interventions provide substantial improvement in shoulder functions and pain control scores with no significant difference between these surgical techniques.

Latissimus dorsi and teres major transfer in reverse shoulder arthroplasty: A systematic review

Background

This paper aims to conduct a systematic review of the current literature to evaluate the clinical outcomes of concurrent latissimus dorsi and teres major (LD/TM) tendon transfer in reverse shoulder arthroplasty (RSA), and to compare that to isolated RSA.

Methods

A comprehensive search on PubMeb, Web of Science, Embase and CINAHL was performed from inception up to January 20, 2023, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Cohort studies, case-control studies, randomized controlled trials and case series that were written in English, which involved patients who underwent RSA with LD/TM transfer were included. Quality of studies was appraised using the Cochrane Risk Of Bias In Nonrandomized Studies of Interventions tool. Systematic review of Constant-Murley Score (CMS) and range of movement (ROM) was conducted.

Results

Eight studies with a total of 265 patients were included. The average mean follow-up time was 42.5 months, with a range of 6 months to 136 months. Of the studies that reported outcomes of RSA with LD/TM transfer, five reported the CMS, five reported external rotation (ER) ROM and six reported forward flexion ROM. Comparing postoperative to preoperative scores, there was an improvement above the minimal clinically important difference for CMS (mean difference (MD) range = 22.40 to 41.80), ER (MD range = 29° to 36°) and forward flexion (MD range = 50° to 75°). Three studies that compared postoperative ER between RSA with and without LD/TM reported no significant difference.

Conclusion

RSA with LD/TM transfer has good clinical outcomes postoperatively, but there is insufficient comparative data to suggest that it is superior or inferior to an isolated RSA.

Effect of electroacupuncture combined with rehabilitation techniques on shoulder function in patients with rotator cuff injuries

BACKGROUND

The rotator cuff is located below the acromion and deltoid muscles and comprises multiple tendons that wrap around the humeral head, maintaining shoulder joint stability.

AIM

To explore the effect of electroacupuncture combined with rehabilitation techniques on shoulder function in patients with rotator cuff injuries.

METHODS

We selected 97 patients with rotator cuff injuries treated in the People's Hospital of Yuhuan from February 2020 to May 2023. Patients were grouped using the envelope method.

RESULTS

After treatment, the study group's treatment effective rate was 94.90% (46/49 patients), significantly higher than that in the control group (79.17%, 38/48 cases; P < 0.05). Before treatment, there was no difference in Constant Murley Score (CMS) scores, shoulder mobility, or 36-Item Short Form Health Survey (SF-36) scale scores (P > 0.05). Compared with those before treatment, the CMS scores (including pain, daily living ability, shoulder mobility, and muscle strength), all aspects of shoulder mobility (forward flexion, posterior extension, external rotation, internal rotation), and SF-36 scale scores (including physiological, psychological, emotional, physical, vitality, and health status) were higher in both groups after treatment and significantly higher in the study group (P < 0.05). There was no difference in the occurrence of complications between the two treatment groups (P > 0.05).

CONCLUSION

Electroacupuncture combined with rehabilitation techniques has a good treatment effect on patients with rotator cuff injuries, helps accelerate the recovery of shoulder function, improves the quality of life, and is highly safe.

Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022

Background

The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs).

Methods

PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes.

Results

432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA.

Conclusion

Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.

Predictive Prognostic Factors in Non-Calcific Supraspinatus Tendinopathy Treated with Focused Extracorporeal Shock Wave Therapy: An Artificial Neural Network Approach

The supraspinatus tendon is one of the most involved tendons in the development of shoulder pain. Extracorporeal shockwave therapy (ESWT) has been recognized as a valid and safe treatment. Sometimes the symptoms cannot be relieved, or a relapse develops, affecting the patient's quality of life. Therefore, a prediction protocol could be a powerful tool aiding our clinical decisions. An artificial neural network was run, in particular a multilayer perceptron model incorporating input information such as the VAS and Constant-Murley score, administered at T0 and at T1 after six months. It showed a model sensitivity of 80.7%, and the area under the ROC curve was 0.701, which demonstrates good discrimination. The aim of our study was to identify predictive factors for minimal clinically successful therapy (MCST), defined as a reduction of ≥40% in VAS score at T1 following ESWT for chronic non-calcific supraspinatus tendinopathy (SNCCT). From the male gender, we expect greater and more frequent clinical success. The more severe the patient's initial condition, the greater the possibility that clinical success will decrease. The Constant and Murley score, Roles and Maudsley score, and VAS are not just evaluation tools to verify an improvement; they are also prognostic factors to be taken into consideration in the assessment of achieving clinical success. Due to the lower clinical improvement observed in older patients and those with worse clinical and functional scales, it would be preferable to also provide these patients with the possibility of combined treatments. The ANN predictive model is reasonable and accurate in studying the influence of prognostic factors and achieving clinical success in patients with chronic non-calcific tendinopathy of the supraspinatus treated with ESWT.

European Society for Surgery of the Shoulder and Elbow (SECEC) rotator cuff tear registry Delphi consensus

Background

The purpose of this study was to establish consensus statements via a Delphi process on the factors that should be included in a registry for those patients undergoing rotator cuff tear treatment.

Methods

A consensus process on the treatment of rotator cuff utilizing a modified Delphi technique was conducted. Fifty-seven surgeons completed these consensus statements and 9 surgeons declined. The participants were members of the European Society for Surgery of the Shoulder and Elbow committees representing 23 European countries. Thirteen questions were generated regarding the diagnosis and follow-up of rotator cuff tears were distributed, with 3 rounds of questionnaires and final voting occurring. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was defined by 100% agreement with a proposed statement.

Results

Of the 13 total questions and consensus statements on rotator cuff tears, 1 achieved unanimous consensus, 6 achieved strong consensus, 5 achieved consensus, and 1 did not achieve consensus. The statement that reached unanimous consensus was that the factors in the patient history that should be evaluated and recorded in the setting of suspected/known rotator cuff tear are age, gender, comorbidities, smoking, traumatic etiology, prior treatment including physical therapy/injections, pain, sleep disturbance, sports, occupation, workmen's compensation, hand dominance, and functional limitations. The statement that did not achieve consensus was related to the role of ultrasound in the initial diagnosis of patients with rotator cuff tears.

Conclusion

Nearly all questions reached consensus among 57 European Society for Surgery of the Shoulder and Elbow members representing 23 different European countries. We encourage surgeons to use this minimum set of variables to establish rotator cuff registries and multicenter studies. By adapting and using compatible variables, data can more easily be compared and eventually merged across countries.

Open repair of subscapularis tendon tears leads to complete relief of symptoms in the majority of patients, but often fails to restore functional range of motion

Purpose

To investigate the outcome of open subscapularis (SSC) repair in terms of complete relief of symptoms, regaining functional range of motion ((ROM), i.e. minimum ROM to complete all tasks of daily living) and retear rate.

Methods

Sixty-one patients who underwent open SSC repair between 2012 and 2019 were included in a retrospective cohort study. Primary outcome measures (complete relief of symptoms, obtaining functional ROM, SSC retears), were assessed at minimum 1-year follow-up. Prognostic factors for these outcome measures were identified.

Results

At final follow-up, 44 patients (72%) reported complete relief of symptoms. Pre-operatively, 23 patients (40%) had a functional ROM, which increased to 33 patients (54%) post-operatively. Eight Patients (13%) had a retear after a median follow-up of 21 months (range: 3-35). Lafosse type IV tears were associated with having persisting symptoms (OR 5, 95 confidence interval (CI) 1.2-17.9, p = 0.024) and retears (OR 7, 95 CI 1.9-37.7, p = 0.031).

Conclusion

The majority of patients reported complete relief of symptoms after SSC repair; however, only 54% obtained a functional ROM. Measuring outcome in terms of complete relief symptoms and regaining functional ROM is useful for the surgeon to evaluate the effect of surgical intervention and provides tangible information for patients.

Comparable results of superior vs antero-inferior plating for the treatment of displaced midshaft clavicle fractures. A comparative study

BACKGROUND

Clavicle fractures represent up to 10 % of all fractures, affecting mainly a young population. Open reduction and internal plate fixation provide good results, but evidence on the best plate positioning is still unclear. Aim of this retrospective study was to compare superior and antero-inferior plating positioning in the surgical treatment of displaced midshaft clavicle fractures.

MATERIALS AND METHODS

104 patients aged > 18 years, treated surgically with plate fixation (51 superior, 53 antero-inferior) for a midshaft clavicle fracture from January 2010 to April 2021 were included. At the time of the visit, mean follow-up time was 6.6 ± 2.6 years. Shoulder function was evaluated with the use of Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Return to sport, aesthetic satisfaction, operative time, radiological outcomes, rate of implant removal, and overall patient satisfaction were documented as well.

RESULTS

Mean CMS was 94.1 ± 10.0 points in the superior plating group and 93.4 ± 11.6 points in the antero-inferior plating group. DASH score: 4.6 ± 11.0 superior, 5.1 ± 10.5 antero-inferior. Return to sport: 8.2 ± 2.9 superior, 8.2 ± 3.0 antero-inferior. Aesthetic satisfaction: 8.9 ± 1.6 superior, 8.8 ± 2.1 antero-inferior. Overall satisfaction: 9.1 ± 1.5 superior, 8.9 ± 1.7 antero-inferior. The comparison between groups showed no statistically significant differences (p = n.s.) for all outcome measures. Operative time: 101.6 ± 27.3 min superior, 113.0 ± 31.6 min antero-inferior (p = 0.05). Radiological follow-up documented one non-union and one mal-union in the antero-inferior plating group. Overall, 63 patients underwent plate removal: 58.8 % in the superior plating group and 62.3 % in the antero-inferior plating group (p = n.s.). Main reason for plate removal was pain/discomfort.

CONCLUSIONS

Both superior and antero-inferior plating provided excellent clinical, functional, and radiological results for the treatment of displaced midshaft clavicle fractures, without significant differences between groups. The superior plating group showed a statistically shorter operative time. High rate of re-interventions with implant removal was documented in both groups.

LEVEL OF EVIDENCE

III.

Assessing complications and functional outcomes in proximal humerus fracture management: a retrospective comparison between conservative and intramedullary nailing treatments

INTRODUCTION

Fractures of the proximal end of the humerus (FPH) are the second most common fractures in the upper limb after fractures of the distal radius and are two to three times as common in women than in men. Therefore, the main objective of the present study was to compare and analyze the complications and the functional outcomes in patients with displaced FPH receiving conservative and surgical treatments with intramedullary nailing.

METHODS

A retrospective cross-sectional study was conducted to establish the differences in complications risks between surgical and non-surgical treatment of the FPH. For this purpose, the clinical and radiological results of 67 consecutive patients were analyzed.

RESULTS

A total of 25 patients were included in the non-surgically treated group. A total of 42 patients were included in the surgically treated group. Complications occurred in a total of 4 (16.0%) patients after the non-surgical treatment. Those included frozen shoulder (n = 2), nonunion (n = 1), and avascular necrosis of the humeral head (n = 1). Complications occurred in a total of 18 (42.6%) patients after the surgical treatment. Non-surgically treated patients had statistically significantly (p < 0.05) lower scores in the Constant-Murley scale in all of the categories.

CONCLUSION

The present study demonstrates an overall prevalence of complications to be 16% in patients treated conservatively and 42.6% in patients treated surgically. In the non-surgical cohort, the frozen shoulder was the most frequently observed complication (8%). Interestingly, non-anatomical repositioning was the most prevalent complication in surgically treated patients. Due to the complexity of the FPH, we believe that the surgeon needs to have comprehensive knowledge regarding the characteristics of this fracture, the available treatment options, and the possible complications that may occur. This can enhance patient safety and provide satisfactory clinical outcomes.

Arthroscopic treatment for rotator cuff injury and frozen shoulder with concomitant rotator cuff injury: analysis of efficacy and factors influencing prognosis

OBJECTIVE

To analyze the efficacy of arthroscopic treatment for patients with rotator cuff injuries and frozen shoulder combined with rotator cuff injuries and assess the factors influencing patient prognosis.

METHODS

A retrospective analysis was performed on 85 patients who underwent arthroscopic surgery at Hanzhong Central Hospital between October 2016 and October 2021, including 42 patients treated for rotator cuff injuries alone (Group A), and 43 patients for frozen shoulder combined with rotator cuff injuries (Group B). Both groups underwent general anesthesia with controlled hypotension during surgery. Treatment outcomes, including shoulder joint functional scores, pain scores, shoulder joint range of motion, and muscle strength were assessed and compared between the two groups before treatment, as well as at 2 weeks and 2 months post-treatment. Quality of life was also evaluated and compared at 2 months post-treatment. Patients were categorized into good and poor prognosis groups based on their outcome, and factors influencing patient prognosis were analyzed.

RESULTS

Before treatment, both groups exhibited relatively low shoulder joint function scores and external rotation angles, coupled with higher pain scores; however, these differences were not significant between groups (all P>0.05). The surgery duration for Group B was notably longer than that of Group A (P<0.05). Nevertheless, there was no significant variance in intraoperative blood loss between the two groups (P>0.05). After a 2-week treatment duration, both groups demonstrated a significant improvement in shoulder joint function score, pain score, and shoulder joint range of motion compared to baseline, but with no statistically significant intergroup differences. However, two months after the treatment, patients in Group A exhibited marked improvements in shoulder joint function score, pain score, shoulder joint range of motion, and overall quality of life compared to Group B (all P<0.05). Furthermore, the therapeutic efficacy in Group A was superior to that in Group B at the 2-month follow-up (P<0.05). Age, comorbid diabetes, metabolic disorders such as thyroid dysfunction, and the extent of shoulder cuff injury were identified as independent risk factors influencing prognosis.

CONCLUSION

Arthroscopic treatment is effective for both frozen shoulder combined with rotator cuff injury and rotator cuff injury alone, with better outcomes observed in patients with rotator cuff injury only. This technique warrants further promotion.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age

INTRODUCTION

The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age.

MATERIALS AND METHODS

This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS).

RESULTS

A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results.

CONCLUSIONS

Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Effectiveness of Pulse Electromagnetic Field Therapy in Patients With Subacromial Impingement Syndrome: A Double-Blind Randomized Sham Controlled Study

OBJECTIVES

To evaluate the 3-month effects of pulsed electromagnetic field therapy (PEMF) in the treatment of subacromial impingement syndrome (SIS).

DESIGN

Planned analysis of a randomized controlled trial with 4- and 12-week follow-ups.

SETTING

Physical medicine and rehabilitation clinic, treatment unit.

PARTICIPANTS

Of the 250 individuals screened for eligibility, participants with a diagnosis of SIS (N=80) were randomized to intervention or control groups.

INTERVENTION

The first group received PEMF + exercise and the second group received sham PEMF + exercise 5 days a week for a total of 20 sessions.

MAIN OUTCOME MEASURES

Visual Analog Scale (VAS), Constant Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), Short Form-36 (SF-36) Quality of Life Questionnaire, and shoulder muscle strength measurement with an isokinetic dynamometer. Evaluations were performed before treatment (T0), after treatment (T1), and 12th week (T2).

RESULTS

Evaluation at T1 and T2 showed improvement in most parameters in both groups compared with baseline. In the comparison between the 2 groups at T1 and T2, more improvement was found in the PEMF group in most parameters.

CONCLUSIONS

In our study, PEMF was found to be superior to sham PEMF in terms of pain, ROM, functionality, and quality of life at the first and third months.

A Rare Combined Injury in Children during Side Impact: The Possible Mechanism and Treatment Results

OBJECTIVE

Proximal humeral fracture combined with contralateral midshaft clavicle fracture is an extremely rare injury in children. Few studies focus on the injury mechanism and treatment scheme. The aim of this study is to propose the possible mechanism of this injury and present the treatment results.

METHODS

This retrospective study included children diagnosed with proximal humeral fractures combined with contralateral midshaft clavicle fractures from August 2016 to March 2019 in the corresponding author's institution. The patients received elastic stable intramedullary nails and external fixation as treatment. The radiological and clinical outcomes of treatments were evaluated using the imaging and the Constant-Murley score (CMS) in follow up.

RESULTS

Twelve patients (eight males and four females) with an average age of 7.83 years old (age 5-12) were included in this research. All the patients had suffered a side impact in a road traffic accident or outdoor environment. Hypothesis about the mechanism was the proximal humerus was directly impacted at first and caused the surgical neck fracture, then the contralateral shoulder hits the solid object and the contralateral midshaft clavicle was fractured. During the average 45.2 months (range 36-57) follow-up, all the patient's fractures achieved clinical and radiological union before 14 weeks without complications. Every patient had a satisfactory score (range from 92 to 100) on the CMS criteria for both shoulders.

CONCLUSION

The hypothesis about the mechanism of this combined injury in this study sounds reasonable. It highlights the need for safety-related education about using a safety seat or wearing a seat belt to parents and caregivers, so as to avoid such injury even if the treatment with external fixation (EF) and proximal humeral and elastic stable intramedullary nailing (ESIN) showed good results.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

Short- to medium-term outcomes and future direction of reverse shoulder arthroplasty: Current concepts

Reverse shoulder arthroplasty is typically indicated for patients with severe shoulder osteoarthritis, rotator cuff tear arthropathy, or proximal humerus fractures that have failed to heal properly. The primary goal of reverse shoulder arthroplasty is to improve shoulder function and reduce pain, while also restoring the ability to perform daily activities. There is a growing body of evidence supporting the effectiveness of reverse shoulder arthroplasty in improving shoulder function and reducing pain in patients with severe shoulder osteoarthritis or rotator cuff tear arthropathy. Reverse shoulder arthroplasty is associated with significant improvements in shoulder function and pain reduction compared to non-surgical treatments. This paper aims to summarize current knowledge, practices and present a summary of the long-term effects of reverse shoulder arthroplasty (RSA) on patient outcomes, including how these outcomes are defined and what measures are typically used to assess them. It will also cover newer definitions of outcomes for RSA that have been developed in recent years in order to better understand the long-term effects of the procedure on patient-reported outcomes and functional ability, as well as information on revision surgery and implant survivorship, and the future of RSA (3D-navigation, patient-specific instrumentation, robotics and artificial intelligence) and its effects on outcomes.

[Effectiveness of Kirschner wire fixation and coracoclavicular ligament reconstruction with suture anchor in treatment of Cho type C distal clavicle fractures]

Objective

To evaluate the effectiveness of Kirschner wire fixation and coracoclavicular ligament reconstruction with suture anchor in the treatment of Cho type ⅡC distal clavicle fractures.

Methods

The data of 17 patients with Cho type ⅡC distal clavicular fractures, who were treated with Kirschner wire fixation and coracoclavicular ligament reconstruction with suture anchor between June 2019 and June 2021, was retrospectively analyzed. There were 11 males and 6 females with an average age of 38.7 years (range, 19-72 years). The fractures were caused by falling in 12 cases and traffic accident in 5 cases. All patients had fresh closed fractures. The interval from injury to operation was 1-5 days (mean, 2.6 days). The preoperative injury severity score (ISS) was 6-27 (mean, 10.2). The operation time, intraoperative blood loss, hospital stay, fracture healing, and postoperative complications were analyzed. The shoulder joint function was evaluated by disabilities of the arm, shoulder, and hand (DASH) score and Constant score at last follow-up.

Results

All operations were completed successfully. The operation time was 20-50 minutes (mean, 31.6 minutes). The intraoperative blood loss was 30-100 mL (mean, 50.6 mL). The hospital stay was 4-9 days (mean, 5.3 days). All incisions healed by first intention. All patients were followed up 12-16 months (mean, 13 months). All clavicle fractures healed, and the healing time was 8-15 weeks (mean, 11 weeks). No complications such as fracture displacement or nonunion caused by internal fixation failure occurred. During the follow-up, skin irritation caused by the Kirschner wire withdrawal occurred in 3 cases. The Kirschner wires were removed after fracture healing in 17 patients. At last follow-up, the Constant score of shoulder joint was 90-100 (mean, 98.2). The DASH score was 0-10 (mean, 1.5).

Conclusion

Kirschner wire fixation combined with coracoclavicular ligament reconstruction with suture anchor in the treatment of Cho type ⅡC distal clavicle fractures has less postoperative complications and slight complications. It is convenient to remove the internal fixator. The Kirschner wire does not fix the distal clavicle fracture through the acromion, which has little effect on shoulder joint function and can obtain good effectiveness.

Test-retest reliability of isometric shoulder muscle strength during abduction and rotation tasks measured using the Biodex dynamometer

BACKGROUND

The Constant score (CS) is often used clinically to assess shoulder function and includes a muscle strength assessment only for abduction. The aim of this study was to evaluate the test-retest reliability of isometric shoulder muscle strength during various positions of abduction and rotation with the Biodex dynamometer and to determine their correlation with the strength assessment of the CS.

METHODS

Ten young healthy subjects participated in this study. Isometric shoulder muscle strength was measured during 3 repetitions for abduction at 10° and 30° abduction in the scapular plane (with extended elbow and hand in neutral position) and for internal and external rotation (with the arm at 15° abduction in the scapular plane and elbow flexed at 90°). Muscle strength tests with the Biodex dynamometer were measured in 2 different sessions. The CS was acquired only in the first session. Intraclass correlation coefficients (ICCs) with 95% confidence interval, limits of agreement, and paired t tests for repeated tests of each abduction and rotation task were calculated. Pearson's correlation between the strength parameter of the CS and isometric muscle strength was investigated.

RESULTS

Muscle strength did not differ between tests (P > .05) with good to very good reliabilities for abduction at 10° and 30°, external rotation and internal rotation (ICC >0.7 for all). A moderate correlation of the strength parameter of the CS with all isometric shoulder strength parameters was observed (r > 0.5 for all).

CONCLUSION

Shoulder muscle strength for abduction and rotation measured with the Biodex dynamometer are reproducible and correlate with the strength assessment of the CS. Therefore, these isometric muscle strength tests can be further employed to investigate the effect of different shoulder joint pathology on muscle strength. These measurements consider a more comprehensive functionality of the rotator cuff than the single strength evaluation in abduction within the CS as both abduction and rotation are assessed. Potentially, this would allow for a more precise differentiation between the various outcomes of rotator cuff tears.

Application of Machine Learning Algorithms for Prognostic Assessment in Rotator Cuff Pathologies: A Clinical Data-Based Approach

AIM

The overall aim of this proposal is to ameliorate the care of rotator cuff (RC) tear patients by applying an innovative machine learning approach for outcome prediction after arthroscopic repair.

MATERIALS AND METHODS

We applied state-of-the-art machine learning algorithms to evaluate the best predictors of the outcome, and 100 RC patients were evaluated at baseline (T0), after 1 month (T1), 3 months (T2), 6 months (T3), and 1 year (T4) from surgical intervention. The outcome measure was the Costant-Murley Shoulder Score, whereas age, sex, BMI, the 36-Item Short-Form Survey, the Simple Shoulder Test, the Hospital Anxiety and Depression Scale, the American Shoulder and Elbow Surgeons Score, the Oxford Shoulder Score, and the Shoulder Pain and Disability Index were considered as predictive factors. Support vector machine (SVM), k-nearest neighbors (k-NN), naïve Bayes (NB), and random forest (RF) algorithms were employed.

RESULTS

Across all sessions, the classifiers demonstrated suboptimal performance when using both the complete and shrunken sets of features. Specifically, the logistic regression (LR) classifier achieved a mean accuracy of 46.5% ± 6%, while the random forest (RF) classifier achieved 51.25% ± 4%. For the shrunken set of features, LR obtained a mean accuracy of 48.5% ± 6%, and RF achieved 45.5% ± 4.5%. No statistical differences were found when comparing the performance metrics of ML algorithms.

CONCLUSIONS

This study underlines the importance of extending the application of AI methods to new predictors, such as neuroimaging and kinematic data, in order to better record significant shifts in RC patients' prognosis.

LIMITATIONS

The data quality within the cohort could represent a limitation, since certain variables, such as smoking, diabetes, and work injury, are known to have an impact on the outcome.

Long-Term Results of Primary Reverse Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Without Glenohumeral Arthritis with a Mean Follow up of 9.4 Years

Background

The aim of this single-center study was to analyze the long-term clinical results of reverse shoulder arthroplasty in patients with massive, irreparable rotator cuff tears without glenohumeral arthritis.

Methods

A retrospective cohort study of 105 patients (115 shoulders) was conducted. The mean age of the patient group was 76 years (range, 65 to 87 years). The mean clinical follow-up was 9.4 years (range, 5 to 17 years). Pain, range of motion, and complication rates were analyzed pre-operatively and at the last follow-up.

Results

The mean Constant-Murley score increased from 29 points (range, 21 to 34 points) preoperatively to 68.1 points (range, 57 to 81 points) postoperatively (p<0.05). Scapular notching was present in 50 shoulders (43.5%) and it was grade 1 or 2 in 47 of 115 cases (40.9%) and grade 3 or 4 in 3 of 115 cases (2.6%). Complications occurred in 19 patients (17%). Seven patients (6%) underwent revision surgery. The mean satisfaction rate was 94%.

Conclusions

Reverse shoulder arthroplasty is a viable treatment for massive, irreparable rotator cuff tears without glenohumeral arthritis with satisfactory clinical outcomes and low complication and reoperation rates with a mean follow up of 9.4 years after surgery.

Patient-reported outcome tools and baseline scores vary by country and region for arthroscopic repair of massive rotator cuff tears: a systematic review

Background

Different patient-reported outcome (PRO) tools are used in patients with arthroscopic rotator cuff repair (ARCR) which complicates outcome comparisons. The purpose of this systematic review was to compare PRO usage and baseline scores across world regions and countries in patients with ARCR of massive rotator cuff tears (MRCT).

Methods

A systematic review was performed on ARCR for MRCT. The search was conducted from September to November of 2022 using the MEDLINE database for articles published in the last 15 years. Thirty-seven articles were included after initial screening and full-text review. In each article, PRO usage, baseline scores, and country of origin were collected. PRO usage was reported in percentages and baseline scores were normalized for each region to facilitate comparisons. Normalization was performed using the PRO means from each article. These averages were converted to fractions using the worst and best possible scores. These were combined into a single numerical value, expressed as a decimal from 0 to 1, using the total sample size for each tool per region. Values closer to 0 represent worse functional outcomes.

Results

Thirty-two percent (n = 12) of articles were from Asia, 43.2% (n = 16) from Europe, 5.4% (n = 2) from the Middle East, and 18.9% (n = 7) from North America. The most commonly reported PRO tools were American Shoulder and Elbow Surgeons (ASES) in 19 papers, Constant-Murley Score (CMS) in 26 papers, Visual Analog Scale for pain (VAS) in 19 papers, and University of California in Los Angeles (UCLA) in 11 papers. ASES was reported in 51% of articles with 63% being from Asia (n = 12) compared to 21% from North America (n = 4). CMS was reported in 70% of studies with 58% being from Europe. Upon normalization, the preoperative score ranged from 0.30 to 0.44. Europe (0.39), and North America (0.40) showed similar scores. The lowest and highest scores were seen in the Middle East (0.3) and Asia (0.44) respectively.

Conclusion

There is no standardized method to report outcomes in patients undergoing ARCR for MRCT. Great variation in usage exists in PROs which complicates data comparison between world regions. With normalization, baseline scores where similar among Asia, North America, and Europe, and lowest in the Middle East.

Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients with Rheumatoid Arthritis

OBJECTIVE

The effectiveness of arthroscopic rotator cuff repair (ARCR) on rheumatoid arthritis (RA) patients remains a controversial topic. This study investigates the mid-term outcomes of ARCR in RA patients and identifies the factors influencing clinical efficacy.

METHODS

This retrospective study enrolled RA patients with small or medium rotator cuff tears (RCTs) between February 2014 and February 2019. Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores were collected at each follow-up time. Ultimately, magnetic resonance imaging (MRI) and X-ray were employed to assess rotator cuff integrity and progression of shoulder bone destruction, respectively. Statistical methods used two-way repeated-measures ANOVA or generalized estimation equations.

RESULTS

A total of 157 patients were identified and divided into ARCR (n = 75) and conservative treatment (n = 82) groups. ARCR group continued to be divided into small tear (n = 35) and medium tear (n = 40) groups. At the final, all scores were better in ARCR group than in the conservative treatment group (p < 0.05). A radiographic evaluation of the final follow-up demonstrated that the progression rate in ARCR group (18.67%) was significantly lower than that of the conservative treatment group (39.02%, p < 0.05). In the comparison of the small tear and medium tear groups, all scores increased significantly after surgery (p < 0.05), and the final follow-up scores were better than preoperative scores (p < 0.05) but worse than those of the 6-month postoperative follow-up (p < 0.05). Comparison between the two groups revealed that all scores of the small tear group were significantly better than those of the medium tear group at 6-month postoperative follow-up (p < 0.05). Although the scores of small tear group remained better than those of the medium group at the final postoperative follow-up, the difference was not statistically significant (p > 0.05). Radiographic assessment of the final follow-up demonstrated that the progression rate in the small tear group (8.57%) was significantly lower than that in the medium group (27.50%, p < 0.05), and the retear rate of small tear group (14.29%) was significantly lower than that of the medium tear group (35.00%, p < 0.05).

CONCLUSION

ARCR could effectively improve the quality of life for RA patients with small or medium RCTs, at least in the medium term. Despite the progression of joint destruction in some patients, postoperative retear rates were comparable to those in the general population. ARCR is more likely to benefit RA patients than conservative treatment.

A prospective multi-centre observational cohort study to evaluate frequency, management and outcomes of acute severe (grade III-VI) acromioclavicular joint injuries in the United Kingdom

To collect data on current management and outcome of acute severe acromioclavicular joint (ACJ) injuries to inform the knowledge base, design and conduct of future research and explore the patient and injury features predicting surgical management. A prospective cohort study was conducted by two trainee collaboratives of acute Grade III to VI ACJ injuries presenting to 12 hospital trusts. 54 Patients were recruited within four weeks of injury regardless of treatment type over a one-year period. Patient reported outcomes and healthcare resource use were collected at six and 12 months post injury. Accounting for Rockwood grade, age, gender and dominant arm injury, the operative group had a statistically lower Oxford Shoulder Score (OSS) at baseline (10.8 vs 25.3, <0.0001) and at six months (37 vs 43.8, p = 0.024) than the non-operative group. There was no statistical difference at 12 months (40 vs 44, p = 0.205). The odds of operative management were inversely correlated with baseline OSS (OR 0.89, p = 0.014). There was no clear preferential method of fixation in the ten patients that received surgery. Future research needs to take into consideration the transitory population of working age, on response to follow up. A future randomised clinical trial (RCT) should be multicentred, pragmatic and stratified for baseline function and injury grade at randomisation.

Relationship between shoulder abduction strength and rotator cuff tear in elderly women: a general population study

OBJECTIVES

To investigate the effect of age-related rotator cuff tears on shoulder strength in a general population cohort.

DESIGN

Cross sectional observational study.

SETTING

This study was set in an outpatient clinic setting in Chingford, North East London, and was a component of the 20 year visit of the Chingford 1000 women cohort.

PARTICIPANTS

Individuals were part of the Chingford 1000 women cohort, a 20-year-old longitudinal population study. This cohort has been extensively characterised as representative of the population of the UK. At the 20 year visit, 446 attended for shoulder assessment and were aged between 64 and 87.

PRIMARY AND SECONDARY OUTCOME MEASURES

Isometric shoulder abduction strength measured using a Nottingham Mecmesin Myometer and the presence of rotator cuff pathology, determined via ultrasound examination (GE voluson i portable ultrasound machine with a 10-16MHz linear probe). Shoulders were classified into normal, abnormal tendon/partial tear, full-thickness tears (>0 and ≤2.5 cm) and full-thickness tears (>2.5 cm). Symptoms were defined using the Oxford Shoulder Score, where an abnormal score was defined as symptomatic.

RESULTS

446 women (891 shoulders) aged 71 (range 65-84) were included in the study. Age, the presence of pain and the non-dominant arm were demonstrated to reduce strength. Rotator cuff tears and pathology had no isolated effect on shoulder strength in those aged under 70. However, in the over 70s full-thickness tears>0 and ≤2.5 cm, and >2.5 cm had mean reductions of 6.3 and 12.7 N, respectively (p<0.001).

CONCLUSION

Rotator cuff tears of all sizes in those aged under 70 were not associated with a loss of shoulder strength. In those aged over 70, strength was reduced by 30% with small and 40% with large full thickness tears. Loss in strength was associated a loss of ability to perform activities of daily living but only for large tears.