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20140721徐州肩关节研究所肩关节镜Journal Club
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20140721徐州肩关节研究所Journal Club
Xuzhou Shoulder Institute Shoulder Arthroscopy Journal Club
时间：2014年7月21日17:30-19:00
Time : 17:30-19:00 July 21st 2014
地点：江苏省徐州市淮海西路99号徐州医学院附属医院新病房大楼9楼北区骨科 徐州肩关节研究所
Place: Department of Orthopaedic Surgery,North District,9th floor,the new in-patient building, the affiliated hospital of Xuzhou Medical College, No.99 Huaihai West Road, Xuzhou, Jiangsu Province, China
主讲：高绪仁
Speaker: Dr. Xuren Gao Xuzhou Shoulder Institute
内容：
Topics:
1
1Department of Orthopedics, The Affiliated Hospital of Guilin Medical College, Guilin, 541001, Guangxi, China, sc821@foxmail.com.
To determine whether immobilization after arthroscopic rotator cuff repair improved tendon healing compared with early passive motion.
MATERIALS AND METHODS:A systematic electronic literature search was conducted to identify randomized controlled trials (RCTs) comparing early passive motion with immobilization after arthroscopic rotator cuff repair. The primary outcome assessed was tendon healing in the repaired cuff. Secondary outcome measures were range of motion (ROM) and American Shoulder and Elbow Surgeons (ASES) shoulder scale, Simple Shoulder Test (SST), Constant, and visual analog scale (VAS) for pain scores. Pooled analyses were performed using a random effects model to obtain summary estimates of treatment effect with 95 % confidence intervals. Heterogeneity among included studies was quantified.
RESULTS:Three RCTs examining 265 patients were included. Meta-analysis revealed no significant difference in tendon healing in the repaired cuff between the early-motion and immobilization groups. A significant difference in external rotation at 6 months postoperatively favored early motion over immobilization, but no significant difference was observed at 1 year postoperatively. In one study, Constant scores were slightly higher in the early-motion group than in the immobilization group. Two studies found no significant difference in ASES, SST, or VAS score between groups.
CONCLUSION:We found no evidence that immobilization after arthroscopic rotator cuff repair was superior to early-motion rehabilitation in terms of tendon healing or clinical outcome. Patients in the early-motion group may recover ROM more rapidly.
LEVEL OF EVIDENCE:Level II; systematic review of levels I and II studies.
2
Rotator cuff tear (RCT) is a common cause of pain and disability among adults. Platelet-rich plasma (PRP) is a fraction of whole blood containing concentrated growth factors and proteins important for tissue healing. This study aimed at investigating the effects of local autologous PRP injection on repaired rotator cuff (RC) tendon repair in rats.
METHODS:Following experimental RCT and suturing, 44 Wistar rats were randomly allocated into two groups: (1) RC repair only (controls); (2) RC repair + PRP administration-shoulders were treated with intra-articular PRP immediately after the repair. Animals were killed after 3 weeks and tendon, were tested biomechanically in tension (12 rats/group). The remaining tendons (10 rats/group) were stained using hematoxylin and eosin and Picro-sirius Red. Histological analysis evaluated the cellular aspects of the repair tissue.
RESULTS:PRP administration following experimental RC tear and suture resulted in a significantly higher maximal load (p < 0.001) and stiffness (p < 0.005) as compared to non-treated animals. Bonar score of PRP-treated tendons was significantly better (p = 0.018) than the control group. Collagen birefringence was significantly higher in PRP shoulders (p = 0.002), indicating improved organization. Vascularity scores were similar in both groups.
CONCLUSION:Application of a single dose autologous PRP in adjunct to surgical repair resultes in improved tendon-to-bone healing, assessed by histological and biomechanical testing in a rat model of acute RCT, when tested at 3 weeks compared to controls. Further studies will be essential to determine the role of PRP in clinical practice.
3
Reverse total shoulder arthroplasty (RSA) is a recent concept that enables good functional outcomes in cases of massive rotator cuff tear and cuff tear arthropathy. Design parameters influence the functional results and complications. The purpose of this study is to present the results of a novel RSA, the Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA), based on a reverse corolla without a stem.
METHODS:We enrolled 101 patients with 105 RSAs in a prospective study, with a minimum follow-up period of 24 months. The analysis concerned 91 RSAs in 87 patients (61 men and 26 women), with a mean age of 73 years, at a mean follow-up of 41 months (range, 24-69 months).
RESULTS:Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. There was no evidence of component loosening.
CONCLUSION:TESS RSA provided encouraging midterm results with favorable outcomes and a low rate of complications. The stemless TESS with a reverse corolla is a reliable, less invasive system.
Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Reverse shoulder arthroplasty; humeral fixation; rotator cuff arthropathy; scapular notching; shoulder; shoulder arthroplasty; stemless prosthesis
4
We propose that the measurement of the bone mineral density (BMD) of the proximal humerus be standardized using the dual energy X-ray absorptiometry (DXA) in patients supposed to undergo rotator cuff repair surgery as well as those with the fracture of the proximal humerus as the BMD of the proximal humerus is decreased in these patients.
INTRODUCTION:We propose that the measurement of the BMD of the proximal humerus be standardized using the DXA in patients who are supposed to undergo rotator cuff repair surgery as well as those with the fracture of the proximal humerus.
METHODS:We conducted the prospective study in 213 patients with unilateral rotator cuff tear but without contralateral shoulder pain or disease. In these patients, we preoperatively measured the BMD of the bilateral proximal humeri with a repeat measurement in 20 patients. We predefined three regions of interest (ROIs) in the proximal humerus with the consideration of the rotator cuff repair surgery as well as proximal humeral fractures.
RESULTS:The measurement of the BMD of the proximal humerus using the DXA showed excellent reliability (intraclass correlation coefficient > .90). BMD values of all three ROIs in the affected shoulder were significantly lower than those in asymptomatic shoulder (all p < 0.05). In female patients, the BMD values of ROIs in bilateral shoulder were significantly lower than those in male patients (all p < 0.001). In multiple regressions, however, there were no significant correlations between other clinical characteristics, except for the gender, and the BMD of GT in the affected shoulder.
CONCLUSIONS:It is imperative that the bone quality of the proximal humerus be accurately evaluated prior to surgery in patients who are supposed to undergo rotator cuff repair using suture anchors as well as in those with proximal humeral fractures. This is because the BMD of the proximal humerus is decreased in these patients.
5
Since the original Neer humeral replacement in the 1950s, the standard primary anatomic total shoulder arthroplasty design has slowly evolved. Most recently, the humeral stem has become progressively shorter to help combat stem-related complications. Currently, there are several companies who have developed and marketed a stemless humeral arthroplasty component..
MATERIALS AND METHODS:Manufacturers' data for 5 stemless shoulder arthroplasty components currently on the market were analyzed and reviewed. A literature review of short-term results for stemless shoulder arthroplasty was completed.
RESULTS:Of the stemless shoulder arthroplasty systems available on the market, 3 are currently undergoing clinical trials in the United States. The Tornier Simpliciti (Tornier, Edina, MN, USA) clinical trial began in 2011. The study with 2-year minimum follow-up results is scheduled for completion in November 2014. The Arthrex Eclipse (Arthrex, Naples, FL, USA) clinical trial was started in January 2013. The tentative study completion date is 2017. The Biomet Nano (Biomet, Warsaw, IN, USA) clinical trial began in October 2013 and also has a tentative completion date of 2017. No other clinical trial is currently under way in the United States. Early results for stemless shoulder arthroplasty indicate clinical results similar to standard stemmed shoulder arthroplasty. Radiographic analysis indicates implant stability without migration or subsidence at 2- to 3-year minimum follow-up..
CONCLUSIONS:Several stemless shoulder arthroplasty implants are available outside the United States. Early clinical and radiographic results are promising, but well-designed clinical studies and midterm results are lacking. Three clinical trials are currently under way in the United States with initial availability for use anticipated in 2015.
6
Glenoid bone loss is a factor that has been inversely associated with the success of shoulder instability repair. Recently, patients with an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion have also been identified as having a higher failure rate after surgical repair.
PURPOSE:To determine differences in the amount of glenoid bone loss and to compare demographic factors of instability in patients with and without ALPSA tears.
STUDY DESIGN:Case-control study; Level of evidence, 3.
METHODS:Over a 3-year period, all patients (N = 83) who were treated for anterior shoulder instability at a single institution were reviewed retrospectively. A total of 39 (47%) were identified as having an ALPSA lesion and 44 (53%) as having no ALPSA tear. Glenoid bone loss was determined in 2 ways: (1) radiographically by 3-dimensional computed tomography (3D CT) (humeral head digitally subtracted by 3 blinded observers) and (2) with arthroscopic techniques at the time of surgery. Demographic data such as the time from the initial instability event to advanced imaging and surgery were noted. These data were then analyzed with the Student t test to determine any significant differences between the 2 groups.
RESULTS:The patients with an ALPSA lesion had more preoperative instability events than those without (8.2 vs 3.6, respectively; P = .04). The mean glenoid bone loss measured by 3D CT was 12.7% (range, 0%-22.3%) for those with ALPSA tears versus 6.25% (range, 0%-23.1%) for those without (P = .002). The mean duration of total instability for those with ALPSA tears was 42.9 months versus 46.3 months for those without (P = .95). Lastly, the mean bone loss based on arthroscopic measures was 11.4% for patients with ALPSA tears and 4.3% for those without ALPSA tears (P = .017). From the existing magnetic resonance imaging/arthrography scans reviewed, 82% of patients could be correctly identified as having an ALPSA lesion.
CONCLUSION:Patients with anterior shoulder instability who have an ALPSA lesion have nearly twice the amount of glenoid bone loss as those with a standard Bankart tear (no ALPSA lesion). Patients with ALPSA lesions had statistically more instability events, and this may be an additional factor in either developing an ALPSA lesion or glenoid bone loss or both.
© 2014 The Author(s).
anterior instability; anterior labroligamentous periosteal sleeve avulsion (ALPSA); bone loss; glenoid
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