Arhewoh Reme, Hill J Ryan, Sefko Julianne, Aleem Alexander, Chamberlain Aaron, Keener Jay, Zmistowski Benjamin
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
Clin Orthop Relat Res. 2025 Jan 1;483(1):152-159. doi: 10.1097/CORR.0000000000003199. Epub 2024 Dec 19.
Deficient internal rotation after shoulder arthroplasty can inhibit specific essential activities of daily living that require behind-the-back arm positioning. Although postoperative internal rotation deficits occur, their impact on outcomes of total shoulder arthroplasty (TSA) is not well established. Previous authors have validated the Single Assessment Numeric Evaluation (SANE) as a patient-reported assessment of acceptable outcomes of TSA.
QUESTIONS/PURPOSES: (1) Is there an association between postoperative internal rotation and acceptable outcomes following TSA as assessed by SANE? (2) Is there a threshold for internal rotation after TSA beyond which increasing internal rotation no longer improves odds of acceptable outcomes?
A single institution's longitudinally maintained shoulder arthroplasty registry was used to identify patients undergoing primary anatomic or reverse TSA (RTSA). The registry provides postoperative patient-reported outcomes, including SANE scores. Postoperatively, patients complete a previously validated ROM self-assessment to quantify their current abduction, forward elevation, external rotation in adduction and abduction, and internal rotation in adduction. Data on patient age, preoperative Patient-Reported Outcomes Measurement Information System mental health scores, gender, surgery performed, and hand dominance were also obtained. In all, 784 patient-reported surveys were available. Thirty-four percent (268 of 784) of the surveys were collected at 1 year, 52% (410 of 784) at 2 years, 11% (87 of 784) at 5 years, and 2% (19 of 784) at 10 years. More than 50% percent (446 of 784) of patients underwent RTSA, 48% were men, and the mean ± SD age was 68 ± 8 years at the time of surgery. A logistic multivariate analysis was used to assess the association of internal rotation with an acceptable outcome (defined as a SANE score of > 75%). A receiver operating characteristic curve was used to assess an internal rotation threshold associated with an acceptable SANE score.
After accounting for age, gender, hand dominance, pain level, and surgical procedure, patients with internal rotation below the upper back had lower odds of achieving a SANE score of > 75% (p < 0.05). The threshold for SANE scores > 75% was identified to be internal rotation to the midback and higher, resulting in an area under the curve of 0.71 (95% CI 0.67 to 0.75; p < 0.001) with sensitivity of 57% (95% CI 0.56 to 0.58) and specificity of 75% (95% CI 0.73 to 0.77).
After shoulder arthroplasty, shoulder normalcy was associated with postoperative internal rotation. Although our study has not proven a causal relationship between limited internal rotation and poorer SANE scores, our clinical experience combined with these findings suggests that limited internal rotation indeed is likely clinically important in this context, and so addressing postoperative internal rotation deficits, especially for RTSA, may improve the quality of shoulder arthroplasty. Further research is needed to understand the modifiable factors that prevent sufficient internal rotation following shoulder arthroplasty.
Level III, therapeutic study.
肩关节置换术后内旋不足会妨碍一些特定的日常生活必需活动，这些活动需要手臂置于背后。尽管术后会出现内旋不足，但它们对全肩关节置换术（TSA）结果的影响尚未明确。此前的作者已验证单评估数值评定法（SANE）可作为患者报告的TSA可接受结果的评估方法。
问题/目的：（1）通过SANE评估，TSA术后内旋与可接受结果之间是否存在关联？（2）TSA术后内旋是否存在一个阈值，超过该阈值后增加内旋不再提高可接受结果的几率？
使用单一机构纵向维护的肩关节置换登记系统来识别接受初次解剖型或反向TSA（RTSA）的患者。该登记系统提供术后患者报告的结果，包括SANE评分。术后，患者完成一项先前验证过的关节活动度自我评估，以量化其当前的外展、前屈、内收和外展时的外旋以及内收时的内旋情况。还获取了患者年龄、术前患者报告的结局测量信息系统心理健康评分、性别、所施行的手术以及利手的数据。总共获得了784份患者报告的调查问卷。其中34%（784份中的268份）在1年时收集，52%（784份中的410份）在2年时收集，11%（784份中的87份）在5年时收集，2%（784份中的19份）在10年时收集。超过50%（784份中的446份）的患者接受了RTSA，48%为男性，手术时的平均年龄±标准差为68±8岁。采用逻辑多变量分析来评估内旋与可接受结果（定义为SANE评分>75%）之间的关联。使用受试者工作特征曲线来评估与可接受SANE评分相关的内旋阈值。
在考虑年龄、性别、利手、疼痛程度和手术方式后，内旋低于上背部的患者获得>75%的SANE评分的几率较低（p<0.05）。确定SANE评分>75%的阈值为内旋至中背部及以上，曲线下面积为0.71（95%CI 0.67至0.75；p<0.001），敏感性为57%（95%CI 0.56至0.58），特异性为75%（95%CI 0.73至0.77）。
肩关节置换术后，肩部正常状态与术后内旋相关。尽管我们的研究尚未证明内旋受限与较差的SANE评分之间存在因果关系，但我们的临床经验结合这些发现表明，在这种情况下内旋受限确实可能在临床上具有重要意义，因此解决术后内旋不足问题，尤其是对于RTSA，可能会提高肩关节置换术的质量。需要进一步研究以了解导致肩关节置换术后内旋不足的可改变因素。
III级，治疗性研究。
