What’s New in Shoulder and Elbow Surgery

This update is a review of the most impactful studies related to shoulder and elbow surgery published from April 2020 to March 2021. Included are clinical studies primarily from The Journal of Bone & Joint Surgery, the Journal of Shoulder and Elbow Surgery, and The American Journal of Sports Medicine. Specific emphasis has been placed on higher-quality research (Level-I and II studies) and particularly relevant Level-III studies. Rotator Cuff Repair Clinical decision-making in selecting operative or nonoperative treatment for a rotator cuff tear is a subject of constant debate. Song et al.1 prospectively compared the time to achieve clinically meaningful improvement in pain and function between operative and nonoperative treatment of symptomatic partial-thickness and full-thickness rotator cuff tears. Initially, at 3.3 months, the nonoperative treatment group showed significantly better Shoulder Pain and Disability Index (SPADI) scores. However, at 15.5 and 24.7 months, the operative group showed significantly better outcomes. A significantly higher proportion of patients in the operative group showed >50% improvement in functional scores than the nonoperative group at the later time points. The authors concluded that a surgical procedure may be recommended for patients who want, and are willing to wait longer for, a greater magnitude of improvement from baseline, whereas nonoperative treatment may be recommended for patients who want earlier improvement but will also accept a smaller magnitude of improvement. With regard to rotator cuff repair constructs, double-row repair has been shown to be biomechanically superior to single-row repair, leading to decreased retear rates, but its biomechanical superiority has not clearly translated to superior functional outcomes to date. Imam et al.2 conducted a randomized controlled trial to determine if transosseous-equivalent double-row repair would result in superior functional outcomes to single-row repair at 3 years postoperatively. They found that the 2 repair techniques resulted in comparable improvements of function and quality of life in patients with a smaller tear (<3 cm), whereas transosseous-equivalent double-row repair resulted in greater improvements of shoulder function than single-row repair in patients with a larger tear (>3 cm). Their finding suggests that single-row repair can be considered a preferred repair method for smaller tears, given no clear advantage of transosseous-equivalent double-row repair for smaller tears, and transosseous-equivalent double-row repair is considered more suitable for large to massive tears. With regard to the transosseous-equivalent construct, it has been speculated that excessive bridging suture tension could reduce intratendinous blood supply at the repair site, ultimately increasing the risk of medial rotator cuff failure. Oh et al.3 prospectively compared functional and structural outcomes of transosseous-equivalent double-row repairs between a maximum bridging suture tension group (mean tension, 199 N) and an optimum bridging suture tension group (mean tension, 96 N) in patients with a medium to large rotator cuff tear. At a mean follow-up of 27 months, both groups showed significant improvement of shoulder function, but the maximum tension group showed a significantly lower retear rate at 3% than the optimum tension group at 28%. This finding suggests that higher suture tension is not detrimental to healing and potentially can lead to better anatomic healing without an increased risk of medial rotator cuff failure in transosseous-equivalent double-row repairs. The need for supervised structured physical therapy following rotator cuff repair continues to be challenged. Studies have shown little influence of postoperative immobilization length and type of rehabilitation protocol on clinical outcomes. Karppi et al.4 corroborated this finding with their randomized controlled trial in which they prospectively compared pain, function, and satisfaction between patients undergoing supervised physical therapy and those undergoing a home exercise program following rotator cuff repair. At 3 and 12 months postoperatively, they found no significant differences between the 2 groups except for a significantly lower visual analog scale (VAS) score for pain at 3 months in the supervised physical therapy group at 1.0 than in the home-exercise group at 2.4. Postoperative pain management following rotator cuff repair, especially rebound pain after the regional anesthesia effect wears off, continues to be a challenge. Morita et al.5 prospectively evaluated the benefits of adding dexamethasone to an interscalene brachial plexus block in patients undergoing arthroscopic rotator cuff repair. The authors compared pain scores and duration of analgesia between the isolated levobupivacaine block and the combined levobupivacaine-and-dexamethasone block. They found significantly lower pain scores and longer duration of analgesia in the combined block group, suggesting that the addition of dexamethasone can lessen rebound pain. Baessler et al.6 compared 3 interscalene block treatments to investigate the effect of adding liposomal bupivacaine with or without dexamethasone to a conventional bupivacaine interscalene block in patients undergoing arthroscopic rotator cuff repair. The authors found that adding liposomal bupivacaine significantly lowered narcotic consumption on postoperative days 0 to 4 compared with the conventional interscalene block, but the pain scores were not significantly different between groups. They also found that the addition of dexamethasone prolonged the analgesic effect of the liposomal bupivacaine interscalene block. The efficacy of concomitant suprascapular nerve decompression at the time of rotator cuff repair remains controversial. Gerber et al.7 investigated shoulder function, magnetic resonance imaging (MRI), and electromyography (EMG) and nerve conduction studies in 19 patients undergoing rotator cuff repair randomized into 2 groups: 1 group with concomitant suprascapular nerve decompression and 1 group without such decompression. All patients had normal preoperative EMG and nerve conduction studies and mild fatty degeneration of the supraspinatus and infraspinatus muscles (Goutallier grade 1 or 2). The authors found no significant differences between the 2 groups in any parameters at any time points. Contrary to their expectation, the decompression group showed slightly worsened fatty degeneration of the infraspinatus postoperatively, and 3 of the 9 patients in the decompression group had abnormal EMG findings at 3 months; of these 3 patients, 1 recovered only partially at 12 months and 2 recovered fully. They terminated their study early because of safety concerns: a 33% rate of electrophysiologic complications with no obvious clinical benefits of suprascapular nerve decompression. Longstaffe et al.8 investigated the effect of residual rotator cuff tendon length on repair integrity and outcomes. They prospectively compared 2 groups of patients: 1 with >15 mm of residual tendon length and the other with ≤15 mm of residual tendon length as measured intraoperatively. At 6 months postoperatively, there were no significant differences between the 2 groups in retear rates (19.3% for the ≤15-mm tendon group compared with 13.2% for the >15-mm tendon group) and clinical outcomes. Thus, the authors concluded that a smaller residual tendon length is not a negative predictor of outcomes after arthroscopic rotator cuff repair. Shoulder Arthroplasty Perioperative Management Given the recent opioid misuse epidemic and the adverse events related to opioid misuse, there has been increased interest in multimodal pain control regimens after shoulder arthroplasty. In a randomized controlled trial, Burns et al.9 evaluated the efficacy of celecoxib for pain control in patients undergoing shoulder arthroplasty. In the primary outcome of opioid utilization measured by morphine-equivalent doses (MEDs), patients receiving celecoxib took fewer MEDs at both 3 weeks and 6 weeks. The authors concluded that celecoxib is effective in reducing postoperative pain in patients undergoing shoulder arthroplasty. Concurrent evidence from the same group in patients undergoing rotator cuff repair suggests that celecoxib may have a negative effect on tendon healing and the impact on patients undergoing arthroplasty is uncertain10. Liposomal bupivacaine was approved by the U.S. Food and Drug Administration in 2018 for use in interscalene blocks, and its efficacy in shoulder procedures continues to be evaluated. Hattrup et al.11 performed a double-blinded randomized controlled trial investigating the use of liposomal bupivacaine compared with plain bupivacaine in preoperative interscalene blocks in shoulder arthroplasty. No difference greater than the minimal clinically important difference in the VAS pain score, ≥2, was found between the 2 groups at any time point. Total opioid consumption, time to first opioid rescue, and patient satisfaction with regard to pain management were not different between groups. The addition of liposomal bupivacaine to standard bupivacaine did not provide clinically important benefits regarding pain relief after shoulder arthroplasty. Tranexamic acid (TXA) is commonly used to stem blood loss in total joint arthroplasty and comes in both intravenous and topical formulations. Yoon et al.12 performed a randomized controlled trial in 102 patients undergoing reverse total shoulder arthroplasty using intravenous TXA, topical TXA, and a combination of both. The primary outcome was hemoglobin decrease in the first 24 hours, and it was found to be similar between the 3 groups. The secondary outcomes of drain volume and calculated total blood loss were also similar. This study suggested no difference in blood loss using various formulations of TXA in reverse total shoulder arthroplasty. Cutibacterium and Infection Prevention Many studies in the past few years have suggested that Cutibacterium can be commonly found in the native shoulder joint. The clinical importance and implications behind these findings are not well understood. Hudek et al.13 performed genetic phylotyping and immunohistochemistry from deep-tissue specimens from 23 patients undergoing shoulder surgery. Immunohistochemistry staining and confocal microscopy revealed Cutibacterium acnes residing intracellularly within macrophages and stromal cells in patients, some of whom had negative culture results. It remains unclear if this presence leads to the initiation of pathologic changes or whether these bacteria are innocuous commensal organisms. The inoculation of C. acnes into the surgical wound after skin incision for shoulder arthroplasty remains a concern, given the ability of the bacteria to subsist in sebaceous glands protected from the usual prophylactic measures. In a double-blinded randomized study, van Diek et al.14 compared the use of 5% benzoyl peroxide (BPO) gel and placebo on reduction of C. acnes on the skin in healthy volunteers. C. acnes was present in a higher proportion of participants in the placebo group compared with the BPO group, which confirmed the authors’ hypothesis that BPO reduces skin C. acnes by >50%. These results add to the existing literature suggesting that BPO gel can reduce, but not completely eliminate, C. acnes from the area of the surgical incision. Anatomic Total Shoulder Arthroplasty Stemless, canal-sparing humeral implants have become commonplace worldwide. Two randomized controlled trials compared stemless implants with stemmed implants. Wiater et al.15 prospectively compared a stemless humeral component with a short-stemmed humeral component. The primary outcome of mean American Shoulder and Elbow Surgeons (ASES) scores demonstrated that the stemless cohort was noninferior to the stemmed cohort, and failure rates and patient-reported outcomes were also similar. It is notable that 4 patients in the stemless cohort were found to have glenoid fractures. Romeo et al.16 similarly compared stemless and stemmed prostheses and found that the rate of success as determined by the Composite Clinical Success score was 95% in the stemless prosthesis group and 90% in the stemmed prosthesis group. Other patient-reported outcomes and revision rates were similar between groups. The data from these 2 studies suggest that stemless devices are as safe and effective as traditional stemmed devices in short-term follow-up. Reverse Total Shoulder Arthroplasty The utility of tendon transfers at the time of reverse total shoulder arthroplasty in the treatment of combined loss of elevation and external rotation is controversial. Young et al.17 performed a prospective, randomized study comparing 16 patients who underwent a latissimus dorsi and teres major tendon transfer and 12 patients who did not undergo this treatment for combined loss of elevation and external rotation. Both groups showed significant improvements in the ability to perform activities of daily living requiring active external rotation postoperatively. Hornblower sign resolution occurred postoperatively in 73.3% of patients who underwent the tendon transfer and 58.3% of patients who did not undergo the tendon transfer. The authors concluded that functional improvement in activities requiring external rotation could be achieved via reverse shoulder arthroplasty regardless of a concomitant tendon transfer. One potential devastating complication after reverse total shoulder arthroplasty is acromial and scapular fractures. Taylor et al.18 performed a biomechanical cadaveric study comparing acromial and scapular spine strains in specimens with an intact coracoacromial ligament or a transected coracoacromial ligament. Acromial and scapular spine strains were similar at varying levels of abduction with an intact coracoacromial ligament but increased in the scapular spine and decreased in the acromion with a transected coracoacromial ligament. The data suggest that the coracoacromial ligament distributes the forces exerted on the scapula and helps to dissipate loads imparted by the pull of the deltoid and that surgeons should consider retaining the coracoacromial ligament at the time of surgical exposure for reverse total shoulder arthroplasty. Routman et al.19 recently reported on risk factors for acromial and scapular fractures in reverse total shoulder arthroplasty. In 4,125 shoulders that underwent primary reverse shoulder arthroplasty with 1 prosthesis, acromial and scapular fractures occurred in 1.5% of the shoulders. Multivariate analysis demonstrated female sex, rheumatoid arthritis, diagnosis of cuff tear arthropathy, and using more baseplate screws as significant independent risk factors. Patients with fractures had lower patient-reported outcome scores and poorer range of motion compared with patients without fractures. The data from this study help to identify those patients at risk for this complication. The impact of these fractures on patient-reported outcomes highlights the importance of informing patients of this potential complication after reverse shoulder arthroplasty. Shoulder Instability Investigations into the management of recurrent shoulder instability continue to evaluate patient characteristics associated with outcomes following treatment, including patient-reported outcomes and recurrent instability rates. Magnuson et al.20 evaluated 2-year surgical outcomes based on the and for shoulder instability using the Shoulder Instability were to patients at the time of the surgical with the cohort primarily of patients mean was and of the patients were most commonly with instability that was was was and occurred from a was the most of outcomes significantly in at 2 The rate of recurrent occurred in the and the rate of recurrent occurred in the and and the rate of revision surgery occurred in the and had the failure rates. a lower patient-reported outcomes and higher failure rates was with an increasing of preoperative et evaluated patients in a active cohort undergoing primary arthroscopic repair for recurrent shoulder instability and glenoid loss to identify factors associated with failure and to determine if a of glenoid loss was associated with failure. Patients with glenoid loss to and those without glenoid loss were compared at a mean follow-up of The recurrent instability rate was significantly higher in the glenoid loss group at compared with the group without glenoid loss at the glenoid loss group, glenoid loss of duration of months, and of years were independent risk factors for failure. Patients with glenoid loss of were also found to have significantly lower patient-reported outcomes compared with those with glenoid randomized controlled trials have evaluated different treatment for shoulder et performed a study of patients with shoulder with patients randomized to nonoperative management using an external rotation abduction and patients randomized to arthroscopic repair. At the 2-year no significant differences were found between the groups in patient-reported but the recurrent instability rate was significantly higher in the group at compared with the group at et recently performed a of and II studies comparing nonoperative management with arthroscopic repair for patients with shoulder studies with patients were and arthroscopic repair, compared with nonoperative was found to have a significantly lower rate of recurrent instability compared with and instability surgery compared with as well as a higher rate compared with et performed a randomized clinical trial on the use of TXA in patients undergoing a primary procedure for with randomized to intravenous TXA or No significant difference was found in blood loss between but the TXA group had significantly lower postoperative drain a lower rate of postoperative lower VAS score for pain, and opioid et the effect of of the glenoid in primary arthroscopic with patients randomized to the group and patients randomized to the group for a mean follow-up of The recurrent instability rate was significantly higher in the group than in the group and the mean score was significantly lower in the group. et performed a randomized controlled trial of in patients undergoing primary arthroscopic repair, with patients randomized to the acid group and patients randomized to the acid group. At a mean follow-up of no significant differences were found between groups in shoulder function, patient-reported or recurrent instability The group had significantly more on than the group, but this difference was not on and both had volume The group had significantly more changes than the group on Shoulder on operative or nonoperative management for fractures of the and is with recent studies this of at 6 months following nonoperative management of fractures were evaluated in a cohort study by et was by in of patients, and a predictor of factors present 6 weeks after the was found to have superior compared with a predictor at the time of the of factors present at 6 a of the of the Shoulder and score of no on and on were significant of The risk was if of these factors were present at 6 compared with if were et performed a randomized clinical trial comparing reduction and of humeral fractures with functional outcomes were not significantly different between groups at the but of patients in the group on to and underwent repair surgery. patients in the surgical group had nerve et performed a randomized clinical trial of treatment for primary with patients to anesthesia with arthroscopic with or early structured physical therapy with At a no treatment was clinically superior to based on Shoulder Patients who underwent arthroscopic had significantly higher mean Shoulder than patients who underwent and those who underwent structured physical but the mean group differences to 3 did not the clinically important effect to had the of et performed a randomized trial comparing with by a home exercise for the treatment of primary was better in the group at compared with the group at both groups had significant improvement in patient-reported outcomes and shoulder motion at 12 weeks after the with no significant differences between groups. Elbow Management of of the elbow remains a challenge. In a randomized clinical trial, et prospectively evaluated elbow range of motion and function in patients with elbow to undergo rehabilitation or surgical by Both groups underwent a similar elbow rehabilitation which used therapy and motion and No was used in group. At a the mean and the mean of elbow range of motion were significantly greater in the surgical group than in the rehabilitation group. The patient-reported pain, and complication rates were not significantly different between groups. TXA has been used in arthroplasty of other but its utility for elbow has not been et conducted a randomized trial in which patients undergoing an for elbow were randomized into 2 groups: 1 group with topical TXA and 1 group with topical intraoperatively. The mean blood and postoperative were significantly lower in the TXA group than the group. 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