What’s New in Shoulder and Elbow Surgery

This update is a review of the most impactful studies related to shoulder and elbow surgery from February 2019 to March 2020. Included are clinical studies from The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, and the Journal of Shoulder and Elbow Surgery. Specific emphasis has been placed on higher-quality research (Level-I and II studies). Rotator Cuff Repair The decision to pursue nonoperative compared with surgical repair of a rotator cuff tear is central to the treatment of the most common shoulder disorder. Few studies have longitudinally followed patients and compared treatment outcomes in a prospective randomized fashion. Moosmayer et al.1 performed a prospective randomized study in which they compared operative and nonoperative treatment of small and medium-sized chronic, full-thickness rotator cuff tears and evaluated outcomes at 10 years. The authors determined that, at 10 years, repair provided better function as assessed by the American Shoulder and Elbow Surgeons (ASES) score, the Constant-Murley score, and a visual analog scale (VAS) for pain. Patients who crossed over to the surgical group from the nonoperative group were found to have significantly worse Constant-Murley scores compared with the primary repair group. At 10 years, the outcomes of primary repair were superior to those of nonoperative treatment, although both groups improved significantly over time. Ranebo et al.2 performed a prospective randomized study in which they compared operative and nonoperative treatment of small, acute, traumatic rotator cuff tears. Constant-Murley scores and Western Ontario Rotator Cuff index and Numerical Rating Scale values did not differ between the groups at 12 months postoperatively. The authors found that 6.5% of the tears did not heal after repair, while 29% of the tears treated nonoperatively had >5 mm of tear progression. While the authors reported equivalence between the treatments, the large number with tear progression in a short period of time is of concern, and therefore, the findings of this study lend support to operative repair even for these small tears to prevent tear enlargement. In general, primary repair of small and medium-sized acute and chronic tears should be considered for young (<65 years of age) and active patients. The decision to pursue surgical repair of newly symptomatic rotator cuff tears is similarly unclear. Keener et al.3 performed a prospective evaluation of asymptomatic degenerative rotator cuff tears that became newly painful in order to determine factors associated with the decision to undergo repair. Forty-eight of 169 newly symptomatic tears were managed surgically in the series. Surgical intervention was associated with pain development earlier in the surveillance period, younger age, a greater increase in pain, a decline in function, and a history of surgery on the contralateral side. Tear characteristics (tear size or enlargement) were not associated with the decision to pursue surgery. The authors concluded that patient characteristics are more predictive of undergoing surgery than anatomic factors in the setting of new symptoms in previously asymptomatic rotator cuff tears. The optimal construct for rotator cuff repair is still debated among surgeons, as high-level studies comparing contemporary constructs are not common. Yamakado4 performed a prospective randomized study in which they evaluated a medialized single-row repair construct using triple-loaded anchors compared with a double-row suture-bridge construct for medium-sized supraspinatus tears. The authors reported comparable healing rates between medialized single-row and double-row repairs (2.1% versus 6.5%, respectively), although there was a high rate of medial cuff failure among the double-row repairs and incomplete deep-layer healing among the single-row repairs. In general, both repairs offer a very good option for medium-sized supraspinatus tears. Ma et al.5 evaluated the effects of a suture-spanning augmentation of a single-row repair in a randomized controlled trial. They compared a standard single-row repair and a suture-spanning augmented single-row repair for the treatment of massive rotator cuff tears. The retear rate for augmented repairs was significantly lower than that of the nonaugmented repairs (14% versus 47%; p = 0.002). Suture-spanning augmentation is a simple method that may improve healing rates in massive rotator cuff tear repairs. Augmentation using tissue grafts has been reported to improve healing rates following rotator cuff repair. In a prospective randomized study, Avanzi et al.6 compared the use of a single-row repair versus a single-row repair augmented with a porcine acellular dermal matrix graft. At 2 years, patients were evaluated for healing on the basis of magnetic resonance imaging (MRI) and functional outcomes. The authors reported a healing rate of 97.6% in the graft-augmented group compared with 59.5% in the nonaugmented group. The augmented group showed better strength recovery at 24 months and better Constant-Murley scores at 12 months but not at 24 months postoperatively. The authors concluded that single-row repairs augmented with porcine acellular dermal matrix provide improved healing and strength compared with nonaugmented single-row repairs. Platelet-rich plasma has been extensively researched in the setting of rotator cuff repair as one of the few biologics available to improve healing rates. Information is conflicting regarding the utility of platelet-rich plasma at the time of surgical repair, with most suggesting that it does not improve healing rates and, even if there is a positive effect, the use of platelet-rich plasma is likely not cost-effective. Snow et al.7 performed a randomized controlled study to assess the effect of postoperatively applied platelet-rich plasma on functional outcomes and healing. The authors determined that delayed application of leukocyte-rich platelet-rich plasma by 10 to 14 days after repair did not improve function or healing rates after arthroscopic rotator cuff repair. Schwitzguebel et al.8 evaluated the effects of platelet-rich plasma on interstitial tears without repair of the supraspinatus. In a prospective randomized trial, they compared saline solution and platelet-rich plasma injections and found that the platelet-rich plasma was not associated with better tendon-healing or clinical scores compared with saline solution. On the basis of these data, platelet-rich plasma has limited use in the treatment of rotator cuff tears. Pain management after rotator cuff repair can be challenging. Liposomal bupivacaine has been utilized after shoulder arthroplasty for pain relief. In a randomized controlled study, Sethi et al.9 compared the use of locally injected liposomal bupivacaine and an interscalene block after arthroscopic rotator cuff repair, assessing pain scores and opiate requirements postoperatively. The authors reported that the liposomal bupivacaine group had lower pain scores on postoperative days 1 and 2 and consumed fewer narcotic pills during the 5-day period, with a 64% reduction in total narcotic consumption. The addition of liposomal bupivacaine after arthroscopic rotator cuff repair may reduce pain and narcotic consumption. Corticosteroid injections can be utilized in rotator cuff repair both preoperatively and postoperatively. Concerns with perioperative injections include infection and negative effects on healing. In a prospective randomized trial, Kim et al.10 assessed the use of intra-articular corticosteroid injection given at 2 months after rotator cuff repair compared with a saline solution injection. Pain and ASES scores were better in the corticosteroid group at 3 months, but there were no differences at 6 months postoperatively. There also were no differences in healing rates or complications between the groups. Early postoperative corticosteroid injections do not appear to increase the risk of retear and may be safe and effective in improving range of motion and improving outcomes in the early postoperative period. Postoperative immobilization following rotator cuff repair may have a notable impact not only on healing rates but also on pain and clinical outcomes. Ghandour et al.11 performed a prospective study in which they compared the use of an abduction brace and an antirotation brace on pain and functional outcomes after rotator cuff repair. The authors reported no difference in pain, Constant-Murley scores, or strength at any time point up to 1 year postoperatively, supporting no differences in pain or outcomes according to the type of sling used. The utility of radiographs in determining the presence or absence of a rotator cuff tear using the measures of the critical shoulder angle (CSA) and acromion index (AI) remains a topic of interest. In an evaluation of 174 patients with or without rotator cuff tears, Tang et al.12 determined the CSA and AI for each and correlated these findings with the presence or absence of a rotator cuff tear. Radiographs were evaluated using the Suter-Henninger criteria to determine whether the anteroposterior radiograph was standard or nonstandard on the basis of the criteria13. Only 27% of the radiographs met the requirements of a standard anteroposterior radiograph (type A1 and C1). The CSA was significantly greater than that of the control group only in the group that met radiographic standards (39° versus 30°, respectively), with an area under the curve (AUC) of 0.86 and a cutoff of 33°. The CSA was not predictive in the group that did not meet these standards. With adequate-quality anteroposterior radiographs, the CSA may be predictive of rotator cuff disorders, but it may not be helpful on nonstandard radiographs. Instability Decision-making regarding the optimal surgical option for recurrent anterior shoulder instability remains challenging. The 3 primary options are an open Bankart repair, an arthroscopic Bankart repair, or a Latarjet procedure. Bishop et al.14 investigated the influence of preoperative factors on the selection of surgical treatment using a prospectively collected multicenter database. The choice of a Latarjet procedure was associated with longer symptom duration, a higher number of dislocations, revision surgery, participating in high-risk sports, and bone loss. A history of surgery was the only predictor of open versus arthroscopic Bankart repair. Epidemiologic studies are very helpful in defining the natural history of a disease, and our understanding of shoulder instability has traditionally relied on reports from Sweden and U.S. military studies15-18. Leland et al.19 have added to this body of information with a study in which they used a geographic database of >500,000 patients. The authors identified patients with anterior shoulder instability who were ≤40 years of age. They determined that, with nonoperative treatment, patients ≤15 years of age and those 16 to 20 years of age had a 39% and 47% chance of recurrent instability, respectively, at an average of 10 years of follow-up. Patients 16 to 20 years of age had the highest rate of surgical intervention as well as recurrence after surgery (40% and 25%, respectively). Patients 31 to 40 years of age had an 18% chance of recurrent instability but had the highest rate of developing symptomatic arthritis (16%) compared with other age groups. These data support the natural-history data from Sweden in terms of recurrence after nonoperative management15 and can be used to support decision-making for patients ≤40 years of age who have anterior shoulder instability. The long-term results of arthroscopic repair for anterior instability have been reported by various authors, with some studies supporting durable results, while others suggest higher failure rates. Yapp et al.20 reported on the long-term follow-up of patients in a randomized trial in which arthroscopic Bankart repair was compared with arthroscopic washout in the treatment of a first-time anterior dislocation. At an average follow-up of 14 years, arthroscopic washout led to higher rates of recurrent dislocation compared with arthroscopic Bankart repair (47% versus 12%). Revision surgery was performed on 28% of the arthroscopic washout group compared with 9% of the arthroscopic Bankart group, a significant difference (p = 0.048). Recurrent instability was associated with worse functional outcomes. Overall, arthroscopic Bankart repair was associated with the long-term prevention of recurrent instability and the maintenance of functional outcomes among young patients with a single dislocation. Bone loss on the humeral and glenoid sides has a major impact on the treatment of anterior glenohumeral instability. The development of guidelines regarding treatment options based on bone loss is critical to optimizing outcomes and minimizing risk. Dickens et al.21 furthered the discussion on bone loss and instability through a prospective study in which they evaluated the amount of bone loss associated with a single instability event in the setting of first-time and recurrent dislocation. The authors found that first-time dislocation in young, athletic patients (average age, 20 years) was associated with 6.8% glenoid bone loss. In the setting of recurrent instability, total bone loss averaged 10.2% at the time of enrollment and 22.8%, on average, after a subsequent instability event. Awareness of notable anterior bone loss after a first dislocation, as well as subsequent dislocations, may support a more aggressive approach to young, athletic patients with a first-time dislocation to prevent further bone loss with recurrence. Return to sport at the same or higher level of activity is one of the commonly reported metrics utilized to determine the success of treatment, whether nonoperative or operative, after shoulder instability. Shanley et al.22 performed a prospective cohort study to determine the chance of returning to sport and completing the next full season without additional time loss due to injury among athletes with anterior shoulder instability. The authors determined that nonoperatively treated high school athletes successfully returned to their prior sport without an injury for at least 1 full season 85% of the time, while operatively treated patients returned 72% of the time. Patients with a full dislocation were less likely to return compared with those who sustained a subluxation (26% compared with 89%; p = 0.013). The authors concluded that the majority of athletes return to play without missing additional time for shoulder injury when treated nonoperatively, regardless of sport or injury type, and therefore, aggressive operative treatment for young athletes with shoulder instability may not be warranted to prevent the loss of time from sport in the subsequent season. The role of isolated arthroscopic Bankart repair has come into question with reports of higher rates of mid- and long-term recurrence. Thomazeau et al.23 assessed whether preoperative patient selection based on the Instability Severity Index Score would help improve outcomes through identifying predictive factors associated with recurrence. The authors reported that the Instability Severity Index Score was the only predictive factor in multivariate analysis, with a recurrence rate of 10% for a score of ≤2 compared with 35.6% for a score of 3 or 4. Survival curves out to 9 years showed no new dislocations after year 4 for patients with a score of up to 2 points. The authors concluded that isolated arthroscopic repair for instability is a reasonable choice for patients with an Instability Severity Index Score of up to 2, with low recurrence rates out to 9 years. In cases of bone loss with shoulder instability, anterior glenoid reconstruction can be performed using a variety of techniques. The Latarjet procedure and are 2 surgical options for anterior glenoid et compared the 2 in a prospective randomized The authors determined that the 2 in functional outcomes and rates. was in 27% of the patients in the group. was for the Latarjet procedure. 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The pain score was lower in the total shoulder arthroplasty group compared with the nonoperative group at 12 months, but no other scores The study the nonoperative treatment of most 3 and in although the study did not provide information or or regarding patients of age who may from total shoulder arthroplasty compared with nonoperative In a prospective trial, et compared and total shoulder arthroplasty in the treatment of intra-articular humeral in patients to years of age. At 2 years, Constant-Murley scores were significantly better for the total shoulder group compared with the group treated with open reduction and These data suggest that, in in the if surgery is total shoulder arthroplasty may to better outcomes. Postoperative after total shoulder arthroplasty have been with some motion with the of instability, while others early In a prospective randomized study, et evaluated immobilization range of motion and sling for 6 postoperatively compared with for and active range of motion and from the sling as groups were found to have in and abduction at 3 significant differences were found between the groups for any postoperative range of motion or ASES scores at 1 year postoperatively. There were no differences in or narcotic motion and sling do not to provide greater therefore, earlier and from the sling may be considered to earlier return of function without postoperative risk. Elbow The optimal treatment of humeral remains et reported on the long-term follow-up of a randomized clinical trial in which and total elbow arthroplasty were compared in the treatment of patients with intra-articular humeral At a of years postoperatively, the rate was 3 of in the total elbow arthroplasty group and 4 of in the this difference was not The authors concluded that total elbow arthroplasty remains an effective treatment for this injury in the The optimal approach also to be a of et a prospective study of the optimal surgical approach for of intra-articular humeral Included were patients who a approach and 24 patients who an There were no significant differences in range of or rates between the groups for those with the which intra-articular patients who a approach had significantly worse range of motion and outcomes than patients who an The remains the approach for intra-articular but other can likely be a remains the most common elbow but the majority of cases to nonoperative et a randomized clinical trial in which they compared with While both groups improved with to the of pain at the level of pain at and elbow function were significantly better in the short to 12 for than for can be as a of the nonoperative treatment of there to be regarding the for et a prospective study of 12 to years of age using The majority of the had and in of these these findings during the study with The authors found play to be a significant predictor of elbow and progression of Surgeons young athletes may to play among and The of a large number of studies related to the that a higher of In addition to in this 4 other with a higher of were identified that are to shoulder and elbow surgery. A of those is to this review after the standard have provided a each of the to help further in an in this Bone retear rates after primary arthroscopic rotator cuff a review and Shoulder Elbow 2019 a analysis, the authors evaluated the clinical of the effect of arthroscopic rotator cuff repair with and without bone on rotator cuff healing and functional outcomes. The 4 2 randomized controlled and 2 cohort There were no significant differences in clinical scores between standard repairs and repairs. The retear rates were of and of for patients treated with and without bone respectively, and a significant difference over repair was reported to p = = This study the use of as a method for improving rotator cuff healing. Repair of rotator cuff tears in the does it A Sports 2019 The authors of this review evaluated the results of rotator cuff repair among patients years of age. studies were with patients treated with arthroscopic open rotator cuff repair, with a follow-up of months 12 to Patients a significant increase in clinical and functional outcomes after rotator cuff repair, with high ASES scores showed an from to preoperatively to to postoperatively. Postoperative imaging evaluation was performed on a retear rate of The authors concluded that rotator cuff repair in patients years of age high clinical success rates with good outcomes and pain relief. Rotator cuff repair should an in patient years of age with a symptomatic rotator cuff tear. of associated with clinical outcomes following nonoperative A Shoulder Elbow 2019 2019 A review of 16 studies the criteria assessed the effect of on shoulder function and rates in nonoperatively managed The 16 studies 4 randomized controlled and 12 of the 16 studies to any between and shoulder scores or The authors concluded that there is no significant between and rates or shoulder scores in managed nonoperatively, and therefore, for surgery should be based on the of the development of a and not a bone in primary total shoulder a Shoulder Elbow 2019 2019 The authors of this review assessed the rate of revision and and functional outcomes of glenoid at the time of primary total shoulder studies and patients were The rate was but the rate was among cases using bone = bone grafts had a rate = grafts had an rate of = which improved to when using bone = The revision rate was and the rate was with in range of motion and functional The authors concluded that glenoid during primary total shoulder arthroplasty results in clinical low and revision and high rates for both and

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