What’s New in Shoulder and Elbow Surgery

This article is a review of the most impactful studies related to shoulder and elbow surgery published from April 2022 to March 2023. We included clinical studies primarily from The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, the Journal of Shoulder and Elbow Surgery, and Arthroscopy: The Journal of Arthroscopic & Related Surgery. We placed specific emphasis on higher-quality research (Level-I and II studies) and particularly relevant Level-III studies. Shoulder Arthroplasty Cutibacterium and Infection Prevention Preoperative application of benzoyl peroxide to the skin has been found to reduce Cutibacterium acnes colonization. However, it remains unclear whether this topical application can also reduce C. acnes present in deeper tissue or ultimately lower the incidence of periprosthetic joint infection (PJI). In a randomized clinical trial, Unterfrauner et al.1 investigated possible synergistic effects of benzoyl peroxide and miconazole nitrate on reducing subcutaneous and capsular C. acnes in patients with known C. acnes skin colonization. The experimental group received a 7-day preoperative application of a commercial acne cream that had benzoyl peroxide and miconazole, and the control group did not receive such preoperative treatment. At baseline, 60% of patients in both groups showed skin colonization with C. acnes. In these patients with positive baseline colonization, the experimental group subsequently showed a significant reduction of C. acnes colonization by 56%, whereas the control group showed a 16% reduction. Intraoperative culture specimens taken from the subcutaneous and capsular tissues showed significantly fewer positive cultures in the experimental group (44%) than in the control group (84%). None of the capsular samples from the experimental group was positive, whereas 21% were positive in the control group. Symonds et al.2 conducted a randomized controlled trial to compare the efficacy of 3 different preoperative skin preparations in reducing positive C. acnes culture rates in patients undergoing shoulder arthroplasty. A total of 101 patients were randomized into 3 groups: pHisoHex (hexachlorophene 3% detergent cleanser; sanofi-aventis), 5% benzoyl peroxide, and 5% benzoyl peroxide-clindamycin. Six swab culture specimens were taken in each patient. The application of pHisoHex reduced skin C. acnes colonization by 50%, compared with 73.3% after benzoyl peroxide application and 81.5% after benzoyl peroxide-clindamycin application. However, overall, 22% of cases were still positive for C. acnes at the beginning of the surgical procedure even after 5 applications of the designated skin preparations. There were no significant differences between the groups in the subsequent intraoperative cultures. Perioperative Management The efforts to reduce opioid usage have resulted in the implementation of various opioid-sparing multimodal pain management pathways. In a prospective randomized controlled trial, Jones et al.3 compared the pain scores and patient satisfaction between an opioid-sparing protocol and a traditional opioid-based protocol in patients undergoing shoulder arthroplasty. The opioid-sparing group received 10 tablets of oxycodone at discharge, whereas the opioid-based group received 40 tablets. Both groups received an intraoperative periarticular injection of liposomal bupivacaine. The opioid-sparing group consumed significantly fewer opioids at all time points. No significant differences in the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), or Single Assessment Numeric Evaluation (SANE) scores; range of motion; complications; readmissions; or reoperation were seen between the groups. Jolissaint et al.4 conducted a randomized controlled trial comparing a completely opioid-free pain management pathway with a traditional opioid-containing pathway. Both groups received a preoperative interscalene block. The authors found that the opioid-free group had significantly lower pain levels at 12 hours, 24 hours, and 2 weeks than the opioid-based group. There were no readmissions or increased complications in the opioid-free group. Although effective and widely used in shoulder procedures, an interscalene block carries the risk of various complications and rebound pain. Ewing et al.5 conducted a randomized clinical trial to investigate whether local infiltration analgesia could serve as an effective alternative to an interscalene block for postoperative pain management following shoulder arthroplasty. The local infiltration analgesia group received a joint cocktail injection, which included ropivacaine, epinephrine, and ketorolac, before wound closure. The local infiltration group was noninferior to the interscalene block group with respect to the mean pain score during the first 24 hours, and the 2 groups were not significantly different in pain scores at any postoperative time points except at 8 hours, when the local infiltration group had a significantly higher mean pain score. No significant difference in opioid consumption was observed between the groups at any time points, but the local infiltration group had significantly higher intraoperative opioid consumption. Anatomic Total Shoulder Arthroplasty The optimal technique for managing the subscapularis during anatomic total shoulder arthroplasty (TSA) remains controversial, as the existing literature has not conclusively demonstrated the superiority of any of the 3 available techniques over the others. Baisi et al.6 analyzed a randomized controlled trial to compare the anatomic outcomes between the subscapularis tenotomy and peel techniques. Ultrasound was used to examine the healing and thickness of the subscapularis tendon between 12 and 24 months postoperatively. In analyzing the data from a total of 88 patients, the authors found a significantly higher healing rate of 95% in the tenotomy group compared with 75% in the peel group. The mean tendon thickness was 4 mm and was not significantly different between the groups. The rate of a positive belly-press test, internal rotation strength, ASES score, and Western Ontario Osteoarthritis of the Shoulder (WOOS) Index were not significantly different between the healed and non-healed tendons. Humeral stems with a variable neck-shaft angle were developed to help surgeons to more accurately restore the native neck-shaft angle of patients and to ultimately improve surgical outcomes. Joyce et al.7 conducted a randomized controlled trial to investigate if the native joint anatomy could be better restored for patients with a fixed or variable-neck-shaft angle prosthesis. They randomized 50 patients with osteoarthritis indicated for primary TSA into 2 groups. The fixed-neck-shaft angle group received a 132.5° humeral neck cut, whereas the variable angle group received 1 of 3 angle options (127.5°, 132.5°, and 137.5°) following the patients’ native neck-shaft angle. They found no significant differences between the groups in net changes from premorbid to postoperative measurements of tuberosity-to-head height, head offset from the humeral shaft axis, or the position of the center of rotation. They concluded that both fixed and variable-neck-shaft angle prostheses could adequately restore premorbid anatomy. Reverse Shoulder Arthroplasty The use of reverse shoulder arthroplasty (RSA) for treating osteoarthritis in patients with an intact rotator cuff has been a growing trend. However, there has been a limited amount of current literature comparing RSA and TSA in the setting of osteoarthritis. Kirsch et al.8 conducted a retrospective propensity-score-matched cohort analysis to compare clinical outcomes between RSA and TSA in 134 patients with primary osteoarthritis. At a mean follow-up of 30 months, no significant differences were observed in patient-reported outcome measures (PROMs) (i.e., ASES, SANE, and VAS pain scores) between RSA and TSA. However, TSA was associated with significantly better range of motion in all directions: external rotation, internal rotation, and forward elevation. One TSA case underwent revision to RSA, and no RSA case underwent revision. Rotator Cuff Nonoperative Management Multiple studies have examined the role of injectable orthobiologics in the nonoperative management of rotator cuff disease. Vaquerizo et al.9 compared the clinical efficacy of intratendinous injections of platelet-rich plasma (PRP) (n = 39) with that of corticosteroid injections (n = 40) for chronic rotator cuff tendinopathy in a randomized controlled trial with 1-year follow-up. Although both groups showed a significant improvement in PROMs from baseline to all time points, the PRP group had significantly higher PROMs than the corticosteroid group at 6 and 12 months. In contrast, Godek et al.10 did not find significant differences between groups in PROMs in a 6-month follow-up in a randomized controlled trial comparing subacromial injections of collagen with PRP (n = 27), collagen alone (n = 28), and PRP alone (n = 27) in the treatment of rotator cuff tendinopathy. In a meta-analysis of Level-I and II randomized controlled trials11, Pang et al. compared outcomes of PRP injections with those of corticosteroid injections in the nonoperative management of rotator cuff disease, with 725 patients analyzed across 13 studies. Although minimal clinically important differences (MCIDs) between groups were not consistently found at any time point, PRP showed better medium-term improvement (2 to 6 months) and long-term improvement (≥6 months) than corticosteroid injections in some PROMs that reached the MCID after sensitivity analyses. PRP also had lower rates of subsequent injections or surgical procedures prior to 12 months. Surgical Technique and Biologic Augmentation Long-term follow-up comparing rotator cuff repair techniques is uncommon. Woodmass et al.12 reported long-term follow-up to a previously published randomized controlled trial comparing arthroscopic rotator cuff repair with and without acromioplasty, with 31 of 45 patients in the group without acromioplasty and 25 of 41 patients in the acromioplasty group returning at a mean of 11 years following the initial procedure. There was no significant difference in Western Ontario Rotator Cuff (WORC) Index scores between groups, with both groups maintaining significant improvement from preoperative scores. Imaging of the repair was not performed in this study, but the group without acromioplasty had a significantly higher rate of reoperation (16%) than the acromioplasty group (2%). Multiple studies have examined the effect of creating bone holes or channels at the greater tuberosity repair site as a form of bone marrow stimulation to enhance rotator cuff repair healing. In a randomized controlled trial, Toro et al.13 compared the debridement of the greater tuberosity alone (n = 47) with microfracture (crimson duvet procedure) of the greater tuberosity (n = 48) in patients undergoing arthroscopic rotator cuff repair. There were no significant differences in repair healing rates at 6 months (85.1% compared with 93.7%) or PROMs at 12 months found between the groups. Similarly, Lapner et al.14 compared patients undergoing arthroscopic rotator cuff repair without (n = 75) and with (n = 75) bone channeling at the rotator cuff repair site in a randomized controlled trial and found no significant differences between groups in healing rates (87% compared with 75%) or PROMs at 24 months. The benefit of PRP for augmentation of rotator cuff repairs continues to be investigated. Zhang et al.15 performed a randomized controlled trial of arthroscopic repair of medium to large rotator cuff tears using a double-row, suture-bridge technique without (n = 46) or with (n = 43) PRP injections given intraoperatively and at 7 and 14-day follow-ups. No significant differences in PROMs were found between groups at 24 months, but the PRP group had a significantly lower retear rate (17.6% compared with 38.1%; p = 0.049) and lower postoperative Goutallier grades on magnetic resonance imaging. Two different systematic reviews with network meta-analyses of Level-I randomized controlled trials also examined the effect of the rotator cuff repair technique and PRP application on outcomes. Lavoie-Gagne et al.16 evaluated small to medium rotator cuff tears specifically and found that single-row and double-row repair techniques with or without PRP had similar retear rates, PROMs, and clinical outcomes. In contrast, Lv et al.17 evaluated arthroscopic repairs in ≤5-cm tears and found that PRP application significantly reduced retear rates for both single-row and suture-bridge repairs and that suture-bridge repairs with PRP application overall produced the lowest retear rate and the best University of California Los Angeles (UCLA) shoulder score. Autologous microfragmented lipoaspirate tissue has been shown to be an available source of adipose-derived mesenchymal stem cells that may enhance tissue healing. Randelli et al.18 performed a randomized controlled trial of arthroscopic, single-row, rotator cuff repair without (n = 22) or with (n = 22) the injection of such lipoaspirates harvested from the abdomen or gluteal region and processed, but found no significant differences between the groups in retear rates at 18 months or PROMs at 24 months. Irreparable Rotator Cuff Tears The optimal surgical treatment for irreparable rotator cuff tears remains debatable. Ono et al.19 randomized patients intraoperatively to superior capsular reconstruction (n = 24) or a bridging graft (n = 23) with human dermal allograft following the arthroscopic partial repair of massive, irreparable tears, but found no significant differences between the groups in graft failure rates at 12 months (25% compared with 36%) or PROMs at 24 months. Patients with intact grafts had greater PROMs and acromiohumeral intervals at 24 months, regardless of the graft group. The subacromial balloon spacer has become another surgical option for the management of irreparable rotator cuff tears, with recent studies evaluating its efficacy. In a randomized controlled trial, Verma et al.20 compared arthroscopic partial repair (n = 91) with a subacromial balloon spacer (n = 93) and found significant and clinically relevant improvements in the ASES score in both groups at 12 and 24 months, including similar rates of patients the clinical and patient The subacromial balloon spacer group significantly time and had significantly greater forward at 12 and 24 months. In contrast, et compared arthroscopic debridement with tenotomy (n = and the procedure with of a subacromial balloon spacer (n = in a randomized controlled trial and found that the debridement group had a significantly better mean Shoulder at 12 months = than the balloon spacer the primary The Index and the were not significantly different between groups. Perioperative Management randomized controlled trials evaluated the benefit of during rotator cuff with et preoperative use of in a total of patients and found significantly better pain scores at 8 weeks and shoulder range of motion at 6 months in the but no differences in pain scores at 3 or PROMs at any time points 1 et performed a of preoperative in a total of patients and found no significant benefit of in the to lower or improve arthroscopic or pain scores at 24 after the surgical procedure. In contrast, and performed a of patients and found significantly better arthroscopic visual and lower pain scores at 8 and 24 after the surgical procedure in the group that received of over the of there remains in pain control after rotator cuff repair. In a randomized controlled trial, et compared a multimodal postoperative protocol with a opioid protocol following arthroscopic rotator cuff repair and found that the group had significantly lower pain scores for the first 10 postoperative and significantly fewer of and et randomized patients to an of or for after arthroscopic rotator cuff repair. scores were significantly lower in the group on postoperative 1 but at no time point, and opioid consumption was not significantly different between groups. Similarly, et did not any clinically differences in pain scores or opioid consumption 2 after arthroscopic rotator cuff repair in patients randomized to or after the surgical procedure. Preoperative Evaluation The preoperative of patients with shoulder is at bone or bone and related to and have in recent In some authors have that the at of and of external is a of bone et performed a cohort of patients years of with shoulder to the of various The had sensitivity for and bone and the more traditional and both had sensitivity for all clinical The use of in arthroscopic repairs the and failure of arthroscopic as as the from However, studies have a failure rate of repair. et performed a randomized controlled trial comparing and in repair performed by a The primary outcome was the score for at 24 months, and it was not significantly different between groups. in of patients in the group and of patients in the group. outcomes including the Western Ontario Shoulder SANE, range of pain and complications were not significantly different between the groups at and 24 months. to patients with a or with repair remains et performed a systematic review and meta-analysis of randomized controlled trials to compare outcomes (2 to 3 and long-term outcomes to 12 following repair compared with treatment for A total of patients from 6 randomized controlled trials were repair was associated with a significantly lower rate of for the and for the and for a subsequent surgical procedure for the and for the The Index scores were significantly higher in the group in the but not the to was not significantly different between the 2 groups in the or Humeral the use of a allograft to enhance in of humeral has been et randomized patients with humeral to or with a The mean for the primary outcome of the of the Shoulder and score at 12 months was not significantly different between groups. The outcomes of scores at time points and 24 range of pain, and changes in the neck-shaft angle and the humeral head were not significantly different between groups. The authors concluded that allograft augmentation no clinical or benefit to In the 2 there has been a to humeral in the with et data from patients randomized to RSA and patients randomized to reduction and internal in the trial to a of was using the and from a were to the reduction and internal was and more effective than The mean were similar between groups. and Joint can be of the small of the available for In a prospective randomized controlled trial, et randomized patients to or with 1 patient in each there were 13 patients in the group and patients in the group. Both groups had a rate at 12 months. were during a procedure when was whereas 1 patient in the group for There was no difference in scores or scores at 6 months or 12 months between the groups. treatment of and joint is In a randomized controlled trial, et compared and in the treatment of joint A total of patients 30 were randomized to nonoperative whereas patients 31 were randomized to of patients in the nonoperative group underwent a surgical procedure. At 3 months, the patients had significantly higher of the and Shoulder scores. At and 24 months, there was no significant difference between treatment groups by The authors concluded that the data not surgical treatment with for and joint Elbow elbow remains a to In a randomized controlled trial on patients with elbow et compared the clinical between a and a including elbow range of and The authors found significantly better with the group than with the for including the score, elbow and elbow and strength, pain with of pain, and and time of the on the Two studies evaluated different nonoperative treatment options for et compared a alone with an with or and found that the group performed the best overall at 3 weeks and 6 months, with the and groups both significantly better outcomes than the et compared patients randomized to receive a corticosteroid injection tendon or by a and did not find an benefit from the corticosteroid or tendon 12 months. The of a large of published studies related to the that received a higher of In to in this 5 were that relevant to shoulder and elbow A of those is to this review after the We have a each of the to help in an in this rotator cuff repair the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty. Shoulder Elbow RSA is associated with a higher revision rate to compared with anatomic TSA. has been that this higher risk of revision to after RSA may be related to a of patients previously underwent a surgical procedure that was not an arthroplasty. et al. conducted a large using the Shoulder Arthroplasty to examine this analysis on patients showed an overall revision rate of to the patients had rotator cuff 11 underwent revision to The rate of revision to was for patients had rotator cuff repair and for patients had not a surgical procedure. The for revision that was to was for patients had a rotator cuff repair compared with patients had not a surgical procedure. The that patients with a of procedures had a higher rate of revision by following the not whether the increased of patients with procedures is a for the increased rate of after RSA, compared with arthroplasty humeral for reverse shoulder a systematic review and Shoulder Elbow 2022 Two of RSA humeral have been widely the and the has its and but it is not humeral the clinical outcomes and following In this systematic review and et al. analyzed 12 studies including patients with a follow-up. The authors found that the group had higher ASES scores than the group which was a significant difference but not a clinically important motion was significantly greater in the group than in the group of in forward in and in external but these differences were not clinically The group showed more of compared with p were more in the group than in the but the difference was not significant compared with p = The authors concluded that both and resulted in similar clinical improvements with a lower rate of be that a of studies included in this meta-analysis the initial the outcomes of the not accurately the of Lavoie-Gagne with subacromial injection is a treatment whereas acromioplasty with is best if nonoperative for the management of subacromial a systematic review and network 2022 Although a range of have been investigated for in treating subacromial the optimal on the current has not been In this systematic review and network meta-analysis of Level-I randomized clinical trials clinical outcomes of subacromial with nonoperative or Lavoie-Gagne et al. analyzed from studies with to pain, PROMs, and range of studies for Arthroscopic subacromial with acromioplasty and demonstrated superior improvements in all 3 outcome whereas corticosteroid injections alone consistently demonstrated significantly outcomes in all 3 the nonoperative with corticosteroid injections demonstrated clinical improvements across all 3 on the the authors with corticosteroid injections as a treatment for patients with However, if nonoperative management the authors subacromial with acromioplasty and This for the treatment in cases of subacromial with is associated with lower shoulder periprosthetic joint infection rates than Bone Joint 2022 Preoperative is the of but the clinical of various in shoulder arthroplasty remains et al. conducted a to examine if different preoperative the rate of following shoulder arthroplasty. shoulder in 101 with C. acnes the most In in which was was greater compared with in which were The of or was associated with a higher risk of both and C. acnes compared with the risk with use of the overall infection risk was higher with and higher with and the risk of C. acnes was higher with and higher with This the that superior infection compared with in shoulder arthroplasty. a for a on this from baseline in patient-reported outcomes at 1 2 years after rotator cuff a systematic review and Sports 2022 In this systematic review and meta-analysis of all randomized controlled trials and prospective cohort studies and et al. examined PROMs at baseline, 1 and 2 years after rotator cuff including the ASES, or scores. There were patients across the studies were but no of was The of the baseline PROMs were points for the points for the ASES score, and points for the score, with mean at 1 of points to for the to for the ASES score, and points to for the score. In contrast, the mean differences from 1 to 2 years were 2 points to 4 for the points 1 to for the ASES score, and points to for the score. There was improvement in all PROMs from baseline to 1 small the were observed between 1 and 2 years after rotator cuff repair. a follow-up of 2 years for of clinical studies. However, the of this in has not been This the of such a when PROMs after rotator cuff repair.

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