Whats New in Shoulder and Elbow Surgery

Chamberlain, Aaron M. MD, MSc; Namdari, Surena MD; Keener, Jay D. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.00823
Specialty Update
Author Information

1Washington University School of Medicine, St. Louis, Missouri

2Rothman Institute, Philadelphia, Pennsylvania

E-mail address for J.D. Keener: keenerj@wudosis.wustl.edu

Article Outline

This update is a review of the most impactful studies related to shoulder and elbow surgery from April 2015 to March 2016. Included are clinical and basic science 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 and IV studies. The level of evidence is provided.

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Shoulder Arthroplasty

Increased length of hospital stay, early readmission, and revision surgical procedures are adverse events that increase the cost of shoulder arthroplasty. Matsen et al. analyzed data from the New York Statewide Planning and Research Cooperative System on more than 17,000 primary shoulder arthroplasties performed over a 13-year period to identify factors associated with prolonged hospitalization and perioperative adverse events requiring readmission or revision procedures1. Longer hospital stays were associated with female sex, advanced patient age, Medicaid insurance, medical comorbidities, arthroplasties to treat fracture, and lower surgeon case volumes. The need for readmission was more likely with advanced patient age and select medical comorbidities related to heart and lung disease or electrolyte imbalance. Revision procedures were more common in younger patients and in patients with a diagnosis of primary or posttraumatic glenohumeral arthritis. That study demonstrated medical comorbidities as the primary reason for readmission following shoulder arthroplasty.

Wirth reported successful short-term results of hemiarthroplasty and biologic glenoid resurfacing with meniscal allograft in 20092. Given concerns for deterioration of results over time, Bois et al. obtained intermediate-term follow-up on the same series of patients at a mean follow-up of 8.3 years3. The authors reported that radiographic indices of posterior subluxation did not significantly increase from the immediate postoperative imaging to the latest radiographs, but the glenohumeral joint space demonstrated a gradual decrease. Although functional outcomes scores were maintained, 9 (30%) of 30 shoulders underwent reoperation and the estimated 10-year survival rate was 56.3%.

Shoulder arthroplasty is most often performed with a takedown of the subscapularis muscle that necessitates protection of the repair during the early postoperative period. Ding et al. examined the radiographic results of total shoulder arthroplasty performed with subscapularis tenotomy compared with a subscapularis-sparing approach in a Level-II prospective randomized trial4. Ninety-six patients were enrolled and early radiographic findings were compared. The authors found no significant difference with most radiographic parameters of humeral-head reconstruction. Retained residual humeral osteophytes and humeral-head diameter outliers were more common in the subscapularis-preserving approach. No data regarding clinical outcomes or glenoid positioning were provided, although the rate of complications was similar between groups.

Blood transfusion rates after shoulder arthroplasty have previously been reported to be low at 8.1% and are often related to surgical complexity5. A study in hip and knee arthroplasty demonstrated significantly reduced blood loss and a lower need for transfusion with the use of tranexamic acid, an antifibrinolytic agent6. The 2015 Neer Award recipients, Gillespie et al., in a Level-I study, randomized 111 patients who underwent primary shoulder arthroplasty in a double-blinded controlled trial to receive either 100 mL of saline with 2 g tranexamic acid applied topically or saline alone applied to the wound at closure7. The mean blood loss was significantly less (p = 0.017) with tranexamic acid (108 mL) compared with the control group (170 mL). Likewise, there was a significantly smaller decrease (p < 0.001) in hemoglobin level following tranexamic acid (1.7 g/dL) compared with the control group (2.6 g/dL). The authors demonstrated that the use of tranexamic acid in shoulder arthroplasty represents an effective blood conservation strategy.

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Reverse Shoulder Arthroplasty

There has been a substantial focus recently on the biomechanical and clinical performance of reverse arthroplasties. One particular area of interest has been the concept of lateralization of reverse arthroplasty components. Although many implant systems lateralize the glenosphere to minimize scapular notching, the functional consequences of lateralization remain unclear. In a Level-I prospective study, Greiner et al. randomized patients undergoing primary reverse arthroplasty to either lateralization (n = 17) or no lateralization (n = 17) by use of a 1-cm autologous humeral-head graft on the glenoid8. Incorporation of the glenoid graft was noted on postoperative computed tomographic (CT) scans in all patients. At a mean follow-up of 22 months, patients in both groups demonstrated significantly increased functional results compared with results at baseline without significant differences between groups. When patients with teres minor muscle degeneration were excluded, the lateralized group showed significantly greater improvement in external rotation motion. This may indicate that lateralization is important for patients with a functional posterior rotator cuff, but it does not add a substantial functional benefit to those without posterior cuff insufficiency.

Another factor with substantial surgical variability is the optimal retroversion at which a humeral component is placed during reverse arthroplasty. Although most components are placed in between 0° and 30° of retroversion, there is little anatomic or clinical evidence to guide surgical decision-making. Rhee et al. performed a Level-III retrospective comparative study in which the humeral component was inserted with 20° of retroversion in 30 patients and with 0° of retroversion in 32 patients9. Range of motion after reverse total shoulder arthroplasty did not significantly differ between groups. Most daily movements did not differ between the 2 groups, but patients in the 0° retroversion angle group scored better on activities related to internal rotation. Although these data may indicate an advantage to placing components in 0° of retroversion for patients in whom internal rotation may need to be maximized, further data will be needed to determine the corresponding impact of retroversion of component impingement and notching.

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Patient-Specific Instrumentation

The use of patient-specific instrumentation for the optimization of glenoid components during shoulder arthroplasty has shown improved accuracy over unassisted placement. Throckmorton et al. further studied the use of patient-specific instrumentation in arthritic cadaveric shoulders10. This Level-I prospective randomized trial used patient-specific instrumentation compared with unassisted component placement for unconstrained total shoulder arthroplasty and reverse shoulder arthroplasty for surgeons with varying levels of experience and varying degrees of glenoid deformity. With postsurgical CT scans, the authors noted improved accuracy of patient-specific instrumentation compared with unassisted component placement for both version and inclination angle after total shoulder arthroplasty but not reverse shoulder arthroplasty that was not influenced by surgeon experience.

In a Level-III study, Iannotti et al. compared glenoid component positioning with CT scans following total shoulder arthroplasty for primary osteoarthritis in which the glenoid was placed after surgeon review of two-dimensional imaging and standard instrumentation compared with three-dimensional CT scan images with and without a patient-specific guide based on three-dimensional software11. They noted improved accuracy (more likely to be within 5° of inclination and 10° of desired corrected version) with both three-dimensional techniques compared with the two-dimensional method; however, no differences were noted with or without use of the patient-specific instrumentation guide with the three-dimensional methods. The clinical impact of patient-specific instrumentation remains unanswered, but this study highlights the potential advantage of patient-specific instrumentation for optimizing glenoid component placement.

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Shoulder Infection

Propionibacterium acnes is a common organism responsible for infection after a shoulder surgical procedure. In a Level-III study, Sethi et al. examined the rates of positive P. acnes cultures from specimens obtained at the time of primary shoulder arthroscopy12. All patients received preoperative antibiotics and were prepared with 2% chlorhexidine gluconate (ChloraPrep; CareFusion). The rate of positive P. acnes cultures increased from 16% at the beginning of the surgical procedure to 40% at closure. Fifty-six percent of all subjects had ≥1 positive culture. Positive cultures were more likely in men. In a similar nonclinical study, Mook et al. examined the rate of positive P. acnes cultures from specimens obtained from noninfected shoulders through an open deltopectoral approach13. Overall, 21% of shoulders had at least 1 positive culture and 13% of control swabs were positive. Risk factors for positive P. acnes included male sex and ≥2 previous corticosteroid injections. These studies highlight the potential for wound contamination with normal skin flora that may cloud interpretation of true periprosthetic joint infections.

The diagnosis of periprosthetic joint infection after shoulder arthroplasty continues to be elusive given the often indolent nature of the process. In a Level-III study, Frangiamore et al. examined the use of synovial fluid alpha-defensin in 33 revision arthroplasty cases utilizing strict and accepted definitions of periprosthetic joint infection (11 confirmed infections)14. Alpha-defensin analysis showed sensitivity of 63%, specificity of 95%, and an area under the receiver operating characteristic (ROC) curve of 0.78. A recommended cutoff alpha-defensin value is >0.50 to rule in infection compared with <0.20 to rule out infection.

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Rotator Cuff
Natural History

The natural history of rotator cuff disease remains an active area of research. Keener et al. published a Level-I prospective study of asymptomatic rotator cuff tears that examines patterns of rotator cuff tear progression in degenerative rotator cuff tears15. The study included 139 full-thickness degenerative tears followed over 6 years. Most degenerative tears were noted to spare the anterior supraspinatus cable. Tears that disrupted the anterior cable were larger at baseline (median, 19 mm compared with 10 mm). No difference in risk for tear enlargement or time to enlargement was noted when comparing cable-intact tears with cable-disrupted tears.

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Genetic Analysis

Genetic research is an evolving area of focus in understanding the risk for developing rotator cuff disease. Tashjian et al. performed a genomewide association, Level-III study using 311 full-thickness rotator cuff tear cases compared with 2,641 genetically matched controls16. Two single-nucleotide polymorphisms (SNPs) were identified that were strongly associated with rotator cuff tearing. These SNPs were located on SAP30BP on chromosome 17 and SASH1 on chromosome 6. These genes are associated with cellular apoptosis. Future genetic research may provide helpful information about which patients may be at risk for developing rotator cuff tears.

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Treatment of Rotator Cuff Tears

The optimal treatment of symptomatic, degenerative rotator cuff tears is a topic of much debate. In a Level-I study, Kukkonen et al. randomized 180 shoulders of patients who were ≥55 years of age and had painful, atraumatic, isolated supraspinatus tears into one of three treatments: physical therapy alone, acromioplasty and physical therapy, and rotator cuff repair, acromioplasty, and physical therapy17. Among the 167 shoulders available for 2 years of follow-up, no significant differences among the three interventions were seen in the Constant score, visual analog scale (VAS) pain score, or patient satisfaction. The patients who underwent a surgical procedure had a smaller mean tear size at the 2-year follow-up compared with the patients in the two groups without repair. Although the data support a trial of initial conservative treatment in older patients with degenerative atraumatic cuff tears, the importance of residual tear size over time and the true age cutoff that separates older patients from younger patients remains to be determined. Given the correlation between age and rotator cuff healing, it is important to note that patients in all groups had a mean age of approximately 65 years (range, 55 to 81 years).

In a similar investigation with a younger patient cohort, Lambers Heerspink et al. performed a Level-I randomized controlled trial of patients with degenerative full-thickness cuff tears in which 31 patients were managed with subacromial corticosteroid infiltration, physiotherapy, and analgesic medication and 25 patients were managed with rotator cuff repair18. Patients in this study had a mean age of 61 years in each group. The authors reported that VAS pain (p = 0.04) and VAS disability (p = 0.02) were significantly lower in the surgical procedure group at the 12-month follow-up.

Tendon quality and vascularity of the repair environment are known to be important factors for rotator cuff healing. Although most research has focused on tendon vascularity, the microvascularity of the bone may play an equally important role in healing. In a Level-I study, Bonnevialle et al. obtained core biopsies from the rotator cuff footprint in 48 patients undergoing repair of a chronic rotator cuff tear with a single-row technique19. The authors determined the microvascularization of the bone with an immunohistochemistry technique using anti-CD34 antibodies. The authors found that a lower rate of microvessels within the bone decreased the tendon integrity and healing potential after repair. Patients with a history of corticosteroid injection had a lower rate of microvascularization than those without that history. Mechanisms to enhance healing of rotator cuff repairs have been employed with varying levels of success.

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Rotator Cuff Repair: Biologic Supplementation

The use of platelet-rich plasma injections has been shown in multiple previous high-quality studies to have no beneficial effect following arthroscopic rotator cuff repair. Wang et al. performed a Level-I prospective randomized trial comparing arthroscopic supraspinatus repair with or without platelet-rich plasma injections in which two separate injections were given at 1 and 2 weeks postoperatively20. Results at 16 weeks demonstrated no difference in clinical outcomes, strength, or tendon integrity on postoperative magnetic resonance imaging (MRI) between groups. Jo et al. performed a Level-I randomized controlled trial in which 74 patients underwent arthroscopic repair of medium to large rotator cuff tears via either platelet-rich plasma-augmented repair or conventional repair21. For the platelet-rich plasma group, platelet counts were adjusted with saline solution to 1,000 × 103 platelets/μL and were delivered to the repair site. There was no difference between the two groups in the Constant score, VAS for pain, range of motion, muscle strength, overall satisfaction and function, and other functional scores. The retear rate of the platelet-rich plasma group (3.0%) was significantly lower (p = 0.032) than that of the conventional group (20.0%).

In a Level-II study, Verhaegen et al. prospectively compared the results of arthroscopic debridement or needling with those of debridement with platelet-rich plasma augmentation for the treatment of rotator cuff calcific tendinitis22. No difference in clinical outcomes or the rate of postoperative tendon defects was noted at 1 year postoperatively.

A Level-I meta-analysis of prior Level-I studies evaluating the effect of platelet-rich plasma on tendon healing in arthroscopic rotator cuff repair was performed by Cai et al.23. Clinical outcome scores were similar between platelet-rich plasma and non-platelet-rich plasma-treated groups as no significant differences were identified in the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) Shoulder Rating Scale, and the Simple Shoulder Test. However, groups treated with platelet-rich plasma exhibited better tendon healing rates in small or moderate-sized full-thickness tears compared with groups not treated with platelet-rich plasma.

In addition to platelet-rich plasma, interest is high in other potential biologic supplementation solutions. With the support of the SECEC (Société Européenne pour la Chirurgie de l’Epaule et du Coude) Research Grant 2008, Zumstein et al. performed a Level-I prospective randomized controlled study in which patients were randomized to undergo arthroscopic rotator cuff repair with leukocyte and platelet-rich fibrin applied to the repair site or to undergo repair without leukocyte and platelet-rich fibrin24. No beneficial effect of leukocyte and platelet-rich fibrin was found in overall clinical outcome, healing rate, postoperative defect size, and tendon quality at the 1-year follow-up.

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Shoulder Instability

Although the short-term recurrence rate after an open Bankart repair is generally low, the reported recurrence rates at a minimum of 10 years are surprisingly high, ranging from 9.1% to 57.6%25-28. In a Level-IV study, Moroder et al. performed a long-term investigation of open Bankart repair for the treatment of anterior glenohumeral instability without substantial glenoid bone loss confirmed by a preoperative CT scan29. The authors evaluated 40 patients at a minimum follow-up of 20 years (maximum, 25 years). Seven patients (17.5%) had a recurrence of instability, and 6 of those patients had instability that occurred >8 years following the surgical procedure. The mean Western Ontario Shoulder Instability Index score was 256.7 points, the mean Rowe score was 88.7 points, and the mean Subjective Shoulder Value was 90.1%. The authors demonstrated overall good long-term results in terms of subjective and objective outcome measurements; however, late dislocations are not uncommon after early promising results, and recurrent instability in this study was 17.5% despite the exclusion of substantial osseous glenoid defects.

Glenoid bone loss has been shown in multiple studies to influence the rate of recurrent instability after anterior shoulder stabilization. In a Level-III study, Shaha et al. evaluated the influence of anterior glenoid bone loss on outcomes following arthroscopic stabilization in military personnel30. Glenoid bone loss was divided into quartiles based on MRI. Similar to previous studies, worsening bone loss correlated with greater risks of instability. Novel analysis demonstrated, in the absence of recurrent instability, that worsening functional scores (Western Ontario Shoulder Instability) correlated with greater degrees of bone loss. The authors identified a subcritical degree of bone loss at 13.5% of the glenoid diameter that negatively influences clinical outcomes in the absence of recurrent instability.

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Adhesive Capsulitis

Previous studies have evaluated the efficacy of injections in the treatment of adhesive capsulitis. Yoon et al. performed a Level-I prospective randomized trial comparing the efficacy of intra-articular injection, subacromial injection, and hydrodilation in the treatment of adhesive capsulitis31. The study found that although hydrodilation yielded greater early improvement in range of motion, VAS for pain, and functional outcome scores, results among the three modalities were similar at 6 months.

Ranalletta et al. performed a Level-I randomized trial comparing a non-image-guided intra-articular corticosteroid injection followed by physical therapy with oral nonsteroidal anti-inflammatory drugs and physical therapy in the treatment of adhesive capsulitis32. Results demonstrated that patients treated with corticosteroid injections achieved faster pain relief during the first 8 weeks, but no significant difference between the two groups was noted at the latest follow-up at 12 weeks. Similarly, no significant differences were noted in function and motion at the time of the latest follow-up.

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Clavicular Fractures

Previous studies have highlighted the potential benefits of surgical procedures for the treatment of displaced midshaft clavicle fractures. Melean et al. performed a Level-I prospective randomized trial of displaced clavicle fractures in patients with Workers’ Compensation33. The authors noted more complete healing at earlier time points as measured by CT scans, faster return to work (2.9 months compared with 3.7 months), and slightly better Constant scores at 6 and 12 months in the surgical group. Two separate, Level-I, randomized controlled trials were performed comparing flexible intramedullary nailing with open reduction and internal fixation with plates for the treatment of displaced midshaft clavicle fractures34,35. Functional outcomes (Disabilities of the Arm, Shoulder and Hand [DASH] scores and Constant scores) were no different between groups at 6 and 12 months following the surgical procedure, although early return of function was greater with the plating group in one study. Reoperation and complication rates were similar between groups, with the most common complication related to symptomatic implants. One study demonstrated no difference in time to union but slightly greater clavicular shortening in the plating group. These studies support previous research demonstrating no difference in healing or outcomes between these two methods of fixation for midshaft clavicle fractures.

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Elbow Fractures

Distal humeral fractures that cannot be reconstructed with plates and screws represent a difficult treatment challenge, particularly in the younger patient. Although total elbow arthroplasty can yield excellent functional results, the majority of late complications of total elbow arthroplasty, including polyethylene bushing wear and wear-induced osteolysis, are usually related to the ulnar component and the linked implants. Elbow hemiarthroplasty is not currently approved by the Food and Drug Administration (FDA) in the United States. Elbow hemiarthroplasty has the theoretical advantage of avoiding complications related to the ulnar component and linked articulation in total elbow arthroplasty and the theoretical disadvantages of instability with an unlinked implant and cartilage erosion on the ulna. In a Level-IV study from the United Kingdom, Phadnis et al. reported the outcomes of unlinked elbow hemiarthroplasty performed with a modular anatomic prosthesis and a “triceps-on” surgical technique for acute distal humeral fractures36. The authors investigated outcomes in 16 consecutive patients (mean age, 78.7 years) with a minimum 2-year follow-up (mean, 35 months). The mean postoperative scores were 89.6 points for the Mayo Elbow Performance Score, 11.2 points for the QuickDASH (an abbreviated version of the DASH questionnaire) score, and 43.7 points for the Oxford Elbow Score. The range of motion assessment showed good mean functional arcs at 116° for flexion and 172° for pronation-supination. Radial head wear was uncommon and was graded as mild in 3 elbows. Ulnar wear was more common; it was absent in 6 elbows, mild in 8 elbows, and moderate in 2 elbows. Cartilage wear was not related to increased pain or poorer elbow function at a short-term follow-up. Humeral aseptic loosening was noted, and osseous union was achieved in all but 1 patient. That study indicated that elbow hemiarthroplasty with a modular anatomic implant is a reliable technique for the treatment of acute distal humeral fractures not amenable to reconstruction.

Although elbow arthroplasty is a reliable treatment option for complex distal humeral fractures in older patients, certain patients are unfit for surgical treatment because of medical comorbidities or social factors. To our knowledge, there are few studies examining the outcomes of nonoperative treatment of distal humeral fractures. In a Level-IV study, Desloges et al. evaluated 32 low-demand, medically unfit, or older patients with distal humeral fractures who were managed nonoperatively37; 13 patients were excluded, 8 due to death from unrelated causes and 5 lost to follow-up. At a mean follow-up of 27 months, 68% (13 of 19 patients) reported good to excellent subjective outcomes. Eighty-one percent of patients achieved fracture union. Surprisingly, reasonable functional outcomes were seen; the mean score was 16 points for the Patient Rated Elbow Evaluation and 90 points for the Mayo Elbow Performance Index. A moderate range-of-motion loss was seen when the injured side was compared with the uninjured side with regard to extension (22° compared with 8°; p = 0.025) and flexion (128° compared with 142°; p = 0.002). These results indicate that, although loss of elbow motion is likely, nonoperative treatment is a reasonable, approved treatment of distal humeral fractures in lower-demand, medically unfit, or older patients.

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Distal Biceps Repairs

A Level-IV systematic review was performed comparing outcomes of single and double-incision distal biceps repairs with various fixation techniques38. Data from 40 articles (1,074 patients) were included. The authors noted no difference in range of motion or strength between groups with regard to surgical approach or fixation technique. A significantly greater risk of complications was noted in single-incision repairs (most commonly nerve injuries). Controlling for other variables, complications were independently associated with surgical approach, fixation technique, and patient age.

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Upcoming Meetings and Events Related to Shoulder and Elbow Surgery

The 2016 Société Européenne pour la Chirurgie de l’Epaule et du Coude (SECEC) and European Society for Surgery of the Shoulder and the Elbow (ESSSE) annual meeting was held in Antwerp, Belgium, on September 24 and 25, 2016. This international meeting brought together experts to discuss cutting-edge advances and controversies in shoulder and elbow surgery. A combined ASES/AANA (American Shoulder and Elbow Surgeons/Arthroscopy Association of North America) Shoulder and Elbow Course was held in Chicago, Illinois, on September 15 to 17, 2016. This course included a 2-day scientific session and a 1-day cadaveric course at the newly renovated Orthopaedic Learning Center. The ASES will hold its annual open meeting on March 18, 2017, in San Diego, California, during the annual American Academy of Orthopaedic Surgeons (AAOS) proceedings.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 8 other articles with a higher Level of Evidence grade were identified that were relevant to shoulder and elbow surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Articles Related to Shoulder and Elbow Surgery

Carr AJ, Murphy R, Dakin SG, Rombach I, Wheway K, Watkins B, Franklin SL. Platelet-rich plasma injection with arthroscopic acromioplasty for chronic rotator cuff tendinopathy: a randomized controlled trial. Am J Sports Med. 2015 Dec;43(12):2891-7. Epub 2015 Oct 23.

In this Level-I, prospective randomized study including 60 patients diagnosed with rotator cuff tendinopathy, patients were randomized to either arthroscopic acromioplasty alone or arthroscopic acromioplasty in combination with subacromial injection of autologous platelet-rich plasma. After 12 weeks postoperatively, all patients noted a significant improvement in the Oxford Shoulder Score. There was no significant difference in clinical outcome scores between the 2 groups. Tissue biopsy of the tendon was taken at 12 weeks postoperatively and the number of blood vessels and tendon cellularity had significantly decreased in the platelet-rich plasma treatment group. Also, expression of p53-positive apoptotic cells was increased after administration of platelet-rich plasma. This may demonstrate potentially deleterious effects of platelet-rich plasma on healing tendons.

Hettrich CM, Permeswaran VN, Goetz JE, Anderson DD. Mechanical tradeoffs associated with glenosphere lateralization in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Nov;24(11):1774-81. Epub 2015 Jul 31.

The authors performed a finite element analysis testing of the angle of impingement between the scapula and the humeral polyethylene while measuring deltoid force required to move the arm with differing amounts of glenoid lateralization. Tests were performed with static and dynamic scapulae for motion in either the coronal or scapular plane. Increasing lateralization decreased impingement of the humeral polyethylene and the scapula. Deltoid force required to elevate the arm also increased with larger degrees of lateralization. The dynamic scapula model showed greater humeral adduction before impinging. The impingement angle was also substantially affected by osseous prominences on the inferior aspect of the scapula.

Kim YS, Lee HJ, Bae SH, Jin H, Song HS. Outcome comparison between in situ repair versus tear completion repair for partial thickness rotator cuff tears. Arthroscopy. 2015 Nov;31(11):2191-8. Epub 2015 Jul 15.

In this Level-II, prospective, randomized study comparing in situ repair of partial-thickness rotator cuff tears with the tear completion and repair technique, 100 patients were enrolled and all procedures were performed by a single surgeon. Preoperatively, patients were randomized to either in situ repair or tear completion and repair. Clinical outcome scores and repair integrity were assessed. The mean follow-up was 19.1 months. Significant overall clinical improvement in VAS for pain and function was noted in both groups; however, no significant difference in the magnitude of clinical improvement was noted when comparing outcomes between the two groups. Articular-sided, partial-thickness tears had similar retear rates in both groups. The retear rate for bursal-sided, partial-thickness tears was slightly higher in the tear completion and repair group.

Lam PH, Hansen K, Keighley G, Hackett L, Murrell GACA. A randomized, double-blinded, placebo-controlled clinical trial evaluating the effectiveness of daily vibration after arthroscopic rotator cuff repair. Am J Sports Med. 2015 Nov;43(11):2774-82. Epub 2015 Sep 2.

In this Level-I, prospective randomized trial evaluating the effect of high-frequency, low-magnitude vibration on rotator cuff healing after repair, 120 patients undergoing surgical rotator cuff repair were enrolled; half underwent a surgical procedure followed by use of a vibration device applied for 5 minutes daily after the surgical procedure and the other half underwent a surgical procedure followed by use of a placebo device. The primary outcome measure was repair integrity 6 months after repair assessed by ultrasound. Pain at postoperative time points was also assessed. Postoperative retear rates were similar between the 2 groups. Vibration provided significantly better acute pain relief compared with the placebo. Although high-frequency, low-magnitude vibration did not demonstrate improved tendon healing, it may assist in acute postoperative pain management after rotator cuff repair.

Lee HJ, Kim YS, Park I, Ha DH, Lee JH. Administration of analgesics after rotator cuff repair: a prospective clinical trial comparing glenohumeral, subacromial, and a combination of glenohumeral and subacromial injections. J Shoulder Elbow Surg. 2015 May;24(5):663-8. Epub 2015 Jan 31.

In this Level-II, prospective, randomized clinical trial comparing the efficacy of local anesthetic injections in the subacromial space, in the glenohumeral joint, or in both locations after arthroscopic rotator cuff repair, 121 consecutive patients were enrolled and were randomly assigned to receive an injection mix of lidocaine and bupivacaine either in the subacromial space, in the glenohumeral joint space, or split between the two. The VAS for pain was assessed preoperatively and at 1, 2, 6, 12, and 24 hours postoperatively. Demerol (meperidine) was used for breakthrough analgesia and the number of Demerol administrations was recorded at each time point. There was no control group in this study design. There was no significant difference in acute postoperative pain as measured by the VAS for pain between the groups at any time point.

Plaschke HC, Thillemann TM, Brorson S, Olsen BS. Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008. J Shoulder Elbow Surg. 2015 Dec;24(12):1982-90. Epub 2015 Oct 9.

In this Level-III, retrospective, case-control study of outcomes after total elbow arthroplasty and revision total elbow arthroplasty, the study population was patients identified in the Danish National Patient Register; 167 procedures in 141 patients were included and medical records were reviewed. The mean follow-up was 10.5 years for primary total elbow arthroplasty and 7.5 years for revision total elbow arthroplasty. The authors found that there was no difference in the Oxford Elbow Score or the Mayo Elbow Performance Score between linked and unlinked total elbow arthroplasty systems. The flexion-extension range of motion was slightly greater in the linked total elbow arthroplasty group (116° compared with 110°). Revision total elbow arthroplasty was associated with poorer outcomes in all measures compared with primary total elbow arthroplasty. Patients who underwent total elbow arthroplasty for fracture had significantly poorer social-psychological results than patients who underwent total elbow arthroplasty for rheumatoid arthritis.

Sheps DM, Bouliane M, Styles-Tripp F, Beaupre LA, Saraswat MK, Luciak-Corea C, Silveira A, Glasgow R, Balyk R. Early mobilisation following mini-open rotator cuff repair: a randomised control trial. Bone Joint J. 2015 Sep;97-B(9):1257-63.

In this Level-I, prospective randomized trial evaluating the effect of early mobilization compared with delayed mobilization after mini-open rotator cuff repair, 189 patients undergoing mini-open rotator cuff repair for a full-thickness tear were randomized either to remain in a sling for 6 weeks with no active shoulder movement (delayed motion group) or to use a sling as needed but actively use the shoulder for activities of daily living as pain allowed. Patients were assessed at 6 weeks and 3, 6, 12, and 24 months postoperatively. Patient age and tear characteristics were similar between the groups. At 6 weeks postoperatively, the early motion group had significantly greater abduction and scapular plane elevation compared with the delayed motion group. This difference did not remain for any of the other time points. Pain was not different between the two groups at any time point. Postoperative complications and cuff retears were similar among the two groups. This study affirms findings of other studies that show similar outcomes with early or delayed motion after repair of small to medium-sized, full-thickness rotator cuff tears.

Wylie JD, Suter T, Potter MQ, Granger EK, Tashjian RZ. Mental health has a stronger association with patient-reported shoulder pain and function than tear size in patients with full-thickness rotator cuff tears. J Bone Joint Surg Am. 2016 Feb 17;98(4):251-6.

In this Level-II study, the authors prospectively enrolled 169 patients with full-thickness rotator cuff tears. Patients completed outcomes measures including the Short Form-36 (SF-36), VAS for shoulder pain and function, Simple Shoulder Test, and ASES instrument. Tear characteristics and patient demographic data were also collected for each patient. Results showed that the SF-36 Mental Component Summary had the strongest correlation with pain, function, Simple Shoulder Test, and ASES scores. Tear severity only correlated with the VAS for function.

Investigation performed at the Washington University School of Medicine, St. Louis, Missouri, and the Rothman Institute, Philadelphia, Pennsylvania

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: One author of this study (J.D.K.) received a stipend from JBJS for writing this update. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work.

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1. Matsen FA 3rd, Li N, Gao H, Yuan S, Russ SM, Sampson PD. Factors affecting length of stay, readmission, and revision after shoulder arthroplasty: a population-based study. J Bone Joint Surg Am. 2015 ;97(15):1255–63.
2. Wirth MA. Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid. J Bone Joint Surg Am. 2009 ;91(5):1109–19.
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