What’s New in Shoulder and Elbow Surgery

The field of shoulder and elbow surgery continues to refine and grow, with highlighted advances in rotator cuff augmentation and healing, pain management, and upper-extremity fractures. This review synthesizes research within the past year, focusing on high-quality research and development to emphasize advances within the field. Rotator Cuff Nonoperative Care Nonoperative management of rotator cuff tears remains a key area of interest, with physical therapy and evolving injection therapies taking center stage. In a 15-year follow-up to previously published results, Moosmayer et al. compared physical therapy with rotator cuff repair in 81 of 103 patients who were still available for evaluation1. Of the 51 patients initially allocated to physical therapy, 15 ultimately crossed over to surgery. At the 15-year mark, patient-reported outcomes, measured by the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, the 36-item Short Form (SF-36), and patient satisfaction, all favored surgical repair, confirming it as a primary treatment for small to medium-sized rotator cuff tears1. In a separate trial of 70 patients with partial rotator cuff tears, both in-clinic and home-based physical therapy showed improvements in physical and psychosocial health. However, the in-clinic group demonstrated slightly better outcomes in terms of activity-related pain, active range of motion, and pain catastrophizing2. In the context of injection therapies, a systematic review and meta-analysis of 7 articles comparing hyaluronic acid with or without platelet-rich plasma (PRP) showed that hyaluronic acid combined with PRP decreased visual analog scale (VAS) pain scores and increased Constant-Murley scores up to 3 months in patients with partial rotator cuff tears; no differences were observed at 6 months3. Another systematic review of 12 studies evaluating PRP in partial-thickness rotator cuff tears found significantly improved VAS pain scores at 6 weeks, 3 months, and 6 months, remaining increased up to 1 year. However, there was no improvement seen in the ASES and Constant-Murley scores in long-term 1-year follow-up4. Perioperative Management Perioperative management of rotator cuff tears continues to draw attention, especially in optimizing postoperative pain control. A randomized controlled trial (RCT) of 72 patients compared transdermal buprenorphine patches with oral tramadol and Celebrex (celecoxib), finding no difference in the Numeric Rating Scale or ASES scores at any time up to 3 months5. Likewise, a prospective randomized trial evaluating an ultrasound-guided suprascapular nerve block plus an axillary nerve block combined with the cyclooxygenase-2 (COX-2) inhibitor parecoxib compared with parecoxib alone showed improved pain (Numeric Rating Scale score) immediately after surgery, but no difference at 24 hours6. Further, a trial of 142 patients comparing abduction slings with simple slings demonstrated better Pittsburgh Sleep Quality Index scores, lower self-rated anxiety, lower pain levels, and higher satisfaction for up to 6 weeks in the abduction sling group. However, by 1 year, there was no observed difference in outcome measures, including tendon healing7. Surgical Treatment and Adjuvants or Augmentation Optimal treatment strategies for rotator cuff repairs remain an active area of research. In a systematic review of 5 high-quality RCTs encompassing 409 patients, rotator cuff repair performed with or without acromioplasty was compared at a mean follow-up of 52.2 months. No significant differences were observed in retear or complication rates; however, the group without acromioplasty had a higher reoperation rate (5.3% compared with 15.9%), and ASES scores also favored acromioplasty8. For partial rotator cuff tears, a literature review and meta-analysis of in situ repair compared with tear completion before repair found no difference in ASES, Constant-Murley, or VAS pain scores. The mean follow-up was 30 months for in situ repair and 51 months for tear completion, and retear rates were not significantly different between the approaches9. Augmentation and adjuvants to enhance rotator cuff healing remain high priorities for research. In a systematic review and meta-analysis, Warren et al. evaluated patient-reported outcomes, tendon thickness, and complications in primary rotator cuff repairs compared with those augmented with a REGENTEN bioinductive collagen patch (Smith+Nephew). The augmented group demonstrated a lower retear rate, with a similar overall complication rate10. Another RCT using the REGENTEN patch compared patch-only treatment with a traditional double-row repair in small to medium-sized tears (<2.5 cm). At 6 months, biopsies showed more organized collagen fibers in the patch-only group, and magnetic resonance imaging (MRI) scans at 12 and 24 months demonstrated 100% healing. Patient-reported outcomes also indicated higher ASES and Constant-Murley scores, less pain at 6 and 12 months, and greater satisfaction up to 24 months11. Similarly, in an RCT, Kim et al. compared standard rotator cuff repair with a type-I atelocollagen porcine-derived absorbable patch (RegenSeal; CELLONTECH) in 55 patients and found a retear rate of 10% in the augmented group compared with 35% in the non-augmented group at 12 months (assessed by MRI), although there was no difference in the Constant score12. Similarly, a meta-analysis indicated reduced retear rates with augmented repairs. Hurley et al. completed a review including 5 RCTs comparing arthroscopic cuff repair with and without acellular collagen matrix patch augmentation13. The authors found a retear rate of 34% in the group without augmentation and 11% in the augmented group (p = 0.0006). Evidence regarding PRP as an adjuvant has remained mixed. An RCT of 96 patients undergoing arthroscopic rotator cuff repair with or without a 1-time intraoperative leukocyte-poor PRP injection showed a decreased retear rate at 6 months (15.2% compared with 34.1%; p = 0.037), but no significant differences in functional or patient-reported outcomes (ASES, Single Assessment Numeric Evaluation [SANE], or VAS pain scores)14. Conversely, a systematic review and meta-analysis of 9 studies involving 537 patients found no differences in patient-reported pain, function, complications, or retear rates, based on VAS pain, Constant-Murley, and QuickDASH (abbreviated Disability of the Arm, Shoulder and Hand questionnaire) scores, when comparing rotator cuff repairs with or without PRP15. Shoulder Instability Shoulder instability, whether acute or chronic, remains a challenging condition for patients and physicians. Emergency department physicians are often the first point of contact for patients experiencing a shoulder dislocation, and Gonai et al. conducted a comprehensive review of the diagnosis, evaluation, reduction, and treatment or referral of this condition for those initiating shoulder instability care16. These authors completed a review of multiple databases for systematic reviews and meta-analyses, ultimately including 30 studies. One key finding was that diagnostic accuracy for dislocation and related fractures with point-of-care ultrasound was comparable with that of radiographs. Intra-articular anesthesia was as effective as sedation for pain management with closed reduction and also achieved shorter emergency department times with fewer adverse events (risk ratio [RR], 0.16). Three meta-analyses in the umbrella review demonstrated no significant difference in successful closed reduction among various reduction techniques, although better pain management was seen with the FARES (Fast, Reliable, Safe) method. Gonai et al.16 also included 10 studies on Bankart repair and found lower redislocation rates with surgical management compared with nonoperative treatment, especially in younger patients. This review identified that the reported incidence of nerve injury with acute dislocations was between 0.4% and 65.5% (between 39.8% and 65.5% if evaluated with electromyography). This comprehensive review advises emergency personnel on diagnosis, closed reduction, associated neuropathy, and referral messaging for patients with acute dislocations. The surgical management of acute shoulder dislocations after successful reduction continues to be an important area of investigation. Karasuyama et al. conducted a systematic review and network meta-analysis of studies comparing Bankart repair, arthroscopic lavage, external rotation immobilization, and internal rotation immobilization17. The authors ultimately included 15 studies. Their review found that arthroscopic Bankart repair was associated with lower redislocation rates compared with internal rotation immobilization (RR, 0.15 [95% confidence interval (CI), 0.07 to 0.33]). Arthroscopic lavage and external rotation immobilization were slightly better than internal rotation immobilization. Abdel Khalik et al. also conducted a systematic review and meta-analysis of arthroscopic stabilization for first-time shoulder dislocations18. The authors’ review found that arthroscopic stabilization surgery for first-time dislocations resulted in better outcomes (less dislocation, chronic ongoing instability, and subsequent surgeries) compared with immobilization alone or arthroscopic stabilization after recurrence. Remplissage in Shoulder Instability The addition of remplissage to Bankart repair has been an area of interest given recent studies. Pawłuś et al. conducted a systematic review and meta-analysis to study the outcomes of adding remplissage to arthroscopic Bankart repair for patients with a concomitant Hill-Sachs lesion19. Among patients with an engaging Hill-Sachs lesion, the group that underwent Bankart repair plus remplissage had a 9 times lower rate of recurrence of instability compared with Bankart repair alone. The group that underwent Bankart repair plus remplissage also demonstrated increased forward elevation (mean difference, 1.97° [95% CI, 1.49° to 2.46°]; p < 0.001) compared with Bankart repair alone. Ahmed et al. identified similar findings in their meta-analysis of arthroscopic Bankart repair with and without the addition of remplissage20. These authors found that the addition of remplissage resulted in lower postoperative recurrent instability (odds ratio [OR] for the no-remplissage group, 9.36), postoperative dislocations (OR, 6.28), instability-related revision (OR, 3.46), and return to sport at any level (OR, 2.85). Woodmass et al. specifically examined intermediate-term follow-up of the addition of remplissage in traumatic recurrent instability with subcritical bone loss. Patients who underwent Bankart repair without remplissage were found to experience redislocation earlier and had a higher rate of revision or reoperation compared with patients undergoing Bankart repair with remplissage21. These 3 studies found no clinically important loss of external rotation. Gonzalez-Morgado et al. compared Bankart repair alone, Bankart repair with remplissage, and Latarjet procedures in a systematic review and meta-analysis and found no significant loss of external rotation between Bankart repair with or without remplissage22. Surgical and Rehabilitation Techniques for Arthroscopic Stabilization Surgeons and the entire patient care team continue to search for tools to decrease the recurrent instability rates for patients with shoulder instability. Jain et al. evaluated 2 different surgical anchor types in arthroscopic stabilization23. These authors performed a systematic review of knotted anchors compared with knotless anchors and found no difference in the rates of redislocation, subluxation, or revision surgery between the surgical techniques. Yildiz et al. sought to understand if specific postoperative rehabilitation changes might improve shoulder stability24. The authors performed a single-blinded RCT to determine if cross-education as a part of postoperative rehabilitation would improve outcomes after arthroscopic stabilization surgery. This study found that rotator cuff strength was improved in the cross-education group and may help dynamic shoulder instability but did not improve functional outcomes. Arthroplasty Anatomic Total Shoulder Arthroplasty (TSA) Although anatomic TSA rates have been outpaced by those of reverse TSA, anatomic TSA remains a valuable option for patients with primary glenohumeral arthrosis. It is important to evaluate the performance of various anatomic implant types. Chin et al. performed a multicenter RCT evaluating a second-generation uncemented Trabecular Metal-backed glenoid (Zimmer Biomet) compared with a cemented polyethylene glenoid25. The authors recently reported on their 5-year outcomes and found no significant or clinically important differences between the implant types. The 5-year follow-up identified metal debris in 23.9% of patients with a Trabecular Metal-backed glenoid, but the authors reported that this did not negatively affect outcomes. Reverse TSA Despite the advances in reverse TSA and important clinical improvements for patients undergoing this surgery, opportunities remain for improved understanding of reverse TSA technology. Wiater et al. evaluated the effect of humeral version in a prospective, double-blinded RCT26. Sixty-six patients were randomized to either neutral version or 30° of retroversion. The authors found similar active shoulder motion (external rotation, internal rotation, forward elevation, abduction), strength measurements, complication rates, and VAS pain, Patient-Reported Outcomes Measurement Information System Global 10 (PROMIS-10) physical, and ASES scores. Just as implant positioning looks to be optimized in reverse TSA, the ideal management of the subscapularis is a controversial topic. Ameziane et al. looked to understand the effect of subscapularis repair in reverse TSA27. The authors performed a prospective RCT in which they randomized 50 patients to either subscapularis repair or no repair. At the 36-month follow-up, the repaired cohort had better internal rotation, but Constant scores, forward flexion, abduction, and external rotation were not significantly different. Postoperative Pain Management Postoperative pain control after arthroplasty continues to advance via multimodal pain management pathways. Wagner et al. performed an RCT in opioid-naïve patients undergoing TSA. Sixty-seven patients were randomized to either intraoperative dexamethasone only (control group) or intraoperative dexamethasone and a 6-day methylprednisolone taper (study group)28. The study group saw better VAS pain scores on postoperative days 1 to 7 and at 2, 6, and 12 weeks postoperatively. Opioid consumption and opioid-related side effects were lower in the study group. Liposomal bupivacaine also remains an area of interest as an adjuvant in regional anesthesia for shoulder arthroplasty. Finkel et al. performed a prospective, double-blinded RCT comparing a liposomal bupivacaine interscalene block with a non-liposomal bupivacaine interscalene block with adjuvants29. The liposomal bupivacaine interscalene block did not reduce opioid use in the 120 hours after surgery, but pain scores at 24 to 48 hours, 48 to 72 hours, and 72 to 96 hours postoperatively and at postoperative day 60 were significantly lower in the liposomal bupivacaine interscalene block group. Fracture Arthroplasty for Fracture The surgical management of proximal humeral fractures has presented unique challenges across various surgical options. This continues to be an important area of ongoing study, particularly in the treatment of fractures with arthroplasty. Reverse TSA has gained popularity in the management of acute 3-part and 4-part proximal humeral fractures. Recent studies have compared reverse TSA with hemiarthroplasty and nonoperative management. Watts et al. randomized 36 patients who were ≥65 years of age and had acute 3-part or 4-part proximal humeral fractures to either hemiarthroplasty or reverse TSA30. This study found that, at 12 months postoperatively, the Constant score was better in the reverse TSA group (mean [and standard deviation], 51.1 ± 14.9) than in the hemiarthroplasty group (mean, 35.0 ± 13.5) (p = 0.004). There was no difference in the Constant scores at 24 months, although only 78% of patients were available for follow-up at that time. Colasanti et al. performed a network meta-analysis reviewing hemiarthroplasty compared with reverse TSA for elderly patients with a proximal humeral fracture31. The authors included 28 studies and reviewed whether cement was used in the arthroplasty and whether range of motion was started early or delayed. The analysis showed that patients undergoing reverse TSA with press-fit stems and early range of motion had statistically superior outcomes (forward elevation, abduction, internal rotation, ASES score, and tuberosity union rate). Miquel et al. conducted an RCT comparing reverse TSA with nonoperative treatment32. Eighty-one patients with displaced proximal humeral fractures were randomized in this study, and 66 patients were available for a 1-year follow-up. At 1 year postoperatively, the patients in the reverse TSA group had better mean Constant-Murley scores (61.24 ± 13.33) than those in the nonoperatively treated group (52.44 ± 16.22) (p = 0.02). Periprosthetic Fracture Although proximal humeral fractures can be a challenge, periprosthetic fractures represent a unique and potentially devastating problem. Tansey et al. conducted a systematic review and meta-analysis examining the clinical and radiographic outcomes after operative or nonoperative management of periprosthetic fractures after shoulder arthroplasty33. The authors included 20 studies and identified a mean overall complication rate of 46%. Interestingly, there was no significant difference in time to union and nonunion rates between nonoperative and operative treatment. Patients who were treated nonoperatively had higher rates of malunion (19% compared with 1%; p < 0.001) and complications (69% compared with 43%; p = 0.04) than patients who were treated operatively. Within the operatively treated group, patients who underwent revision arthroplasty had more complications (61% compared with 25%; p = 0.04) and higher nonunion rates (22% compared with 0%; p = 0.008) than patients who underwent open reduction and internal fixation. Distal Clavicular Fracture Distal clavicular fractures have been another challenging injury pattern. Thurston et al. performed a systematic review examining nonoperative treatment of distal clavicular fractures34. The authors identified 11 studies and highlighted union rates, complications, and patient-reported outcomes. Patients who underwent nonoperative treatment had a mean union rate of 63.2% compared with 96.3% in patients who underwent operative treatment. No study found a difference in patient-reported outcomes between nonoperative and operative treatment. The complication rate was 45.1% for patients who underwent nonoperative treatment and 41.2% for patients who underwent operative management. This systematic review found that 11.1% of patients who underwent nonoperative treatment required delayed surgery, but, importantly, 40.1% of patients who underwent operative management required a second operation. Adhesive Capsulitis The management of adhesive capsulitis continues to garner attention, and the evolving evidence continues to refine both injection strategy and broader patient management. A 66-trial network meta-analysis including 4,491 patients confirmed that all corticosteroid approaches (single-site intra-articular, rotator-interval, or hydraulic distension) achieve comparable pain and functional gains, yet multisite (4-point) and rotator-interval injections ranked highest at both short-term and intermediate-term time points35. When corticosteroid injections were compared with ultrasound-guided suprascapular nerve blocks (SSNBs), 2 high-level studies diverged: a single-center RCT favored corticosteroids for disability, pain, and range of motion at 12 weeks36; and a 12-trial meta-analysis supported SSNB for greater Shoulder Pain and Disability Index (SPADI) improvement, external rotation range of motion, and pain relief compared with corticosteroids, physiotherapy, or placebo, with no technique-related complications37. Combining the 2 modalities offered only a transient advantage in an RCT of 96 patients that showed that intra-articular steroid with SSNB improved SPADI and VAS pain scores at 2 weeks compared with intra-articular steroid alone, but that difference vanished by week 1238. Therapeutic alternatives to corticosteroids are also evolving. A systematic review and meta-analysis of 7 RCTs found that intra-articular hyaluronic acid delivers equivalent pain and function by 6 to 12 weeks, making it a reasonable option for patients requiring repeat injections or those who are at risk for corticosteroid side effects, despite corticosteroids retaining a modest advantage at 2 and a analysis of patients a higher of within years after a shoulder diagnosis, after for the for at the time of findings and their injection or SSNB as a or as an and that for patients with shoulder may be at and Perioperative and care continue to A network meta-analysis of RCTs comparing confirmed was the that significantly before open or arthroscopic shoulder surgery (OR, with only or and offered no In surgery a systematic review of after type-I proximal humeral and proximal humeral and glenoid procedures showed that all achieved function score of and 5-year implant for which had both and the highest rate and reverse with cement in both Postoperative is A single-center RCT demonstrated that the of to 7 after shoulder procedures opioid by to without pain or ASES pain adding with a for patients with chronic rotator cuff pain clinically in the SPADI and range of motion compared with with for 1 after At a a review found that is not when compared with physiotherapy, and early may be a over anesthesia for shoulder with not as the a systematic review and meta-analysis reported that liposomal bupivacaine nerve blocks traditional blocks and interscalene pain and opioid use 72 hours, although liposomal bupivacaine injections were not superior to nerve blocks and required more intraoperative studies for for favored or over after opioid by regional anesthesia with liposomal and highlighted in shoulder care a Elbow Recent elbow research evidence has in rehabilitation and A systematic review of studies found that with either or comparable pain scores, motion, and complication rates, with no for either although was For chronic elbow a multicenter RCT showed that a standard multimodal physical therapy with tendon plus or clinically in pain, disability, and function at 3 months compared with therapy the for in the trial randomized 60 who were years of age and had fractures to or or early as at 12 months, the of the Arm, Shoulder and Hand scores were equivalent (mean difference, in of the operatively treated p = and only elbow was more with surgery, nonoperative management as a strategy for this and