Shoulder & Elbow

High rate of recurrent instability following arthroscopic revision anterior shoulder stabilization: is it worth it?

Platelet-rich plasma fibrin matrix for rotator cuff repair: no good evidence

Elbow prosthetic joint infection: two-stage revision still the gold standard where possible

Prosthetic joint infection (PJI) following total elbow arthroplasty is reported to vary in incidence, with series giving ranges of 0% to 12%. In general, most series reflect an increased risk of infection when compared with other major joint arthroplasties. The reason for this wide range of reported incidence is likely associated with the heterogeneity of current series in the literature, the small size of many published series, and the varying diagnostic criteria used in each paper to define deep infection. The paucity of studies surrounding single-stage revision in the literature makes comparison of the two now widely recognized techniques of single- and two-stage revision difficult. Across the elbow surgery community, two-stage revision is currently seen as the gold standard and, even with two stages reported, recurrent infection rates range from 12% to 28%. In this retrospective study from Philadelphia, Pennsylvania (USA), the authors present a comparative study of 26 patients with a mean age of 64 years who were managed for PJI of the elbow using either the more modern (but less reported) debridement and implant retention approach (DAIR, n = 10) or two-stage revision or exchange (n = 16).³ Of the total cohort, five patients had diabetes, four had rheumatoid arthritis, and one had HIV. Staphylococcus aureus was the most common causative organism, with six cases having no organism identified. The mean follow-up period was four years and the rate of recurrent infection was around 50% (n = 5) in the DAIR group compared with 25% (n = 3) in the two-stage revision group. Of note, in the two-stage group, only 12 patients went on to have undergone definitive reimplantation. The overall rate of implant retention for the cohort was 42% (11/26). Those patients with recurrent infection were noted to be younger (58 vs 66 years). Like many studies in this area, it is limited by the small sample size. However, as the authors conclude, two-stage revision does seem to be the current gold standard for managing elbow PJI in those patients fit enough for such surgery. This publication supports much of what is given in the recent British Elbow and Shoulder Society (BESS) evidence and consensus-based guidelines for the management of prosthetic joint infection of the shoulder and elbow.

Complications following distal biceps tendon repair in nearly 1000 patients

Distal biceps tendon tears are not common injuries but it is quoted that, following surgical repair, 95% of patients have good or excellent results with comparable strength testing to the contralateral side. Despite this, there is an inherent risk of significant complications that can be potentially catastrophic for the patient. In this retrospective comparative study from Charlotte, North Carolina (USA), the authors report a large database based study covering a 12-year period to identify 970 patients (956 primary and 14 revision), all of whom had undergone a distal biceps tendon repair with a minimum of two months’ follow-up (median 3.8 months).⁴ The primary outcome measure reported here was the major complication rate. As with all databased studies, the results are subject to the fields collected and the limitations associated with regards to data fidelity. There were a large number of surgeons (n = 73) and a variety of surgical techniques were used; a single incision was performed in 652 cases, with a two-incision approach utilized in 318 cases. There were 38 cases that required allograft augmentation at the time of surgery for reconstruction of subacute, chronic, and/or revision tears. The overall major complication rate was 7.5% (n = 73) and included proximal radioulnar synostosis, heterotopic ossification (HO), re-rupture, deep infection, posterior interosseous nerve palsy, and complex regional pain syndrome. The overall reoperation rate was 4.5% (n = 44), with the most common reasons for reoperation being re-rupture, HO, loss of range of movement, and proximal radioulnar synostosis. The minor complication rate was reported to be 21.5%, with lateral antebrachial or superficial radial neuritis or numbness most commonly seen. The authors report that the single-incision approach was associated with an increased risk of neurological complications, while the two-incision approach was associated with an increased risk of proximal radioulnar synostosis (odds ratio 19). Despite the large number of patients in this study, the conclusions are somewhat limited by the retrospective design and the heterogenous nature of the patients included. However, it is one of the largest studies to date documenting the major and minor complication rates for this surgery.

Another clavicle trial

Functional outcomes after arthroscopic suture bridge subscapularis tendon repair

The subscapularis tendon is infrequently torn when compared with the posterosuperior rotator cuff, but it is critical for the anteroposterior force couple. The long-term integrity of repair is therefore an important outcome measure of surgical treatment success. Open repair was historically the gold standard but more recent advances have included arthroscopic approaches, as well as many surgeons promoting single- and double-row repairs in an attempt to recreate the subscapularis footprint and encourage healing. The knotless double-row transosseous-equivalent repair has been well publicized and studied in the posterosuperior cuff. The relative efficacy of double-row techniques compared with single-row techniques for subscapularis tears, however, is less well understood. This group from Funabashi (Japan) retrospectively investigated and reported on their cohort of 101 shoulders subjected to arthroscopic suture bridge repair for full-thickness subscapularis tear at a minimum follow-up of two years.⁶ The study group comprised 57 male and 44 female patients with a mean age of 66 years. All patients were assessed clinically with scores including the University of California, Los Angeles score (UCLA) and the American Shoulder and Elbow Surgeons (ASES) score. All were assessed radiologically for repair integrity and fatty degeneration of the muscle belly using MRI at a mean of 14 months follow-up. Repairs were performed using two medial anchors loaded with three sutures, and a suture bridge was formed and inserted in lateral row anchors in the bicipital groove. The two remaining medial row sutures were then tied as a mattress. The biceps were always treated with a tenotomy or tenodesis and the posterosuperior cuff was repaired using a suture bridge technique if required, but massive or partially repairable tears here were excluded from the study. In terms of outcomes, significant improvements were seen in UCLA, ASES score, internal rotation, and forward flexion at final reported follow-up. The re-tear rates were surprisingly low, with a 5% incidence in this series, and fatty degeneration was significantly improved in the intact group but not in the re-tear group. Clinical muscle strength significantly improved after surgery but weakness did persist in patients who had significant fatty infiltration of their muscle prior to surgery; this was the case even where no re-tear was evident. This transosseous-equivalent series shows better re-tear rates than other reported series of single- or double-row repairs but there is the ever-present possibility of a selection bias given the design of this series. A healed tendon must be the goal as, even where strength is weak, the check-rein effect is likely to be important for function and prognosis. Weaknesses of this report include the relatively low follow-up rate at 66%, but the results presented here are promising and further prospective studies would be welcome.

Recurrence of anterior-inferior instability after Bankart repair in young patients

This study from Iksan (South Korea) examines the outcomes of primary repair in patients below the age of 30 years.⁷ They conducted a retrospective review of patients with anterior-inferior shoulder instability over a six-year period, all of whom were followed up for at least two years. By dividing the cohort into two groups according to the recurrence of instability or otherwise, the authors here were able to undertake a reasonably thorough statistical analysis using binary logistic regression. Overall, in the cohort of 170 shoulders, 32 suffered recurrence, giving a second dislocation rate of 19%. There were significant differences between the groups in terms of the number of preoperative dislocations, such that the adjusted odds ratio for recurrent instability in those suffering two to five prior dislocations was 6.4, compared with 8.8 in those suffering more than five prior events. Patients with a time interval between first dislocation and surgery of greater than six months had an overall odds ratio of 5.6 and those with a Hill–Sachs lesion had an odds ratio for failure of 4.3. Functional outcomes were assessed using Rowe and Walch–Duplay scores reported at two years postoperatively. These were significantly improved in both groups; however, the mean scores were significantly lower in the group of those who suffered an instability recurrence. A limited number of previous studies have shown a correlation with successful stabilization, and an earlier surgical intervention and the British Elbow and Shoulder Society (BESS) guidelines suggest consultation and treatments within a period of weeks. It would therefore have been interesting had the authors analyzed the results of patients treated earlier than six months, but often this approach is compromised by the relatively few numbers of patients involved in the study. The findings are interesting, however, and do seem to suggest benefits to early intervention in this younger age group.