Friday, October 23, 2015

Is there anything new in shoulder surgery? - the Cliff Notes

What’s New in Shoulder and Elbow Surgery?

These authors reviewed what they felt to be the most impactful studies related to advances in shoulder and elbow surgery from March 2014 to March 2015. They placed specific emphasis on higher-quality research (Level-I and II studies) and particularly relevant Level-III and IV studies.

Here is a Cliff Note summary of 18 articles from this report:

Rotator Cuff:
*A longer duration of symptoms did not correlate with more severe rotator cuff disease, and symptom duration was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures.

*An analysis of 434 patients with an atraumatic rotator cuff tears found that shoulder activity was not associated with the severity of the rotator cuff tear.

*In asymptomatic degenerative cuff tears, progression was seen in 49% and the development of shoulder pain was seen in 46% of the cohort.

*The operative treatment of nontraumatic supraspinatus tears is no better than conservative treatment; conservative treatment should be considered as the primary method of treatment for this condition.

*The short-term outcomes of arthroscopic rotator cuff repair performed with and without acromioplasty showed no differences in clinical outcome scores.

*A combined systematic review and meta-analysis of 108 articles from 1980 to 2012, with data for 8011 shoulders showed that the rate of tendon healing and clinical results were not improving with the advent of newer surgical techniques. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes generally improved regardless of the integrity of the repair.

*The treatment effect of surgery for degenerative cuff tears was thought not to be profound enough to justify surgical management of painful degenerative cuff tears on initial presentation.

*Concurrent distal clavicle resection does not improve the results of cuff repair.

*Platelet rich plasma did not improve clinical outcomes or tendon healing in cuff repair.

The Latarjet procedure for shoulder instability
*The axillary and musculocutaneous nerves are at risk

*16% of patients had complications needing reoperation

*Recurrence rate 6%

*20% developed arthritis

*The overall readmission rate was 7.3%, with the highest rate found in the reverse shoulder arthroplasty group. Medical complications contributed to 82% of the readmissions. Infection and dislocation were the most common surgical complications resulting in readmission. Patients with Medicaid insurance had more than a 50% greater risk of readmission compared with patients with Medicare. Procedures performed in medium and high volume hospitals were associated with a lower risk of readmission compared with those in low-volume centers

*Higher surgeon and hospital case volumes led to improved perioperative metrics with all shoulder arthroplasty procedures.

*The rate of revision of metal-backed glenoids was much higher than that of polyethylene glenoids (14.0% versus 3.8%; p < 0.0001).

*The clinical benefit of 3D planning patient specific instrumentation has not been demonstrated.

*The clinical benefit of augmented glenoid components has not been demonstrated.

Comment: Taken as a group, the articles selected for this "what's new" review seem to indicate that the "new" developments have not led to improvements over the time-tested standard approaches to cuff disease, instability or glenohumeral arthritis.


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