Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.
Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.
–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4
–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5
Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:
- Smaller overall lesion size
- No clear margins of the fragment on MRI
- Absence of cyst-like lesions
The authors include a nomogram that clinicians can use to predict healing.
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:
- Position players returned to play sooner than pitchers, but they had lower rates of return to play.
- Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).
These findings could help clinicians set expectations for players undergoing UCL reconstruction.
- Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
- Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
- Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
- Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
- Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
- Niu EL, Tepolt FA, Bae DS, Lebrun DG, Kocher MS. Nonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment success. J Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
- Camp CL, Conte S, D’Angelo J, Fealy SA. Following ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequently. J Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Albert Gee, MD, a co-author of the April 18, 2018 Specialty Update on Sports Medicine, to select the five most clinically compelling findings from among the 30 studies cited in the article.
Anterior Cruciate Ligament (ACL) Reconstruction
–The conversations about graft selection for ACL reconstruction go on. A meta-analysis of 19 Level-I studies comparing 4-strand hamstring autograft with patellar tendon grafts1 revealed no differences in terms of rupture rate, clinical outcome scores, or arthrometer side-to-side testing at >58 months of follow-up. The prevalence of anterior knee pain and kneeling pain was significantly less in the hamstring group, and that group also exhibited a lower rate of extension deficit.
–Fourteen-year outcomes from a randomized controlled trial (n = 80 patients) comparing autologous chondrocyte implantation (ACI) with microfracture for treating large focal cartilage defects included the following:
- No significant between-group difference in functional outcome scores
- Fairly high treatment failure rates in both groups (42.5% in the ACI group; 32.5% in the microfracture group)
- Radiographic evidence of grade 2 or higher osteoarthritis in about half of all patients
These findings raise doubts about the long-term efficacy of these two treatments.
Rehab after Rotator Cuff Repair
–A randomized trial comparing early and delayed initiation of range of motion after arthroscopic single-tendon rotator cuff repair in 73 patients2 found no major differences in clinical outcome, pain, range of motion, use of narcotics, or radiographic evidence of retear. The early motion group showed a small but significant decrease in disability. The findings indicate that early motion after this surgical procedure may do no harm.
Platelet-Rich Plasma (PRP)
–A systematic review of 105 human clinical trials that examined the use of PRP in musculoskeletal conditions revealed the following:
- Only 10% of the studies clearly explained the PRP-preparation protocol.
- Only 16% of the studies provided quantitative information about the compositi0on of the final PRP product.
- Twenty-four different PRP processing systems were used across the studies.
- Platelet composition in the PRP preparations ranged from 38 to 1,540 X 103/µL.
Consequently, care should be taken when drawing conclusions from such studies.
Meniscal Tear Treatment
–A follow-up to the MeTeOR trial (350 patients initially randomized to receive either a partial arthroscopic meniscectomy or physical therapy [PT]) found that crossover from the PT group to the partial meniscectomy group was significantly associated with higher baseline pain scores or more acute symptoms within 5 months of enrollment. Investigators also found identical 6-month WOMAC and KOOS scores between those who crossed over and those who had surgery initially. These findings suggest that an initial course of PT prior to meniscectomy does not compromise outcomes.
- Chee MY, Chen Y, Pearce CJ, Murphy DP, Krishna L, Hui JH, Wang WE, Tai BC,Salunke AA, Chen X, Chua ZK, Satkunanantham K. Outcome of patellar tendon versus 4-strand hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized trials. Arthroscopy. 2017 Feb;33(2):450-63. Epub 2016 Dec 28.
- Mazzocca AD, Arciero RA, Shea KP, Apostolakos JM, Solovyova O, Gomlinski G, Wojcik KE, Tafuto V, Stock H, Cote MP. The effect of early range of motion on quality of life, clinical outcome, and repair integrity after arthroscopic rotator cuff repair. Athroscopy. 2017 Jun;33(6):1138-48. Epub 2017 Jan 19.
As an end-of-year thank-you to the orthopaedic community, we’re offering limited-time full-text access to the five most-read JBJS Reviews articles during 2016.
The fact that several of these most-read articles were published prior to 2016 is testament to the durable utility of the orthopaedic information published in JBJS Reviews.
- Treatment of Proximal Humeral Fractures (2016)
- Arthroscopic Single-Row Versus Double-Row Repair for Full-Thickness Posterosuperior Rotator Cuff Tears
- Treatment of Proximal Humeral Fractures (2014)
- The Evaluation and Treatment of Pediatric Tarsal Coalitions
- Acute Distal Radioulnar Joint Instability in Adults
In May, more than 300 orthopaedic surgeons attended the National Orthopaedic Leadership Conference in Washington, DC. During the conference, attendees took time to recognize the success of the AAOS Project Value initiative, which was started by former AAOS president John R. Tongue, MD. The initiative’s project team set out to quantify the social and economic benefits of musculoskeletal health care.
Four studies have been published as a result of this effort, three of which were published in JBJS:
- “The Direct and Indirect Costs to Society of Treatment for End-Stage Knee Arthritis,” JBJS, August 21, 2013. This article estimated that TKA has already generated lifetime societal savings to the U.S. economy of $12 billion.
- “Societal and Economic Impact of Anterior Cruciate Ligament Tears,” JBJS, October 2, 2013. Analysis found estimated annual savings from ACL reconstruction of $10 billion.
- “The Societal and Economic Value of Rotator Cuff Repair,” JBJS, November 20, 2013. Estimated lifetime savings to the U.S. economy were calculated to be $3.44 billion.
- “How Does Accounting for Worker Productivity Affect the Measured Cost-Effectiveness of Lumbar Discectomy?” Clinical Orthopaedics and Related Research, December 2013.
AAOS also hosts a website to highlight the notion of value in orthopaedics: www.ANationInMotion.org/value.