Shoulder & Elbow

To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) that investigated the effectiveness of tranexamic acid (TXA) among patients undergoing arthroscopic rotator cuff repair (ARCR).

Five databases were screened until December 18, 2022. The included RCTs were assessed for risk of bias, and the endpoints were summarized as mean difference/standardized mean difference (MD/SMD) or risk ratio (RR) with the 95% confidence interval (CI) in a random-effects model.

Seven RCTs with 510 patients (TXA = 261 and control/placebo = 249) were analyzed. The overall risk of bias was “low” and “unclear” in four and three RCTs, respectively. The mean operative time (n = 5 RCTs, MD = −9.64 min, 95% CI [−15.74, −3.54], p = 0.002) and mean postoperative pain score on postoperative day 1 (n = 5 RCTs, MD = −0.56, 95% CI [−1.06, −0.05], p = 0.03) were significantly reduced in the TXA group compared with the control group. However, there were no significant differences between both groups regarding visual clarity, amount of irrigation solution, and estimated intraoperative blood loss.

Among patients undergoing ARCR, preoperative TXA did not reduce intraoperative blood loss or improve visual clarity. However, TXA administration correlated with significant reductions (statistically) in operative time and postoperative day 1 pain score compared with the control group.

Level of evidence: Level I; Systematic Review and Meta-analysis of Randomized Controlled Trials

Conventional techniques for the fixation of displaced proximal humeral fractures include the use of locking plates, intramedullary nailing, hemiarthroplasty and reverse shoulder replacement. Valgus-impacted fractures are a common subtype of proximal humeral fracture, but there are few publications concerning the outcomes of treatment. This study aims to review outcomes following an ‘all-suture’ technique for this fracture subtype without the use of transosseous sutures.

All patients over the age of 18 who presented with 3- or 4-part valgus-impacted proximal humeral fractures and who underwent ‘all-suture’ repair at our centre were included. We reviewed their post-operative imaging and collected data on post-operative complications and patient-reported outcome measures.

We identified 15 patients who had undergone all-suture fixation. The cohort's mean age was 56. Eleven patients were female. Eight patients had 3-part fractures and seven patients had 4-part fractures. There were no major post-operative complications. All fractures united. The mean Oxford Shoulder Score was 43.7 and the mean Single Assessment Numerical Evaluation score was 85.9 at the final follow-up.

Our results suggest that all-suture fixation of proximal humeral fractures presents an attractive alternative to conventional techniques, whilst avoiding complications relating to metalwork implantation.

Anecdotally, upper truncal obesity and large breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature.

To produce radiographic measurements of chest wall soft tissue thickness (STT) and determine association with non-union in diaphyseal humerus fractures.

Two hundred and seventeen consecutive non-operative humeral shaft fractures were included. Radiographic STT measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method, with ratios derived (dividing these figures by the mid-humerus diameter). Bivariate and multivariable analyses were used to assess association with non-union.

There were 58 (26.7%) cases of non-union. On multivariable analysis, the middle (odds ratio (OR) 1.39, p <  0.001) and lower (OR 1.23, p = 0.009) STT measurements were independently associated with non-union. Additionally, the middle (OR 1.85, p < 0.001) and lower (OR 1.47, p < 0.001) STT ratios were independently associated with non-union. A receiver operating characteristic curve determined a threshold value of a middle STT ratio of ≥ 3 (OR 3.73, p < 0.001, sensitivity 69.0%, specificity 62.3%), which was independently associated with non-union.

Chest wall STT is independently associated with humeral shaft non-union. Threshold values can assist in decision making for these fractures.

Age and sex are known predictors of isometric shoulder strength and therefore must be accounted for when noting strength values or administering assessments such as the Constant Score. Given the popularity of the Constant Score, it is important to ensure protocols and values remain clinically relevant and are representative of the intended population.

Isometric shoulder strength was recorded for 511 participants without shoulder pathology using the Chatillon^TM hand-held dynamometer. Data were stratified by age and sex for comparison with published normative strength series. Other demographic variables were evaluated using linear regression models.

Normative values for shoulder strength were generated. Age (p = .003, r 2 = .010 ) and sex (p < .001, r 2 = .026 ) were significant predictors of shoulder strength. Height (p = .03, r 2 = .010 ) was a significant predictor of strength in females and weight was a significant predictor of strength in males (p < .001, r 2 = .017 ). Hand dominance was also significant, with non-dominant shoulder strength associated with higher strength in females (p < .001, r 2 = .081 ) and lower strength in males (p < .001, r 2 = .154 ).

This study generated normative shoulder strength values for a sample of the Australian population and provided a comparison between other normative scores. Significant demographic predictors in addition to age and sex were identified.

III.

The realities of midshaft clavicle fracture distribution have not been described accurately. Consequently, a topographical depiction of midshaft clavicle fractures may help design implants that are more anatomically concordant with the fractured clavicle, leading to better outcomes and fewer complications.

This is a retrospective cohort study. One-hundred sixty-six surgically treated midshaft clavicle fractures of four fellowship-trained shoulder surgeons were evaluated to determine the precise “location” of the fracture on standard radiographs. This location was determined by noting the lateral, central, and medial endpoint of each fracture, expressed as a percentage (0%–100%) of the distance from the lateral to the medial end of the clavicle.

Fractures on average began at the 36% line (SD = 6%), were centered at the 42% line (SD = 6%), and ended at the 48% line (SD = 7%). Ninety percent of fractures were centered lateral to the midpoint, and 64% were completely lateral to the midpoint. Thirty-two percent of midshaft fractures extended into the lateral third of the clavicle, but no fractures extended into the medial third.

Midshaft clavicle fractures in skeletally mature individuals appear to occur predominantly within the lateral metadiaphyseal half of the clavicle, and rarely extend into the medial third. Industry professionals and surgeons alike should consider this when designing and selecting implants. To note, our study relied on two-dimensional radiographs, and future studies should work on fully capturing the complex three-dimensional anatomy of the clavicle.

IV.

Cutibacterium acnes (C. acnes) is a common source of infection in shoulder surgery. 5-Aminolevulinic acid (5-ALA) is a naturally occurring metabolite of C. acnes that creates an exothermic reaction when activated by blue light. The purpose of this study was to evaluate the efficacy of preoperative photodynamic therapy using topical 5-ALA to decrease C. acnes colonization.

Patients were randomized to receive topical 5-ALA skin solution activated by blue light photodynamic therapy or standard of care preoperative skin preparation. Prior to skin incision, two punch biopsy specimens were taken from the portal sites and were incubated for 13 days. Culture positivity rate, days until positive, and semiquantitative growth classification were analyzed.

Fifty patients undergoing arthroscopic shoulder surgery were randomized. The overall positive culture rate was 54%. All cultures were positive for C. acnes except for one. Sixty-four percent of standard preparation patients and 44% of investigational group patients had at least one positive culture for C. acnes. There was no significant difference between groups in patients with at least one positive C. acnes culture (p = 0.49).

The use of photodynamic therapy undergoing arthroscopic shoulder surgery did not significantly reduce colonization of C. acnes as compared to standard preparation.

Level II.

Distal biceps tendon (DBT) injuries are relatively uncommon. Controversies exist regarding the best approach, leading to variations in treatment. This study aims to understand the preferences and practices of orthopedic surgeons regarding management of DBT injuries, as well as assess the feasibility of a future pilot randomized controlled trial (RCT) to evaluate the impact of various surgical factors on patient outcomes.

A cross-sectional international survey was conducted amongst surgeons treating patients with DBT injuries. The survey included questions about treatment preferences, surgical techniques, case volumes, and interest in participating in a future RCT.

Responses from 491 orthopedic surgeons from 26 countries/territories were obtained. Most surgeons had limited exposure to DBT ruptures. Variations were observed in the work-up process, with some relying solely on clinical examinations while others used diagnostic imaging. A single incision approach was the most common surgical technique, and tendon fixation with suspensory cortical buttons was frequently preferred. Most surgeons did not explore or repair the bicipital aponeurosis. Interest in participating in a future RCT varied for different surgical controversies.

This survey provides valuable insights into surgeons’ preferences and practices for DBT injury management. The study highlights the need for standardization in the work-up process and the use of evidence-based guidelines. Current practices may be influenced by factors such as training, implant availability, and costs. The survey also identified surgeons and centers interested in collaboration for future multicenter trials, allowing for equitable access to surgical collaboration opportunities and addressing the lack of evidence in DBT rupture treatment.

Level V, expert-opinion.

Conservative management of displaced proximal humerus fractures involves a period of rest in a sling followed by physiotherapy. The aim of this review is to provide a narrative synthesis of how long immobilisation is used, types of slings, when and how exercises are introduced, and if complications may be associated with these components.

A systematic search of the literature was undertaken. Two researchers screened relevant articles using Covidence software, with a third reviewer consulted for consensus. Data was extracted and a narrative synthesis is presented.

Thirty-nine studies were included (3059 studies screened, 159 full-text reviews). This included a cohort of 2664 patients with a mean age of 70.9. Time immobilised in sling ranged from 1 to 6 weeks. Sling types were variable and were grouped into low, medium and higher levels of support. Exercises were introduced at variable timescales tending to introduce passive and pendular exercises first. Complications were reported in 243 incidences (9.1%).

There was vast variation in how long patients were immobilised for, types of slings used and when and how exercises were introduced and progressed. No relationship was found between complications and these components. Research to identify the most effective approach is required.