Time flies, the white horse flies, and another year passes in a blink of an eye. Today, we will take stock of the new concepts and technologies in the diagnosis and treatment of shoulder injuries in the past year, in order to share the new discoveries in the field of shoulder sports injuries for the majority of colleagues. Based on the recent article "What's New in Shoulder and Elbow Surgery" published in JBJS and literature search, we mainly describe the latest progress in the diagnosis and treatment of shoulder joint injuries from five aspects: rotator cuff injury, shoulder instability, shoulder replacement, proximal humerus fracture, clavicle and acromioclavicular joint injury.
Rotator cuff injury
1. Application of steroids and biologics
In recent years, injection techniques have become more and more widely used in rotator cuff diseases, especially corticosteroids and biologics such as platelet-rich plasma (PRP). In a retrospective cohort study conducted by Professor Chen Shiyi's team at Huashan Hospital affiliated to Fudan University, there was no significant difference in postoperative retear rate, pain, and range of motion between the two groups after an average follow-up of 3 years after arthroscopic rotator cuff repair in patients with rotator cuff tears with or without corticosteroid injection [1]. Professor Tang Xin's team from West China Hospital of Sichuan University conducted a meta-analysis of level I and level II randomized controlled trials comparing the clinical efficacy of PRP injection and corticosteroid injection in the non-surgical treatment of rotator cuff tendinopathy, and found that PRP injection was more effective in improving patient-reported outcome measures (PROMs) in the medium and long term [2]. In contrast, in a randomized controlled trial comparing subacromial collagen injection in combination with PRP, collagen injection alone, and PRP injection alone for rotator cuff tendinopathy, Godek et al. found no significant difference in PROMs between the three groups at a six-month follow-up [3]. Professor Wang Yue's team from the First Affiliated Hospital of Zhejiang University conducted a randomized controlled trial in which PRP was not injected during arthroscopic rotator cuff bridge suture repair or PRP was injected at 7 and 14 days of follow-up, and found that although there was no significant difference in PROMs between the two groups, the retear rate in the PRP injection group was significantly lower than that in the non-injection group, and the Goutallier grade was lower on postoperative magnetic resonance imaging [4].
In addition to PRP, stem cell therapy has also provided new ideas for the treatment of rotator cuff tendinopathy, such as autologous microfragmented adipose tissue has been shown to be a usable source of adipose-derived mesenchymal stem cells that promote tissue healing, but in a randomized controlled trial of arthroscopic rotator cuff repair conducted by Randelli et al., there was no significant difference in retear rates between the two groups at 18 to 24 months of follow-up [5]. Therefore, the clinical transformation of stem cell therapy still needs a lot of research and exploration.
2. Diagnosis, surgery and postoperative rehabilitation
With the rapid development of artificial intelligence technology, its application in the medical system is becoming more and more extensive. Professor Yang Rui's team at Sun Yat-sen Memorial Hospital of Sun Yat-sen University has developed a machine learning model that uses interpretable AI to identify important clinical features associated with rotator cuff tears, which can effectively predict rotator cuff tears, and the algorithm has been integrated into digital applications to provide predictions in an outpatient setting, helping doctors quickly diagnose and provide timely treatment [6].
In recent years, most studies comparing the long-term efficacy of different rotator cuff repair techniques have shown that there is no significant difference in surgical efficacy between different techniques. Woodmass et al. compared the clinical efficacy of arthroscopic rotator cuff repair with acromoplasty and found that the functional scores of patients in both groups were significantly improved compared with preoperative conditions, but there was no significant difference in Western Ontario Rotator cuff (WORC) index scores between the two groups, and the reoperation rate was significantly higher in the group without acromioplasty (16%) than in the acromoplasty group (2%) [7]. In addition, studies on the use of bone marrow stimulation to enhance rotator cuff repair healing in the imprint area of the greater tuberosity have also attracted widespread attention, with Toro et al. and Lapner et al. finding that rotator cuff repair with bone marrow stimulation at the same time as the meil of the footprint has no significant effect on rotator cuff healing [8,9]. The team of Professor Shang Xiliang from Huashan Hospital affiliated to Fudan University conducted a systematic review and meta-analysis on the merits of the rotator cuff articular surface partial tear perforation tendon repair technique and post-full-thickness tear repair, and found that there were no significant differences between the two surgical methods in terms of postoperative VAS score, ASES score, Constant score, range of motion, postoperative adhesive capsulitis, tendon integrity, and patient satisfaction [10].
With the continuous iteration and update of rehabilitation technology, postoperative rehabilitation is becoming more and more important, such as extracorporeal shock waves, low-frequency pulsed electrical stimulation, targeted muscle exercises and other methods are becoming more and more abundant and effective. Professor Li Yunxia's team from Huashan Hospital of Fudan University conducted a randomized clinical trial to observe the effect of extracorporeal shock wave therapy (ESWT) on pain and tendon healing after rotator cuff repair, and found that the combination of ESWT and rehabilitation can effectively reduce early pain and promote tendon healing after rotator cuff repair, but ESWT may not be more effective than rehabilitation alone in terms of functional outcomes at short-term follow-up [11].
3. Huge irreparable rotator cuff tear
The treatment of massive irreparable rotator cuff tears (MIRCT) has been a hot topic of debate in the field of sports medicine. Ono et al. compared the use of upper capsule reconstruction and bridging repair techniques (allogeneic dermal grafts) in patients with MIRCT and found no significant difference in rotator cuff retear rates between the two groups at 12 months [12]. Verma et al.'s randomized controlled trial comparing the clinical efficacy of arthroscopic partial repair with the subacromial balloon technique found that both groups had significant improvement in ASES scores at 12 and 24 months, with minimal clinically important difference (MCID), The proportion of patients with significant clinical efficacy and acceptable symptom status was similar, but the subacromial balloon technique group had a relatively short duration of surgery and a more pronounced improvement in forward flexion range of motion at 12 and 24 months [13].
In view of the current difficulties in the treatment of MIRCT, Professor Chen Shiyi from Huashan Hospital affiliated to Fudan University proposed the superior capsular reconstruction (SCR) technique of long head of biceps tendon (LHBT) transposition and fixation. In 2016, Dr. Johannes Barth, a traveling scholar from France, visited and became very interested in the method, and after returning to China, he developed the technology and named it "Chinese Way" SCR, since then the "Chinese Way" SCR technology has quickly spread around the world, and a series of biomechanical and clinical studies have been carried out. The biomechanical studies showed that LHBT transposition treatment for MIRCT reduced the subacromial contact pressure, reduced the upward displacement of the humeral head, and did not limit the range of motion. The improvement of external rotation range of motion is more significant, and it can more effectively reduce the scapulohumeral space and reduce the postoperative retear rate, while there is no significant difference between ASES score, VAS score, and UCLA score, which fully demonstrates that LHBT-SCR is a reliable and economical technique for the treatment of MIRCT [14].
4. Perioperative management
In perioperative management, three randomised controlled trials evaluating tranexamic acid in rotator cuff repair have had mixed results. Mackenzie et al., who reported the use of intravenous tranexamic acid in 89 patients preoperatively, found that tranexamic acid injection group had significantly better pain scores at eight weeks and shoulder range of motion at six months, but no significant difference in pain scores at three days and PROMs at any time point [15]. Nicholson et al. also conducted a study of 100 patients with intravenous tranexamic acid before surgery and found no clear benefit of tranexamic acid in reducing pump pressure, improving arthroscopic vision, operative time, or pain scores at 24 hours postoperatively [16]. Bildik and Pehlivanoglu, on the other hand, found that intra-articular tranexamic acid injection improved arthroscopic visual clarity, operative time, and pain scores [17].
There is also growing interest in the study of non-opioid analgesic regimens after rotator cuff repair due to concerns about analgesic drug abuse. Jildeh et al., a randomized controlled trial comparing a multimodal nonopioid postoperative analgesic regimen with a standard opioid regimen, found that the nonopioid group had significantly lower pain scores at 10 days postoperatively and shorter duration of side effects of constipation and gastric upset [18]. Alaia et al., who randomized patients to oral cannabidiol tablets and placebo for 14 days for analgesia after arthroscopic rotator cuff repair, found that pain scores were significantly lower in the cannabidiol group on day 1, but there was no significant difference at other time points [19].
5. Basic research
Tendon degeneration caused by aging is an important cause of rotator cuff tendinopathy and is closely related to mitochondrial function. Professor Zhao Qichun's team from the First Affiliated Hospital of the University of Science and Technology of China found that nicotinamide phosphoribosyltransferase (NAMPT, a kind of NAD+) was found in mouse animal experimentsThe synthetic rate-limiting enzyme improved the mitochondrial function indexes, improved the mitochondrial ultrastructure of the tendon under electron microscopy, alleviated the degeneration of the rotator cuff tendon in the elderly, and showed that the collagen content and fiber walking were significantly improved, and more importantly, the biomechanical experiments found that NAMPT increased the strength of the tendon tissue, which is of great significance for the prevention of re-tearing after the geriatric degenerative rotator cuff [20].
Tendon and bone have completely different biological characteristics, so how to promote the integration of tendon-bone interface and improve rotator cuff healing has always been the focus and difficulty of research. The team of Prof. Xiao Chen and Prof. Weiliang Shen from the Second Affiliated Hospital of Zhejiang University proposed a biomimetic mineralization strategy for tendon collagen fibers to prepare mineralized tendons, which can induce mesenchymal stem cells to osteogenic differentiation in vitro and achieve good tendon-bone integration in vivo, providing a new idea for the treatment of rotator cuff injuries [21].
The research on rotator cuff artificial mesh in the treatment of MRCT has also attracted more and more attention. The team of Professor Chen Shiyi and Professor Chen Jun from Huashan Hospital of Fudan University found that PET mesh can not only reconstruct the mechanical support of torn tendons immediately after surgery, but also promote tendon regeneration and maturation by inducing the formation of fibrocartilage [22]. Therefore, PET mesh is a promising graft for MRCT bridging reconstruction.
Shoulder instability
The shoulder joint is the most susceptible to dislocation in the body, and more than 95% of them are anterior dislocations. At present, the main treatment methods include Bankart repair, Bankart combined with Remplissage, Latarjet and other procedures. Studies have shown that the use of knotless anchors and knotted suture anchors during arthroscopic Bankart repair was associated with similar Rowe score and redislocation rates at 24 months after surgery, and the Western Ontario Shoulder Instability Index score (WOSI) and Single Assessment Numeric Assessment at 6, 12, and 24 months between the two groups Numeric evaluation (SANE), range of motion, pain scores, and complications were not significantly different [23]. In patients with a primary anterior dislocation, Bankart repair may be more effective than conservative management in reducing redislocation rates and achieving higher WOSI scores, but there is no significant difference in return to exercise between the two groups in the short or long term [24].
In view of the treatment of recurrent anterior dislocation of the shoulder joint with glenoid defect, the team of Professor Lu Wei of Shenzhen Second People's Hospital compared the differences in the clinical efficacy of open and arthroscopic Latarjet surgery. There was no significant difference between the two procedures in terms of external rotation and major complications, and arthroscopic Latarjet had a lower WOSI score and a higher healing rate, but it also had a long learning curve and a high revision rate [25]. Professor Cui Guoqing's team from Peking University Third Hospital compared the clinical efficacy differences between arthroscopic Latarjet surgery and arthroscopic Bristow surgery, and found that both could achieve satisfactory clinical outcomes, although graft healing in the Bristow group was lower than that in the Latarjet group, arthroscopic Bristow surgery took less operation time, had a lower incidence of early moderate to severe glenohumeral osteoarthritis, had a better range of motion, and had a higher rate of return to exercise [26].
Shoulder replacement
1. Prevention of P. acnes infection
Prophylactic use of benzoyl peroxide and miconazole nitrate in preoperative skin preparation reduces colonization of P. acnes and the incidence of periprosthetic joint infection. In a randomized controlled trial, Unterfrauner et al. found that cutaneous prophylactic use of benzoyl peroxide and miconazole nitrate reduced P. acnes colonization in subcutaneous tissues in shoulder replacement patients compared with controls, suggesting that benzoyl peroxide and miconazole nitrate components can significantly reduce P. acnes colonization and thus the incidence of periprosthetic joint infections [27]. However, Symonds et al. found that this method did not completely remove P. acnes from tissues and eliminate the risk of infection, and in a study in which they performed five specified skin preparations prior to surgery, 22 percent of patients had positive P. acnes cultures at the start of surgery [28].
2. Perioperative management
Compared with the conventional regimens that focus on opioid analgesics, new multimodal analgesic approaches such as brachial plexus interscalene block, local infiltration anesthesia, and non-steroidal anti-inflammatory drugs combined with cocktail injections can significantly reduce patients' dependence on opioids. Jones et al., using prospective randomized controlled trials, found that a multimodal postoperative analgesic regimen significantly reduced opioid use compared with opioid-based analgesic regimens without increasing pain or affecting surgical outcomes [29]. In addition, due to the risk of various complications and rebound tenderness associated with brachial plexus interscalene block in shoulder surgery, Ewing et al. attempted to test whether local infiltration anesthesia could be an alternative to brachial plexus interscalene block, and found that local infiltration anesthesia, as an alternative analgesic method, was comparable to brachial plexus interscalene block for pain control after shoulder arthroplasty, but with a higher intraoperative opioid consumption [30].
3. Anatomical total shoulder arthroplasty
The optimal management of the subscapular tendon during anatomic total shoulder arthroplasty remains controversial. In studies comparing subscapular tenotomy with subscapular tendon insertion, they found that the healing rate was significantly higher in the tenotomy group than in the stripping group, but there was no significant difference in tendon thickness or other clinical markers between the two groups [31]. Previous studies have expressed a similar view: the development of humeral stems with variable neck shaft angles can help surgeons more accurately restore the patient's natural neck shaft angle and improve surgical outcomes [32].
4. Trans shoulder arthroplasty
In recent years, trans shoulder arthroplasty has been increasingly used to treat patients with rotator cuff intact osteoarthritis in addition to mirct and rotator cuff tear arthropathy. In terms of postoperative PROM and ASES, SANE, and VAS scores, the clinical efficacy of trans shoulder arthroplasty and total shoulder arthroplasty is similar, but the range of motion (external rotation, internal rotation, and forward flexion and abduction) after total shoulder arthroplasty is greater [33], and patients who have failed total shoulder arthroplasty can undergo revision with trans shoulder arthroplasty.
Proximal humerus fracture
There has been a lack of high-level evidence for the use of fibular allografts to augment medial column support in locking plate fixation of proximal humeral fractures. In a study by Chen Yunfeng and Wang Lei's team, 80 patients with proximal medial column crush were randomly assigned to either a locking plate fixation group alone or a locking plate fixation group with a fibular allograft [34]. The study found no significant difference between the two groups in terms of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire score or other secondary outcomes (e.g., constant score, range of motion, pain, satisfaction, complications, and changes in neck shaft angle and humeral head height) at 12 months;
Clavicle and acromioclavicular joints
In a study by Orlandi et al., which compared clavicle hook plate fixation with anatomical plate fixation for clavicle fractures, there was no significant difference in DASH score or Constant score at six or 12 months postoperatively, and the healing rate at 12 months was 100 percent [35]. For Rockwood type III and V acromioclavicular joint dislocations, Boström Windhamre et al.'s study compared the clinical efficacy of clavicle hook plate fixation and physiotherapy, and found that after 3 months, patients who did not undergo surgery had significantly higher Quick DASH and functional scores. However, there was no clear difference between the two groups at 6 months, 12 months, and 24 months, and the authors conclude that current data do not support surgical treatment of clavicle hook plate fixation in patients with Rockwood type III and V acromioclavicular joint dislocations [36].
brief summary
In 2023, new advances in the field of shoulder sports injuries have ushered in new advances in diagnosis and treatment, providing patients with more personalized and effective treatment options. Although there are still challenges in many areas, scholars around the world are working to improve research and breathe new life into the field of diagnosis and treatment of shoulder sports injuries. Let's work together to achieve a new breakthrough in the diagnosis and treatment of shoulder injuries. At the same time, due to the limited space, it is inevitable that there will be omissions, and I hope that you will criticize and correct.
About the Author
Shang Xiliang
Doctor, chief physician, master's supervisor, deputy director of the Department of Sports Medicine, Huashan Hospital, Fudan University
Academic positions: Deputy head of the limbology group of the Sports Medicine Branch of the Chinese Medical Association, member of the Youth Committee of the Sports Medicine Branch of the Chinese Medical Association, member of the shoulder and elbow group of the Sports Medicine Physician Branch of the Chinese Medical Doctor Association, member of the shoulder and elbow professional committee of the Chinese Medical Education Association, member of the Sports Health Branch of the Chinese Geriatrics Society, member of the Sports Medicine Committee of the Shanghai Medical Association and deputy leader of the minimally invasive group, vice chairman of the Sports Medicine Committee of the Shanghai Association of Integrative Medicine, member of the Standing Committee of the Sports Medicine Committee of the Yangtze River Delta Hospital Alliance, He is a member of the editorial board of the Chinese Electronic Journal of Shoulder and Elbow Surgery, and a young editorial board member of Burns &Trauma.
He has presided over 4 projects of the National Natural Science Foundation of China, participated in more than 10 national, provincial and ministerial projects, published nearly 40 papers in core journals at home and abroad as the first author/corresponding author, and participated in the compilation of 8 monographs.
Yang Yimeng
Attending physician of Huashan Hospital affiliated to Fudan University, specializing in sports medicine
He has presided over 1 project of the National Natural Science Foundation of China, 1 general project of the Shanghai Natural Science Foundation, 2 original exploration projects of Fudan University, etc., and was selected into the Shanghai Youth Science and Technology Rising Star Program, and published 14 SCI papers in well-known journals such as Advanced Science and AJSM, including 3 papers with an impact factor of more than 10 points.
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Author: Shang Xiliang Yang Yimeng
Affiliation: Department of Sports Medicine, Huashan Hospital, Fudan University
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