What’s New in Shoulder and Elbow Surgery

This article is a review of the most impactful studies related to shoulder and elbow surgery published from April 2022 to March 2023. We included clinical studies primarily from The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, the Journal of Shoulder and Elbow Surgery, and Arthroscopy: The Journal of Arthroscopic & Related Surgery. We placed specific emphasis on higher-quality research (Level-I and II studies) and particularly relevant Level-III studies. Shoulder Arthroplasty Cutibacterium and Infection Prevention Preoperative application of benzoyl peroxide to the skin has been found to reduce Cutibacterium acnes colonization. However, it remains unclear whether this topical application can also reduce C. acnes present in deeper tissue or ultimately lower the incidence of periprosthetic joint infection (PJI). In a randomized clinical trial, Unterfrauner et al.1 investigated possible synergistic effects of benzoyl peroxide and miconazole nitrate on reducing subcutaneous and capsular C. acnes in patients with known C. acnes skin colonization. The experimental group received a 7-day preoperative application of a commercial acne cream that had benzoyl peroxide and miconazole, and the control group did not receive such preoperative treatment. At baseline, 60% of patients in both groups showed skin colonization with C. acnes. In these patients with positive baseline colonization, the experimental group subsequently showed a significant reduction of C. acnes colonization by 56%, whereas the control group showed a 16% reduction. Intraoperative culture specimens taken from the subcutaneous and capsular tissues showed significantly fewer positive cultures in the experimental group (44%) than in the control group (84%). None of the capsular samples from the experimental group was positive, whereas 21% were positive in the control group. Symonds et al.2 conducted a randomized controlled trial to compare the efficacy of 3 different preoperative skin preparations in reducing positive C. acnes culture rates in patients undergoing shoulder arthroplasty. A total of 101 patients were randomized into 3 groups: pHisoHex (hexachlorophene 3% detergent cleanser; sanofi-aventis), 5% benzoyl peroxide, and 5% benzoyl peroxide-clindamycin. Six swab culture specimens were taken in each patient. The application of pHisoHex reduced skin C. acnes colonization by 50%, compared with 73.3% after benzoyl peroxide application and 81.5% after benzoyl peroxide-clindamycin application. However, overall, 22% of cases were still positive for C. acnes at the beginning of the surgical procedure even after 5 applications of the designated skin preparations. There were no significant differences between the groups in the subsequent intraoperative cultures. Perioperative Management The efforts to reduce opioid usage have resulted in the implementation of various opioid-sparing multimodal pain management pathways. In a prospective randomized controlled trial, Jones et al.3 compared the pain scores and patient satisfaction between an opioid-sparing protocol and a traditional opioid-based protocol in patients undergoing shoulder arthroplasty. The opioid-sparing group received 10 tablets of oxycodone at discharge, whereas the opioid-based group received 40 tablets. Both groups received an intraoperative periarticular injection of liposomal bupivacaine. The opioid-sparing group consumed significantly fewer opioids at all time points. No significant differences in the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), or Single Assessment Numeric Evaluation (SANE) scores; range of motion; complications; readmissions; or reoperation were seen between the groups. Jolissaint et al.4 conducted a randomized controlled trial comparing a completely opioid-free pain management pathway with a traditional opioid-containing pathway. Both groups received a preoperative interscalene block. The authors found that the opioid-free group had significantly lower pain levels at 12 hours, 24 hours, and 2 weeks than the opioid-based group. There were no readmissions or increased complications in the opioid-free group. Although effective and widely used in shoulder procedures, an interscalene block carries the risk of various complications and rebound pain. Ewing et al.5 conducted a randomized clinical trial to investigate whether local infiltration analgesia could serve as an effective alternative to an interscalene block for postoperative pain management following shoulder arthroplasty. The local infiltration analgesia group received a joint cocktail injection, which included ropivacaine, epinephrine, and ketorolac, before wound closure. The local infiltration group was noninferior to the interscalene block group with respect to the mean pain score during the first 24 hours, and the 2 groups were not significantly different in pain scores at any postoperative time points except at 8 hours, when the local infiltration group had a significantly higher mean pain score. No significant difference in opioid consumption was observed between the groups at any time points, but the local infiltration group had significantly higher intraoperative opioid consumption. Anatomic Total Shoulder Arthroplasty The optimal technique for managing the subscapularis during anatomic total shoulder arthroplasty (TSA) remains controversial, as the existing literature has not conclusively demonstrated the superiority of any of the 3 available techniques over the others. Baisi et al.6 analyzed a randomized controlled trial to compare the anatomic outcomes between the subscapularis tenotomy and peel techniques. Ultrasound was used to examine the healing and thickness of the subscapularis tendon between 12 and 24 months postoperatively. In analyzing the data from a total of 88 patients, the authors found a significantly higher healing rate of 95% in the tenotomy group compared with 75% in the peel group. The mean tendon thickness was 4 mm and was not significantly different between the groups. The rate of a positive belly-press test, internal rotation strength, ASES score, and Western Ontario Osteoarthritis of the Shoulder (WOOS) Index were not significantly different between the healed and non-healed tendons. Humeral stems with a variable neck-shaft angle were developed to help surgeons to more accurately restore the native neck-shaft angle of patients and to ultimately improve surgical outcomes. Joyce et al.7 conducted a randomized controlled trial to investigate if the native joint anatomy could be better restored for patients with a fixed or variable-neck-shaft angle prosthesis. They randomized 50 patients with osteoarthritis indicated for primary TSA into 2 groups. The fixed-neck-shaft angle group received a 132.5° humeral neck cut, whereas the variable angle group received 1 of 3 angle options (127.5°, 132.5°, and 137.5°) following the patients’ native neck-shaft angle. They found no significant differences between the groups in net changes from premorbid to postoperative measurements of tuberosity-to-head height, head offset from the humeral shaft axis, or the position of the center of rotation. They concluded that both fixed and variable-neck-shaft angle prostheses could adequately restore premorbid anatomy. Reverse Shoulder Arthroplasty The use of reverse shoulder arthroplasty (RSA) for treating osteoarthritis in patients with an intact rotator cuff has been a growing trend. However, there has been a limited amount of current literature comparing RSA and TSA in the setting of osteoarthritis. Kirsch et al.8 conducted a retrospective propensity-score-matched cohort analysis to compare clinical outcomes between RSA and TSA in 134 patients with primary osteoarthritis. At a mean follow-up of 30 months, no significant differences were observed in patient-reported outcome measures (PROMs) (i.e., ASES, SANE, and VAS pain scores) between RSA and TSA. However, TSA was associated with significantly better range of motion in all directions: external rotation, internal rotation, and forward elevation. One TSA case underwent revision to RSA, and no RSA case underwent revision. Rotator Cuff Nonoperative Management Multiple studies have examined the role of injectable orthobiologics in the nonoperative management of rotator cuff disease. Vaquerizo et al.9 compared the clinical efficacy of intratendinous injections of platelet-rich plasma (PRP) (n = 39) with that of corticosteroid injections (n = 40) for chronic rotator cuff tendinopathy in a randomized controlled trial with 1-year follow-up. Although both groups showed a significant improvement in PROMs from baseline to all time points, the PRP group had significantly higher PROMs than the corticosteroid group at 6 and 12 months. In contrast, Godek et al.10 did not find significant differences between groups in PROMs in a 6-month follow-up in a randomized controlled trial comparing subacromial injections of collagen with PRP (n = 27), collagen alone (n = 28), and PRP alone (n = 27) in the treatment of rotator cuff tendinopathy. In a meta-analysis of Level-I and II randomized controlled trials11, Pang et al. compared outcomes of PRP injections with those of corticosteroid injections in the nonoperative management of rotator cuff disease, with 725 patients analyzed across 13 studies. Although minimal clinically important differences (MCIDs) between groups were not consistently found at any time point, PRP showed better medium-term improvement (2 to 6 months) and long-term improvement (≥6 months) than corticosteroid injections in some PROMs that reached the MCID after sensitivity analyses. PRP also had lower rates of subsequent injections or surgical procedures prior to 12 months. Surgical Technique and Biologic Augmentation Long-term follow-up comparing rotator cuff repair techniques is uncommon. Woodmass et al.12 reported long-term follow-up to a previously published randomized controlled trial comparing arthroscopic rotator cuff repair with and without acromioplasty, with 31 of 45 patients in the group without acromioplasty and 25 of 41 patients in the acromioplasty group returning at a mean of 11 years following the initial procedure. There was no significant difference in Western Ontario Rotator Cuff (WORC) Index scores between groups, with both groups maintaining significant improvement from preoperative scores. Imaging of the repair was not performed in this study, but the group without acromioplasty had a significantly higher rate of reoperation (16%) than the acromioplasty group (2%). Multiple studies have examined the effect of creating bone holes or channels at the greater tuberosity repair site as a form of bone marrow stimulation to enhance rotator cuff repair healing. In a randomized controlled trial, Toro et al.13 compared the debridement of the greater tuberosity alone (n = 47) with microfracture (crimson duvet procedure) of the greater tuberosity (n = 48) in patients undergoing arthroscopic rotator cuff repair. There were no significant differences in repair healing rates at 6 months (85.1% compared with 93.7%) or PROMs at 12 months found between the groups. Similarly, Lapner et al.14 compared patients undergoing arthroscopic rotator cuff repair without (n = 75) and with (n = 75) bone channeling at the rotator cuff repair site in a randomized controlled trial and found no significant differences between groups in healing rates (87% compared with 75%) or PROMs at 24 months. The benefit of PRP for augmentation of rotator cuff repairs continues to be investigated. Zhang et al.15 performed a randomized controlled trial of arthroscopic repair of medium to large rotator cuff tears using a double-row, suture-bridge technique without (n = 46) or with (n = 43) PRP injections given intraoperatively and at 7 and 14-day follow-ups. No significant differences in PROMs were found between groups at 24 months, but the PRP group had a significantly lower retear rate (17.6% compared with 38.1%; p = 0.049) and lower postoperative Goutallier grades on magnetic resonance imaging. Two different systematic reviews with network meta-analyses of Level-I randomized controlled trials also examined the effect of the rotator cuff repair technique and PRP application on outcomes. Lavoie-Gagne et al.16 evaluated small to medium rotator cuff tears specifically and found that single-row and double-row repair techniques with or without PRP had similar retear rates, PROMs, and clinical outcomes. In contrast, Lv et al.17 evaluated arthroscopic repairs in ≤5-cm tears and found that PRP application significantly reduced retear rates for both single-row and suture-bridge repairs and that suture-bridge repairs with PRP application overall produced the lowest retear rate and the best University of California Los Angeles (UCLA) shoulder score. Autologous microfragmented lipoaspirate tissue has been shown to be an available source of adipose-derived mesenchymal stem cells that may enhance tissue healing. Randelli et al.18 performed a randomized controlled trial of arthroscopic, single-row, rotator cuff repair without (n = 22) or with (n = 22) the injection of such lipoaspirates harvested from the abdomen or gluteal region and processed, but found no significant differences between the groups in retear rates at 18 months or PROMs at 24 months. Irreparable Rotator Cuff Tears The optimal surgical treatment for irreparable rotator cuff tears remains debatable. Ono et al.19 randomized patients intraoperatively to superior capsular reconstruction (n = 24) or a bridging graft (n = 23) with human dermal allograft following the arthroscopic partial repair of massive, irreparable tears, but found no significant differences between the groups in graft failure rates at 12 months (25% compared with 36%) or PROMs at 24 months. Patients with intact grafts had greater PROMs and acromiohumeral intervals at 24 months, regardless of the graft group. The subacromial balloon spacer has become another surgical option for the management of irreparable rotator cuff tears, with recent studies evaluating its efficacy. In a randomized controlled trial, Verma et al.20 compared arthroscopic partial repair (n = 91) with a subacromial balloon spacer (n = 93) and found significant and clinically relevant improvements in the ASES score in both groups at 12 and 24 months, including similar rates of patients achieving the MCID, substantial clinical benefit, and patient acceptable symptom state (PASS). The subacromial balloon spacer group required significantly less operative time and had significantly greater forward elevation at 12 and 24 months. In contrast, Metcalfe et al.21 compared arthroscopic debridement with biceps tenotomy (n = 59) and the same procedure with insertion of a subacromial balloon spacer (n = 55) in a randomized controlled trial and found that the debridement group had a significantly better mean Oxford Shoulder Score at 12 months (p = 0.037) than the balloon spacer group, the primary study outcome. The WORC Index and the EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) were not significantly different between groups. Perioperative Management Three randomized controlled trials evaluated the benefit of tranexamic acid during rotator cuff repair, with varying results. Mackenzie et al.22 studied preoperative use of intravenous tranexamic acid in a total of 89 patients and found significantly better pain scores at 8 weeks and shoulder range of motion at 6 months in the tranexamic acid group, but no differences in pain scores at 3 days or PROMs at any time points up until 1 year. Nicholson et al.23 similarly performed a study of preoperative intravenous tranexamic acid administration in a total of 100 patients and found no significant benefit of tranexamic acid in the ability to maintain lower pump pressures or improve arthroscopic visualization, operative time, or pain scores at 24 hours after the surgical procedure. In contrast, Bildik and Pehlivanoglu24 performed a study of intra-articular tranexamic acid involving 63 patients and found significantly better arthroscopic visual clarity, shorter operative time, and lower pain scores at 8 and 24 hours after the surgical procedure in the group that received tranexamic acid intra-articularly. Because of concerns over the misuse of narcotics, there remains interest in investigating nonopioid pain control regimens after rotator cuff repair. In a randomized controlled trial, Jildeh et al.25 compared a multimodal nonopioid postoperative analgesic protocol (17 patients) with a standard opioid protocol (23 patients) following arthroscopic rotator cuff repair and found that the nonopioid group had significantly lower pain scores for the first 10 postoperative days and significantly fewer days of constipation and upset stomach. Alaia et al.26 randomized patients to take an oral tablet of cannabidiol (52 patients) or placebo (47 patients) for 14 days after arthroscopic rotator cuff repair. Pain scores were significantly lower in the cannabidiol group on postoperative day 1 but at no other time point, and opioid consumption was not significantly different between groups. Similarly, Su et al.27 did not observe any clinically meaningful differences in pain scores or opioid consumption within 2 days after arthroscopic rotator cuff repair in patients randomized to take duloxetine (60 patients) or placebo (60 patients) after the surgical procedure. Instability Preoperative Evaluation The preoperative evaluation of patients with anterior shoulder instability is often aimed at detecting subcritical bone loss (≥13.5%) or critical bone loss (≥25%), and concepts related to on-track and off-track lesions have gained attention in recent years. In previous studies, some authors have suggested that the bony apprehension test (apprehension at 45° of abduction and 45° of external rotation) is a physical examination maneuver predictive of critical bone loss. James et al.28 performed a prospective, single-blinded cohort study of 92 patients ≥18 years of age with recurrent anterior shoulder instability to test the predictive ability of various physical examination maneuvers. The bony apprehension test had poor sensitivity (≤50%) for detecting subcritical and critical bone loss, engaging Hill-Sachs lesions, and off-track lesions. Alternatively, the more traditional anterior apprehension test and relocation test both had 100% sensitivity for all clinical parameters tested. Clinical Outcomes The use of knotless anchors in arthroscopic Bankart repairs overcomes the difficulty and potential failure of arthroscopic knots as well as the potential articular cartilage damage from knots. However, previous studies have suggested a high failure rate of knotless repair. Lobo et al.29 performed a randomized controlled trial comparing knotted and knotless suture anchors in Bankart repair performed by a single surgeon. The primary outcome was the Rowe score for instability at 24 months, and it was not significantly different between groups. Recurrent instability occurred in 16.7% of patients in the knotted anchor group and 18.8% of patients in the knotless anchor group. Secondary outcomes including the Western Ontario Shoulder Instability (WOSI) Index, SANE, range of motion, pain scores, and complications were not significantly different between the groups at 6, 12, and 24 months. Whether to manage patients with a first-time anterior dislocation conservatively or with Bankart repair remains controversial. Alkhatib et al.30 performed a systematic review and meta-analysis of randomized controlled trials to compare short-term outcomes (2 to 3 years) and long-term outcomes (5 to 12 years) following Bankart repair compared with conservative treatment for first-time dislocations. A total of 348 patients from 6 randomized controlled trials were analyzed. Bankart repair was associated with a significantly lower rate of recurrent instability (risk ratio [RR], 0.15 for the short term and 0.23 for the long term) and need for a subsequent stabilization surgical procedure (RR, 0.19 for the short term and 0.17 for the long term). The WOSI Index scores were significantly higher in the operatively treated group in the long term but not the short term. Return to sport was not significantly different between the 2 groups in the short or long term. Proximal Humeral Fractures High-level evidence regarding the use of a fibular allograft to enhance medial column support in locking plate fixation of proximal humeral fractures has been lacking. Wang et al.31 randomized 80 patients with proximal humeral medial column comminution to either locking plate fixation only or locking plate fixation with a fibular allograft. The unadjusted mean value for the primary outcome of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score at 12 months was not significantly different between groups. The secondary outcomes of DASH scores at other time points (3, 6, and 24 months), Constant scores, range of motion, pain, satisfaction, complications, and changes in the neck-shaft angle and the humeral head height were not significantly different between groups. The authors concluded that fibular allograft augmentation provided no additional clinical or radiographic benefit to locking plate fixation alone. In the last 2 decades, there has been a trend to treat proximal humeral fractures in the elderly population with RSA. Bjørdal et al.32 utilized data from 64 patients randomized to RSA and 60 patients randomized to open reduction and internal fixation in the DelPhi trial to perform a cost-utility analysis. Health-related quality of life was measured using the 15D QoL (15-dimensional quality-of-life) questionnaire, and costs from a health-care perspective were analyzed. Contrary to the authors’ hypothesis, open reduction and internal fixation was less costly and more effective than RSA. The mean quality-adjusted life-years were similar between groups. Clavicle and Acromioclavicular Joint Addressing displaced distal-third clavicular fractures can be challenging because of the small distal fragment of the clavicle available for screw purchase. In a prospective randomized controlled trial, Orlandi et al.33 randomized 32 patients to either hook plate fixation or anatomically contoured locking plate fixation augmented with coracoclavicular fixation. After excluding 1 patient in each group, there were 13 patients in the hook plate group and 17 patients in the locking plate group. Both groups had a 100% union rate at 12 months. All hook plates were removed during a second procedure when osseous union was achieved, whereas only 1 patient in the locking plate group elected for plate removal. There was no difference in DASH scores or Constant scores at 6 months or 12 months between the groups. Optimal treatment of Rockwood Type-III and V acromioclavicular joint dislocations is controversial. In a randomized controlled trial, Bostrӧm Windhamre et al.34 compared hook plate fixation and physical therapy in the treatment of acute acromioclavicular joint dislocations. A total of 63 patients (33 type III, 30 type V) were randomized to nonoperative treatment, whereas 61 patients (30 type III, 31 type V) were randomized to hook plate fixation. Eighteen percent of patients in the nonoperative group underwent a surgical procedure. At 3 months, the nonoperatively treated patients had significantly higher QuickDASH (the abbreviated version of the DASH questionnaire), Constant, and Subjective Shoulder Value scores. At 6, 12, and 24 months, there was no significant difference between treatment groups stratified by injury type. The authors concluded that the data do not support surgical treatment with hook plate fixation for Rockwood type-III and V acromioclavicular joint dislocations. Elbow Posttraumatic elbow stiffness remains a challenge to address. In a randomized controlled trial on patients with posttraumatic elbow stiffness, Birinci et al.35 compared the clinical results between a graded motor imagery motor-cognitive intervention program (25 patients) and a standard physical therapy program including elbow range of motion, stretching, and strengthening exercises (25 patients). The authors found significantly better results with the graded motor imagery group than with the standard physical therapy program for several outcomes, including the DASH score, active elbow flexion and extension, elbow flexion and extension muscle strength, pain with activity, fear of movement-related pain, and recognition accuracy and response time of the hand on the involved side. Two studies evaluated different nonoperative treatment options for lateral epicondylitis. Altaş et al.36 compared a home exercise program alone (26 patients) with an exercise program combined with either kinesiotaping (26 patients) or dry needling (26 patients) and found that the exercise program plus dry needling group performed the best overall at 3 weeks and 6 months, with the exercise program plus kinesiotaping and dry needling groups both having significantly better outcomes than the home exercise program alone. Couppé et al.37 compared patients randomized to receive a corticosteroid injection (21 patients), tendon needling (17 patients), or placebo needling (20 patients), followed by a home exercise program, and did not find an additional benefit from either the corticosteroid or tendon needling through 12 months. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 5 other articles were identified that are relevant to shoulder and elbow surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Jensen ML, Jensen SL, Bolder M, Hanisch KWJ, Sørensen AKB, Olsen BS, Falstie-Jensen T, Rasmussen JV. Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2023 Jan;32(1):111-20. RSA is associated with a higher revision rate due to PJI compared with anatomic TSA. It has been speculated that this higher risk of revision due to PJI after RSA may be related to a high proportion of patients who previously underwent a surgical procedure that was not an arthroplasty. Jensen et al. conducted a large database study using the Danish Shoulder Arthroplasty Registry to examine this speculation. Data analysis on 2,217 patients showed an overall revision rate of 4.0% (1.8% due to PJI). Of the 272 patients (12.3%) who had undergone previous rotator cuff repair, 11 (4.0%) underwent revision due to PJI. The 14-year cumulative rate of revision due to PJI was 14.1% for patients who had undergone previous rotator cuff repair and 2.7% for patients who had not undergone a previous surgical procedure. The adjusted hazard ratio for revision that was due to PJI was 2.2 for patients who had undergone a previous rotator cuff repair compared with patients who had not undergone a previous surgical procedure. The study revealed that patients with a history of procedures had a higher rate of revision cause by PJI following RSA. Nevertheless, the study does not explicitly address whether the increased proportion of patients with previous procedures is a determining factor for the increased rate of PJI-related revisions after RSA, compared with other arthroplasty options. Larose G, Fisher ND, Gambhir N, Alben MG, Zuckerman JD, Virk MS, Kwon YW. Inlay versus onlay humeral design for reverse shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022 Nov;31(11):2410-20. Two distinct categories of RSA humeral component designs have been widely used: the inlay designs and the onlay designs. Each design has its own theoretical advantages and disadvantages, but it is not clear how humeral component designs affect the clinical outcomes and complication profiles following RSA. In this systematic review and meta-analysis, Larose et al. analyzed 12 eligible studies including 1,447 patients with a minimum 12-month follow-up. The authors found that the inlay group had higher ASES scores than the onlay group (mean difference, 2.53), which was a significant difference but not a clinically important one. Postoperative motion was significantly greater in the onlay group than in the inlay group (differences of 5° in forward flexion, 3° in abduction, and 4° in external rotation), but these differences were not clinically important. The inlay group showed more instances of scapular notching (28.8% compared with 16.8%; p < 0.001). Scapular spine fractures were slightly more common in the onlay group than in the inlay group, but the difference was not significant (3.76% compared with 3.58%; p = 0.09). The authors concluded that both inlay and onlay designs resulted in similar clinical improvements postoperatively, with onlay designs having a lower rate of scapular notching. It should be noted that a considerable number of studies included in this meta-analysis utilized the initial Grammont-style inlay prostheses. Consequently, the outcomes of the study might not accurately represent the performance of newer lateralized-style inlay prostheses. Lavoie-Gagne O, Farah G, Lu Y, Mehta N, Parvaresh KC, Forsythe B. Physical therapy combined with subacromial cortisone injection is a first-line treatment whereas acromioplasty with physical therapy is best if nonoperative interventions fail for the management of subacromial impingement: a systematic review and network meta-analysis. Arthroscopy. 2022 Aug;38(8):2511-24. Although a broad range of interventions have been investigated for their effectiveness in treating subacromial impingement, the optimal approach based on the current high-level evidence has not been fully elucidated. In this systematic review and network meta-analysis of Level-I randomized clinical trials reporting clinical outcomes of subacromial impingement with nonoperative or operative treatment, Lavoie-Gagne et al. analyzed 3,643 shoulders from 35 studies with regard to pain, PROMs, and range of motion. Most studies displayed low concern for bias. Arthroscopic subacromial decompression with acromioplasty and physical therapy demonstrated superior improvements in all 3 outcome domains, whereas corticosteroid injections alone consistently demonstrated significantly inferior outcomes in all 3 domains. Of the nonoperative treatments, physical therapy with corticosteroid injections demonstrated moderate-to-excellent clinical improvements across all 3 domains. Based on the analysis, the authors recommended physical therapy with corticosteroid injections as a first-line treatment for patients with substantial symptoms. However, if nonoperative management fails, the authors recommended subacromial decompression with acromioplasty and physical therapy. This study’s findings offer validation for the treatment approach commonly employed in cases of subacromial impingement. Marigi EM, Bartels DW, Yoon JH, Sperling JW, Sanchez-Sotelo J. Antibiotic prophylaxis with cefazolin is associated with lower shoulder periprosthetic joint infection rates than non-cefazolin alternatives. J Bone Joint Surg Am. 2022 May 18;104(10):872-80. Preoperative antibiotic prophylaxis is currently the standard of care, but the clinical effectiveness of various antibiotic regimens in shoulder arthroplasty remains unclear. Marigi et al. conducted a large, single-institution, database study to examine if different preoperative antibiotic choices affect the rate of PJI following shoulder arthroplasty. Of 7,713 shoulder arthroplasties, PJI occurred in 101 arthroplasties (1.3%), with C. acnes being the most common pathogen (43.6%). In arthroplasties in which cefazolin was given, PJI-free survivorship was greater compared with arthroplasties in which non-cefazolin antibiotics were given. The administration of vancomycin or clindamycin was associated with a higher risk of both all-cause PJI and C. acnes PJI. Specifically, compared with the risk with perioperative use of cefazolin, the overall infection risk was 2.3 times higher with vancomycin and 5.1 times higher with clindamycin, and the risk of C. acnes PJI was 2.9 times higher with vancomycin and 8.0 times higher with clindamycin. This study’s findings challenge the established belief that vancomycin offers superior infection prophylaxis compared with first-generation cephalosporins in shoulder arthroplasty. It prompts a need for a fresh debate on this matter. Sahoo S, Stojanovska M, Imrey PB, Jin Y, Bowles RJ, Ho JC, Iannotti JP, Ricchetti ET, Spindler KP, Derwin KA, Entezari V. Changes from baseline in patient-reported outcomes at 1 year versus 2 years after rotator cuff repair: a systematic review and meta-analysis. Am J Sports Med. 2022 Jul;50(8):2304-14. In this systematic review and meta-analysis of all randomized controlled trials and prospective cohort studies (Level I and II), Sahoo et al. examined shoulder-specific PROMs at baseline, 1 year, and 2 years after rotator cuff repair, including the WORC Index, ASES, or Constant scores. There were 1,371 patients across the 15 studies analyzed. Studies were highly heterogeneous, but no evidence of major publication bias was observed. The weighted means of the baseline PROMs were 38.8 points for the WORC Index, 46.2 points for the ASES score, and 46.4 points for the Constant score, with weighted mean increases at 1 year of 42.9 points (95% confidence interval [CI], 37.3 to 48.4 points) for the WORC Index, 41.1 (95% CI, 36.0 to 46.2 points) for the ASES score, and 34.2 points (95% CI, 28.8 to 39.6 points) for the Constant score. In contrast, the weighted mean differences from 1 to 2 years were only 2 points (95% CI, −0.1 to 4 points) for the WORC Index, 2.3 points (95% CI, 1 to 3.6 points) for the ASES score, and 3.2 points (95% CI, 1.9 to 4.4 points) for the Constant score. There was considerable improvement in all PROMs from baseline to 1 year; however, only very small gains, below the MCIDs, were observed between 1 and 2 years after rotator cuff repair. Many orthopaedic journals mandate a minimum follow-up of 2 years for publication of clinical studies. However, the validity of this requirement in individual medical conditions has not been substantiated. This study presents evidence contradicting the necessity of such a requirement when reporting PROMs after rotator cuff repair.