PERSPECTIVES

Drs. Khan and Bhandari talked about the trending topics of shoulder conditions, important studies to read and the research questions yet to be answered. Our discussion uncovered 4 core themes. These themes and their supporting insights are highlighted below.

1. Surgery does not show benefit for shoulder impingement syndrome

The role of surgery for shoulder impingement syndrome (SIS) is currently a very hot topic. There have been a number of recent trials that were published in the LANCET [1], the BMJ (British Medical Journal) [2] and other journals or conferences [3-7]. Dr. Khan said that these studies had shown no significant benefit of surgery for SIS compared to nonoperative treatments including placebo or sham surgery. A systematic review and meta-analysis that was published in 2020 in BJSM (British Journal of Sports Medicine) provides an overview of the topic and investigates several subacromial decompression surgical approaches for adults with shoulder pain [8]. The article is accompanied with a BMJ clinical practice guideline on the topic [9]. Drs. Khan and Bhandari regard that based on the available evidence, there is likely an additional added benefit of nonoperative treatments including exercise therapy, anti-inflammatory medications and subacromial corticosteroid injection than surgical decompression alone for patients with SIS.

Articles recommended by Dr. Khan - The role of surgery in shoulder impingement syndrome

1. ACE Report: No clinically relevant benefit of subacromial decompression for subacromial shoulder pain

2. ACE Report: Decompression of no statistical benefit over sham, and no clinical benefit over exercise for SIS

3. ACE Report: Exercise vs acromioplasty and exercise for shoulder impingement syndrome

4. ACE Report: Arthroscopic acromioplasty may not be efficacious for shoulder impingement syndrome

5. ACE Report: Long-term outcome of surgery favoured over physiotherapy alone for subacromial impingement syndrome

6. ACE Report: No difference between surgery and nonoperative treatment for shoulder impingement

7. Khan, M., Alolabi, B., Horner, N., Bedi, A., Ayeni, O. R., & Bhandari, M. (2019). Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ open, 7(1), E149. DOI: 10.9778/cmajo.20180179

8. Lähdeoja, T., Karjalainen, T., Jokihaara, J., Salamh, P., Kavaja, L., Agarwal, A., ... & Ardern, C. L. (2020). Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. British journal of sports medicine, 54(11), 665-673. DOI: 10.1136/bjsports-2018-100486

9. Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., ... & Poolman, R. W. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ, 364. DOI: 10.1136/bmj.l294

2. The role of biologics in rotator cuff surgery

Drs. Khan and Bhandari regard biologics as a fast-moving specialty and a hot topic in rotator cuff surgery. From Dr. Khan’s perspective, platelet rich plasma (PRP) is beneficial in improving the biology of the healing environment among patients undergoing rotator cuff surgery [10]. In terms of formulations, Dr. Khan indicates that a recent network meta-analysis showed that leukocyte-poor formulations resulted in decreased retear rates and had benefit for the patients [11]. Other biologics being studied include growth hormone injection, bioinductive collagen and patches.

Articles recommended by Dr. Khan - Biologics in rotator cuff surgery

10. ACE Report: Small-medium sized rotator cuff tears may benefit from PRP application

11. Hurley, E. T., Colasanti, C. A., Anil, U., Luthringer, T. A., Alaia, M. J., Campbell, K. A., ... & Strauss, E. J. (2020). The Effect of Platelet-Rich Plasma Leukocyte Concentration on Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of Randomized Controlled Trials. The American Journal of Sports Medicine, 0363546520975435. DOI: 10.1177/0363546520975435

3. Instability

Dr. Khan also highlighted a question regarding different treatments for shoulder dislocation of various levels of severity. A meta-analysis suggested a seven-fold reduction in recurrent instability with arthroscopic Bankart repair compared to conservative treatment for the first-time dislocation [12]. The investigation of the best procedure for recurrent instability or severe instability with a significant amount of bone loss remains a hot topic [13].

Articles recommended by Dr. Khan - Instability

12. Hurley, E. T., Manjunath, A. K., Bloom, D. A., Pauzenberger, L., Mullett, H., Alaia, M. J., & Strauss, E. J. (2020). Arthroscopic Bankart Repair versus Conservative Management for First-Time Traumatic Anterior Shoulder Instability-A Systematic Review & Meta-Analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. DOI: 10.1016/j.arthro.2020.04.046

13. Gouveia, K., Abidi, S. K., Shamshoon, S., Gohal, C., Madden, K., Degen, R. M., ... & Khan, M. (2020). Arthroscopic Bankart Repair with Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability with Bipolar Bone Loss: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. DOI:https://doi.org/10.1016/j.arthro.2020.08.033

4. The role of templating and augmented reality in shoulder arthroplasty

Dr. Khan thinks that preoperative templating and translating that template using augmented reality in the operating room or navigation in shoulder arthroplasty are also hot areas of investigation. In Dr. Khan’s opinion, this technology may help the surgeon in developing a more precise understanding of the patient’s anatomy. However, there is not much research on the long-term clinical impact of this technology. More evidence is needed.

SENSE-MAKING

Dr. Khan shared updates on the hot topics in shoulder across four main areas: the role of surgery in SIS, biologics in rotator cuff surgery, instability and the role of templating and augmented reality in shoulder arthroplasty. Dr. Khan recommended important papers to read in order to get a better understanding of these trending topics. Optimal treatment for massive rotator cuff tears remains an unanswered question and needs more evidence.