Orthogate Subspecialty Journal Scan: Shoulder and Elbow

Curated critical appraisals of recent high-impact trials and clinical evidence across shoulder and elbow surgery, evaluating total elbow arthroplasty versus internal fixation for elderly distal humerus fractures, tear-size thresholds for double-row rotator cuff repair across 18 randomized trials, and wound protector barrier efficacy in primary total shoulder arthroplasty.

Featured Shoulder and Elbow Studies This Edition (October 2026)
Shoulder and Elbow

1. Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for Intra-articular Distal Humerus Fractures in Patients 65 Years or Older: A Meta-analysis.

Authors: Boutros M, Awad G, Adio A, Lawand J, Boufadel P et al. | Journal: The Journal of the American Academy of Orthopaedic Surgeons (Aug 2026) | View Source / DOI

Situation

Complex intra-articular distal humerus fractures (AO/OTA type 13-B and 13-C) in patients aged 65 years and older present severe surgical challenges due to osteoporotic bone stock, metaphyseal comminution, and articular impaction. This meta-analysis compared clinical, functional, and complication outcomes between open reduction and internal fixation (ORIF) and primary total elbow arthroplasty (TEA).

Background

While ORIF preserves native anatomy and avoids lifelong weight-bearing restrictions, osteoporotic fixation failure and post-traumatic stiffness remain major risks. TEA permits immediate elbow mobilization and reliable pain relief, but carries long-term bushing wear, aseptic loosening, and periprosthetic infection risks, creating substantial debate over optimal initial surgical strategy.

Assessment & Findings
  • Study Design & Cohort: Systematic review and meta-analysis of 7 comparative studies encompassing 1,347 patients aged 65 years or older with intra-articular distal humerus fractures treated with either ORIF or primary TEA.
  • Range of Motion Outcomes: Primary TEA was associated with a statistically significant improvement in elbow flexion-extension range of motion arc compared to ORIF (mean difference: 9 degrees, 95% CI, 3.28 to 14.72 degrees; P = 0.002).
  • Functional & Perioperative Metrics: No statistically significant differences were observed between TEA and ORIF regarding Mayo Elbow Performance Score (MEPS), DASH functional scores, hospital length of stay, or operative time (all P > 0.05).
  • Safety & Revision Profiles: Overall complication rates, deep infection rates, and revision surgery rates showed no statistically significant differences between the two cohorts at mid-term follow-up (all P > 0.05).
Recommendation & Practice Takeaway

Clinical Pearl: The 9-degree flexion-extension arc benefit for TEA falls below established thresholds for minimal clinically important difference (MCID). Surgeons should adopt an individualized approach: prioritize parallel-plate ORIF when stable articular reconstruction is achievable to preserve bone stock and avoid permanent lifting restrictions; reserve primary semi-constrained TEA for low-demand, osteoporotic, or physiologically frail elderly patients with unreconstructible distal column comminution who cannot tolerate prolonged immobilization.

Shoulder and Elbow

2. Double-Row Repair Improves Outcomes for Large Rotator Cuff Tears but Offers No Advantage for Small-to-Medium Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Authors: Seok H, Park J, Park S | Journal: Arthroscopy: The Journal of Arthroscopic and Related Surgery (Oct 2026) | View Source / DOI

Situation

Arthroscopic rotator cuff repair is among the most common shoulder procedures, but controversy persists regarding whether double-row (DR) suture-bridge repair provides meaningful clinical or structural advantages over single-row (SR) repair across different tear sizes.

Background

Double-row repair restores a wider anatomical tendon footprint and provides superior initial biomechanical strength, but requires additional suture anchors, increased operative time, and higher implant costs. Whether these biomechanical benefits translate into improved patient outcomes in small and medium tears has remained contentious.

Assessment & Findings
  • Study Design & Cohort: Meta-analysis restricted exclusively to 18 randomized controlled trials (RCTs) including 1,308 patients, evaluating structural healing (retear rates), functional scores (UCLA, Constant, ASES), range of motion, and operative duration, with prespecified tear-size subgroup stratification (threshold: 30 mm).
  • Overall Functional & Structural Outcomes: Double-row repair demonstrated significantly superior UCLA functional scores (standardized mean difference [SMD] = -0.28; 95% CI, -0.44 to -0.12; I2 = 7%), improved forward flexion (SMD = -0.38; 95% CI, -0.58 to -0.19; I2 = 26%), lower overall retear rate (OR = 1.88; 95% CI, 1.33 to 2.66; I2 = 27%), and lower partial-thickness retear rate (OR = 2.81; 95% CI, 1.50 to 5.24; I2 = 3%).
  • Tear Size Stratification: In tears 30 mm or greater (large-to-massive tears), double-row repair consistently delivered statistically and clinically superior functional scores and structural tendon integrity. Conversely, in tears less than 30 mm (small-to-medium tears), single-row and double-row repairs yielded completely comparable clinical outcomes and retear rates.
  • Operative Duration: Single-row repair was associated with significantly reduced operative time across all studies (SMD = -0.74; 95% CI, -1.04 to -0.43; I2 = 81%).
Recommendation & Practice Takeaway

Clinical Pearl: The 3-cm tear dimension represents a definitive clinical threshold. For small-to-medium rotator cuff tears (less than 3 cm), single-row repair achieves equivalent structural healing and functional scores while saving significant operative time and hardware costs. Double-row or transosseous-equivalent constructs should be reserved for tears 3 cm or greater, where wider footprint coverage and reduced tension significantly decrease structural retear rates.

Shoulder and Elbow

3. Do wound protectors reduce contamination in total shoulder arthroplasty? A randomized controlled trial.

Authors: Kirkham M, Carlson H, Merrill E, Operti N, Christy K et al. | Journal: Journal of Shoulder and Elbow Surgery (Oct 2026) | View Source / DOI

Situation

Cutibacterium acnes (formerly Propionibacterium acnes) is the primary pathogen causing shoulder periprosthetic joint infection (PJI), with cutaneous skin edges serving as a presumed source of deep intraoperative inoculation. This Level-I randomized trial evaluated whether disposable ring wound protector devices reduce deep bacterial contamination and soft tissue crush trauma during primary total shoulder arthroplasty (TSA).

Background

Wound protectors isolate dermis and subcutaneous adipose tissue from surgical instrumentation. While widely adopted in gastrointestinal surgery, their efficacy in preventing C. acnes deep colonization and shielding the deltopectoral interval from retractor-induced muscular trauma had not been established in a prospective randomized trial.

Assessment & Findings
  • Study Design & Cohort: Prospective, randomized controlled trial of 100 patients undergoing primary TSA randomized to wound protector (n = 48 analyzed) or standard draping control (n = 47 analyzed). Deep wound swabs were taken after definitive implant seating. Deltoid, pectoralis major, and cephalic vein injuries were graded using modified Tscherne soft tissue injury criteria (grades 0 to 3).
  • Microbiological Contamination: The use of a wound protector did not significantly alter positive deep culture rates for C. acnes (15% in protector vs 21% in control, P = 0.593) or overall bacterial species (15% vs 26%, P = 0.304). After excluding likely broth contaminants (growth greater than 7 days, single colony), rates remained comparable (9% vs 17%, P = 0.355 for C. acnes; 9% vs 19%, P = 0.231 for all bacteria).
  • Soft Tissue Protection: The wound protector cohort demonstrated significantly superior soft tissue injury scores with markedly less crush and contusion injury to the deltoid muscle (P < 0.001) and pectoralis major muscle (P < 0.001).
  • Safety & Efficiency: Cephalic vein injury rates (P > 0.05) and total surgical operative times were identical between cohorts.
Recommendation & Practice Takeaway

Clinical Pearl: Ring wound protectors do not eliminate Cutibacterium colonization in total shoulder arthroplasty, as the organism resides deep within sebaceous glands and hair follicles rather than purely superficial epidermis. However, wound protectors provide substantial mechanical shielding against retractor-induced muscular crush injury to the deltopectoral musculature without adding operative time. Surgeons utilizing these devices should value them for myofascial protection rather than relying on them as standalone antibacterial barriers.

Orthogate Weekly Journal Scan is curated and synthesized by ORION (Orthopaedic Research, Intelligence & Operations Navigator) for orthopaedic surgeons, fellows, and residents. Evidence synthesized under the clinical direction of Christian Veillette, MD, MSc, FRCSC.