Orthogate Subspecialty Journal Scan: Shoulder and Elbow

Curated critical appraisals of recent high-impact trials and clinical evidence across shoulder and elbow surgery, evaluating liposomal bupivacaine interscalene blocks for postoperative pain control, surgical duration as the primary driver of intraoperative suture contamination, and the impact of preoperative stiffness on long-term rotator cuff repair outcomes.

Featured Shoulder and Elbow Studies This Edition (November 2026)
Level I Shoulder and Elbow

1. Liposomal Bupivacaine + Bupivacaine Versus Bupivacaine Interscalene Nerve Block Effect on Pain After Rotator Cuff Repair: A Randomized Control Trial.

Authors: Fedorka C, Tornberg H, Rivera-Pintado C, Gentile P, Russo D et al. | Journal: The Journal of the American Academy of Orthopaedic Surgeons (Aug 2026) | View Source / DOI

Situation

Single-center prospective randomized trial evaluating whether interscalene nerve blocks (ISB) using bupivacaine alone (B) versus liposomal bupivacaine plus bupivacaine (LBB) improves postoperative analgesia and reduces narcotic consumption following arthroscopic rotator cuff repair (RCR).

Background

Interscalene nerve blocks are commonly used for perioperative pain control after shoulder arthroscopy, with bupivacaine historically serving as the primary local anesthetic. In 2018, the Food and Drug Administration approved liposomal bupivacaine for interscalene blocks, prompting investigation into whether combination infiltration offers meaningful clinical superiority.

Assessment & Findings
  • Study Design & Cohort: Prospective, double-blinded, randomized controlled trial conducted between January 2020 and April 2024 enrolling 128 opiate-naive patients undergoing arthroscopic rotator cuff repair. Patients were randomized 1:1 into bupivacaine alone (25 cc of 0.5% bupivacaine) or liposomal combination (133 mg [10 mL] liposomal bupivacaine plus 15 cc 0.5% bupivacaine), with daily morphine milligram equivalents (MME) and visual analog scale (VAS) scores tracked for 14 days.
  • Analgesic & Opioid Metrics: On postoperative day 2, the liposomal bupivacaine group consumed lower MMEs (0.0 [0.0 to 7.5] versus 0.0 [0.0 to 15.0]; P = 0.04) and demonstrated lower VAS scores (4.8 ± 3.0 versus 6.0 ± 2.8; P = 0.03). However, no differences were observed on other days, and total 14-day MME consumption was low across both cohorts (median MME 35.6 [7.5 to 88.1] or 5 [1 to 12] oxycodone pills).
Recommendation & Practice Takeaway

Clinical Pearl: Although liposomal bupivacaine produced statistically lower VAS scores and less opioid consumption on postoperative day 2, the absolute difference was modest, equivalent to one oxycodone tablet, and did not achieve the minimal clinically important difference. With low overall narcotic consumption in both groups across the first 2 weeks, standard bupivacaine remains cost-effective and clinically sufficient for routine outpatient rotator cuff repair.

Level I Shoulder and Elbow

2. Surgical Time Is More Predictive of Suture Contamination During Arthroscopic Rotator Cuff Repair Compared With Skin-Preparation Method: A Prospective Randomized Study on Male Patients.

Authors: Kamijo H, Matsuki K, Takahashi N, Hoshika S, Matsuba T et al. | Journal: Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association (Nov 2026) | View Source / DOI

Situation

Prospective randomized trial comparing 3 skin preparation antiseptics and assessing surgical factors associated with suture contamination during arthroscopic rotator cuff repair in male patients.

Background

Cutibacterium acnes resides deep within sebaceous glands of the shoulder girdle and is frequently implicated in postoperative shoulder infection. Determining whether skin antiseptic selection or operative duration dictates suture contamination helps optimize perioperative infection prevention protocols.

Assessment & Findings
  • Study Design & Cohort: Prospective randomized trial of 150 male patients undergoing rotator cuff repair between July 2021 and October 2022, randomly assigned to 1 of 3 antiseptic groups: povidone-iodine (P), alcohol-containing povidone-iodine (AP), or olanexidine gluconate (O). Surgeons were categorized into 3 duration groups based on preliminary operating times, and cut sutures following medial knot tying were cultured for up to 3 weeks.
  • Microbiological & Structural Findings: C. acnes was detected in 92 shoulders (61%) and miscellaneous bacteria in 34 shoulders (23%), predominantly coagulase-negative Staphylococcus. No differences in C. acnes rates were observed between antiseptics. Overall bacterial contamination was significantly higher with olanexidine than alcohol-containing povidone-iodine (odds ratio, 3.82; P = 0.013). Shorter surgical duration and shorter suture exposure times directly correlated with lower contamination rates, whereas contamination showed no relation to repair retear on magnetic resonance imaging.
Recommendation & Practice Takeaway

Clinical Pearl: C. acnes remains the predominant contaminant during shoulder arthroscopy, and skin antiseptic choice alone does not eliminate bacterial recovery. Minimizing operating room time and suture exposure duration represents the most impactful modifiable factor to reduce intraoperative suture contamination, with alcohol-containing povidone-iodine performing favorably over olanexidine.

Level II Shoulder and Elbow

3. Preoperative Shoulder Stiffness Was Accompanied by Distinct Supraspinatus Tendon Inflammatory Signatures but Not Inferior Long-term Outcomes After Rotator Cuff Repair.

Authors: Liu M, Cai H, Tang C, Luo J, Wang X et al. | Journal: Clinical orthopaedics and related research (Nov 2026) | View Source / DOI

Situation

Prospective observational cohort investigation evaluating whether concomitant preoperative shoulder stiffness alters functional outcome improvement trajectories, achievement of minimum clinically important differences (MCID), or biological inflammatory signatures in torn supraspinatus tendons after arthroscopic repair.

Background

Rotator cuff tears presenting with concomitant shoulder stiffness create a therapeutic dilemma, as aggressive mobilization to regain motion may conflict with immobilization strategies designed to protect tendon healing. Clarifying longitudinal recovery patterns and underlying tendon biology helps guide operative timing and patient counseling.

Assessment & Findings
  • Study Design & Cohort: Prospective observational cohort study evaluating 474 patients screened between March 2020 and December 2023 with full-thickness supraspinatus tears measuring 3 cm or less. Overall, 186 patients met strict criteria (mean age 62 ± 7 years, mean BMI 24.1 ± 2.8 kg/m 2 , 68% women [127 of 186]) and were stratified into stiffness (92 patients) or non-stiffness (94 patients) groups based on passive motion under 120° forward flexion, under 30° external rotation, or internal rotation below L3. Final analysis included 151 patients (75 with stiffness, 76 without) at 24 months, with clinical scores evaluated alongside intraoperative tendon histology (Bonar score) and bulk RNA sequencing.
  • Clinical & Biological Outcomes: At 3 months, a greater proportion of patients with stiffness achieved MCID for CMS (43% [32 of 75] versus 13% [10 of 76], OR 4.9 [95% CI 2.2 to 11.0]; p < 0.001) and OSS (59% [44 of 75] versus 21% [16 of 76], OR 5.3 [95% CI 2.6 to 10.9]; p < 0.001). At 24 months, MCID achievement for CMS was 100% (75 of 75) in the stiffness group versus 83% (63 of 76) without stiffness (OR 32.1 [95% CI 1.9 to 550.8]; p < 0.001), with longitudinal trajectory differences resolving after adjusting for baseline score (p = 0.63). Tendon analysis in the stiffness cohort revealed 254 upregulated and 554 downregulated genes, enriched inflammatory tendinopathy signatures (NES 2.6; adjusted p < 0.01), and higher Bonar inflammation scores.
Recommendation & Practice Takeaway

Clinical Pearl: Concomitant preoperative shoulder stiffness is characterized by distinct inflammatory tendon signatures but does not compromise long-term functional recovery or structural tendon healing after arthroscopic cuff repair. Surgeons can reassure stiff patients that substantial clinically meaningful improvement is reliably achieved, avoiding unnecessary operative delays for prolonged preoperative physical therapy.

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.