Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair

Hyaluronate Acid Plus Platelet-Rich Plasma Is Superior to Steroids for Pain Relief Less Than 6 Months Using Injection Therapy of Partial Rotator Cuff Tears: A Systematic Review and Network Meta-analysis

PURPOSE

To compare the efficacy of steroid injections to other injectable therapies in partial-thickness rotator cuff (RC) tears.

METHODS

A systematic literature search was performed until October 25, 2021, in 3 databases (Cochrane Central Register of Controlled Trials, Embase, MEDLINE). Eligible studies compared the efficacy of steroid, hyaluronic acid (HA), platelet-rich plasma (PRP), the combination of HA and PRP (HA + PRP), and adipose-derived regenerative cells in RC tears. The primary outcomes were the visual analog scale (VAS), Constant-Murley Shoulder Outcome Score (CMS) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. Using paired and network meta-analysis, we calculated pooled mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

We included a total of 7 articles in the quantitative synthesis. In shorter periods, the HA + PRP combination was superior to the other substances we investigated (HA + PRP: VAS [0-4 weeks]: MD: -0.99 [95% CI, -1.62 to -0.36]; CMS [0-3 months]: 20.56 [95% CI, 16.18 to 24.94]. This combination was followed by the use of HA or PRP alone, depending on the duration of follow-up and the outcome being studied. In our study, short-term results suggest that saline is superior to steroids for partial tears, but this trend is reversed at 6-month follow-up.

CONCLUSIONS

The HA and PRP combination is currently the most effective in partial RC tear treatment in the short term. After 6 months, there is no meaningful difference, so the benefits of the combination are short term.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of Level I and II studies.

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy

OBJECTIVE

Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair.

METHODS

Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables.

RESULTS

Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk.

CONCLUSION

The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Partial-Thickness Rotator Cuff Tears: Current Concepts

» Partial-thickness rotator cuff tears (PTRCTs) are a common pathology with a likely high asymptomatic incidence rate, particularly in the overhead athlete.» The anatomy, 5-layer histology, and relationship to Ellman's classification of PTRCTs have been well studied, with recent interest in radiographic predictors such as the critical shoulder angle and acromial index.» Depending on the definition of tear progression, rates of PTRCT progression range from 4% to 44% and appear related to symptomatology and work/activity level.» Nearly all PTRCTs should be managed conservatively initially, particularly in overhead athletes, with those that fail nonoperative management undergoing arthroscopic debridement ± acromioplasty if <50% thickness or arthroscopic conversion repair or in situ repair if >50% thickness.» Augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust body of supportive data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments require more rigorous studies before regular usage.

Judicious use of corticosteroid injections prior to shoulder arthroplasty does not compromise outcomes at a minimum of 2 years following surgery

BACKGROUND

The use of total shoulder arthroplasty is continuing to rise with its expanding indications. For patients with chronic conditions, such as glenohumeral arthritis and rotator cuff arthropathy, nonoperative treatment is typically done prior to arthroplasty and often includes corticosteroid injections (CSIs). Recent studies in the shoulder arthroplasty literature as well as applied from the hip and knee literature have focused on the risk of periprosthetic infection. Literature is lacking as to whether the judicious use of corticosteroids in the year prior to arthroplasty influences patient-reported outcomes (PROs). The purpose of this study was to determine if preoperative CSIs prior to shoulder arthroplasty affected 2-year PROs.

METHODS

Retrospective review of anatomic and reverse total shoulder arthroplasty (RSA) patients (n = 230) was performed at a single institution including multiple surgeons. Patients were included if they had preoperative and a minimum of 2-year postoperative PROs, including: American Shoulder and Elbow Surgeons (ASES), visual analog scale, Single Assessment Numeric Evaluation, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score. Patients were included in the injection group if they had received an injection, either glenohumeral or subacromial, within 12 months prior to arthroplasty (inject = 134). Subgroup analysis included anatomic (total shoulder arthroplasty [TSA] = 92) and RSA (RSA = 138) as well as those with no injection within 12 months prior to surgery. An analysis of variance was used to compare outcomes between patients who received an injection and those who did not prior to TSA and RSA.

RESULTS

There were 230 patients included with 134 patients in the injection group and 96 in the no injection group. Patients who received an injection in the year prior to arthroplasty displayed a significantly higher ASES (82 [16.23 standard deviation] vs. 76 [19.43 standard deviation], P < .01) and Single Assessment Numeric Evaluation (70 [24.49 standard deviation] vs. 63 [29.22 standard deviation], P < .01) scores vs. those who had not received injection. There was no difference when comparing preoperative injection vs. no injection in patients undergoing TSA. Those patients undergoing RSA displayed significantly higher ASES scores (P < .01). There were no significant differences in visual analog scale, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score among any analysis (P > .05), and the minimal clinically important difference in ASES was not different between groups (P.09).

CONCLUSION

CSIs within 12 months prior to anatomic and RSA do not compromise PROs during a minimum of 2-year follow-up. Although more complications occurred in the injection group, it did not reach statistical significance and warrants further study in a larger population.

Editorial Commentary: Corticosteroid Injections Administered Within 4 Weeks Before Shoulder Arthroscopy Are Associated With an Increased Risk of Infection

Corticosteroid injections are a frequently used modality for addressing shoulder pain. The widespread utilization of corticosteroid injections is supported by clinical practice guidelines and consensus statements including the 2019 American Academy for Orthopaedic Surgeons (AAOS) guidelines for the management of rotator cuff injuries. However, steroids may be detrimental to healing potential following cuff repair and increase the risk of re-tear. In addition, corticosteroid injections administered within 4 weeks prior to shoulder arthroscopy are associated with an increased risk of infection. The degree of risk is dependent on the timing of surgery with longer time intervals between injection and shoulder arthroscopy being associated with less risk. The next version of the AAOS clinical practice guidelines for managing rotator cuff tears should incorporate commentary on the specific risk of surgical site infection following pre-operative corticosteroid injections, as well as on the timing of injections, with the aim of increasing awareness of these potentially devastating adverse effects.

Three-month Delay in Rotator Cuff Repair: 2-year Follow-up

INTRODUCTION

This study examined 2-year outcomes of patients who underwent delayed rotator cuff repair (RCR) compared with those who underwent RCR without delay.

METHODS

In this prospective comparative study, two groups were formed: (1) patients planning RCR during a 6-week elective surgery ban and (2) patients undergoing RCR at least 6 weeks after the ban. The Simple Shoulder Test, American Shoulder and Elbow Surgeon score, and visual analog scale for pain were collected preoperatively and at 2 years postoperatively. Magnetic resonance imaging assessed healing 6 months postoperatively.

RESULTS

With a 93.3% 2-year follow-up (13/15 delay group, 15/15 control), there was an 87-day difference in presentation to surgery (P = 0.001), with no significant preoperative demographic or tear characteristic differences between groups. Intraoperatively, there were no differences between groups in repair characteristics. Preoperative versus postoperative differences in American Shoulder and Elbow Surgeon score (P < 0.001), visual analog scale (P < 0.001), and Simple Shoulder Test scores (P < 0.001) were significant but not between groups (P = 0.650, 0.586, 0.525). On MRI, 58% in the delay group and 85% in the control group had healed (P = 0.202).

DISCUSSION

Although a 3-month delay showed no statistically significant effect on outcomes, the delay group had an approximately 27% higher failure rate. Thus, although a 3-month period of nonsurgical treatment before RCR may be reasonable, larger studies are warranted for definitive conclusions.

Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair

Background

Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI.

Methods

An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05).

Results

There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05).

Conclusion

Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.

Ultrasound-guided bursal injections

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections

BACKGROUND

Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair.

PURPOSE

To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes-including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness-were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9.

RESULTS

Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy.

CONCLUSION

No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.

Editorial Commentary: Platelet-Rich Plasma May Be Superior to Corticosteroid Injection for Rotator Cuff Disease Because of Improved Chance of Healing, Longer-Lasting Pain Relief, and No Detriment if Surgery Is Needed

Both corticosteroid and platelet-rich plasma (PRP) injections have benefits for patients with rotator cuff tendinopathy. Currently, the published clinical differences are small, and statistical differences aren't as significant without a clinical difference, so the answer is personal. PRP is expensive, but rotator cuff healing is possible, resulting in the best chance to avoid surgery. And, if surgery is required, PRP results in no detriment, unlike corticosteroid. PRP may result in lasting pain relief. Based on the current literature, we prefer PRP despite the cost.

When Is It Safe to Operate After Therapeutic Carpal Tunnel Injections?

BACKGROUND

Recent studies suggest increased complications when surgery closely follows corticosteroid injection. The purpose of this study was to understand the occurrence of surgical site infection (SSI), wound complications, and reoperation rates after carpal tunnel release (CTR) when corticosteroid injections were given within 180 days preoperatively.

METHODS

Data were collected from the Truven MarketScan database from 2009 to 2018. Cohorts were created based on preoperative timing of injection (<30, 30-60, 61-90, 91-180 days) and number of injections (0, 1, 2, 3+). Logistic regression was performed to assess the contribution of preoperative injections on 90-day surgical site complications and 1-year reoperation while controlling for demographics and comorbidities.

RESULTS

Overall, 223 899 patients underwent CTR. Of these, 17 391 (7.76%) had a preoperative injection in the 180 days preceding surgery. Univariate analysis demonstrated a relationship between timing of injections and noninfectious wound complications (P = .006) and rate of 1-year reoperation (P = .045). Univariate analysis demonstrated a relationship between number of injections and 1-year reoperation (P < .001). On multivariate analysis, those receiving injections within 30 days preoperatively had increased rates of SSI (P = .034) and noninfectious wound complications (P = .006) compared with those with no injection or at other time points. Patients with 2 (P = .002) or 3 or more injections (P < .001) in the 180-day preoperative period had increased odds of 1-year reoperation.

CONCLUSION

Our study suggests increased risk of SSI, wound complications, and 1-year reoperation when corticosteroid injections are administered in the 30-day preoperative period. In addition, multiple steroid injections may increase the risk of 1-year reoperation.

Risk Analysis of Perioperative Injections in Arthroscopic Reconstruction of the Rotator Cuff of the Shoulder - A Systematic Review

BACKGROUND

The present study used a systematic review to analyse the risk of perioperative injections during arthroscopic reconstruction of the rotator cuff of the shoulder. The questions of interest were whether perioperative local injection increases the infection risk and whether the number of postoperative revisions is increased.

MATERIAL AND METHODS

A systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) database and the Cochrane Library was performed using the PRISMA checklist. The keywords used were "shoulder" and "arthroscopy" and "injection" and "risk". In the course of the study, work that was not also primarily concerned with the reconstruction of the rotator cuff was excluded. English original articles and case series were included that contained at least some arthroscopic reconstructions of the rotator cuff. The risk of bias was determined using the Newcastle-Ottawa Scale. The content of the articles relevant to the research questions was analysed.

RESULTS

48 hits were primarily generated. 9 articles corresponded to the inclusion criteria and were analysed. In the 6 studies with details on the injected substances, cortisone was used in 98 - 100% of the cases. The reported infection and revision rates based on insurance data were higher with injection than without. The risk of bias in the studies analysed here was rather low based on the Newcastle-Ottawa Score. The risk of infection after a cortisone injection before, during or after surgery was increased. Injection was associated with infection in up to 8% of cases with injections within two weeks of surgery. The risk of infection was increased by up to 11 times with injections within 4 weeks after the operation. Likewise, the risk of revision surgery after injection was increased, with the time intervals between injection and surgery sometimes differing between studies.

DISCUSSION

Local infections and to a lesser extent revision surgery are associated with perioperative injections (with cortisone) within 3 months preoperatively and 4 weeks postoperatively. However, there were only database studies of insurance data with several studies from a few centres. Thus, no causal relationships could be proven. Currently, however, the following can be recommended using a cautious approach: The interval between injection with cortisone before surgery should be at least 2 weeks, better 3 months. No cortisone injections should be applied intraoperatively. Postoperatively, cortisone should not be injected for at least 4 weeks. If, in exceptional cases, deviations from these time limits are required, patients should be informed about an increased risk of complications.

Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment

Purpose

To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.

Methods

The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ² tests, and Fisher exact tests were used with an α level of .05 set as significant.

Results

We identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group.

Conclusions

Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.

Level of Evidence

Level III, retrospective cohort study.

The Effect of Sex Hormone Deficiency on the Incidence of Rotator Cuff Repair: Analysis of a Large Insurance Database

BACKGROUND

The purpose of the present study was to analyze the association between sex hormone deficiency and rotator cuff repair (RCR) with use of data from a large United States insurance database.

METHODS

A retrospective analysis of insured subjects from the Truven Health MarketScan database was conducted, collecting data for RCR cases as well as controls matched for age, sex, and years in the database. Multivariable logistic regression models adjusted for matching variables were utilized to compare RCR status with estrogen deficiency status and testosterone deficiency status. These associations were confirmed with use of data from the Veterans Genealogy Project database, with which the relative risk of RCR was estimated for patients with and without sex hormone deficiency.

RESULTS

The odds of RCR for female patients with estrogen deficiency were 48% higher (odds ratio, 1.48; 95% confidence interval, 1.44 to 1.51; p < 0.001) than for those without estrogen deficiency. The odds of RCR for males with testosterone deficiency were 89% higher (odds ratio, 1.89; 95% confidence interval, 1.82 to 1.96; p < 0.001) than for those without testosterone deficiency. Within the Veterans Genealogy Project database, the relative risk of estrogen deficiency among RCR patients was 2.58 (95% confidence interval, 2.15 to 3.06; p < 0.001) and the relative risk of testosterone deficiency was 3.05 (95% confidence interval, 2.67 to 3.47; p < 0.001).

CONCLUSIONS

Sex hormone deficiency was significantly associated with RCR. Future prospective studies will be necessary to understand the pathophysiology of rotator cuff disease as it relates to sex hormones.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Positive Correlation between Steroid Injections and Cuff Tendon Tears: A Cohort Study Using a Clinical Database

This cohort study aimed to investigate the association between steroid injections for shoulder diseases and the increased incidence of cuff tendon tears. The Kaohsiung Veterans General Hospital clinical database was used in this study. Patients were enrolled using the corresponding diagnostic codes for shoulder diseases. Patients who received steroid injections were included in the case group, and those without steroid injections were included in the control group. The outcome measure was the occurrence of cuff tendon tears during the study period. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis adjusted for sex, age, and comorbidities. Of the 1025 patients with shoulder disease, 205 were in the case group and 820 were in the control group. The incidence of cuff tendon tears was 9.8% in patients who received steroid injections (p < 0.001). The adjusted hazard ratios for steroid injections, smoking, and chronic liver disease were 7.44 (p < 0.001), 2.40 (p = 0.046), 3.25 (p = 0.007), respectively. Steroid injections on the shoulder were associated with a raised risk of cuff tendon tears by 7.44 times compared to non-injection. The incidence of cuff tendon tears increased by 3.25 times with concurrent chronic liver disease and by 2.4 times with smoking.

Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review

Purpose

To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects.

Methods

A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications.

Results

Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month.

Conclusions

Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events.

Level of Evidence

Systematic review of level I-IV studies.

Management of Acute Rotator Cuff Tears

Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Background

Preoperative opioid use has been shown to be a negative predictor of patient outcomes, complication rates, and resource utilization in a variety of different orthopaedic procedures. To date, there are no studies investigating its effect on outcomes after hip arthroscopy in the setting of femoroacetabular impingement (FAI).

Purpose

To determine the association of preoperative opioid use with postoperative outcomes after hip arthroscopy in patients with FAI.

Study Design

Cohort study; Level of evidence, 3.

Methods

The Truven Health MarketScan Commercial Claims and Encounters Database was queried for all patients who underwent hip arthroscopy for FAI between 2011 and 2018. Opioid prescriptions filled in the 6 months preceding surgery were queried, and the average daily oral morphine equivalents (OMEs) in this period were computed for each patient. Patients were divided into 4 cohorts: opioid naïve, <1 OME per day, 1 to 5 OMEs per day, and >5 OMEs per day. Postoperative 90-day complications, health care utilization, perioperative costs, postoperative opioid use, and 1- and 3-year revision rates were then compared among cohorts.

Results

A total of 22,124 patients were ultimately included in this study; 31.2% of these patients were prescribed opioids preoperatively. Overall, the percentage of preoperative opioid-naïve patients increased from 64.5% in 2011 to 78.9% in 2018. Patients who received preoperative opioids had a higher rate of complications, increased resource utilization, and increased revision rates. Specifically, on multivariate analysis, patients taking >5 OMEs per day (compared with patients who were preoperatively opioid naïve) had increased odds of a postoperative emergency department visit (Odds Ratio, 2.23; 95% confidence interval [CI], 1.94-2.56; P < .001), 90-day readmission (OR, 2.25; 95% CI, 1.77-2.87; P < .001), increased acute postoperative opioid use (OR, 25.56; 95% CI, 22.98-28.43; P < .001), prolonged opioid use (OR, 10.45; 95% CI, 8.92-12.25; P < .001), and 3-year revision surgery (OR, 2.14; 95% CI, 1.36-3.36; P < .001). Perioperative adjusted costs were increased for all preoperative opioid users and were highest for the >5 OMEs per day cohort ($6255; 95% CI, $5143-$7368).

Conclusion

A large number of patients with FAI are prescribed opioids before undergoing hip arthroscopy, and use of these pain medications is associated with increased health care utilization, increased costs, prolonged opioid use, and early revision surgery.

The Association of Preoperative Opioid Use With Revision Surgery and Complications Following Carpometacarpal Arthroplasty

PURPOSE

Preoperative opioid use has been shown to be associated with poor outcomes following different upper-extremity surgeries. We aimed to examine the relationship between preoperative opioid use and outcomes following carpometacarpal (CMC) arthroplasty. We hypothesized that patients prescribed higher daily average numbers of preoperative oral morphine equivalents (OMEs) would show higher rates of complications and revision surgery.

METHODS

In the Truven Health MarketScan Database, we identified all patients who underwent CMC arthroplasty from 2009 to 2018. We separated them into cohorts based on average daily OMEs prescribed in the 6 months prior to the surgery: opioid naïve, <2.5, 2.5 to 5, 5 to 10, and >10 OMEs per day. We retrieved 90-day complications and 3-year revision surgery data, and we compared these outcomes by opioid-use groups.

RESULTS

We identified 40,141 patients. The majority (55.9%) were opioid naïve, with the next most common group receiving a daily average of <2.5 OMEs (19.2%). Complications increased with increased preoperative OMEs. Multivariable analysis revealed that patients taking >10 OMEs per day had a 1.45% increase in 3-year revision surgery compared with opioid-naïve patients, which equated to 2.12 (confidence interval [CI]: 1.33-3.36) times increased odds. Additionally, patients taking >10 OMEs had increased odds of an emergency department visit (odds ratio [OR]: 1.60, CI: 1.43-1.78), a 90-day hospital admission (OR: 2.34, CI: 1.97-2.79), and surgical site infection (OR, 2.02, CI: 1.59-2.54) compared with opioid-naïve patients, with absolute differences of 4.53%, 2.78%, and 1.22% compared with opioid-naïve patients, respectively. Additionally, preoperative opioid use predicted both number of prescriptions filled in the short term and long term continued opioid use.

CONCLUSIONS

Preoperative opioid use of >10 OMEs per day is associated with a higher risk for complications and revision surgery following CMC arthroplasty. Our findings demonstrate a dose-dependent relationship between opioid use and postoperative complications. Further study is necessary to determine if reducing opioid use prior to CMC arthroplasty may reduce the likelihood of these negative outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

COVID-19-related rotator cuff repair delay

Background

Although nonoperative treatment is effective for degenerative rotator cuff tears (RCTs), it remains unclear whether the delay created by a trial of nonoperative treatment negatively influences the outcome of a subsequent surgical repair. In March 2020, the COVID-19 pandemic resulted in an involuntary delay in the surgical treatment of rotator cuff disease, creating a natural experiment. The purpose of this study was to evaluate the outcomes and healing of patients who underwent delayed surgical treatment of chronic degenerative RCTs as compared with the nondelayed surgical treatment of RCTs.

Methods

This was a prospective study of two groups: patients planned to undergo arthroscopic rotator cuff repair between March 16, 2020 and May 1, 2020-the end of the ban on elective surgery-and patients who underwent rotator cuff repair starting six weeks after the ban on elective surgery had been lifted. Preoperatively and at six months postoperatively, we collected the Simple Shoulder Test, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale for pain. We also obtained magnetic resonance imaging (MRI) at six months postoperatively. A power analysis was conducted, and assuming a mean ± standard deviation ASES score of 93.1 ± 13.9 points and a minimum clinically important difference in the ASES score of 27.1 points, 7 patients per group (14 patients in total) would be necessary to have 90% chance of finding a difference.

Results

We included 15 patients within each group and obtained 100% follow-up at six months. In the delay group, the mean ± standard deviation delay was 63 ± 24 days. There were no significant preoperative differences between groups in demographics or tear characteristics. Intraoperatively, there were no differences between groups in repair characteristics. Using a repeated-measures analysis of variance, there were significant preoperative vs. postoperative differences in ASES scores (P < .001), visual analog scale scores (P < .001), and Simple Shoulder Test scores (P < .001), but no differences between groups (P = .910, .519, and 0.852, respectively). On MRI, within the delay group, 58% had healed, whereas within the control group, 85% had healed (P = .202).

Conclusion

COVID-19 caused a two-month delay in the operative treatment of RCTs. This delay did not significantly alter patient-reported outcomes. This delay resulted in a 27% difference in MRI healing rates, which was not statistically significant in this small study. Larger studies should be conducted as our results suggest that a delay in treatment may negatively impact healing rates.

Increased nerve growth factor expression in the synovial tissues of patients with rotator cuff tears

Background

Rotator cuff tears (RCTs) are often associated with severe shoulder pain. Non-steroidal anti-inflammatory drugs, not recommended for long-term use, do not effectively manage RCT-induced pain, resulting in reduced quality of life. To improve management, a better understanding of the fundamental properties of RCT pain is needed. Here, we aimed to compare the expression levels of nerve growth factor (NGF) and cyclooxygenase-2 (COX-2) mRNA in the synovial tissues of patients with RCT-induced pain and patients with non-painful recurrent shoulder dislocation (RSD).

Methods

The study included 32 patients with RCT who underwent arthroscopic rotator cuff repair and 28 patients with non-painful RSD who underwent arthroscopic Bankart repair. Synovial tissue samples were harvested from subacromial bursa and rotator interval of RCT patients and from the rotator interval of RSD patients. Samples were analyzed quantitatively expression levels for NGF and COX2 mRNA and NGF protein.

Results

NGF mRNA and protein levels were significantly higher in the rotator interval of RCT patients than in the rotator interval of RSD patients (p = 0.0017, p = 0.012, respectively), while COX2 mRNA levels did not differ significantly between the two patient groups. In RCT patients, COX2 mRNA was more highly expressed in the rotator interval than in the subacromial bursa (p = 0.038), whereas the mRNA and protein levels of NGF did not differ between the two tissues. The expression of NGF mRNA in the synovium of the rotator interval was significantly correlated with the numeric rating scale of pain (ρ = 0.38, p = 0.004).

Conclusion

NGF mRNA and protein levels were elevated in patients with painful RCT compared with those in patients with non-painful RSD, whereas COX-2 levels were comparable in the two patient groups. These findings provide insights into novel potential strategies for clinical management of RCT.

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures

PURPOSE

To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures.

METHODS

Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016.

RESULTS

In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001).

CONCLUSIONS

The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

Administrative Databases Used for Sports Medicine Research Demonstrate Significant Differences in Underlying Patient Demographics and Resulting Surgical Trends

PURPOSE

To discern differences between the PearlDiver and MarketScan databases with regards to patient demographics, costs, reoperations, and complication rates for isolated meniscectomy.

METHODS

We queried the PearlDiver Humana Patient Records Database and the IBM MarketScan Commercial Claims and Encounters database for all patients who had record of meniscectomy denoted by Current Procedure Terminology 29880 or 29881 between January 1, 2007, and December 31, 2016. Those that had any other knee procedure at the same time as the meniscectomy were excluded, and the first instance of isolated meniscectomy was recorded. Patient demographics, Charlson Comorbidity Index, reoperations, 30- and 90-day complication rates, and costs were collected from both databases. Pearson's χ² test with Yate's continuity correction and the Student t test were used to compare the 2 databases, and an alpha value of 0.05 was set as significant.

RESULTS

We identified 441,147 patients with isolated meniscectomy from the MarketScan database (0.36% of total database), approximately 10 times the number of patients (n = 49,924; 0.20% of total database) identified from PearlDiver. The PearlDiver population was significantly older (median age: 65-69) than the MarketScan cohort, where all patients were younger than 65 (median age: 52; P < .001). Average Charlson Comorbidity Index was significantly lower for MarketScan (0.172, standard deviation [SD]: 0.546) compared with PearlDiver (1.43, SD: 2.05; P < .001), even when we restricted the PearlDiver cohort to patients younger than 65 years (1.02, SD: 1.74; P < .001). The PearlDiver <65 years subcohort also had increased 30- (relative risk 1.53 [1.40-1.67]) and 90-day (relative risk 1.56 [1.47-1.66]) postoperative complications compared with MarketScan. Overall, laterality coding was more prevalent in the PearlDiver database.

CONCLUSIONS

For those undergoing isolated meniscectomy, the MarketScan database comprised an overall larger and younger cohort of patients with fewer comorbidities, even when examining only subjects younger than 65 years of age.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears

BACKGROUND

Factors affecting a rotator cuff symptomatic retear after arthroscopic repair have yet to be clearly identified, since they usually influence the surgical decisions.

METHODS

Consecutive patients with full-thickness tear of the supraspinatus who underwent arthroscopic repair were retrospectively analyzed. Cases of symptomatic retear, defined as Sugaya type IV and V on magnetic resonance imaging, associated with intensive pain and/or functional impairment were identified at follow-up. The patients with no symptomatic retear were selected as the control group. Information from potential risk factors of symptomatic retear, including depression and subacromial corticosteroid injections, was extracted from the medical records. The statistical analysis included multivariant logistic regression.

RESULTS

The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration. They also had had more frequently subacromial corticosteroid injections and depression. However, following the multiple logistic regression analysis, only massive tears and moderate to severe fatty infiltration remained significantly associated. Similarly, in relation to the study hypothesis, both corticosteroid injections (odds ratio [OR] 6.66, 95% confidence interval [CI] 1.49, 29.81; P = .013) and depression (OR 8.26, IC 1.04, 65.62; P = .046) were significantly associated with symptomatic retear risk.

CONCLUSIONS

This study found support for the hypothesis that both depression and corticosteroid infiltration before surgery are independent risk factors for symptomatic retear after arthroscopic repair of rotator cuff.

The Simplified Science of Corticosteroids for Clinicians

Clinicians should be aware of the differences in corticosteroid formulations as these differences dictate which agent is best in various clinical situations. Corticosteroids work primarily by modulating transcriptional, post-transcriptional, and post-translational mechanisms within cellular nuclei to decrease the production of inflammatory mediators. Because this process requires change at the cellular level, clinical effects typically take days. The main consideration when selecting a corticosteroid is solubility. Less-soluble agents have a longer onset of action and a longer duration. However, they can have negative side effects on soft-tissue structures. They are ideal for intra-articular use. More-soluble agents have a faster onset of action but are rapidly cleared. They are ideal for extra-articular soft-tissue structures. Fluorinated compounds have decreased solubility, which further increases duration of action, but they have been shown to be associated with tendon rupture and atrophy.

Preoperative Opioid Use Is a Risk Factor for Revision Surgery, Complications, and Increased Resource Utilization After Arthroscopic Rotator Cuff Repair

BACKGROUND

Studies have shown preoperative opioid use to influence outcomes after various surgical procedures. Researchers have not assessed this relationship after rotator cuff repair (RCR).

HYPOTHESIS/PURPOSE

The purpose was to assess the relationship between preoperative opioid use and outcomes after arthroscopic RCR. We hypothesized that patients prescribed higher daily averages of preoperative oral morphine equivalents (OMEs) would show increased rates of 90-day complications and 3-year revision surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The MarketScan claims database was utilized to identify patients who underwent arthroscopic RCR between 2009 and 2018. We used preoperative opioid use status to divide patients into groups based on the average daily OMEs consumed in the 6 months before surgery: opioid-naïve, <1, 1-<5, 5-<10, and ≥10 OMEs per day. We retrieved 90-day complication and 3-year revision surgery rates. Opioid use groups were then compared with binomial logistic regression and generalized linear models.

RESULTS

We identified 214,283 patients. Of those patients, 50.7% did not receive any preoperative opioids, while 7.7%, 26.8%, 6.3%, and 8.6% received <1, 1-<5, 5-<10, and ≥10 OMEs per day over a 6-month time period, respectively. Complications increased with increasing preoperative OMEs. Multivariate analysis revealed that any patient using ≥1 OME per day had increased rates of 3-year revision surgery, reoperations, and infections. Specifically, patients averaging ≥10 OMEs per day showed a 103% (odds ratio, 2.03 [95% CI, 1.62-2.54]; P < .001) increase in the odds of revision surgery compared with opioid-naïve patients. Rates of hospital admissions and postoperative emergency department encounters were higher in all opioid use groups. Adjusted differences in 6-month preoperative and 3-month postoperative health care costs were seen in the opioid use groups compared with opioid-naïve patients, ranging from US$1307 to US$5820 (P < .001).

CONCLUSION

Preoperative opioid use was a risk factor for complications and revision surgery after arthroscopic RCR. We also observed a dose-dependent response between opioid use and postoperative complications.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review

PURPOSE

To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs).

METHODS

A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies.

CONCLUSIONS

CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Factors Influencing the Reparability and Healing Rates of Rotator Cuff Tears

PURPOSE OF THE REVIEW

To discuss tear- and patient-related factors that influence the healing potential of rotator cuff tears and to clarify the terminology surrounding this topic.

RECENT FINDINGS

Over the last few years, further insight has been gained regarding rotator cuff tear features that are associated with poor healing rates after rotator cuff repair. Some of these features have been incorporated in prediction models developed to accurately predict rotator cuff healing rates utilizing preoperative risk factors weighted by importance. Rotator cuff tears may be considered functionally irreparable based on their size, chronicity, absence of adequate tendon length, atrophy, and fatty infiltration. Furthermore, advanced age, use of tobacco products, diabetes, and other patient-related factors may impair tendon healing. Careful analysis and discussion of all these factors with patients is essential to determine if surgical repair of a rotator cuff tear should be recommended, or if it is best to proceed with one of the several salvage procedures reviewed in this topical collection, including augmentation of the repair, superior capsular reconstruction, tendon transfers, and other.

Trans-coracoacromial Ligament Glenohumeral Injection With Arthroscopic Confirmation

PURPOSE

To arthroscopically evaluate the trans-coracoacromial ligament glenohumeral (GH) injection technique by understanding intra-articular needle-tip placement and potential misplacement and complications.

METHODS

The technique relies on the palpation of 3 bony landmarks: anterolateral corner of the acromion, superolateral border of the coracoid tip, and curved depression of the distal clavicle. The skin entry site lies on the line connecting the curved depression of the distal clavicle and superolateral border of the coracoid tip, two-thirds of the way from the former and one-third of the way from the latter. The direction of the needle is perpendicular to the triangle formed by the 3 bony landmarks. The technique is used to insufflate the GH joint at the start of shoulder arthroscopy procedures with patients in the beach-chair position. Saline solution is injected, and the position of the needle tip in the GH joint is evaluated arthroscopically. An injection is considered successful if saline solution can be injected and the needle tip can be visualized intra-articularly.

RESULTS

This study enrolled 195 patients undergoing shoulder arthroscopy. Successful needle placement in the GH joint occurred in 179 patients (91.8%); placement occurred through the rotator interval in 122 of these, adjacent or through the long head of the biceps tendon in 41, through the upper subscapularis or anterior supraspinatus in 13, and through the anterior labrum in 3. Regarding the 16 failures (8.2%), the needle position did not allow saline solution to be injected because of high resistance in 3 patients whereas the needle tip was not visualized in 13. The needle tip was presumed to rest within the subscapularis muscle or tendon or the labrum in 10 failed injections.

CONCLUSIONS

The trans-coracoacromial ligament injection technique showed a high success rate (91.8%) in anesthetized patients about to undergo arthroscopy, whereas the failed injections mainly occurred because the needle was inserted into the subscapularis or labrum. This technique can be used for awake patients with different diagnoses in multiple settings.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis

PURPOSE

To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed.

RESULTS

A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls.

CONCLUSIONS

The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR.

LEVEL OF EVIDENCE

Level III, systematic review of Level I and III studies.

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review

PURPOSE

To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR).

METHODS

A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon.

RESULTS

A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]).

CONCLUSION

Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months.

LEVEL OF EVIDENCE

IV, systematic review of Level III and IV studies.

Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair-Is It Time to Rethink a Conservative Treatment Paradigm?

The standard of care for most rotator cuff conditions over the past half century or longer has been a trial of nonoperative treatment including nonsteroidal anti-inflammatory agents, physiotherapy, and steroid injections prior to surgery. There is compelling basic science data to suggest a negative effect of corticosteroids on tissue quality. Chronicity of the tear is a risk factor for unsuccessful repair, but other factors including use of tobacco products, repair technique, and postoperative management all have an impact. Evidence either in favor of or against use of steroid injections as a treatment option is limited or weak at best. Given advances in rotator cuff repair techniques and successful long-term outcomes, treating surgeons should be mindful of how injections might affect surgical outcomes owing to either delayed surgical intervention or a direct effect on tissue quality.

Preoperative Shoulder Corticosteroid Injection Is Associated With Revision After Primary Rotator Cuff Repair

Rotator cuff surgery should be delayed in patients receiving frequent or recent shoulder steroid injections. That said, success rates after rotator cuff surgery are high, and injection is but one of a number of factors associated with retear after rotator cuff repair.