A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors

Increased patient resilience scores are related to positive postoperative outcomes in rotator cuff repairs

HYPOTHESIS

We sought to determine whether patients' preoperative resilience scores predict postoperative outcomes in arthroscopic rotator cuff repair surgery.

METHODS

Patients were prospectively enrolled and underwent data collection preoperatively and at 3, 6, 12, and 24 months postoperatively. Data collected included demographic characteristics and the Brief Resilience Scale (BRS) score, visual analog scale score, Veterans RAND 12-Item Health Survey scores (mental component [VR-12M] and physical component [VR-12P]), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numeric Evaluation score, and Simple Shoulder Test (SST) score.

RESULTS

In total, 131 patients had complete 1- or 2-year postoperative outcome measures. Female patients comprised 56.5% of our sample, and the average age was 57.6 years. Between the low, normal, and high resilience groups, there were significant differences in the VR-12M scores at 0, 12, and 24 months postoperatively (P < .01 for all). The VR-12P scores at 12 months were 44.2, 47.4, and 49.8 in the low, normal, and high resilience groups, respectively, showing a trend upward, but this failed to reach the level of significance (P = .08). The SST scores of the low, normal, and high resilience groups at 12 months were 69.1, 79.9, and 85.1, respectively, again showing a trend upward, but this failed to reach the level of significance (P = .07). The SST scores at 0 and 24 months did not differ between groups. There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores at 0, 12, or 24 months postoperatively. We found a significant positive correlation between the BRS score and SST score at 12 months (R = 0.18), VR-12M score at 12 months (R = 0.38), VR-12M score at 24 months (R = 0.31), and VR-12P score at 12 months (R = 0.21).

CONCLUSIONS

Our study provides evidence that BRS scores in patients undergoing arthroscopic rotator cuff repair are related to postoperative outcomes, measured through the VR-12M and SST scores at 2-year follow-up.

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design

INTRODUCTION AND PURPOSE

Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules.

RESULTS

After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration.

DISCUSSION

The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up.

CONCLUSION

CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

The impact of social deprivation on healthcare utilization patterns following rotator cuff repair

BACKGROUND

Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized.

METHODS

This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared.

RESULTS

A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients.

CONCLUSIONS

Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review

INTRODUCTION

Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment.

METHODS

The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023.

INCLUSION CRITERIA

RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs.

RESULTS

Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status.

DISCUSSION

An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL.

CONCLUSION

This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.

Influence of Pain Sensitivity on Surgical Outcomes of Arthroscopic Rotator Cuff Repair: A Prospective Cohort Study

BACKGROUND

The Pain Sensitivity Questionnaire (PSQ) has been found to be a valid tool, and PSQ scores have been shown to be predictive of outcomes after surgery for lumbar stenosis. The effect of pain sensitivity on outcomes of rotator cuff repair (RCR) surgery has not been examined.

HYPOTHESIS

PSQ scores would be associated with surgical outcomes after arthroscopic RCR surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients 18 to 80 years old scheduled for RCR were consecutively enrolled. Patients with glenohumeral arthritis grade ≥2 or RCR revision surgery were excluded. PSQ was completed preoperatively. The Disabilities of the Arm, Shoulder and Hand score and American Shoulder and Elbow Surgeons score were used as patient-reported outcome measurements (PROMs), and visual analog scale pain score was documented as well. Active shoulder external rotation (ER), internal rotation, and anterior forward elevation range of motion (ROM) were recorded. PROMs and ROM measurements were recorded preoperatively and at 3 months, 6 months, and 1 year after surgery. Rotator cuff tear size, type of repair, and concomitant procedures were documented. Patients were classified as having high or normal pain sensitivity based on PSQ scores.

RESULTS

Of 100 enrolled patients, 38 patients were classified as having high pain sensitivity. Patients with high pain sensitivity had worse American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder and Hand scores preoperatively, 6 months postoperatively, and 1 year postoperatively (P < .01). From the preoperative assessment to 3 months postoperatively, PROMs improved more in patients with high versus normal pain sensitivity. However, for patients with high pain sensitivity, PROMs plateaued after 3 months but continued to improve for patients with normal pain sensitivity (P < .01). Visual analog scale pain scores were higher at all time points for patients with high pain sensitivity (P < .05). Preoperatively, patients with high pain sensitivity had restricted active ROM compared with patients who had normal pain sensitivity for anterior forward elevation, ER, and internal rotation (P = .009, P = .012, and P = .006, respectively). By 1 year after surgery, ER ROM was still restricted in patients with high pain sensitivity.

CONCLUSION

Pain sensitivity is an important factor influencing RCR outcomes. Patients with high pain sensitivity undergoing RCR showed less improvement in active ROM and worse PROMs after surgery compared with patients who had normal pain sensitivity. Preoperative PSQ may predict postoperative improvements.

Associations between Preoperative Patient Socioeconomic Status and Pain-Related Outcomes with Pain and Function in Patients Undergoing Rotator Cuff Repairs

BACKGROUND

Patients undergoing rotator cuff repairs commonly experience postoperative pain and functional limitations. Various socioeconomic and pain-related factors have been recognized as influential in the prognosis of such patients. This study aims to investigate the associations between postoperative pain and functionality and preoperative pain-related outcomes and socioeconomic status in patients undergoing rotator cuff repairs.

METHODS

This cross-sectional study examines the relationship between the outcomes of rotator cuff repairs and participants' socioeconomic status and pain-related measures. Socioeconomic status was assessed through indicators such as educational level, monthly household income, and occupation. Pain-related outcomes included measures of kinesiophobia and pain self-efficacy.

RESULTS

A total of 105 patients (68 male, 37 female) were included in the analysis. The findings revealed no significant association between postoperative pain or functionality and the patients' socioeconomic status (p > 0.05). However, postoperative pain levels demonstrated a significant association with preoperative kinesiophobia (p < 0.05) and pain self-efficacy (p < 0.013). In contrast, functionality did not exhibit a significant association with these measures (p < 0.072 and 0.217, respectively).

CONCLUSIONS

Preoperative pain-related outcomes play a role in postoperative pain levels among patients undergoing rotator cuff repairs. However, they do not appear to be related to functionality. Additionally, socioeconomic status does not significantly impact either pain or functionality.

Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption

Purpose

To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR).

Methods

In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively.

Results

Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day.

Conclusions

No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study.

Level of Evidence

Level II, prospective cohort study.

One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon

Background

This study's purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS).

Methods

We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike's Information Criterion.

Results

518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement.

Conclusion

Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.

Female Sex and Higher Infraspinatus Fatty Infiltration Are Linked to Dissatisfaction at a Minimum Follow-Up of 4 Years after Arthroscopic Repair of Massive Rotator Cuff Tears

Purpose

To evaluate patient satisfaction at a minimum of 4 years after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCT), to identify preoperative and intraoperative characteristics associated with satisfaction, and to compare clinical outcomes between satisfied and dissatisfied patients.

Methods

A retrospective review on prospectively collected data was conducted on ARCRs of MRCTs performed at 2 institutions between January 2015 and December 2018. Patients with a minimum 4-year follow-up, preoperative and postoperative data, and primary ARCR of MRCTs were included for analysis. Patient satisfaction was analyzed according to patient demographics, patient-reported outcome measures (American Shoulder and Elbow Surgeons score [ASES], visual analog scale [VAS] for pain, Veteran Rands 12-item health survey [VR-12], and Subjective Shoulder Value [SSV]), range of motion (forward flexion [FF], external rotation [ER], and internal rotation [IR]), tear characteristics (fatty infiltration, tendon involvement, and tear size), and clinical significant measures (minimal clinical important difference [MCID], substantial clinical benefit [SCB], and patient-acceptable symptomatic state [PASS]) for ASES and SSV. Rotator cuff healing was also assessed with ultrasound in 38 patients at final follow-up.

Results

A total of 100 patients met the study's criteria. Overall, 89% of patients were satisfied with ARCR of a MRCT. Female sex (P = .007) and increased preoperative infraspinatus fatty infiltration (P = .005) were negatively associated with satisfaction. Those in the dissatisfied cohort had significantly lower postoperative ASES (80.7 vs 55.7; P = .002), VR-12 (49 vs 37.1; P = .002), and SSV scores (88.1 vs 56; P = .003), higher VAS pain (1.1 vs 4.1; P = .002) and lower postoperative range of motion in FF (147° vs 117°; P = .04), ER (46° vs 26°; P = .003), and IR (L2 vs L4; P = .04). Rotator cuff healing did not have an influence on patient satisfaction (P = .306). Satisfied patients were more likely to return to work than dissatisfied patients (97% vs 55%; P < .001).

Conclusions

Nearly 90% of patients who undergo ARCR for MRCTs are satisfied at a minimum 4-year follow-up. Negative preoperative factors include female sex and increased preoperative infraspinatus fatty infiltration, but no association was observed with rotator cuff healing. Furthermore, dissatisfied patients were less likely to report a clinically important functional improvement.

Level of Evidence

Level IV, prognostic case series.

Anxiety and Depressive Symptoms Correlated to Patient-Reported Outcome Measures after Rotator Cuff Repair: A Prospective Study in the Perioperative Period

Anxiety and depressive symptoms adversely affect surgical outcomes in patients with rotator cuff tear (RCT) undergoing surgical repair. Patients without a diagnosis of mood disorders, such as anxiety and depression, before rotator cuff repair (RCR) can be considered an optimal candidate for surgery. The objective of this prospective observational study was to evaluate the relationship between anxiety and depressive symptoms, using the Hospital Anxiety and Depression Scale (HADS) as an assessment tool, and patient-reported outcome measures in RCT after repair surgery. This study included patients with RCT undergoing arthroscopic rotator cuff repair (RCR). Forty-three patients were included who had completed the HADS, Constant Murley Score (CMS), and Short Form Health Survey 36 (SF-36) questionnaires before surgery and in the postoperative follow-up, at 1 month, 3 months, and 6 months. The Friedman test showed that there were statistically significant changes in the different times point for HADS (p < 0.001), anxiety subscale of HADS, i.e., HADS-A (p < 0.001), depression subscale of HADS, i.e., HADS-D (p < 0.001), CMS (p < 0.001), and SF-36 (p < 0.001). The average scores of HADS, HADS-A, and HADS-D improved at each follow-up, showing improvement in discomfort. From the third month after surgery, there was an improvement in anxiety and depression disorders related to improved quality of life, functionality, and pain perception. The trend remained stable until the sixth month of follow up. This study shows that anxiety and depressive symptoms in RCT patients are significantly reduced after RCR with subsequent important improvements in terms of functionality, ability to carry out activities of daily living, perceived pain, and quality of life.

Social determinants of health influence clinical outcomes of patients undergoing rotator cuff repair: a systematic review

BACKGROUND

Social determinants of health (SDOH) are the collection of environmental, institutional, and intrinsic conditions that may bias access to, and utilization of, health care across an individual's lifetime. The effects of SDOH are associated with disparities in patient-reported outcomes after hip and knee arthroplasty, but its impact on rotator cuff repair (RCR) is poorly understood. This study aimed to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following RCR.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and guidelines outlined by the Cochrane Collaboration. A search of PubMed, the Cochrane Library, and Embase from inception until March 2022 was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following RCR. The search term was created with reference to the PROGRESS-Plus framework. Methodological quality of included primary studies was appraised using the Newcastle-Ottawa Scale (NOS) for nonrandomized studies, and the Cochrane Risk of Bias Tool for randomized studies.

RESULTS

Thirty-two studies (level I-IV evidence) from 18 journals across 7 countries, published between 1999 and 2022, met inclusion criteria, including 102,372 patients, 669 physical therapy (PT) clinics, and 71 orthopedic surgery practices. Multivariate analysis revealed female gender, labor-intensive occupation and worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial or ethnic minority status, low-income place of residence and low-volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to health care and/or more severe disease state on presentation. Black race patients were found to have significantly worse postoperative clinical and patient-reported outcomes and experienced more pain following RCR. Furthermore, Black and Hispanic patients were more likely to present to low-volume surgeons and low-volume facilities. A lower education level was shown to be an independent predictor of poor surgical and patient-reported outcomes as well as increased pain and worse patient satisfaction. Patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes CONCLUSIONS: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.

Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair

PURPOSE

To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated.

RESULTS

In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01).

CONCLUSIONS

Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

In the Shoulder or in the Brain? Behavioral, Psychosocial and Cognitive Characteristics of Unilateral Chronic Shoulder Pain with Symptoms of Central Sensitization

The recognition of central sensitization (CS) is crucial, as it determines the results of rehabilitation. The aim of this study was to examine associations between CS and catastrophizing, functionality, disability, illness perceptions, kinesiophobia, anxiety, and depression in people with chronic shoulder pain (SP). In this cross-sectional study, 64 patients with unilateral chronic SP completed a few questionnaires including the Central Sensitization Inventory, the Oxford Shoulder Score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale, the Brief Illness Perception Questionnaire and the “arm endurance” test. On the basis of three constructed linear regression models, it was found that pain catastrophizing and depression (model 1: p < 0.001, R = 0.57, R2 = 0.33), functionality (model 2: p < 0.001, R = 0.50, R2 = 0.25), and helplessness (model 3: p < 0.001, R = 0.53, R2 = 0.28) were significant predictors for CS symptoms in chronic SP. Two additional logistic regression models also showed that depression (model 4: p < 0.001, Nagelkerke R2 = 0.43, overall correct prediction 87.5%) and functionality (model 5: p < 0.001, Nagelkerke R2 = 0.26, overall correct prediction 84.4%) can significantly predict the classification of chronic SP as centrally sensitized. Patients who were classified as centrally sensitized (n = 10) were found to have significantly worse functionality, psychological factors (anxiety, depression, kinesiophobia, catastrophizing), and pain intensity (p < 0.05). Catastrophizing, depression, and functionality are predictive factors of CS symptoms in patients with chronic shoulder pain. Health care providers should adopt a precision medicine approach during assessment and a holistic rehabilitation of patients with unilateral chronic SP.

Effects of Preexisting Depression and Anxiety on Postoperative Outcomes following Arthroscopic Rotator Cuff Repair

Background

Rotator cuff repairs (RCRs) are one of the most commonly performed shoulder surgeries in the United States. Psychological health has been shown to influence postoperative outcomes in orthopedic procedures. The purpose of this study is to evaluate the relationship between depression and anxiety (DA) and psychotropic medication and postoperative outcomes following RCR.

Methods

A single institution retrospective observational cohort study of 816 patients undergoing arthroscopic RCR from January 2014 to October 2020 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes; multivariate analysis was used to evaluate risk factors for postoperative complications.

Results

Patients with DA were more likely to have a higher first (3.60 vs. 3.00, P = .004) and last (1.23 vs. 0.96, P = .042) postoperative pain scores, lower first (18.67 vs. 21.85, P = .008) and last (61.87 vs. 64.71, P = .014) Upper Extremity Functional Score (UEFS), more likely to experience an emergency department visit postoperatively (9.1 vs. 5.0%, P = .028), have a symptomatic recurrent tear (8.2 vs. 3.3%, P = .003), and persistent pain (4.3 vs. 1.2%, P = .011). After controlling for age, sex, body mass index, American Society of Anesthesiologists score, diabetes, smoking, coronary artery disease, asthma, hypertension, psychotropic medication and DA, having DA at the time of surgery was independently predictive of any complication (odds ratio, 2.033; P = .028) and persistent pain (odds ratio, 8.232; P ≤ .001). Patients with and without DA showed significant improvement in postoperative pain and UEFS from the first to the last measurement (P < .001).

Conclusion

DA is not a deterrent for RCR but targeted interventions may be needed to decrease the occurrence of complications.

Predictors of postoperative pain, opioid consumption, and functionality after arthroscopic shoulder surgery: A prospective observational study

PURPOSE

This study aims to identify predictors of postoperative pain and opioid consumption after shoulder surgery to help optimize postoperative pain protocols.

STUDY DESIGN

Observational cohort study.

METHODS

One thirty-four patients undergoing arthroscopic shoulder repair were included. Variables related to the patient, surgery and anesthesia were collected and correlated with postoperative pain intensity, analgesic consumption, and functionality up to 1-month post-surgery. We used mixed-effect linear models to estimate the association of gender, interscalene block (ISB), preoperative shoulder pain, non-steroidal anti-inflammatory drugs (NSAIDs) consumption before surgery, and type of surgery with each of the following outcomes: postoperative pain scores, opioid consumption, and functionality. We further analyzed the data for pain scores and opioid consumption per body weight using the multiple linear regression analysis to demonstrate the aforementioned associations specifically at 1 h, 6 h, 12 h, 24 h, 72 h, 1 week and 1 month after surgery.

RESULTS

Omitting the ISB was associated with higher postoperative pain and cumulative opioid consumption over the first 24 h after surgery. Rotator cuff repair and stabilization surgeries were found to be predictive of higher postoperative pain at 24 h, 72 h, and 1 week and lower functionality at 1 week after surgery. Preoperative shoulder pain and NSAIDs consumption were also predictive of postoperative pain and cumulative opioid consumption.

CONCLUSION

Omitting a single shot ISB is a strong predictor of postoperative pain and opioid consumption in the early postoperative phase, beyond which the type of surgery, particularly rotator cuff repair and stabilization surgery, emerges as the most important predictor of postoperative pain and functionality.

Impact of patient resilience on early recovery from rotator cuff repair

AIMS

We sought to evaluate early recovery from rotator cuff repair by assessing the correlation between patient resilience and postoperative shoulder pain and function, and physical and mental health.

METHODS

Patients scheduled to undergo arthroscopic rotator cuff repair were prospectively enrolled. Resilience was assessed using the Brief Resilience Scale (BRS), pain and function was measured by American Society of Shoulder and Elbow Surgeons (ASES) shoulder scores, and physical and mental health was measured by the Patient-Reported Outcome Measurement Information System Global Health-10 (PROMIS-10). All scores were obtained preoperatively and postoperatively at three- and six months. Spearman correlation coefficient (r) was used to assess the relationship between variables.

RESULTS

Ninety-eight patients ultimately underwent rotator cuff repair; 76 and 68 patients provided three- and six-month follow-up, respectively. There was no statistically significant correlation between preoperative BRS and three- and six-month ASES. However, there was a statistically significant correlation between preoperative BRS and three-month PROMIS-10 (r = 0.3763, p = 0.009) and concurrent BRS and PROMIS-10 at three months (r = 0.5657, p = 0.0025) and six months (r = 0.5308, p = 0.0025).

DISCUSSION

Resilience appears to be more predictive of global physical and mental health than shoulder pain and function in early recovery from rotator cuff repair.

Arthroscopic rotator cuff repair: Is healing enough?

HYPOTHESIS/BACKGROUND

Arthroscopic rotator cuff repair most commonly results in good clinical outcomes, however understanding of predictive factors influencing the final clinical outcome is limited.

AIM

The purpose of our study was to evaluate clinical outcomes of patients with healed supraspinatus tendon after arthroscopic rotator cuff repair and to identify its pre- and peri-operative predictive factors of good clinical results.

METHODS

A multi-center prospective study followed up 188 patients, who had a healed tendon after an arthroscopic repair of isolated supraspinatus tear. Inclusion criteria were: age under 70 years old, isolated supraspinatus tear, stage 0 or I of fatty infiltration, healed supraspinatus tendon at one year postoperatively and the same arthroscopic double row rotator cuff repair used in all patients. Clinical assessment used Constant Murley Score (CMS) and Subjective Shoulder Value (SSV) preoperatively and at one year postoperatively. Ultrasound (US) control checked tendon repair quality based on Sugaya classification. Types I-II-III were considered as healed.

RESULTS

The average age of our cohort was 57.57 (range; 41 to 70) years and the female to male ratio was 1.14 (range; 100 to 87). The average preoperative CMS was 53.75±13.50 (mean±SD; range; 16 to 83). At final follow up, the average postoperative CMS was 79.95±12.05 (mean±SD; range; 28 to 100). 12.22% (23/188) of patients, who had a CMS score below 70, had a clinically significant difference compared to the average CMS, due to the fact that the minimal clinically significant difference (MCID) in CMS is 10. A statistical analysis has shown that in patients with lower scores there was only a significant dominance of females (p-value=0.001). No difference was found in regards to age, preoperative CMS, fatty degeneration and other factors.

CONCLUSION

Our study showed that despite all patients had a healed repair of supraspinatus, not all of them experienced a good final clinical outcome. The only factor negatively influencing the final clinical outcome was a female gender. No other structural factors seemed to influence the final clinical results. Futures studies should focus more on analyzing which personality traits and other psychosocial factors play an important role in determining the final outcome after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

III; retrospective cohort study.

The American Shoulder and Elbow Score Is Highly Correlated With the Western Ontario Rotator Cuff Index and Has Less Responder and Administrator Burden

Purpose

To compare the correlation, responsiveness, and responder and administrator burdens of the American Shoulder and Elbow Score (ASES) with the Western Ontario Rotator Cuff Index (WORC) for patients undergoing arthroscopic rotator cuff repair to determine whether one score is superior to the other to limit the use of multiple scoring measures when tracking patient outcomes.

Methods

A retrospective review of a database of patients undergoing arthroscopic rotator cuff repair was reviewed where the ASES was simultaneously recorded with the WORC. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of both scores. Responder and administrator burden was examined using 50 consecutively scored WORC and ASES scores by determining the number of questions accurately answered and the length of time taken to score each questionnaire.

Results

Correlation was excellent for the ASES and WORC (r = 0.90). The correlation of preoperative scores was strong-moderate (r = 0.69), and the correlation of postoperative scores was excellent (r = 0.86). The standardized response mean WORC = 2.3; ASES = 2.2) and the effect size (WORC = 2.9; ASES = 2.8) demonstrated comparable responsiveness. In total, 71.5% of the WORC questions were able to be scored compared with 93.3% for the ASES (P < .0001). The mean time to score the WORC was significantly greater than the ASES (154 vs 23 seconds; P < .0001).

Conclusions

There is excellent correlation and comparable responsiveness between the ASES and WORC. Since there is greater responder and administrative burden for the WORC score, the authors recommend using the ASES over the WORC in patients undergoing rotator cuff repair.

Level of Evidence

Level IV, diagnostic series.

Non-Adherence to Pain Medication Increases Risk of Postoperative Frozen Shoulder

Background

Postoperative frozen shoulder (FS) or adhesive capsulitis is a relatively frequent complication (5-20%), even after simple arthroscopic shoulder surgeries. The pathophysiology is still unclear, but psychological factors may play a pivotal role. From clinical experience, we hypothesized that patients, who are reluctant to take medications, particularly "pain-killers," have an increased incidence of postoperative FS.

Methods

We identified twenty patients who underwent limited arthroscopic operations of the shoulder and developed postoperative FS. Twenty patients with matching type of surgery, age, and gender served as control group (n = 20). All patients were at least one year postoperative and asymptomatic at the time of examination. Demographic data, the patient's adherence to self-medication (including self-medicating scale, SMS), development the Quality of life (QoL), and depression scale (PHQ-4-questionnaire) were assessed.

Results

Patients with FS had a 2-fold longer rehabilitation and 3-fold longer work inability compared to the patients without FS (P < 0.009 and P < 0.003, respectively). Subjective shoulder value SSV (P = 0.075) and post-operative improvement of QoL (P = 0.292) did not differ among the groups. There was a trend-but not significant-toward less coherence to self-medication in the FS-group (26.50 vs. 29.50; P = 0.094). Patients with postoperative FS significantly more often stated not to have "taken pain-killers as prescribed" (P = 0.003).

Conclusions

Patients reporting unwillingness to take the prescribed pain medications had a significantly higher incidence of postoperative FS. It remains unclear whether the increased risk of developing FS is due to reduced postoperative analgesia or a critical attitude toward taking medication. However, patients who are reluctant to take painkillers should strongly be encouraged to take medications as prescribed.

Editorial Commentary: The Evolution of Regional Anesthesia in Arthroscopic Rotator Cuff Repair: From Throbbing Shoulders to Paralyzed Diaphragms

Rotator cuff repair may result in significant postoperative pain. Although opioids were once the gold standard, addiction and other side effects are of significant concern. Nonsteroidal anti-inflammatory drugs reduce pain, sleep disturbance, and need for opioids, but they may impair soft tissue healing. The use of gabapentinoids is equivocal. Intralesional analgesia carries a risk of glenohumeral chondrolysis. Cryotherapy is beneficial, but it is often not covered by insurance companies. Suprascapular nerve block addresses innervation of only 70% versus interscalene block, but the latter has a higher incidence of unintended, temporary motor and sensory deficits of the upper extremity and hemidiaphragmatic paresis, despite similar pain scores. Although neurodeficits and diaphragmatic hemiparesis resolve by 3 weeks, temporary complications affect length of hospital stay, initiation of physical therapy, and patient satisfaction. These variables contribute to the challenge of postoperative pain control amid a growing wave of modalities aimed at improving the extent and duration of patient-focused analgesia, especially the application of continuous block infusions.

An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair

Background

In the realm of shoulder surgery, arthroscopic rotator cuff repair (RCR) is one of the most painful procedures and is often associated with higher opioid consumption. The purpose of this study was to evaluate effectiveness of preoperative and postoperative patient education and multimodal pain management to achieve an opioid-free postoperative recovery after RCR.

Methods

Sixty patients who underwent RCR were divided in 2 groups. All patientsreceived an interscalene nerve block and multimodal pain management. The opioid intervention group (OIG) in addition received preoperative education on expectations of pain, non opioid pain protocols, and alternate therapiesto minimize pain as well as customized postoperative instructions. Patients were compared on pain levels, opioid consumption, and outcomes scores preoperatively and at 48 hours, 2 weeks, and final follow-up. Patient-reported outcomes and opioid usage were compared and analyzed using student’s t-tests and logistic regression.

Results

At 48 hours, 15% of OIG patients reported use of rescue opioids after surgery compared with 100% of control group patients. Zero percent of OIG patients reported opioid use at 2 weeks compared to 90% of control group patients (P = .0196). Patients in both groups showed significant improvements in all outcome scores (P ≤ .05). At 6 weeks, functional, Constant, and satisfaction outcome scores were all higher in the OIG (P < .05). At last follow-up, there were no significant differences for all patient-reported outcomes between groups.

Conclusions

Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes.

Preoperative characteristics predictive of PROMIS Pain Interference two years after shoulder surgery

Introduction

The objective of this study was to identify preoperative characteristics associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) two years after shoulder surgery.

Methods

This was a retrospective analysis of prospectively collected data on 293 patients who underwent elective shoulder surgery. Survey questionnaires were collected within one week of surgery and then two years postoperatively. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables.

Results

Worse two-year PROMIS PI was significantly correlated with older age, higher BMI, greater comorbidities, more prior surgeries, and multiple socio-demographic factors. Less improvement in PROMIS PI was significantly correlated with greater comorbidities, more previous surgeries, unemployment, prior orthopaedic surgery on the operative joint, and a higher American Society of Anesthesiologists (ASA) score. Better scores on all preoperative patient-reported outcome measures correlated with better two-year PROMIS PI. Multivariable analysis demonstrated that worse two-year PROMIS PI was independently predicted by the following preoperative factors: Workers' Compensation claim, opioid use, worse whole body Numeric Pain Score, and worse PROMIS PI. Less improvement in two-year PROMIS PI was predicted by the same preoperative factors.

Conclusion

Worse PROMIS PI after shoulder surgery was associated with older age, greater comorbidities, mental health impairment, and lower socioeconomic status. Preoperative predictors of worse pain interference two years after shoulder surgery included Workers' Compensation, opioid use, worse whole body pain, and worse PROMIS PI.

Level of evidence

III.

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BACKGROUND

Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.

QUESTION/PURPOSE

After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?

METHODS

Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.

RESULTS

This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001).

CONCLUSION

Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.

LEVEL OF EVIDENCE

Level II, prognostic study.

Ultrasound evaluation of postsurgical shoulder after rotator cuff repair: comparison of clinical results

BACKGROUND

The relationship between the imaging parameters on postoperative ultrasound (US) other than repaired tendon integrity with clinical outcome such as postoperative residual pain has not been well defined.

PURPOSE

To investigate whether the repaired tendon thickness and subdeltoid fluid collection after rotator cuff repair are correlated with early postoperative clinical outcome.

MATERIAL AND METHODS

This retrospective study included 54 patients who underwent repair of the arthroscopic rotator cuff either by suture-bridge or single-row technique and postoperative US. We assessed the relationship between the sonographic parameters, including repaired supraspinatus tendon thickness and subdeltoid fluid collection, with the clinical outcome represented by the Korean Shoulder Scoring system (KSS) score using correlation coefficients (R). Also, the subgroup analysis was done to assess the differences by surgical technique and patients' age.

RESULTS

There was a significant inverse relationship between the amount of subdeltoid fluid collection and degree of self-assessed pain improvement of the patients (P < 0.05), although every KSS category showed statistically insignificant tendency of inverse relationship with the fluid thickness. However, there was no statistically significant relationship between the thickness of repaired supraspinatus tendon and KSS scores. In patients aged >60 years, a statistically significant inverse relationship between thickness of subdeltoid fluid collection and difference value of the KSS scores in category of function was observed with both interpreters (P = 0.015 and P = 0.04, respectively).

CONCLUSION

Subdeltoid fluid collection measured on US after repair of the arthroscopic rotator cuff in the early postoperative period has significant association with the patients' subjective clinical outcome.

The influence of psychosocial factors on patient-reported outcome measures in rotator cuff tears pre- and post-surgery: a systematic review

PURPOSE

Recent research shows that major levels of psychological distress correlate with higher pain and reduced function in patients with shoulder and rotator cuff pathology. A systematic review updating a review published in 2016 was conducted to determine the degree of consistency and the strength of association between psychosocial factors and patient-reported outcomes (PROMs) in patients with rotator cuff repair (RCR) with new high-quality literature.

METHODS

The bibliographic searches were conducted from May to June 2020 within the following databases: MEDLINE/PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Web of Science. The articles included should discuss the association between psychosocial factors and outcomes in patients with documented or diagnosed rotator cuff tears through clinical and/or radiological examination. The Methodological Index for Non-Randomized Studies (MINORS) tool was used to assess the methodological quality.

RESULTS

Fifteen articles were included. Negative psychosocial factors were found consistently associated with worse function and disability in the pre- and post-operative period. In particular, psychosocial factors regarding emotional or mental health were associated with a weak to a substantial degree with preoperative and postoperative function/disability and pain intensity in patients undergoing RCR.

CONCLUSION

In patients undergoing repair of the rotator cuff tear, there was a correlation between poor psychological function before surgery and worsening post-surgical outcomes, such as persistence of postoperative pain intensity and worse levels of function/disability.

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review

Background

Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention.

Methods

This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against.

Results

Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome.

Conclusions

Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.

The Effect of Patient and Surgical Factors on Opioid Prescription Requests Following Arthroscopic Rotator Cuff Repair

Purpose

To determine whether differences in total morphine equivalent doses (MEDs) prescribed after arthroscopic rotator cuff repair (RCR) existed because of age younger than or older than 55 years and sex and to characterize potential risk factors for needing an opioid medication refill, visiting a provider other than the surgeon (either in the emergency department or ambulatory settings), and postoperative pain control requiring opioids approximately 6 weeks from the date of surgery.

Methods

A retrospective cohort study of 100 patients who underwent arthroscopic RCR between July 1, 2018, to November 30, 2018, in a single institution was performed. Data including demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Our primary hypotheses were evaluated with the Wilcoxon-Mann-Whitney test. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values.

Results

There was a difference (P = .038) in total MEDs used (in 5 mg oxycodone tablets) between males (median 56 tablets; interquartile range, 50-98 tablets) and females (median 78 tablets; interquartile range, 56-116 tablets). Age younger than 55 years was a risk factor for seeking an opioid refill (OR = 2.51; CI, 1.11-5.66; P = .026). A significant risk factor for visiting another provider was preoperative opiate use (OR = 15.0; CI, 1.79-125.8; P = .013). Age younger than than 55 years (aOR = 2.51; CI, 1.01-6.02; P = .047), body mass index (aOR = 1.08; CI, 1.01-1.17; P = .046), and shorter surgical duration (aOR = 0.97; CI, 0.95-0.99, P =.007) were independent predictive factors for requiring opioids for pain control 6 weeks after surgery.

Conclusions

After arthroscopic RCR, MED prescription is higher for females than males. The risk factors for requesting opioid prescription refill for pain control 6 weeks after surgery were age younger than 55 years and shorter surgical duration.

Level of Evidence

Level III, retrospective comparative study.

Factors Predicting Frequency and Severity of Postoperative Pain After Arthroscopic Rotator Cuff Repair Surgery

BACKGROUND

Postoperative pain after arthroscopic rotator cuff repair (RCR) is difficult to predict and manage. The experience of pain is thought to be influenced by a range of different factors. Determining which patient factors contribute to the pain may help us to better understand and manage it.

PURPOSE

To evaluate the preoperative patient characteristics that may be predictive of, and correlated with, postoperative pain after arthroscopic RCR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study evaluated 2172 patients who underwent an arthroscopic RCR between February 2004 and December 2015. Pain frequency and severity were measured preoperatively and at 6 weeks after surgery using a modified L'Insalata questionnaire with Likert scales. This 6-week time point was chosen as previous studies have shown patients rank this time point as high in terms of pain after RCR. Logistic regression analysis was conducted to examine the relationship between postoperative pain scores and preoperative pain scores, age, sex, tear size, strength, level of sporting and work activity, and work-related injury status.

RESULTS

The severity of preoperative pain at night (r = 0.33; P < .001), preoperative pain at rest (r = 0.32; P < .001), and frequency of extreme pain (r = 0.31; P < .001) were the strongest independent associations with the frequency of pain at 6 weeks postoperatively. Other associations with postoperative pain frequency included reduced liftoff strength (r = -0.21; P < .001), work-related injury status (P < .001), younger age (P = .001), and female sex (P = .04). Tear size was inversely related with pain severity (R² = 0.85). The severity of preoperative pain had the strongest independent association with the severity of postoperative pain at 6 weeks after surgery (r = 0.35; P < .001). Other associations with postoperative pain severity included increased patient-ranked preoperative stiffness (P < .001), a poorer impression of one's shoulder (P < .001), reduced level of sporting activity (P < .001), and work-related injury status (P < .001).

CONCLUSION

Multiple risk factors have been identified for postoperative pain after RCR, the strongest of which is preoperative pain. However, of note, the magnitude of the correlations between preoperative severity and frequency of pain and postoperative severity and frequency of pain were found to be weak to moderate (r = 0.30-0.35). This suggests that while preoperative pain and its severity are associated with postoperative pain, other factors are likely involved in predicting pain. Smaller tear size, younger age, female sex, and work-related injuries were also associated with postoperative pain at 6 weeks after surgery.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis

PURPOSE

To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

METHODS

The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

RESULTS

Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

CONCLUSION

Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

Editorial Commentary: Mental Health Comorbidities Are Associated With Increased Cost, Opioid Use, and Inferior Outcomes After Shoulder Rotator Cuff Repair

In patients undergoing rotator cuff repair (RCR), patient comorbidities including mental health diagnoses of anxiety and depression are very common and are known to adversely affect surgical outcomes. This study highlights the complex interplay of mental health with other important considerations in outcomes following RCR, namely opioid use and health care costs. The extent to which we can mitigate opioid use and health care costs in patients with comorbid mental health disorders undergoing RCR remains unclear but worthy of concerted efforts to improve patient outcomes. Improving recognition of the role of mental health comorbidities in outcomes of RCR will be critical in future efforts to improve preoperative counseling and optimize perioperative management of patients electing RCR.

A comparison of ice wrap and subacromial injection for postoperative pain and edema control following arthroscopic rotator cuff repair

Background

Postoperative pain and edema are the most common problems associated with arthroscopic rotator cuff repair. The purpose of the present study was to compare ice wrap and subacromial injection (SI) as treatments for early postop pain and edema control and to contrast them with a control group.

Materials and methods

59 patients treated with arthroscopic rotator cuff repair were randomized into three groups: 23 patients who received an ice wrap, 20 patients who received a SI, and a control group of 16 patients.

Results

Patient demographics, comorbidities, tear retraction, degree of fatty muscle degeneration, surgical procedures, and amount of irrigation fluid were similar for the three groups, which also showed similar results regarding postoperative pain and edema control as well as analgesic consumption.

Conclusions

The present study failed to show any difference in effectiveness between the two most common pain management modalities, or between those modalities and the control group.

Level of evidence

IV, prospective observational study.

Do patients who smoke tobacco have success with primary arthroscopic rotator cuff repair? A comparison with nonsmokers

BACKGROUND

It is recommended that patients cease smoking before rotator cuff repair. However, not all patients want to or are able to successfully cease smoking. This raises the question if these patients should be advised to pursue surgical intervention or if surgery should be contraindicated until patients successfully cease smoking.

METHODS

A retrospective analysis of patients undergoing rotator cuff repair was performed to examine the effects of smoking tobacco on patient-determined outcomes (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons score [ASES], Simple Shoulder Test [SST], and Single Assessment Numeric Evaluation [SANE]). Patients who smoked tobacco at the time of surgery were compared with patients who were not smoking to determine if differences in (1) severity of preoperative and postoperative symptoms and (2) the postoperative improvements were statistically significant.

RESULTS

Thirty-one patients were smokers and 205 were nonsmokers. Preoperative scores were worse for smokers compared with nonsmokers: WORC (32 vs. 43; P = .0002), ASES (32 vs. 43; P = .001), SST (3.5 vs. 4.6; P = .04), and SANE (34 vs. 38; P = .35). Postoperative scores were worse for smokers compared with nonsmokers: WORC (79 vs. 89; P = .001), ASES (82 vs. 89; P = .04), SST (9.0 vs. 10.2; P = .02), and SANE (84 vs. 89; P = .09). There were no significant differences in change in scores over time or percentage of patients achieving the minimal clinically important difference of the score between groups.

CONCLUSIONS

From examining the patients' subjective patient-determined outcome scores, it does not appear that rotator cuff repair should be strictly contraindicated in active smokers. Postoperative improvements in smokers were similar to nonsmokers. Smokers have lower baseline preoperative and postoperative outcome scores compared with nonsmokers.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs

BACKGROUND

Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood.

PURPOSE/HYPOTHESIS

This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores.

RESULTS

A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R² in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs.

CONCLUSION

Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Postoperative residual pain is associated with a high magnetic resonance imaging (MRI)-based signal intensity of the repaired supraspinatus tendon

PURPOSE

To assess patients with and without postoperative residual pain and to compare clinical function and magnetic resonance imaging (MRI) appearance of the repaired supraspinatus tendon between patients with and without pain.

METHODS

One-hundred and seventeen patients with supraspinatus tear were included in this study. Visual Analog Scale (VAS) scores for pain were assessed at a follow-up of at least 1 year. Patients with residual shoulder pain were enrolled in the residual pain group (RP group) and patients without pain enrolled in the no pain group (NP group). The American Shoulder and Elbow Surgeons (ASES) shoulder evaluation form, the modified University of California at Los Angeles (UCLA) score and the Fudan University Shoulder Score (FUSS) were also used to evaluate shoulder function. MRI examinations were performed to evaluate rotator cuff integrity according to the Sugaya method, and muscular hypotrophy, fatty infiltration, and signal/noise quotient (SNQ) of the rotator cuff tendon.

RESULTS

Thirty-five patients had residual pain (RP group) and 82 patients had no pain (NR group). At the final follow-up, there was a significant difference in ASES (92 ± 8 points vs 76 ± 10 points; p < 0.001), UCLA (32 ± 3 points vs 28 ± 3 points; p < 0.001), FUSS (90 ± 7 points vs 80 ± 9 points; p < 0.001) and strength (9 ± 3 kg vs 6 ± 2 kg; p < 0.001) between the NP group and the RP group, respectively. Postoperative MRI revealed that there was no significant difference in the retear rate (9.8% vs 8.6%; ns), the muscular hypotrophy (ns), and the fatty infiltration index (0.9 ± 0.2 vs 0.9 ± 0.2; ns) between the NP and the RP groups, respectively. The postoperative tendon SNQ of the RP group was significantly higher than that of the NP group (4.6 ± 2.5 vs 3 ± 1.7; p < 0.001). There was a significant association between tendon SNQ and VAS for this cohort ([Formula: see text] = 0.29; p = 0.003).

CONCLUSION

Postoperative residual pain is associated with a high MRI signal intensity of the repaired supraspinatus tendon. Since high signal intensity of tendon tissue indicates degenerated tendon tissue quality, it highlighted the necessity of debriding the degenerated rotator cuff tendon tissue.

LEVEL OF EVIDENCE

III.

Intersection of catastrophizing, gender, and disease severity in preoperative rotator cuff surgical patients: a cross-sectional study

HYPOTHESIS AND BACKGROUND

Surgical outcomes are dependent on multiple clinical and patient factors. One patient factor is pain catastrophizing, which is associated with poorer outcomes in other surgical populations. Our purpose was to examine relationships between gender, patient-reported disease severity, and catastrophizing in patients in whom rotator cuff surgery is planned. We hypothesized that patients with more catastrophizing would report greater disease severity.

METHODS

Patients undergoing surgery for unilateral symptomatic rotator cuff disease aged 35 to 75 years were prospectively evaluated. Data collected included demographic characteristics; imaging characteristics; range of motion; and Western Ontario Rotator Cuff Index (WORC), Pain Catastrophizing Scale (PCS), and Short Form 36 scores.

RESULTS

A total of 156 patients (87 men and 69 women) aged 54 ± 8 years participated. The mean WORC score was similar between men and women (1286 ± 343 vs. 1327 ± 370, P = .38). The mean PCS score was 14.7 ± 10.6 for men and 17.9 ± 12.4 for women (P = .08). A moderate positive correlation was found between the WORC and PCS scores (r = 0.59, P < .001). Women had poorer WORC-Lifestyle subscale scores (P = .012). Range of motion, Short Form 36 scores, and tear severity were not related to measures of either the WORC or PCS.

DISCUSSION AND CONCLUSIONS

The direct relationship between the WORC and PCS scores is consistent with research in other patient populations. Contrary to other work, no gender-based PCS score differences were observed. Differences on the WORC-Lifestyle subscale suggest that women may experience greater functional impacts to specific lifestyle elements than men. Catastrophizing is related to patient-reported disease severity in preoperative rotator cuff patients. Further research will clarify whether this relationship leads to poorer outcomes following surgery.

Surgical Versus Nonsurgical Management of Rotator Cuff Tears: A Matched-Pair Analysis

BACKGROUND

Rotator cuff disease is a major medical and economic burden due to a growing aging population, but management of rotator cuff tears remains controversial. We hypothesized that there is no difference in outcomes between patients who undergo rotator cuff repair and matched patients treated nonoperatively.

METHODS

After institutional review board approval, a prospective cohort of patients over 18 years of age who had a full-thickness rotator cuff tear seen on magnetic resonance imaging (MRI) were retrospectively evaluated. After clinical evaluation, each patient elected to undergo either rotator cuff repair or nonsurgical treatment. Demographic information was collected at enrollment, and self-reported outcome measures (the Normalized Western Ontario Rotator Cuff Index [WORCnorm], American Shoulder and Elbow Surgeons score [ASES], Single Assessment Numerical Evaluation [SANE], and pain score on a visual analog scale [VAS]) were collected at baseline and at 6, 12, and >24 months. The Functional Comorbidity Index (FCI) was used to assess health status at enrollment. The size and degree of atrophy of the rotator cuff tear were classified on MRI. Propensity score analysis was used to create rotator cuff repair and nonsurgical groups matched by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy. The Student t test, chi-square test, and regression analysis were used to compare the treatment groups.

RESULTS

One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics. For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS. In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair.

CONCLUSIONS

Patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Psychosocial Factors on Outcomes in Patients With Rotator Cuff Tears: A Systematic Review

PURPOSE

To determine whether psychosocial factors affect patient-reported outcomes in individuals with rotator cuff tears or after rotator cuff repair.

METHODS

A systematic review was conducted using a computerized search of the PubMed and Web of Science electronic databases in adherence with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Articles were then evaluated based on inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess study quality and risk of bias. Because of study heterogeneity and varied levels of evidence, meta-analysis was not possible.

RESULTS

Of 980 identified articles, 15 met the inclusion and exclusion criteria. In those reported, the visual analog scale correlation with distress scales ranged from -0.476 to 0.334, depending on outcome, with a trend toward increased pain in patients with distress. The depression subscale of the Hospital Anxiety and Depression Scale was negatively correlated with the American Shoulder and Elbow Surgeons score in 2 of 3 studies (-0.309 to 0.235). Six studies evaluated the presence of psychosocial factors and their correlation with patient-reported outcomes prior to surgery. These showed a significant correlation between rotator cuff pathology and psychological distress (i.e., depression or anxiety) as identified on standardized patient-reported outcome measures. Nine studies evaluated psychosocial factors either before and after surgery or only postoperatively. Of these 9 studies, 3 found no statistically significant differences in outcomes as related to psychosocial factors. In contrast, 6 of 9 reported an association between outcomes and psychosocial factors. Moreover, 2 of these 6 studies reported a direct relationship between patient expectations and outcomes, with 1 of these 2 studies finding that higher expectations improved baseline scores on the mental component summary of the Short Form 36 (r = 0.307). One study found significant differences in mental status in patients with rotator cuff tears based on age and sex.

CONCLUSIONS

This review found that most studies support that psychosocial factors do significantly influence the level of disability and pain experienced by patients preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. These studies, however, do support that there is a direct relation between patient expectations and outcomes in rotator cuff surgery.

LEVEL OF EVIDENCE

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

Should We Question the External Validity of Database Studies? A Comparative Analysis of Demographics

PURPOSE

To define the external validity of national and institutional databases for common sports medicine procedures.

METHODS

Patient demographic data including age, sex, body mass index (BMI), and 4 racial categories were aggregated between 2007 and 2016 across 2 databases for 4 common sports medicine procedures: anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair (RCR), partial meniscectomy (PMx), and both arthroscopic and open shoulder stabilization. The first database of interest was a prospectively collected institutional database. The second was the National Surgical Quality Improvement Program (NSQIP) database. Two-sample t tests were performed to examine mean differences (MDs) in age and BMI, and χ² testing was used to test differences in sex and race.

RESULTS

A total of 7,019 institutional and 108,881 NSQIP patients were examined. The NSQIP cohort was significantly older (MD, 1.40 years), included more female patients (42.60% female patients vs 35.67% female patients), and showed a different racial distribution compared with the institutional data (all P < .0001). The NSQIP PMx cohort (MD, 7.38 years) was significantly older and the NSQIP RCR cohort (MD, 1.97 years) was significantly younger than their institutional counterparts (all P < .0001). The NSQIP anterior cruciate ligament reconstruction cohort (MD, 2.53) showed a greater average BMI (P < .0001). The NSQIP RCR cohort (41.8% female patients vs 33.3% female patients) and PMx cohort (46.0% female patients vs 37.9% female patients) also included more female patients. Race was distributed variably between databases for each procedure code (all P < .0001).

CONCLUSIONS

Significant differences in age, BMI, sex, and race distributions were observed between an institutional database and the NSQIP database. This study underlines the importance of defining the generalizability of database research, particularly when significant demographic differences between databases may underlie differences in postoperative outcomes.

LEVEL OF EVIDENCE

Level III, cross-sectional study.