Use of a shoulder abduction brace after arthroscopic rotator cuff repair: A study on gait performance and falls

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol

Purpose

To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery.

Methods

This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM.

Results

The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function.

Conclusions

No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery.

Level of Evidence

Level III, retrospective comparative study.

Shoulder brace has no detrimental effect on basic spatio-temporal gait parameters and functional mobility after arthroscopic rotator cuff repair

BACKGROUND

The risk of falls in patients undergoing orthopedic procedures is significant in terms of health and socioeconomic effects.

RESEARCH QUESTION

Is there an influence of the shoulder abduction brace (SAB) on gait parameters in patients undergoing arthroscopic rotator cuff repair (ARCR)?

METHODS

Thirty-five patients undergoing ARCR, who used a 15° SAB in the postoperative period, were included in a prospective study. Participants underwent gait analysis preoperatively (T0), 24 h after surgery (T1), 1 week (T2), and 4 weeks after surgery (1 week after SAB removal) (T3) by using a wearable inertial sensor (BTS G-Walk sensor). Gait Parameters (cadence, speed, right (R) and left (L) step length, gait and propulsion-R and L symmetry indices) and functional mobility (agility and balance) were assessed using the 10-meter test (10MWT) and the Timed Up and Go (TUG) test, respectively.

RESULTS

There were 22 men and 13 women with a median age of 56 (IQR 48.0-61.0) years. The right upper limb was involved in 83% of cases. Regarding the 10MWT, speed was significantly higher at T0 than at T1 (p < 0.01) and significantly lower at T1 than at T3 (p < 0.05). Cadence was significantly lower at T1 than at T3 (p < 0.05). Propulsion-R was significantly higher at T3 than at T1 (p < 0.01), whereas propulsion-L was significantly lower at T1 than at T0 (p < 0.05) and significantly higher at T2 and T3 than T1 (p < 0.01 for all). No significant differences were found for R and L step lengths as well as for symmetry index (p > 0.05). Regarding TUG test, the final turning phase was significantly higher at T2 than at T3 (p < 0.01).

SIGNIFICANCE

The results demonstrated that the use of the SAB affected gait speed and propulsion only 24 h after ARCR, but no effects were reported at long-term observations.

Sling Versus Abduction Brace Shoulder Immobilization After Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background

The optimal immobilization position of the shoulder after rotator cuff repair is controversial.

Purpose

To compare the clinical outcomes and incidence of retears after arthroscopic rotator cuff repair between patients who used an abduction brace versus a sling for postoperative shoulder immobilization.

Study Design

Systematic review; Level of evidence, 1.

Methods

This systematic review and meta-analysis was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, MEDLINE, and Embase electronic databases for randomized controlled trials (RCTs) that compared abduction brace and sling immobilization after arthroscopic rotator cuff repair using single-row, double-row, or suture-bridge fixation. Clinical scores, pain severity, and retear rates were compared between patients with abduction brace versus sling immobilization.

Results

Of 1572 retrieved studies, 4 RCTs with a total of 224 patients (112 patients with abduction brace and 112 patients with sling) were included in the qualitative analysis, and 3 of the RCTs were included in the quantitative analysis (meta-analysis). There were no significant differences between the abduction brace and sling immobilization groups in the Constant-Murley score at 3 months (weighted mean difference [WMD], 0.26 [95% CI, -1.30 to 1.83]; P = .74; I 2 = 84%), 6 months (WMD, 1.91 [95% CI, -0.17 to 4.00]; P = .07; I 2 = 85%), and 12 months (WMD, 0.55 [95% CI, -1.37 to 2.47]; P = .57; I 2 = 0%); the visual analog scale score for pain at 1 week (WMD, 0.10 [95% CI, -0.20 to 0.41]; P = .51; I 2 = 0%), 3 weeks (WMD, -0.12 [95% CI, -0.34 to 1.00]; P = .29; I 2 = 0%), 6 weeks (WMD, -0.12 [95% CI, -0.30 to 0.06]; P = .20; I 2 = 0%), and 12 weeks (WMD, -0.13 [95% CI, -0.27 to 0.02]; P = .09; I 2 = 18%); or the retear rate at 3 months (risk ratio, 0.63 [95% CI, 0.09 to 4.23]; P = .64; Z = 0.47%) postoperatively.

Conclusion

Our systematic review demonstrated a lack of significant differences between the abduction brace and sling immobilization groups regarding postoperative clinical scores, pain severity, and tendon healing.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

The effect of postoperative sling immobilization and early mobilization on clinical and functional outcomes after arthroscopic rotator cuff repair: A propensity score-matched analysis

BACKROUND

Optimal postoperative management is controversial after arthroscopic rotator cuff repair (ARCR).

OBJECTIVE

The aim of the study was to evaluate outcomes of patients with and without postoperative sling immobilization after undergoing arthroscopic RCR rotator cuff repair.

METHOD

369 arthroscopic full thickness superior rotator cuff tears (RCT) with a minimum follow-up of 6 months were included in this study. Propensity score matching was performed for age, sex, BMI, and tear size. Pain (VAS score), shoulder range of motion (ROM), functional outcome (ASES, Constant-Murley [CM] and Oxford shoulder score [OSS]), and health related quality of life (SF-36) scores were compared between patients with and without sling immobilization.

RESULTS

According to the propensity match score, 92 patients (50 sling immobilization and 42 no sling immobilization) were matched to be almost identical in age (62.5 ± 8.0 vs. 61.8 ± 5.9), sex (female 78% vs. 76.2%), BMI (28.1 ± 2.8 vs. 27.8 ± 2.6), and tear size (2.7 ± 1.1 vs. 2.9 ± 0.8). The postoperative physical functioning domain of SF-36 scores was found to be significantly higher in the no sling group (p= 0.034).

CONCLUSION

Early mobilization after arthroscopic small and medium sized full thickness superior rotator cuff repair is associated with improved ROM and quality of life scores.

Does immobilization of the shoulder in different positions affect gait?

BACKGROUND

The shoulder joint is immobilized in various positions after injury or reconstructive operative intervention. It is not clear how these immobilization positions in the shoulder joint affect gait.

RESEARCH QUESTION

Does the immobilized shoulder joint in different positions following shoulder surgery or injury affect gait?

METHODS

A total of 38 healthy individuals with a mean age of 25.94 years and BMI of 25.66 kg/m², underwent gait analysis in 4 different immobilized positions and normal gait. Gait parameters were evaluated using the GAITRite electronic walkway, and to determine symmetry, the bilateral spatiotemporal gait parameters were calculated using the Symmetry Index. Repeated-measures one way analysis of variance was used to compare the walking parameters in different positions.

RESULTS

Velocity, step length and stride length were significantly decreased, and step width and single support time were increased in some immobilized positions (p < 0.05). Differences in asymmetry were determined in the gait parameters of the immobilized positions but not significantly. When the shoulder was immobilized in abduction, step width asymmetry tended to increase but it was not significant.

SIGNIFICANCE

This cross-sectional simulation study may be important in demonstrating the clinical changes of gait in injuries, pathologies, and postoperative rehabilitation that require the immobilization of the shoulder joint. It could be recommended that arm swing is included in gait rehabilitation, gait and balance training can be provided to patients after shoulder immobilization.

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk

INTRODUCTION

Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations.

METHODS

A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation.

RESULTS

Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χ² = 8.9, P = .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P = .11).

DISCUSSION

Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk.

CONCLUSION

Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Current concepts in the rehabilitation of rotator cuff related disorders

Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.

High prevalence of outpatient falls following elective shoulder arthroplasty

BACKGROUND

This study characterized the prevalence and risk factors of inpatient and outpatient postoperative falls in patients undergoing elective shoulder arthroplasty.

METHODS

A retrospective chart review of 198 patients undergoing anatomic or reverse total shoulder arthroplasty or hemiarthroplasties at one institution between 2015 and 2017 was reviewed to determine the prevalence of inpatient and outpatient falls up to 90 days after discharge. Univariate and multivariate analyses were conducted to assess potential risk factors for postoperative falls including demographics, indication for surgery, surgical procedure, medical history, length of hospital stay, perioperative hemoglobin, need for transfusion, and discharge disposition.

RESULTS

There were 23 falls in 22 patients within a 90-day postoperative period. The inpatient fall rate was 1.0% (2 of 198). The outpatient fall rate was 10.6% (21 of 198). Outpatient falls resulted in emergency department evaluation in 23.8% of cases (5 of 21), readmission in 19.0% (4 of 21), injury to an anatomic site other than the shoulder in 19.0% (4 of 21), and injury at the surgical site (eg, periprosthetic humeral fracture) in 4.8% (1 of 21). No significant risk factors were identified for inpatient falls. Independent risk factors for an outpatient fall were female sex (adjusted odds ratio [aOR] = 4.79; 95% confidence interval [CI]: 1.32, 17.4; P = .007), increased length of hospital stay (aOR = 1.23; 95% CI: 1.04, 1.45; P = .02), and history of a movement disorder (aOR = 7.20; 95% CI: 1.22, 42.6; P = .03).

CONCLUSION

A high outpatient fall rate of 10.6% within 90 days after discharge raises the concern that falls after shoulder arthroplasty are significantly higher than previously reported.

Immediate self-rehabilitation after open Latarjet procedures enables recovery of preoperative shoulder mobility at 3 months

PURPOSE

To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation.

METHODS

The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR).

RESULTS

The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05).

CONCLUSIONS

Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events.

LEVEL OF EVIDENCE

Level IV.

Editorial Commentary: Optimizing Postoperative Care After Rotator Cuff Repair: What Do We Know and Understand?

Optimization of the management of rotator cuff tears is still needed. Preoperative patient selection, perioperative surgical techniques, and postoperative care are all important topics that are studied extensively. This commentary will examine the current situation and important fields of interest for future research. Postoperative pain management is scrutinized in relation to the level of abduction using an abduction brace.

Does The Type of Shoulder Brace Affect Postoperative Pain and Clinical Outcome After Arthroscopic Rotator Cuff Repair?

PURPOSE

To compare postoperative pain and clinical outcome after arthroscopic rotator cuff repair in patients immobilized with an abduction brace versus patients placed in an antirotation brace.

METHODS

One hundred twenty patients (72 women and 48 men) with symptomatic degenerative complete tear of the supraspinatus or infraspinatus tendons were included in the study. Exclusion criteria were history of trauma/traumatic tears, concomitant shoulder pathology, psychological illnesses, and previous shoulder surgery. The Constant-Murley score (CMS) was obtained before surgery and at 3 months, 6 months, and 1 year after surgery. The visual analogue scale (VAS) was done on the day of surgery and at 1 week, 3 weeks, 6 weeks, and 3 months after surgery. Postoperative isokinetic muscle strength evaluation was done for the shoulder external rotator at 1 year.

RESULTS

Mean age was 50.4 years for the abduction brace group (ABG) and 50.8 years for the open pouch arm sling group (PASG). The mean level of the VAS score ranged from 75.6 for the ABG and 74.9 for the PASG on the day of the operation to 17.7 and 18.5 at 3 months after surgery. In both groups, the repeated measure analysis of variance showed that there were highly significant changes (P < .001) in the VAS from the day of operation to 3 months after surgery. A significant improvement was detected in both groups in the mean level of the CMS, from 40.9 for the ABG and 41.2 for the PASG before surgery to 84.7 and 84.5 at 1 year after the operation. There was no statistically significant difference between the 2 groups regarding the isokinetic muscle strength, VAS, or the CMS.

CONCLUSIONS

Our study did not find a significant difference between abduction brace and antirotation sling in patient-oriented outcome measures or postoperative pain after rotator cuff repair.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Postoperative Mobilization After Superior Rotator Cuff Repair: Sling Versus No Sling: A Randomized Prospective Study

BACKGROUND

Patients are commonly advised to wear a sling for 4 to 6 weeks after rotator cuff repair despite negative effects of early immobilization and benefits of motion rehabilitation. The aim of this study was to compare clinical and radiographic outcomes up to 6 months following rotator cuff repair with and without postoperative sling immobilization.

METHODS

We randomized 80 patients scheduled for arthroscopic repair of a small or medium superior rotator cuff tear into sling and no-sling groups (40 patients each). Passive mobilization was performed in both groups during the first 4 postoperative weeks, and this was followed by progressive active mobilization. Patients were evaluated clinically at 10 days and 1.5, 3, and 6 months and using ultrasound at 6 months. Univariable and multivariable analyses were performed to determine if postoperative scores were associated with sex, age at surgery, immobilization, arm dominance, a biceps procedure, resection of the distal part of the clavicle, or preoperative scores.

RESULTS

The sling and no-sling groups had similar preoperative patient characteristics, function, and adjuvant procedures. At 10 days, there was no difference in pain between the 2 groups (mean pain score [and standard deviation], 5.2 ± 2.3 versus 5.2 ± 1.9, p = 0.996). In comparison with the sling group, the no-sling group showed greater mean external rotation (23.5° ± 15.6° versus 15.3° ± 14.6°, p = 0.017) and active elevation (110.9° ± 31.9° versus 97.0° ± 25.0°, p = 0.038) at 1.5 months as well as better mean active elevation (139.0° ± 24.7° versus 125.8° ± 24.4°, p = 0.015) and internal rotation (T12 or above in 50% versus 28%, p = 0.011) at 3 months. Ultrasound evaluation revealed no significant differences at 6 months in tendon thickness anteriorly (p = 0.472) or posteriorly (p = 0.639), bursitis (p = 1.000), echogenicity (p = 0.422), or repair integrity (p = 0.902). Multivariable analyses confirmed that the mean American Shoulder and Elbow Surgeons (ASES) score increased with patient age (beta, 0.60; p = 0.009), the Single Assessment Numeric Evaluation (SANE) decreased with sling immobilization (beta, -6.33; p = 0.014), and pain increased with sling immobilization (beta, 0.77; p = 0.022).

CONCLUSIONS

No immobilization after rotator cuff repair is associated with better early mobility and functional scores in comparison with sling immobilization. Postoperative immobilization with a sling may therefore not be required for patients treated for a small or medium tendon tear.

LEVEL OF EVIDENCE

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