Preoperative NSAIDs, non-acute onset and long-standing symptoms predict inferior outcome at long-term follow-up after rotator cuff repair

Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique - Minimum 5-years follow-up

Background

The primary aim of this study was to assess the long-term patient reported outcomes of arthroscopic rotator cuff tear (ARCR) using a single anchor tension band (TB) technique for small and medium supraspinatus tears at minimum 5-years follow-up.

Methods

A retrospective cohort study of consecutive ARCRs of small and medium supraspinatus tears using a knotless single anchor TB technique with minimum 5-year follow-up was carried out. Outcomes of interest included: range of motion (ROM) on examination under anaesthesia (EUA), visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores, Oxford Shoulder Score (OSS) and Short-Form (SF-12).

Results

From 243 consecutive ARCR procedures, 82 patients with a mean age of 55 ± 9.5 years met the inclusion criteria at 6.7 ± 1.5 years follow-up. There were significant improvements in VAS (5.5 ± 2.2 vs. 0.7 ± 1.5), ASES (47.6 ± 16.8 vs. 92.8 ± 13.0), OSS (31.3 ± 7.2 vs. 45.3 ± 3.5) and SF-12 (37.6 ± 7.6 vs. 50.3 ± 7.7) post-operatively (all p < 0.001).

Conclusions

The single anchor TB ARCR technique has excellent patient reported outcomes at a minimum of 5 years and is suitable for supraspinatus tears smaller than 20 mm in the sagittal plane.

Level of evidence

Level IV; Consecutive Case Series.

The Effectiveness of Rehabilitation after Open Surgical Release for Trigger Finger: A Prospective, Randomized, Controlled Study

BACKGROUND

It is not clear whether rehabilitation after surgery for trigger finger is effective. The aim of this study was to reveal its effectiveness for trigger finger.

METHODS

This study was a randomized, controlled trial that included patients who underwent operations for trigger fingers. The patients in the rehabilitation group had postoperative occupational therapy (OT) for 3 months, while the patients in the control group were not referred for rehabilitation but received advice for a range of motion exercises. We evaluated the severity of trigger finger, Disability of Arm-Shoulder-Hand (DASH) score, pain-visual analogue scale (VAS), grip strength, whether they gained a full range of motion (ROM), and complications before and after surgery.

RESULTS

Finally, 29 and 28 patients were included in the control and rehabilitation groups, respectively. At final follow-up, the DASH score, grip strength, and ROM were significantly improved in the rehabilitation group compared to that preoperatively. At final follow-up, pain was significantly improved in both groups from that preoperatively. There were no significant differences in the results, including the DASH score, grip strength, ROM and pain-VAS between the control and rehabilitation groups at the final follow-up. Subgroup analysis showed that there is a significant difference in the DASH score of patients doing housework or light work and those with a duration of symptoms >12 months between the control and rehabilitation groups at the final follow-up.

Non-selective NSAIDs do not increase retear rates post-arthroscopic rotator cuff repair: A meta-analysis

BACKGROUND

Arthroscopic rotator cuff repairs (RCRs) are known to be associated with substantial pain and post-operative pain management is critical in overall patients' outcomes. Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used oral medications and can reduce opioid usage. However, controversies arise due to its postulated effect on postoperative tendon healing. As the evidence of safety and efficacy of NSAIDs remains unclear, this study aims to investigate the effect of NSAIDs on retear rates and clinical outcomes.

METHODS

A systematic search of four databases (PubMed, EMBASE, Scopus, and Cochrane Library) was conducted, identifying studies that compared cohorts with post-RCR NSAIDs use versus control groups without NSAID use. Meta-analysis was conducted for retear rate as well as pain and functional outcomes (Visual Analogue Scale and American Shoulder and Elbow Surgeons Shoulder score). Subgroup analysis was conducted for retear rates to determine the overall treatment effect of including selective COX-2 inhibitors.

RESULTS

Six studies were included in the meta-analysis. The total baseline cohort size was 916, with 443 (48.3%) patients in the NSAID group and 473 (51.6%) patients in the control group. There were no statistically significant differences in the baseline characteristics between the two groups. Meta-analysis between the two groups showed that there were no statistically significant differences in retear rates (p ​= ​0.70), early and late post-operative Visual Analogue Scale score (p ​= ​0.10 and p ​= ​0.10, respectively) and latest American Shoulder and Elbow Surgeons Shoulder score (p ​= ​0.31). However, subgroup analysis of retear rates revealed a statistically significant difference between the subgroup including COX-2 selective inhibitor versus non-selective COX inhibitor (p ​< ​0.01).

CONCLUSION

NSAID use in post-arthroscopic RCR pain relief does not increase retear rates and can provide similar clinical outcomes compared to a non-NSAID regimen.

LEVEL OF EVIDENCE

Meta-analysis, level of evidence, 4.

Healing rates after rotator cuff repair for patients taking either celecoxib or placebo: a double-blind randomized controlled trial

Background

Use of anti-inflammatory medications (NSAIDs) is an important component of multimodal pain control after orthopedic procedures to avoid opioid overutilization and abuse. However, the deleterious effects of NSAIDs on tendon healing are of particular concern in rotator cuff repair (RCR). The purpose of this study was to evaluate the effect of celecoxib or placebo on healing rates after RCR when administered in the perioperative and immediate postoperative period using MRI evaluation at one year postoperatively. A secondary aim was to determine whether clinical differences existed between patients with intact or non-intact repairs.

Methods

Patients aged ≤65 years with partial- or full-thickness rotator cuff tear (<25x25 mm) were randomized to receive celecoxib 400 mg or placebo 1 hour before the procedure and 200mg bid for 3 weeks postoperatively. All patients were treated as clinically indicated at the time of surgery and followed standard postoperative protocol. Repair integrity was evaluated with MRI using the Sugaya classification for repair integrity. Data were analyzed using multivariable logistic regression by intent to treat.

Results

Seventy-nine patients were enrolled; 21 were lost to follow-up, 6 did not have cuff repair, 5 were revised, and 2 declined follow-up, leaving 45 patients with one-year follow-up. Five of these patients did not complete MRI, leaving 40 patients for review. Eighteen of 20 patients (90%) who received celecoxib completed all doses of study medication as did 15 of 20 patients (75%) who received placebo. The patient groups were similar for demographics, clinical results, and healing rate. After adjusting for tear size, no statistically significant difference in healing rate was found between groups, with 10 of 20 celecoxib patients (50%) having intact repair at 1 year compared with 14 of 20 placebo patients (70%) (OR = 0.53, 95% CI: 0.14, 2.08, P = 0.35).

Conclusion

Half of the patients who received celecoxib had an intact repair compared with 70% intact repair for patients receiving placebo. Although not statistically significant in this small study, larger studies are needed to clarify this important clinical concern. The authors do not recommend use of celecoxib for postoperative pain control after RCR.

Perioperative pain management for shoulder surgery: evolving techniques

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.

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.

Influence of preoperative opioid use on postoperative outcomes and opioid use after arthroscopic rotator cuff repair

BACKGROUND

Recent orthopedic research has questioned the effect of opioid use on surgical outcomes. This study investigated this in the context of arthroscopic rotator cuff repair. We hypothesized that preoperative opioid use would be associated with inferior outcomes and greater postoperative opioid requirements.

METHODS

A database query identified adult patients with full-thickness or partial-thickness supraspinatus tears surgically treated between 2011 and 2015. Preoperative and postoperative outcomes scores (active range of motion [AROM], American Shoulder and Elbow Surgeons [ASES], Constant scores, Simple Shoulder Test [SST], and visual analog scale [VAS] for pain) and postoperative opioid use were retrospectively recorded. Patients with less than 2 years of follow-up data at the time of the retrospective review were contacted for prospective ASES, SST, and VAS data collection.

RESULTS

A total of 200 patients, 44 of whom received opioids preoperatively, were identified for inclusion. Patients prescribed preoperative opioids had consistently inferior preoperative and postoperative outcomes scores; however, the magnitudes of improvement were not significantly different between groups. Postoperatively, patients in the preoperative opioid group received 1.91 (95% confidence interval, 1.31-2.78) times more opioids over a postoperative course of treatment that was 2.73 (95% confidence interval, 1.62-4.59) times longer. In addition to having a greater proportion of women, this group also had significantly higher rates of certain comorbidities, including back pain, depression, degenerative joint disease, and chronic pain conditions.

CONCLUSIONS

All patients demonstrated significant improvements in outcomes scores after surgical repair that were not significantly different between groups. However, patients taking opioids preoperatively did not ultimately reach the same level of functionality and had substantially greater opioid requirements postoperatively.

Long-term results after surgical treatment of subacromial pain syndrome with or without rotator cuff tear

PURPOSE

Some studies suggest a common degenerative path might contribute to a range of shoulder diseases involving subacromial pain syndrome and full-thickness rotator cuff tears. One could therefore theorize arthroscopic subacromial decompression and rotator cuff repair as interventions at different stages of a degenerative shoulder disease. Few studies have compared long-term outcomes after these two procedures.

METHOD

Matched case-controls undergoing arthroscopic rotator cuff repair combined with subacromial decompression (N = 180) or subacromial decompression only (N = 180) were evaluated pre- and 7.5 years postoperatively using QuickDASH score, VAS of function, VAS of pain and VAS of satisfaction. New surgery and complications were recorded. Baseline characteristics were related to outcomes to investigate predictors of good/poor outcome.

RESULTS

A general improvement from baseline was seen - from 51 to 14 (QuickDASH) in the combined group and from 53 to 16 in the decompression only group. No differences in outcomes were seen between groups (n.s.). Age above 55 at surgery predicted better VAS of function (P = .04) while acute onset of symptoms predicted better QuickDASH in the combined group (P = 0.03). None in the decompression group had undergone later rotator cuff repair.

CONCLUSION

Major improvements in pain/function were seen at mid- to long-term after isolated arthroscopic subacromial decompression and combined decompression/rotator cuff repair. Several patient-specific factors predicting worse outcomes were identified.

The Effect of Rotator Cuff Repair on Natural History: A Systematic Review of Intermediate to Long-Term Outcomes

Background:

Rotator cuff disease can have a progressive natural history of increasing tear size and worsening function. It remains unknown whether rotator cuff repair alters this natural history.

Methods:

A systematic review of the intermediate to long-term (minimum 5-year) results of operative rotator cuff repair and no repair of rotator cuff injuries was performed to compare (1) patient-based outcomes, (2) future surgical intervention, (3) future tear progression or recurrence, and (4) tear size. The no-repair group included both conservative treatment and surgical treatment without repair. After the application of selection criteria, 29 studies with 1,583 patients remained. Meta-regression was conducted to adjust for baseline age, sex, tear size, and duration of follow-up.

Results:

Comparison of the repair and no-repair groups revealed no significant differences in terms of age (p = 0.36), sex (p = 0.88), study level of evidence (p = 0.86), or Coleman methodology score (p = 0.8). The duration of follow-up was significantly longer for the no-repair group (p = 0.004), whereas baseline tear size was significantly larger in the repair group (p = 0.014). The percentage of patients requiring additional surgery was significantly higher in the no-repair group after adjustment for age, sex, duration of follow-up, and tear size (9.5% higher in estimated means between groups [95% confidence interval, 2.1% to 17%]; p = 0.012). The likelihood of a recurrent defect (repair group) or extension of the prior tear (no-repair group) was not different between groups after adjustment for age, sex, duration of follow-up, and tear size (p = 0.4). There were no differences between the repair and no-repair groups in terms of the Constant score after adjustment for age, sex, duration of follow-up, and tear size (p = 0.31). The final tear size was significantly larger in the no-repair group than the repair group (967 mm² higher in estimated means between groups [95% confidence interval, 771 to 1,164 mm²]; p < 0.001).

Conclusions:

At intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased need for future surgery after adjusting for age, sex, duration of follow-up, and tear size. The likelihood of a recurrent defect after rotator cuff repair did not differ from that of tear extension after nonoperative treatment. Thus, rotator cuff repair may not alter natural history.

Level of Evidence:

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