Incidence and prognostic factors for postoperative frozen shoulder after shoulder surgery: a prospective cohort study

Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy

Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.

Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions

BACKGROUND

Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions.

METHODS

This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years).

RESULTS

Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05).

CONCLUSIONS

Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA.

LEVEL OF EVIDENCE

This is a level III prognostic study.

Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus

BACKGROUND

Hyperglycemia is a known risk factor for tendon degeneration due to oxidative stresses from production of advanced glycosylation end products. In patients with diabetes mellitus (DM), analysis of glycated hemoglobin (HbA1c) provides a 3-month window into a patient's glucose control. No guidelines exist for ideal preoperative HbA1c and glucose control prior to arthroscopic rotator cuff repair. This study evaluated if a critical HbA1c level is associated with reoperation following arthroscopic rotator cuff repair.

METHODS

We retrospectively evaluated patients with DM who underwent primary arthroscopic rotator cuff repair from January 2014 to December 2018 at a single institution. Patients required a preoperative HbA1c within 3 months of surgery. Medical records were queried to evaluate for reoperation and identify the subsequent procedures performed. Univariate statistical analysis was performed to assess factors associated with reoperation (P < .05 considered significant). Threshold, area under the curve (AUC), analysis was performed to assess if a critical HbA1c value was associated with reoperation.

RESULTS

A total of 402 patients met inclusion criteria. Patients had an average age of 65.5 years (range 40-89) at time of surgery; 244 (60.6%) patients were male; and average body mass index was 32.96 ± 5.81. Mean HbA1c was 7.36 (range 5.2-12). Thirty-three patients (8.2%) underwent subsequent reoperation. Six patients (1.5%) underwent capsular release and lysis of adhesions, 20 patients (5.0%) underwent a revision rotator cuff surgery, combination revision rotator cuff repair and lysis of adhesions, graft-augmented revision repair, or superior capsular reconstruction, and 7 patients (1.7%) underwent revision to reverse shoulder arthroplasty (1.7%). There were no cases of reoperation for infection. On AUC analysis, no critical HbA1c value was identified to predispose to reoperation. Interestingly, elevated preoperative American Society of Anesthesiologists (ASA) physical status classification score (2.8 vs. 2.28, P = .001) was associated with a higher reoperation rate.

DISCUSSION

In patients with DM, preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation. Stable glycemic control is important to a patient's overall health and may play a role in minimizing postoperative medical complications, but an elevated preoperative HbA1c should not be a strict surgical contraindication for arthroscopic rotator cuff repair. In patients with DM, an elevated ASA score is associated with an increased rate of subsequent reoperation; diabetic patients should be counseled accordingly.

Is preoperative elevated glycated hemoglobin (HbA1c) a risk factor for postoperative shoulder stiffness after posterior-superior rotator cuff repair?

Background

Postoperative shoulder stiffness (POSS) affects a large number of patients undergoing rotator cuff repair (RCR). Diabetes may increase the risk of POSS. Preoperative glycated hemoglobin (HbA1c) is a convenient measure of glucose control in this group. The aim of the present study was to determine a relationship between preoperative HbA1c and POSS in patients undergoing postero-superior RCR.

Methods

Two hundred fifty patients with full-thickness postero-superior rotator cuffs who underwent RCR were followed for 6 months. Pre- and post-operative external rotation with arm by the side at 3 and 6 months were measured. Patient demographics, tear characteristics, preoperative HbA1c level, and surgical details were recorded. Patients with subscapularis tears, concomitant instability, partial thickness tears, arthritis, and irreparable rotator cuff tears were excluded. Univariate and multivariate logistic regression were used to determine the association between patient characteristics and POSS at 6 months.

Results

At the end of 6 months, 16% (41/250) of patients had POSS. Multivariate analysis demonstrated an elevated preoperative HbA1c level was a statistically significant predictor of POSS at 6 months (odds ratio 7.04, P < .01) after posterior superior RCR. Lower preoperative external rotation (P = .02) and female sex (P < .01) were also risk factors associated with POSS. Age, hand dominance, worker's compensation claim status, etiology, and size of the tear, surgical technique, and additional treatments were not statistically significant predictors.

Conclusion

Elevated preoperative HbA1c level is associated with POSS after RCR. Measuring HbA1c preoperatively may assist clinicians to identify patients at risk of POSS. HbA1c is a modifiable parameter that could then be optimized preoperatively in order to improve outcomes.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Exploration of the Usual Care Pathway for Rotator Cuff Related Shoulder Pain in the Western Australian Workers' Compensation System

PURPOSE

Investigate components of care for rotator cuff related shoulder pain in workers' compensation in relation to claim outcomes (claim duration, total medical spend, total claim cost, return to work outcome).

METHODS

Engagement with (had care, time to care) four components of care (prescribed exercise, imaging, injections, surgery) were obtained from auditing 189 closed workers' compensation files. Associations were analysed between components of care and claim outcomes.

RESULTS

80% received prescribed exercise, 81% imaging, 42% injection and 35% surgery. Median time to imaging (11 days) was shorter than the prescribed exercise (27 days), with injection at 38 days and surgery 118.5 days. With univariable regression analysis higher age, the involvement of legal representation and the presence of rotator cuff pathology from diagnostic imaging (partial thickness tear or full thickness tear) were all associated with increased claim duration, total medical spend, total claim cost and less successful return to work outcomes. After adjusting for these three associations, having an injection or surgery were both positively associated with longer claim duration and greater medical spend, and surgery with greater total claim costs. In general, longer time to receiving components of care was associated with increased claim duration and reduced odds of returning to full duties at work.

CONCLUSION

Early management was not consistent with clinical guidelines for managing workers' compensation rotator cuff related shoulder pain. This may negatively affect claims outcomes.

De Quervain Tenosynovitis as a Risk Factor of New-Onset Adhesive Capsulitis: A Nationwide Cohort Study

This study investigated the association of de Quervain tenosynovitis (DQT) with subsequent adhesive capsulitis (AC) development. Patients with DQT between 2001 and 2017 from the Taiwan National Health Insurance Research Database were the DQT cohort. The 1:1 propensity score matching method was applied for creating control cohort. The primary outcome was defined as new-onset of AC at least 1 year after the date of confirmed diagnosis of DQT. In total, 32,048 patients with mean age 45.3 years were included. DQT was significantly positively associated with risk of new-onset AC after adjustment for baseline characteristics. Furthermore, severe DQT requiring rehabilitation was positively associated with risk of new-onset AC. In addition, male gender and age under 40 may be additional risk factors for new-onset AC, compared to female gender and age over 40. Cumulative incidence of AC after 17 years was 24.1% among patients with severe DQT requiring rehabilitation and was 20.8% among patients with DQT without rehabilitation. This is the first population-based study to demonstrate an association between DQT and new-onset AC. The findings recommend that preventive occupational therapy, including active modification for the shoulder joint and adjustments to daily activities, may be necessary for patients with DQT to reduce their risk of developing AC.

Profibrotic behavior of fibroblasts derived from patients that develop posttraumatic shoulder stiffness

Background and Aims

Arthrofibrosis is a severe scarring condition characterized by joint stiffness and pain. Fundamental to developing arthrofibrotic scars is the accelerated production of procollagen I, a precursor of collagen I molecules that form fibrotic deposits in affected joints. The procollagen I production mechanism comprises numerous elements, including enzymes, protein chaperones, and growth factors. This study aimed to elucidate the differences in the production of vital elements of this mechanism in surgical patients who developed significant posttraumatic arthrofibrosis and those who did not.

Methods

We studied a group of patients who underwent shoulder arthroscopic repair of the rotator cuff. Utilizing fibroblasts isolated from the patients' rotator intervals, we analyzed their responses to profibrotic stimulation with transforming growth factor β1 (TGFβ1). We compared TGFβ1-dependent changes in the production of procollagen I. We studied auxiliary proteins, prolyl 4-hydroxylase (P4H), and heat shock protein 47 (HSP47), that control procollagen stability and folding. A group of other proteins involved in excessive scar formation, including connective tissue growth factor (CTGF), α smooth muscle actin (αSMA), and fibronectin, was also analyzed.

Results

We observed robust TGFβ1-dependent increases in the production of CTGF, HSP47, αSMA, procollagen I, and fibronectin in fibroblasts from both groups of patients. In contrast, TGFβ1-dependent P4H production increased only in the stiff-shoulder-derived fibroblasts.

Conclusion

Results suggest P4H may serve as an element of a mechanism that modulates the fibrotic response after rotator cuff injury.

Adhesive Capsulitis

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

The relationship between clinical outcomes of arthroscopic rotator cuff repair and hemoglobin A1c

Background

The clinical outcomes of diabetic patients who underwent arthroscopic rotator cuff repair have been reported. However, few studies have focused on the relationship between these clinical outcomes and postoperative hemoglobin A1c. This study compared clinical outcomes of diabetic patients with a hemoglobin A1c < 7% to those with a hemoglobin A1c ≥ 7% at 12 months post-arthroscopic rotator cuff repair.

Methods

This retrospective study involved 51 consecutive patients who underwent arthroscopic rotator cuff repair from 2015 to 2020. Approximately 26 and 25 shoulders were assigned to a Low group (hemoglobin A1c < 7%) and High group (hemoglobin A1c ≥ 7%) at 12 months postoperatively, respectively. Patients with poorly controlled diabetes were preoperatively hospitalized for perioperative diabetic control. Clinical outcomes were shoulder range-of-motion, Constant Shoulder Score, and University of California, Los Angeles Score preoperatively and at 12 months postoperatively. Complications were also evaluated.

Results

Both groups showed significant improvement in their range-of-motion, Constant Shoulder Score, and University of California, Los Angeles score at 12 months post-arthroscopic rotator cuff repair (p < 0.05) except external rotation in High group. These improvements were significantly inferior in the High group compared to the Low group (Low/High group; 167.3 ± 7.7°/159.5 ± 16.3° for forward flexion; p = 0.013, 94.9 ± 7.6/90.1 ± 9.9 points for Constant Shoulder Score; p = 0.033, 32.6 ± 3.6/30.6 ± 4.1 points for University of California, Los Angeles score, p = 0.037). Hemoglobin A1c at 12 months postoperatively was also significantly inferior in the High group (Low/High group; 6.5 ± 0.3%/7.6 ± 0.8%; p < 0.05). The rate of rotator cuff retear was not significantly different between groups (Sugaya type4; p = 0.49, type5; p = 0.322) and there were no cases of infection or shoulder stiffness in either group.

Conclusion

Diabetic patients showed improvement of their range-of-motion and function after arthroscopic rotator cuff repair; however, patients with poorly controlled diabetes had significantly inferior improvement.

The Effect of Manipulation Under Anesthesia for Secondary Frozen Shoulder: A Randomized Controlled Trial

INTRODUCTION

Manipulation under anesthesia (MUA) is often used for frozen shoulder treatment, but controversy still exists regarding MUA compared with conservative treatment. This research was conducted to compare the outcome between MUA and celecoxib (CLX) in secondary frozen shoulder.

METHODS

Patients with secondary frozen shoulder were randomized into two groups, an MUA plus exercise (EX) group and a CLX plus EX group. Clinical outcomes were documented at baseline and at 1 day, 2, 4, and 12 weeks after intervention, including Constant-Murley Score (CMS) for function, Pain Rating Index (PRI) and Present Pain Intensity (PPI) for pain, passive range of motion (ROM) measurements including external rotation, internal rotation, forward flexion, and abduction. Primary outcome was CMS. Secondary outcomes were PRI, PPI, and passive ROM.

RESULTS

Sixty-seven patients out of 68 in the MUA group and 66 out of 68 in the CLX group finished the entire study period. There were no significant differences in basic properties of the two groups before intervention. As the primary outcome, CMS changes in the MUA group improved faster than the CLX group. Secondary outcomes, passive ROM, and pain PPI were faster and significant in the MUA group from 1 day after intervention compared with CLX (P < 0.05). At 12 weeks, a statistically significant difference was not observed in the PPI (P > 0.05). A statistically significant difference was not observed in the PRI between groups in 1 day (P > 0.05). For the primary outcome, from 0 to 12 weeks the mean changes in CMS were 44.00 for MUA plus EX (95% CI 43.07-44.93, P < 0.001) and 27.09 for CLX plus EX (26.20-27.98, P < 0.001). The significant difference in improvement appeared from 2 weeks.

CONCLUSION

To treat secondary frozen shoulder with MUA, this treatment could achieve better therapeutic effects on improvement of function, pain, and passive ROM than CLX did.

CLINICAL TRIAL REGISTRATION

The trial was registered at www.chictr.org.cn , identifier ChiCTR2200060269.

Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets

BACKGROUND

Disparities in access, utilization and outcomes exist throughout the healthcare system for minority groups, including racial and ethnic minorities; these disparities have wide-reaching implications for individuals as well as the healthcare system as a whole. This study will examine the impact of race on short and medium term outcomes for patients undergoing rotator cuff repair (RCR) using matched cohorts.

METHODS

Patients undergoing arthroscopic rotator cuff repair from 2016 to 2018 were extracted from two national databases: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and TriNetX Research Network. Using the ACS-NSQIP database, univariate analysis was performed to identify differences in comorbidities between white and minority patients. Patients were propensity score matched based on significant differences between groups and 30-day postoperative outcomes were assessed. These comorbidities were then used to propensity score match white and minority patients in the TriNetX database and two-year postoperative outcomes were evaluated.

RESULTS

Following propensity score matching, 3716 patients remained in each group from the ACS-NSQIP database and 4185 patients remained in each group from the TriNetX database. The OR time for minority patients was longer than white patient in the ACS-NSQIP database (92.2 vs. 87.6 min, p < .001). There was no difference in medium-term outcomes for repeat RCR, infection or frozen shoulder between white and minority patients in the TriNetX database.

CONCLUSION

After propensity score matching the only significant short-term outcome between white and minority patients undergoing RCR was a difference in OR time; there were no differences in medium-term outcomes. This may indicate that the source of racial disparities is one of access to healthcare rather than an innate difference in the patients' outcomes. Further study is needed to elucidate this issue.

Prediction of Shoulder Stiffness After Arthroscopic Rotator Cuff Repair

BACKGROUND

Postoperative shoulder stiffness (POSS) is a prevalent adverse event after arthroscopic rotator cuff repair (ARCR) that is associated with major limitations in everyday activities and prolonged rehabilitation.

PURPOSE/HYPOTHESIS

The purpose was to develop a predictive model for determining the risk of POSS within 6 months after primary ARCR. We hypothesized that sufficient discrimination ability of such a model could be achieved using a local institutional database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Consecutive primary ARCRs documented in a local clinical registry between 2013 and 2017 were included, and patients who experienced POSS before the final clinical 6-month follow-up were identified. A total of 29 prognostic factor candidates were considered, including patient-related factors (n = 7), disease-related factors (n = 9), rotator cuff integrity factors (n = 6), and operative details (n = 7). We used imputed data for the primary analysis, and a sensitivity analysis was conducted using complete case data. Logistic regression was applied to develop a model based on clinical relevance and statistical criteria. To avoid overfitting in the multivariable model, highly correlated predictors were not included together in any model. A final prognostic model with a maximum of 8 prognostic factors was considered. The model's predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC). Internal validation was performed using bootstrapping.

RESULTS

Of 1330 ARCR cases (N = 1330 patients), 112 (8.4%) patients had POSS. Our final model had a moderate predictive ability with an AUC of 0.67. The predicted risks of POSS ranged from 2.3% to 38.9% and were significantly higher in women; patients with partial tears, low baseline passive shoulder abduction, and lack of tendon degeneration; and when no acromioplasty was performed.

CONCLUSION

A prognostic model for POSS was developed for patients with ARCR, offering a personalized risk evaluation to support the future decision process for surgery and rehabilitation.

Early postoperative pain as a risk factor of shoulder stiffness after arthroscopic rotator cuff repair

BACKGROUND

The role of postoperative pain in incidence of shoulder stiffness (SS) after shoulder arthroscopy has not been thoroughly investigated. The present study was conducted to assess the effects of early postoperative pain (EPOP) on onset of SS after arthroscopic rotator cuff (RC) repair.

MATERIALS AND METHODS

In a retrospective analysis of a prospectively collected database, 335 patients who underwent arthroscopic RC repair were evaluated. RC tendons were sutured to the bone using the double-row technique. EPOP was evaluated 1 week after surgery using the visual analog scale (VAS). SS was assessed 3 months after surgery and was categorized into moderate or severe based on shoulder range of motion (ROM). Each type of complication including SS was identified and recorded.

RESULTS

Postoperative shoulder stiffness (POSS) was identified in 121 patients (36.2%) that was moderate in 86 patients (70.1%) and severe in 35 patients (28.9%). After 1 week, VAS pain score was equal to 7.7 ± 3.1 and 4.5 ± 2.1 in the patients with and without stiffness, respectively (p < 0.001). Diabetes and traumatic tear were found to be associated with postoperative stiffness (p = 0.046 and p < 0.001, respectively). Similar associations were found on multivariate analysis of data. VAS pain score was higher in the patients with severe stiffness compared with those with moderate stiffness (p < 0.001).

CONCLUSIONS

Our findings revealed that EPOP is associated with shoulder stiffness after arthroscopic RC repair. Therefore, strategies to ameliorate EPOP could be opted to decrease rate of POSS.

LEVEL OF EVIDENCE

Level IV.

Is routine gleno-humeral exploration a risk factor for adhesive capsulitis after arthroscopic removal of rotator cuff calcifications? A comparative retrospective study in 340 cases

BACKGROUND

Arthroscopic surgery has earned its place as the reference standard treatment for rotator cuff calcific tendinopathy refractory to conservative medical treatment. Adhesive capsulitis of the shoulder is the most common complication (12%). Standard practice involves routine gleno-humeral exploration before calcification removal. The objective of this study was to identify risk factors for adhesive capsulitis.

HYPOTHESIS

The development of adhesive capsulitis is associated with gleno-humeral exploration.

METHODS

We conducted a multicentre, multi-surgeon, retrospective cohort study of 340 consecutive patients who underwent arthroscopic removal of rotator cuff calcifications between 1 January 2012 and 1 January 2018. We collected epidemiological data (age, sex, work-related physical activity), the history of previous treatments (local injections, needling), the type and location of the calcifications as assessed radiologically, the clinical findings (Constant score before and 6 months after surgery, diagnosis of adhesive capsulitis defined as shoulder pain with motion range limitation in all directions), and the surgical details (type of anaesthesia, gleno-humeral exploration).

RESULTS

Of the 340 patients, 251 underwent routine gleno-humeral exploration and 89 did not. Adhesive capsulitis developed in 40 (12%) patients. By multivariate analysis, gleno-humeral exploration was an independent risk factor for adhesive capsulitis (p=0.022; odds ratio, 5.60). Of the 251 gleno-humeral explorations, 8% identified concomitant lesions and only 4% led to a curative procedure.

CONCLUSION

Given our results and the data in the literature, we believe that routine gleno-humeral exploration during the arthroscopic treatment of rotator cuff calcific tendinopathy is inadvisable.

LEVEL OF EVIDENCE

III; case-control study.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

INTRODUCTION

In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

METHODS AND ANALYSIS

A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

ETHICS AND DISSEMINATION

This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

TRIAL REGISTRATION NUMBER

NCT04321005.

PROTOCOL VERSION

Version 2 (13 December 2019).

Arthroscopic bursectomy less effective in the degenerative shoulder with chronic subacromial pain

Background

Varying results after surgery in patients with subacromial pain syndrome (SAPS) have raised the question on whether there is a subgroup of patients that can benefit from surgery. Therefore, we aimed to identify preoperative and peroperative factors associated with a favorable patient-reported outcome after arthroscopic bursectomy in patients with SAPS.

Methods

Patients with chronic SAPS who underwent arthroscopic bursectomy after failed conservative management were included (n = 94). Patients were evaluated at the baseline, and 2 weeks, 8 weeks, 6 months, and 1 year after surgery. The primary outcome was the Western Ontario Rotator Cuff index (WORC) score one year after surgery. The secondary outcome measure was a visual analog scale for pain. Mixed model analyses were used to identify prognostic factors.

Results

The mean WORC (mean difference 39%, 95% confidence interval (CI) 32.8-45.3, P < .001) and visual analog scale pain scores (mean difference 41 mm points, 95% CI 3.37-4.88, P < .001) significantly improved one year after surgery. Nineteen patients (20%) developed a postoperative frozen shoulder. A longer duration of preoperative complaints and the peroperative identification of degenerative glenoid cartilage were associated with significantly worse WORC scores, with -0.086% per month (95% CI -0.156 to -0.016, P = .016) and -20% (95% CI -39.4 to -1.26, P = .037), respectively.

Conclusion

We identified demographic and clinical factors that predict the course after arthroscopic subacromial bursectomy. We found that arthroscopic bursectomy is less effective in patients with SAPS with a degenerative shoulder. This finding suggests that an improved treatment effect of arthroscopic subacromial bursectomy can be expected in patients with chronic SAPS if intra-articular pathologies such as glenohumeral osteoarthritis are sufficiently excluded.

Arthroscopic Outside-in Shoulder Release for Patients With an Inaccessible Glenohumeral Joint

Severe shoulder contracture, which usually results from severe frozen shoulder or traumatic arthrofibrosis, is clinically quite common. This condition requires surgical release resulting from severe functional impediment. However, most surgeons are reluctant to operate on such patients because the glenohumeral joint is always inaccessible because of contracture severity. Thus, we introduced an outside-in shoulder release technique starting from the posterior side of the glenohumeral joint. This procedure includes the fabrication of posterior and inferior posterior portals, locating the glenohumeral space out of the capsule, creating working space just posterior to the posterior capsule, releasing the posterior capsule, and thereafter releasing the inferior and superior capsules. Our clinical experience indicates that this procedure can be performed safely and effectively when certain guidelines are followed and can allow for subsequent access to the glenohumeral joint in most cases. We think the introduction of this technique will provide a special surgical option for patients with severe joint contracture.

Type 1 Complex Regional Pain Syndrome After Subacromial Shoulder Surgery: Incidence and Risk Factor Analysis

INTRODUCTION

Complex Regional Pain Syndrome type 1 (CRPS1) is a potential complication, affecting the prognosis of functional joint recovery. Its incidence ranges from 2 to 40% depending on the series and the joints involved. Very few studies have evaluated the incidence of CRPS after shoulder surgery. The objective of our study was to determine the incidence of CRPS1 and to identify any pre-operative risk factors associated with its emergence after extra-articular subacromial space surgery.

MATERIAL AND METHODS

This is a retrospective single-centre study of patients who underwent surgery for a subacromial extra-articular shoulder pathology from January 2016 to December 2016 and included a follow-up period of at least 6 months. The primary inclusion criterion was developing a CRPS1 as defined by Veldman. A pre- and post-operative clinical assessment was performed based on the Constant (Cst) score.

RESULTS

Among the 287 patients, with an average follow-up period of 6.5 months, included in the study, 38 (13%) presented with post-operative CRPS1. Treated hypothyroidism (OR = 3.79; 95% CI 1.58;9.07; p = 0.003), open surgery (OR = 2.92; 95% CI 1.35-6.32; p = 0.007) and the level of daily physical activity from the Cst score (OR = 0.088; 95% CI 0.79;0.97; p = 0.015) were found to be significantly associated with the onset of CRPS1.

CONCLUSION

CRPS1 affected more than 10% of patients who underwent surgery for a subacromial shoulder pathology. The current study identified hypothyroidism, open surgery, and pre-operative clinical status as risk factors for the onset of this complication. These parameters should, therefore, be taken into consideration during the patient's pre-operative consultation.

Effect of affective temperament on outcome of rotator cuff surgery

INTRODUCTION

Although numerous risk factors have been described, the effects of temperament, which is defined as a risk factor for certain disorders, on the outcome of patients undergoing rotator cuff surgery have not been investigated.

HYPOTHESIS

We investigated whether a relationship exists between affective temperament and the outcome of patients undergoing rotator cuff surgery.

MATERIAL AND METHODS

The outcomes of 176 patients undergoing rotator cuff surgery were examined using the Oxford and Constant questionnaires as well as visual analog scale values preoperatively and postoperatively. Inclusion criteria were defined as 1) dissatisfaction with pain despite 6 months of nonoperative treatment; 2) rotator cuff defects with full-thickness, small- to large-sized defects; 3) presence of a single dominant temperament or nondominant temperament; 4) no history of a diagnosed psychiatric disorder; and 5) a minimum of greater than 1 year of follow-up after surgery. Exclusion criteria were 1) other comorbid shoulder pathology; 2) irreparable or partial rotator cuff rupture; 3) grade 3 retractions; 4) grade 3-4 fatty infiltration; 5) other comorbid diseases such as diabetes, thyroid disorders, or inflammatory diseases; 6) history of shoulder surgery; 7) infection of the shoulder joint; 8) neurologic deficit in muscles around the shoulder; 9) two or more dominant temperaments; and 10) history of acromioclavicular joint resection and/or biceps tenodesis with cuff repair. All patient temperaments were evaluated according to the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto questionnaire version.

RESULTS

The mean follow-up time was 45.5 months. The outcomes of patients with depressive temperament were worse than of patients with a nondominant temperament. This situation was observed both preoperatively and postoperatively. However, a similar relationship between nondominant and anxious temperament groups was observed only postoperatively.

CONCLUSION

We noticed that depressive and anxious temperaments had a negative effect on patient outcomes after rotator cuff surgery; however, nondominant temperaments had a positive effect on patient outcomes.

LEVEL OF EVIDENCE

Level III; Retrospective Comparative Study.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

The Association of Perioperative Glycemic Control With Adverse Outcomes Within 6 Months After Arthroscopic Rotator Cuff Repair

PURPOSE

To determine the association between glycemic control and adverse events after arthroscopic rotator cuff repair (RCR).

METHODS

Patients with a diagnosis of diabetes mellitus who underwent arthroscopic RCR and had a hemoglobin A_1c (HbA_1c) level determined within 3 months before or after surgery were identified in a national database and stratified by HbA_1c level. The incidence of postoperative infection within 6 months was determined using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) curve analysis was performed to determine whether a threshold HbA_1c level existed above which the risk of infection, revision rotator cuff surgery, and lysis of adhesions (LOA)-manipulation under anesthesia (MUA) after arthroscopic RCR was significantly increased. This threshold was then tested using a logistic regression analysis.

RESULTS

The study included 3,740 patients with an infection rate ranging from a low of 0.29% to a high of 1.14% after RCR. The inflection point of the ROC curve for infection corresponded to an HbA_1c level between 7.0 and 8.0 mg/dL (P = .035; area under the curve, 0.648; specificity, 61%; sensitivity, 59%). We then used 8.0 mg/dL as a threshold to test for adverse outcomes. We found a significant difference in infection rates for patients with levels below versus above the threshold (0.30% vs 0.84%; OR, 2.0; 95% confidence interval, 1.2-3.4; P = .014) but no difference in revision rates (P = .240) or LOA-MUA (P = .650) in patients with levels above versus below the threshold.

CONCLUSIONS

The risk of infection after RCR in patients with diabetes mellitus increases as the perioperative HbA_1c level increases and, although statistically significant, remains low. ROC curve analysis determined that a perioperative HbA_1c level above 8.0 mg/dL could serve as a threshold level; however, the area under the curve and low sensitivity reflected the poor utility of this test as an independent predictor. This study did not find an association between increased perioperative HbA_1c levels and rates of revision rotator cuff surgery or LOA-MUA after RCR.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Rotator cuff repair is more painful than other arthroscopic shoulder procedures

AIM

To evaluate the influence of the specific procedure performed and other variables on the intensity of acute postoperative pain following outpatient shoulder arthroscopy.

METHODS

One hundred patients undergoing outpatient shoulder arthroscopy under single-shot interscalene block plus general anaesthesia were prospectively studied. Acetaminophen with ibuprofen was prescribed for postoperative pain control and tramadol HCl as rescue medication. Patients scored pain intensity at 2, 6, and 24 h postoperatively. The influence of the surgical procedure, age, gender, surgery duration, and irrigation volume used on the intensity of postoperative pain was studied.

RESULTS

Five patients were excluded due to ineffective block or protocol deviation. Among the 95 remaining patients, 51 underwent rotator cuff tear repair, 25 shoulder stabilisation, and 19 subacromial decompression. While there were no differences at 2 and 6 h after surgery, pain intensity was significantly higher among those undergoing rotator cuff tear repair (5.2, 1-10) at 24 h compared to stabilisation (4.1, 1-8) or subacromial decompression (5, 1-8) (p < 0.0001). No association was found between pain intensity and other variables.

CONCLUSION

A higher degree of acute postoperative pain should be expected in patients undergoing arthroscopic rotator cuff tear repair compared to other arthroscopic shoulder procedures, and additional pain treatment is recommended.

Effectiveness of extracorporeal shock-wave therapy for frozen shoulder: A protocol for a systematic review of randomized controlled trial

BACKGROUND

This systematic review aims to explore the effectiveness and safety of extracorporeal shock-wave therapy (ESWT) for patients with frozen shoulder.

METHODS

The sources of Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and Websites of Clinical Trials Registry will be searched. All databases and other sources will be searched from inception to the date of the search will be run. Only randomized controlled trials of ESWT for frozen shoulder will be considered for inclusion in this systematic review. Two authors independently screen the studies, extract the data, and evaluate the methodology quality for included trials. If sufficient trials will be included with fair heterogeneity, the data will be pooled, and the meta-analysis will be performed by using RevMan 5.3 software.

RESULTS

This systematic review will assess the effectiveness and safety of ESWT for frozen shoulder. The primary outcome includes pain intensity. The secondary outcomes consist of shoulder function, quality of life, and also the adverse events.

CONCLUSION

Its findings may provide latest evidence of ESWT for the treatment of frozen shoulder.

ETHICS AND DISSEMINATION

No research ethics approval is required in this study, because it is a systematic review and will not use individual data. The results of this study are expected to publish at peer-reviewed journals.

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial

OBJECTIVE

To assess the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy, in a more pragmatic setting.

DESIGN

Multicentre, three group, randomised, double blind, sham controlled trial.

SETTING

Orthopaedic departments at three public hospitals in Finland.

PARTICIPANTS

210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015.

INTERVENTIONS

ASD, diagnostic arthroscopy (placebo control), and exercise therapy.

MAIN OUTCOME MEASURES

Shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15.

RESULTS

In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were -4.6 (95% confidence interval -11.3 to 2.1) points (P=0.18) at rest and -9.0 (-18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events. In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (-7.5, -14.0 to -1.0, points; P=0.023) and VAS on arm activity (-12.0, -20.9 to -3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group.

CONCLUSIONS

In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00428870.

Risk Factors for Shoulder Stiffness: Current Concepts

Shoulder stiffness is a condition of painful restriction of the glenohumeral range of motion. Numerous risk factors for primary and postoperative shoulder stiffness have been described. This article summarizes the known aspects of the pathophysiology of shoulder stiffness, with special attention to elements of molecular biology and genetics, which could influence the risk of developing shoulder stiffness. Furthermore, the role of hormonal and metabolic factors, medical disorders, drugs, and of other published risk factors for primary and postoperative shoulder stiffness is reviewed and discussed. Finally, aspects related to shoulder surgery and postoperative rehabilitation protocols, which could influence the development of postoperative stiffness are presented.