Abduction Brace Versus Antirotation Sling After Arthroscopic Cuff Repair: The Effects on Pain and Function

Current Evidence Based Recommendations on Rehabilitation following Arthroscopic Shoulder Surgery: Rotator Cuff, Instability, Superior Labral Pathology, and Adhesive Capsulitis

PURPOSE OF REVIEW

Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis.

RECENT FINDINGS

For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3 cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release. Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research.

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.

Positioning efficacy and comfort profile of shoulder support braces: A randomized repeated-measures study using three-dimensional kinematic analysis

BACKGROUND

Shoulder bracing is very common in musculoskeletal rehabilitation.

OBJECTIVE

In this study, the positioning efficacy of shoulder support braces was investigated by analyzing their three-dimensional kinematic properties, as well as their perceived comfort was investigated with user ratings.

STUDY DESIGN

A randomized repeated-measures study.

METHODS

Seventeen asymptomatic participants were included. Scapular, humeral, and thoracic kinematics for all participants were measured using an electromagnetic tracking device in 6 experiments in randomized order: no brace, neutral brace, abduction brace, internal rotation brace, 15-degree external rotation brace (ER15-B), and 30-degree external rotation brace (ER30-B). Also, comfort ratings were obtained during each session.

RESULTS

Internal rotation brace achieved a mean of 29.34° of humerothoracic internal rotation while providing increased scapular internal rotation and upward rotation ( p < 0.05). Abduction brace achieved a mean of 45.39° of humerothoracic and 39.58° of glenohumeral elevation coupled with increased scapular upward rotation, posterior tilt, and humeral internal rotation ( p < 0.05). 30-Degree external rotation brace achieved a mean of 33.25° of glenohumeral external rotation and resulted in increased scapular external rotation, upward rotation, posterior tilt, and humeral external rotation ( p < 0.05). Abduction brace, internal rotation brace, ER15-B, and ER30-B moved the thoracic spine into a more axial rotation in the contralateral direction. Internal rotation brace, ER15-B, and ER30-B were rated more uncomfortable when compared with the no brace condition, with no significant differences observed among the braces.

CONCLUSIONS

The positioning efficacy was enhanced when an abduction pillow and external rotation wedge were applied. Selection of commercially available shoulder support braces should involve consideration of whether it can achieve the desired position and orientation as well as its comfort profile.

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.

Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review

Rotator cuff (RC) tears are among the most common musculoskeletal disorders and can be associated with pain, weakness, and shoulder dysfunction. In recent years, there have been significant advances with regard to the understanding of rotator cuff disease and its management. With technological improvements and advanced diagnostic modalities, there has been much progress as to improved understanding of the pathology. Similarly, with advanced implant designs and instrumentation, operative techniques have evolved. Furthermore, refinements in postoperative rehabilitation protocols have improved patient outcomes. In this scoping review, we aim to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight recent advances in its management.

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.

Aktuelle Aspekte der Behandlung der Rotatorenmanschette

Rotatorenmanschettenrupturen gehören zu den häufigsten muskuloskeletalen Erkrankungen und können mit ausgeprägten Schmerzen und Funktionseinschränkungen einhergehen. Für ihre Entstehung ist eine Vielzahl von Faktoren relevant, u. a. die individuelle Anatomie des Akromions. Mit Hilfe der heutigen technischen Möglichkeiten wurde nun festgestellt, dass zusätzlich zu seiner lateralen Ausdehnung auch die sagittale Ausdehnung des Akromions eine Rolle zu spielen scheint. Die bildgebende Darstellung der Rotatorenmanschette (RM) hat von den technischen Fortschritten der letzten Jahrzehnte ebenfalls profitiert. Magnetresonanztomographie (MRT) und MR-Arthrographie werden heute flächendeckend eingesetzt. Letztere bietet die höchste Sensitivität für die Entdeckung selbst kleiner Partialläsionen. Neue Sequenzen und Nachbearbeitungsmöglichkeiten können als hilfreiche tools für die operative Planung eingesetzt werden. Grundsätzlich richtet sich die Behandlung der RM neben der Symptomatik nach der Rupturgenese und -morphologie sowie der erwarteten Gewebequalität des Muskel-Sehnen-Kontinuums. Auch das Gesamtprofil, die Erwartungshaltung und die Rehabilitationsmöglichkeiten des Patienten sind wichtig. Die heutigen operativen Techniken werden durch spannende Entwicklungen der Industrie mitbestimmt, die in den letzten Jahren immer bessere Fadenankersysteme, aber auch Augmentationsmaterialien auf den Markt gebracht hat. Letztere zielen nicht nur auf die mechanische Verstärkung der Sehnenrekonstruktion, sondern auch auf die Optimierung der biologischen Eigenschaften des Konstrukts ab. Hinsichtlich Fixation konnte die biomechanische Forschung zeigen, dass zweireihige oder Suture-Bridge-Fixationen einreihigen oder transossären Fixationen überlegen sind. Diese Überlegenheit im Labor spiegelt sich noch nicht klar in den klinischen Ergebnissen wider, dennoch sind die meisten Chirurgen heute auf diese Technik übergegangen. Was die postoperative Nachbehandlung angeht, stellen jüngste randomisiert-kontrollierte Untersuchungen das Konzept der postoperativen Immobilisation in Abduktion in Frage. Hier scheint das letzte Wort noch nicht gesprochen zu sein.

Effect of Abduction Brace Wearing Compliance on the Results of Arthroscopic Rotator Cuff Repair

The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

Background

The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.

Methods

According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.

Results

The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.

Conclusions

No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

Postoperative Rehabilitation of Rotator Cuff Repair: A Systematic Review

Rotator cuff tears are the most common cause of shoulder disability and can cause significant pain and dysfunction. This systematic review summarizes the latest research on rehabilitation following arthroscopic rotator cuff repair. Studies were eligible for inclusion if they pertained to postoperative rehabilitation following arthroscopic rotator cuff repair and were published between 2003 and 2019 with a level of evidence of 1 or 2. Two blinded reviewers screened, graded, and extracted data from articles and recommendations on various aspects of rehabilitation were summarized. A total of 4067 articles were retrieved from the database search and 22 studies were included for data extraction. We noted similar outcomes between early and delayed mobilization following surgery. Reviewed articles support the use of supervised physical therapy, bracing in 15 degrees external rotation, and adjunctive transcutaneous electrical nerve stimulation for pain management. Early isometric loading improved outcomes in 1 study. Evidence is lacking for exercise prescription parameters and postoperative rehabilitation of the subscapularis.

Does application of abduction brace after arthroscopic rotator cuff repair improve blood flow around posterosuperior rotator cuff and repair site, affecting pain levels and clinical and structural outcomes? A pilot randomized controlled trial

Background

As per some cadaveric studies, blood flow in posterosuperior rotator cuff tendons improves in the abducted shoulder position compared with the neutral position. In a clinical post–rotator cuff repair scenario, the impact of abduction on altered blood flow in and around the posterosuperior rotator cuff tendons is unknown in terms of clinical outcomes and structural healing.

Materials and methods

This study included 42 eligible patients aged between 40 and 70 years with clinically diagnosed and radiologically confirmed rotator cuff tears undergoing arthroscopic rotator cuff repair. Patients were randomly allocated to undergo application of either an abduction brace (group 1) or an arm pouch (group 2). On postoperative day 1, power Doppler scanning was performed on the index shoulder in adduction and 30° of abduction in each patient; the allocated treatment (abduction brace or arm pouch) was then applied. Power Doppler scanning was repeated at 6 weeks in the immobilization position assigned to the patient (abduction or adduction). The vascular flow in 6 regions was noted as per the criteria of Fealy et al. A visual analog scale score was assessed preoperatively and at 1, 3, 6, 12, and 56 weeks postoperatively. Clinical assessment was performed with the Constant-Murley score at 1 year, and structural healing of the cuff was assessed using ultrasonography at 3 and 12 months.

Result

On the first postoperative day, blood flow was significantly higher in all 6 areas of the shoulder in group 1 than in group 2. The mean total vascular score was significantly higher in group 1 than in group 2 on postoperative day 1 (P = .0001) and remained so at 6 weeks (P = .0001). However, significantly higher vascular flow was noted only in the peribursal region at 6 weeks in group 1 (P = .04). No significant difference in the visual analog scale score was noted between the 2 groups at any given point of follow-up. Furthermore, no clinical and structural healing differences were noted between the 2 groups at final follow-up.

Conclusion

Higher blood flow in and around the posterosuperior rotator cuff owing to an abducted shoulder position with an abduction brace in the first 6 weeks postoperatively fails to offer any advantage in terms of lower pain levels, better clinical scores, or superior cuff healing.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Non-inferiority and cost-effectiveness trial of isolated biceps tenotomy versus tenotomy with rotator cuff repair in patients with stage 2-3 Goutallier fatty degenerative cuff lesions (TenCuRe study): protocol of a multicentre randomised controlled trial

INTRODUCTION

For patients who are diagnosed with lesions of the rotator cuff that present advanced levels of fatty degeneration, arthroscopic repair of the rotator cuff remains controversial. This controversy can be attributed to the frequently reported high failure rate of the tendon fixation and the fact that it remains unclear why repair for these tears results in significant clinical improvement independent of the occurrence of such a re-tear. Recent publications have reported comparable clinical improvements when merely a tenotomy of the long head of the biceps tendon was performed and the rotator cuff tear was left untreated. These observations raise questions on the value of performing the more extensive cuff repairs in degenerative cuff tears. Even more, rehabilitation after an isolated tenotomy is much less cumbersome as compared with rehabilitation after rotator cuff repair and, therefore, might result in improved patient satisfaction. The goal of this trial is to study function and quality-of-life of patients undergoing arthroscopic biceps tenotomy with or without an additional cuff repair and to include an economic evaluation.

METHODS AND ANALYSIS

This multicentre randomised controlled non-inferiority trial, including an economic evaluation, is designed to compare the short-term and long-term outcome of patients who underwent an arthroscopic tenotomy of the long head of the biceps tendon with or without a cuff repair. We will include 172 patients with stage 2-3 Goutallier fatty infiltration cuff tears and with clinical symptoms of biceps pathology. Primary outcome is the rotator cuff specific quality-of-life (Western Ontario Rotator Cuff index) on the short term (6 months postoperatively). Secondary outcomes are quality-of-life 1, 2 and 5 year postoperatively and function (Constant-Murley score, glenohumeral range of motion), recovery status, pain (visual analogue scale), economic evaluation, satisfaction of treatment on the short-term and long-term and re-tear rate at 6 months determined with an ultrasound.

ETHICS AND DISSEMINATION

This trial has been approved by the Medical Research Ethics Committees United (MEC-U), Nieuwegein, the Netherlands (NL54313.100.15) and will be performed in accordance with the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results of this study will be reported in peer-reviewed journals and at (inter)national conferences. Furthermore, we will share our findings with the appropriate guideline committees.

TRIAL REGISTRATION NUMBER

The Dutch Trial Registry (NL4010).

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Compliance with wearing an abduction brace after arthroscopic rotator cuff repair: A prospective, sensor-controlled study

BACKGROUND

Immobilization, using a shoulder abduction brace, may be important after rotator cuff repair to achieve successful tendon-to-bone healing. Compliance with wear time is a concern.

OBJECTIVES

Therefore, the abduction brace wearing time was assessed with temperature-sensitive sensors to objectively measure the abduction brace wearing compliance rate.

STUDY DESIGN

Level of evidence I, prospective observational study.

METHODS

A temperature sensor was implanted into 54 standard shoulder abduction braces, worn by 50 patients (27 women; mean age, 56 years). At 6 weeks post-surgery, patients reported the number of hours they had worn the brace. The patient-reported and sensor data were compared, and the compliance rate (relative to the recommended wearing time) was determined, with compliance being the primary end-point and the discrepancy between the measured and patient-reported wear time being the secondary end-point.

RESULTS

Compliance was ⩾80% in 24 (48%) patients. Sensor-based compliance was lower than self-reported compliance (75% versus 96%, p ⩽ 0.001). Compliance was not predicted by age, sex, smoking, educational, employment, living status, or handedness.

CONCLUSIONS

Roughly 50% of patients did not wear the brace at least 80% of the recommended time. Self-reported compliance is significantly lower than sensor-based compliance. Compliance was not predicted by measured demographic variables.

CLINICAL RELEVANCE

This is the first study in which the abduction brace adherence of patients after rotator cuff repair was assessed by the use of a temperature-sensitive sensor. The postoperative use of these braces is questionable as the patient's abduction brace adherence is low. The self-reported wearing compliance is unreliable.

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.

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study

BACKGROUND

To date, no studies have been published that have assessed the optimal position of sling immobilization after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis.

METHODS

Thirty-six patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling versus an internal rotation sling. The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score; Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year.

RESULTS

All patient-determined outcome scores for both groups revealed statistically significant improvements (P < .0001) from enrollment to final follow-up. There were statistically significant advantages to the neutral rotation sling group compared with the internal rotation sling group when we evaluated the improvements in (1) active external rotation (42° vs 25°, P = .03), (2) passive external rotation (44° vs 26°, P = .02), (3) passive horizontal adduction (7.7 cm vs 3.7 cm, P = .05), and (4) pain relief with passive adduction (VAS score, 6.2 cm vs 3.5 cm; P = .002). There was a trend toward greater improvements in the neutral rotation sling group when we measured (1) active horizontal adduction (8.3 cm vs 2.9 cm, P = .06) and (2) active internal rotation behind the back (18 cm vs 11.1 cm, P = .09). At 2 weeks, the neutral rotation sling group had significantly less night pain than the internal rotation sling group (mean VAS score, 18 mm vs 34 mm; P = .047).

CONCLUSIONS

Neutral rotation sling use after anatomic total shoulder arthroplasty resulted in statistically significant improvements in external rotation and adduction, as well as decreased night pain, compared with an internal rotation sling.

No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial

PURPOSE

The aim of this study was to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff (RC) repair in a prospective randomized controlled non-inferiority trial.

METHODS

One hundred twenty patients were included after RC surgery for a small- to medium-sized tear of supraspinatus and upper infraspinatus tendons. Group A was immobilized in a simple sling for 3 weeks, and group B had a brace with a small abduction pillow with the arm in neutral position for 6 weeks. All patients started active range of motion when they removed the sling/brace. One hundred eighteen (98%) patients were assessed at 1-year follow-up. They underwent magnetic resonance imaging (MRI) of the shoulder, filled out the Western Ontario Rotator Cuff (WORC) index, and were evaluated with a Constant Murley (CM) score.

RESULTS

Statistical non-inferiority was demonstrated for the 2 groups on the basis of the WORC index, the primary endpoint at 1 year. The objective for the non-inferiority test was to determine whether the expected mean WORC index for group A was at most 13% worse than standard treatment (Group B). The WORC index at 1 year was similar in both groups, with mean percent scores of 83% in group A and 87% in group B (mean difference = -4; 95% one-sided CI -9, -4). Age-adjusted CM scores were also similar, with means of 86 in group A and 90 in group B (mean difference = -4; 95% CI -13, 5; P = .37). MRI after 1 year showed 50 (89%) patients in each group with healed RC repair. Four patients in group A had complications: 1 acute postoperative infection, 2 cases of postoperative capsulitis treated with corticosteroid injections, and 1 repeat operation because of a loose anchor and subacromial pain. No patients in group B had complications.

CONCLUSION

RC repair resulted in improved postoperative shoulder function, regardless of whether the shoulder was immobilized for 3 or 6 weeks. Three weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace with regard to the WORC index at 12 months' follow-up. MRI indicated similar degrees of healing between the groups. Based on these findings, it is safe to immobilize patients in a simple sling for 3 to 6 weeks after repair of small to medium RC tears.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with statistically significant differences.

Editorial Commentary: Better Care, Better Health, Better Cost: Is Scientific Evidence Negatively Impacting the Transformation of Health Care?

The selection of an immobilization device and arm positioning may play a role in postoperative pain and healing after arthroscopic rotator cuff repair. Although the current evidence is inconclusive, it is important that we aim as a profession to produce meaningful evidence that will advance the care of our patients while controlling health care costs.

Getting Back to Basics: The "Primary" Outcome Measure Determines a Study's Conclusion

In this month's issue, Hollman, Wolterbeek, Zijl, van Egeraat, and Wessel from Nieuwegein, The Netherlands, investigate an essential and most basic concern: how does an abduction brace compare to a simple sling after arthroscopic rotator cuff repair? A criticism of the study, well noted in Editorial Commentary by Kevin Plancher, is that Hollman et al. selected postoperative pain (rather than long-term clinical outcome) as their "primary" outcome measure. The primary outcome measure determines the conclusion of a study. Accurate conclusions require adequate statistical power, particularly if potentially underpowered secondary outcome measures (in this case, long-term clinical outcome) show no difference between 2 treatment options. Research clinicians, patients, and payers comparing abduction brace versus sling after shoulder rotator cuff repair ultimately need to understand if there is a difference in long-term clinical outcomes between the treatment options.