Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?

A Systematic Review and Meta-analysis of Risk Factors for the Increased Incidence of Revision Surgery After Arthroscopic Rotator Cuff Repair

BACKGROUND

Approximately 90% of patients who undergo arthroscopic rotator cuff repair (RCR) are satisfied with their pain levels and function after surgery. However, a subset of patients experience continued symptoms that warrant revision surgery. Preoperative risk factors for RCR failure requiring revision surgery have not been clearly defined.

PURPOSE

To (1) determine the rate of RCR failure requiring revision surgery and (2) identify risk factors for revision surgery, which will help surgeons to determine patients who are at the greatest risk for RCR failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were performed. The initial search resulted in 3158 titles, and 533 full-text articles were assessed for eligibility. A total of 10 studies met the following inclusion criteria: (1) human clinical studies, (2) arthroscopic RCR, (3) original clinical research, and (4) evaluation of preoperative risk factors for revision.

RESULTS

After a full-text review, a total of 16 risk factors were recorded and analyzed across 10 studies. Corticosteroid injection was the most consistent risk factor for revision surgery, reaching statistical significance in 4 of 4 studies, followed by workers' compensation status (2/3 studies). Patients with corticosteroid injections had a pooled increased risk of revision surgery by 47% (odds ratio, 1.44 [95% CI, 1.36-1.52]). Patients with workers' compensation had a pooled increased risk of revision surgery by 133% (odds ratio, 2.33 [95% CI, 2.09-2.60]). Age, smoking status, diabetes, and obesity were found to be risk factors in half of the analyzed studies.

CONCLUSION

Corticosteroid injections, regardless of the frequency of injections, and workers' compensation status were found to be significant risk factors across the literature based on qualitative analysis and pooled analysis. Surgeons should determine ideal candidates for arthroscopic RCR by accounting for corticosteroid injection history, regardless of the frequency, and insurance status of the patient.

Postoperative Antiosteoporotic Treatment with Zoledronic Acid Improves Rotator Cuff Healing but Does Not Improve Outcomes in Female Patients with Postmenopausal Osteoporosis: A Prospective, Single-Blinded, Randomized Study

PURPOSE

To investigate the effect of the antiosteoporotic agent zoledronic acid (ZA) on rotator cuff healing and clinical outcomes in patients with postmenopausal osteoporosis.

METHODS

We prospectively enrolled 138 female patients with postmenopausal osteoporosis who were scheduled to undergo arthroscopic rotator cuff repair (ARCR) from March 2020 to March 2021. Patients were randomly allocated to the ZA group (ARCR followed by intravenous ZA infusions at postoperative Day 1 and 1 year later) and the control group (ARCR alone). All patients were followed up for 24 months. Tendon healing was evaluated by ultrasonography at 6 weeks and 24 months after surgery. The American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and Numeric Rating Scale (NRS) for pain were recorded at each follow-up, and the minimal clinically important difference (MCID) was calculated.

RESULTS

A total of 124 patients were included in the final analysis, 61 in the ZA group and 63 in the control group. There was no statistically significant difference in participant characteristics between the 2 groups. The ZA group had a significantly higher tendon healing rate than the control group at 2 years after surgery (odds ratio = 5.0; 95% confidence interval [CI], 1.4-18.7; P = .014). Regarding clinical outcomes, 100% of patients exceeded the MCID in both groups, and no significant differences were found at 2 years after surgery between the 2 groups (ASES: 2.5 [95% CI, -2.2 to 7.2; P = .291]; WORC index: 4.5 [95% CI, -0.117 to 9.117; P = .056]; NRS: -0.1 [95% CI, -0.3 to 0.1; P = .394]).

CONCLUSIONS

Antiosteoporotic treatment with ZA reduced the retear rate but did not significantly influence the clinical outcomes after ARCR in female patients with postmenopausal osteoporosis. Outcomes of ARCR showed good results in both groups and exceeded the MCID.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Editorial Commentary: Corticosteroid Injections Administered Within 4 Weeks Before Shoulder Arthroscopy Are Associated With an Increased Risk of Infection

Corticosteroid injections are a frequently used modality for addressing shoulder pain. The widespread utilization of corticosteroid injections is supported by clinical practice guidelines and consensus statements including the 2019 American Academy for Orthopaedic Surgeons (AAOS) guidelines for the management of rotator cuff injuries. However, steroids may be detrimental to healing potential following cuff repair and increase the risk of re-tear. In addition, corticosteroid injections administered within 4 weeks prior to shoulder arthroscopy are associated with an increased risk of infection. The degree of risk is dependent on the timing of surgery with longer time intervals between injection and shoulder arthroscopy being associated with less risk. The next version of the AAOS clinical practice guidelines for managing rotator cuff tears should incorporate commentary on the specific risk of surgical site infection following pre-operative corticosteroid injections, as well as on the timing of injections, with the aim of increasing awareness of these potentially devastating adverse effects.

Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair

Background

Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI.

Methods

An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05).

Results

There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05).

Conclusion

Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.

Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections

BACKGROUND

Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair.

PURPOSE

To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes-including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness-were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9.

RESULTS

Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy.

CONCLUSION

No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.

Effects of Platelet-Rich Plasma in Tear Size Reduction in Partial-Thickness Tear of the Supraspinatus Tendon Compared to Corticosteroids Injection

OBJECTIVES

Corticosteroid (CS) injection is commonly used in partial-thickness rotator cuff tears to decrease pain. However, this could result in unwanted side effects, such as tendon rupture. Alternatively, platelet-rich plasma (PRP) injection is frequently used to treat tendinopathies because it enhances healing. This study aimed to compare the differences in tear size and functional scores between intralesional PRP and subacromial CS injections.

METHODS

Patients with symptomatic partial-thickness tears of the supraspinatus tendon who underwent conservative treatment for ≥ 3 months were enrolled. All patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis. Fourteen and 15 patients were randomized to receive intralesional PRP and subacromial CS injections, respectively. Tears were measured in the coronal and sagittal planes. The patients underwent another MRI 6 months after the injection. Tear size was compared between the two MRI results. The American Shoulder and Elbow Surgeons Shoulder score (ASES) and Constant-Murley score (CMS) were also obtained.

RESULTS

The baseline data were similar between the groups. In the coronal plane, PRP and CS showed tear size reductions of 3.39 mm (P = 0.003) and 1.10 mm (P = 0.18), respectively. In the sagittal plane, PRP and CS showed tear size reductions of 2.97 mm (P = 0.001) and 0.76 mm (P = 0.29), respectively. Functional scores improved 6 months after injection in both groups, but PRP showed better functional scores than CS (P = 0.002 for ASES, P = 0.02 for CS).

CONCLUSION

Intralesional PRP injection can reduce the tear size in partial-thickness tears of the supraspinatus tendon. Subacromial steroid injection did not significantly affect the tear size. While CS improved functional scores compared with baseline, PRP resulted in better improvement 6 months post-injection. Trial registration Thai Clinical Trials Registry, TCTR20210428004. Registered 28 April 2021-retrospectively registered, TCTR20210428004 .

Older age and higher body mass index are independent risk factors for tendon healing in small- to medium-sized rotator cuff tears

PURPOSE

Many previous research efforts have been made to identify prognostic factors for rotator cuff healing. However, majority of these studies were conducted with heterogeneous cohorts consisted of different tear characteristics. Healing properties of a rotator cuff tear may differ depending on tear characteristics such as tear size or fatty infiltration. Therefore, studies with subgroups confined by these variables may reflect more accurate results. This study aims to investigate predictive factors for rotator cuff healing in a subgroup with small- to medium-sized tears without significant fatty infiltration.

METHODS

This retrospective case-control study was conducted with 94 patients with small- to medium-sized rotator cuff tears. Mean age of patients was 56.0 ± 9.0 years and mean follow-up duration was 38.3 ± 8.1 months. Post-operative magnetic resonance imaging assessment showed that there were 75 (79.8%) successfully healed repairs and 19 (20.2%) healing failures. Age, gender, hand dominancy, body mass index (BMI), smoking habit, diabetes, corticosteroid injection, baseline clinical status, duration of surgery and biceps procedure were variables evaluated as predictive factors.

RESULTS

Both study groups showed significant improvement from baseline regarding clinical outcome measures (p < 0.05). However, successfully healed patients had significantly higher post-operative functional scores and lower pain scores (p < 0.05). The univariate analysis revealed that healing was significantly affected by age (p = 0.004), BMI (p = 0.01) and diabetes (p = 0.03). In the multivariate analysis, age (p = 0.02) and BMI (p = 0.02) were found to be significant independent factors for healing. Cutoff values for oldest age and highest BMI were 63 years and 28.1 kg/m², respectively, for a successful healing according to receiver-operating characteristic curve analysis.

CONCLUSION

Healing failure after rotator cuff repair in small- to medium-sized tears is associated with poorer outcomes. Age and BMI are independent predictive factors for healing. A successful repair is more likely in patients younger than 63 years and with BMI less than 28.1 kg/m². Surgeons should consider this information during risk assessment, decision making and patient counselling.

LEVEL OF EVIDENCE

Level III.

Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review

Purpose

To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects.

Methods

A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications.

Results

Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month.

Conclusions

Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events.

Level of Evidence

Systematic review of level I-IV studies.

The impact of chronic steroid use on early postoperative complications in shoulder surgery

OBJECTIVES

Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications.

RESULTS

We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51-3.21], p < 0.001), minor (OR 2.32[1.13-3.2], p < 0.001), and infectious complications (OR 1.90[1.13-3.2], p = 0.01).

CONCLUSIONS

Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.

A Primary Care Provider's Guide to Shoulder Pain After Spinal Cord Injury

Shoulder pain is a common occurrence after spinal cord injury (SCI) and can have significant negative effects on health and function as many individuals with SCI are reliant on their upper extremities for mobility and self-care activities. Shoulder pain after SCI can be caused by acute injury or chronic pathology, but it is most often related to overuse injuries of the rotator cuff. Both acute strain and chronic overuse shoulder injuries in persons with SCI typically result from increased weight bearing on the upper extremities during transfers, weight-relief raises, and wheelchair propulsion, which are often performed in poor postural alignment owing to strength deficits. This article discusses management of patients with SCI who present with shoulder pain from the perspective of primary care physicians including evaluation and diagnostic procedures, interventions appropriate for both acute and chronic shoulder pain, and strategies for prevention.

How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair

INTRODUCTION

Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair.

HYPOTHESIS

The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair.

METHODS

This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848).

RESULTS

Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197).

CONCLUSION

This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery.

LEVEL OF EVIDENCE

II, low-powered placebo-controlled, randomized study.

Health Care Utilization and Costs in the Year Prior to Arthroscopic Rotator Cuff Repair

Background:

A majority of cost-control strategies in arthroscopic rotator cuff repair (RCR) have been concentrated on the perioperative and post–acute care periods, with the preoperative health care period being largely overlooked.

Purpose:

To report the distribution of costs associated with health care utilization within the year prior to arthroscopic RCR.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2007 through 2015 (third quarter) Humana Administrative Claims database was queried using Current Procedural Terminology code 29827 to identify patients undergoing arthroscopic RCR for only degenerative rotator cuff tears. The study cohort was divided into 2 distinct groups based on insurance plan: commercial or Medicare Advantage (MA). Total 1-year costs, per-patient average reimbursements (PPARs), and trends in utilization for the following preoperative health care resource categories were studied: office visits, radiographs, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, steroid injections, hyaluronic acid (HA) injections, physical therapy, and pain medications (opioids + nonopioids).

Results:

A total of 18,457 MA and 6530 commercial beneficiaries undergoing arthroscopic RCR over the study period were included. Total 1-year preoperative costs (in US$) amounted to $16,923,595 ($916/patient) and $8,397,291 ($1285/patient) for MA and commercial beneficiaries, respectively. The largest proportion of total 1-year costs for both MA and commercial beneficiaries was accounted for by MRI scans (36% and 56%, respectively). PPARs for each health care resource category were as follows: office visits (MA, $240; commercial, $249), radiographs (MA, $60; commercial, $93), MRI scans (MA, $385; commercial, $813), CT scans (MA, $223; commercial, $562), steroid injections (MA, $97; commercial, $137), HA injections (MA, $422; commercial, $602), physical therapy (MA, $473; commercial, $551), and pain medications (MA, $208; commercial, $136). High health care utilization within the past 3 months before surgery was noted for radiographs, physical therapy, opioids, steroid injections, and office visits, with up to 40% to 90% of 1-year PPARs being accounted for within this time period alone.

Conclusion:

Approximately $900 to $1300 per patient was spent in rotator cuff–related health care resource use in the year prior to undergoing arthroscopic RCR. As we begin to implement value in shoulder surgery, judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review

PURPOSE

To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs).

METHODS

A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies.

CONCLUSIONS

CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates.

LEVEL OF EVIDENCE

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

Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis

PURPOSE

To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed.

RESULTS

A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls.

CONCLUSIONS

The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR.

LEVEL OF EVIDENCE

Level III, systematic review of Level I and III studies.

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review

PURPOSE

To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR).

METHODS

A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon.

RESULTS

A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]).

CONCLUSION

Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months.

LEVEL OF EVIDENCE

IV, systematic review of Level III and IV studies.

Preoperative lumbar epidural steroid injections administered within 6 weeks of microdiscectomy are associated with increased rates of reoperation

PURPOSE

Lumbar epidural steroid injections (LESIs) are widely utilized for back pain. However, as studies report adverse effects from these injections, defining a safe interval for their use preoperatively is necessary. We investigated the effects of preoperative LESI timing on the rates of recurrent microdiscectomy.

METHODS

This study utilized the PearlDiver national insurance claims database. Microdiscectomy patients were stratified by the timing of their most recent LESI prior to surgery into bimonthly cohorts (0-2 months, 2-4 months, 4-6 months). This first cohort was further stratified into biweekly cohorts (0-2 weeks, 2-4 weeks, 4-6 weeks, 6-8 weeks). The 6-month reoperation rate was assessed and compared between each injection cohort and a control group of patients with no injections within 6 months before surgery. Univariate analyses of reoperation were conducted followed by multivariate analyses controlling for risk factors where appropriate.

RESULTS

A total of 12,786 microdiscectomy patients were identified; 1090 (8.52%) received injections within 6 months before surgery. We observed a significant increase in the 6-month reoperation rates in patients who received injections within 6 weeks prior to surgery (odds ratio [OR] 1.900, 1.218-2.963; p = 0.005) compared to control. No other significant differences were observed.

DISCUSSION

In this study, microdiscectomy performed within 6 weeks following LESIs was associated with a higher risk of reoperation, while microdiscectomy performed more than 6 weeks from the most recent LESI demonstrated no such association with increased risk. Further research into the interaction between LESIs and recurrent disk herniation is necessary.

Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates

PURPOSE

To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes.

METHODS

Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates.

RESULTS

Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P = .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group.

CONCLUSIONS

This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Timing of Corticosteroid Injections After Arthroscopic Shoulder Procedures Affects Postoperative Infection Risk

BACKGROUND

Corticosteroid injections are sometimes used in the postoperative period after shoulder arthroscopy; however, a well-defined safety profile has not been established.

PURPOSE

To examine the association between the timing of postoperative corticosteroid injections and rates of infection after shoulder arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Private payer and Medicare national insurance databases were queried for patients who underwent arthroscopic rotator cuff repair, debridement, or subacromial decompression. Patients who underwent corticosteroid injections within 1, 2, 3, or 4 months postoperatively were identified and compared with a matched control group that underwent the same procedures without a postoperative steroid injection. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify rates of postoperative infection within 90 days after injection for the study groups and controls. Multivariate binomial logistic regression analysis was used to compare groups, and adjusted odds ratios (ORs) and 95% CIs were calculated, with P < .05 considered significant.

RESULTS

A total of 3946 patients were identified, including 264 patients who received an injection within 1 month after surgery, 471 within 2 months, 1037 within 3 months, 1874 within 4 months, and 2640 matched controls. When compared with controls, patients who underwent a corticosteroid injection within 1 month postoperatively had a significantly higher rate of infection (private payer: OR, 2.63; P = .014; Medicare: OR, 11.2; P < .0001). There were no differences in infection rates at all other time points ( P = .264-.835).

CONCLUSION

This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. Although causality cannot be determined on the basis of this database review, the authors found a significant association between intra-articular corticosteroid injections administered 1 month postoperatively and an increased rate of postoperative infection in Medicare and private payer patient cohorts as compared with a control group.

Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery

PURPOSE

To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery.

METHODS

Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders.

RESULTS

A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations.

CONCLUSIONS

A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: "Doctor, Are You Sure the Steroid Injection Won't Harm My Shoulder?" Perhaps We Should Stop Injecting Corticosteroids and Just Repair Those Rotator Cuffs

Analysis of insurance records indicates that 2 or more corticosteroid injections before rotator cuff repair could triple the odds of revision. The cause-and-effect relationship cannot be ascertained because it remains unclear whether steroids worsen outcomes or are injected in shoulders that are worse to start with. Registry studies cannot adjust for lesional determinants of prognosis and should be interpreted with caution to avoid depriving patients from safe and simple treatments to delay or circumvent surgery. The risks of corticosteroids could be mitigated using radiographically guided infiltration and, ultimately, by rapid surgical repair in young patients before the advent of fatty infiltration and tendon retraction.