Do shoulder patients insured by workers' compensation present with worse self-assessed function and health status?

History of mood and anxiety disorders affects return to work and return to sports after rotator cuff repair

INTRODUCTION

After rotator cuff repair (RCR), return to work and return to sports is affected by various psychosocial factors. The role of one of these factors - mood and anxiety disorders (MAD) - is still not clear. The primary objective of this study was to determine the influence of prior MAD on the return to work and return to sports after RCR. Our hypothesis was that patients with a history of MAD would take longer to return to work and to sports after RCR, and the rate of return would be lower, than for patients without MAD.

MATERIALS AND METHODS

This was a retrospective single-center study of patients who underwent arthroscopic RCR (distal supraspinatus tear). Patients who were employed and those who participated in sports before the surgery were included in the "working" and "sports" groups, respectively. The primary outcomes were the time to return to work and return to sports after surgery. The secondary outcomes were the ratio of patients returning to work and to sports at 3, 6 and 12 months; rate of return to same level of sports; need to change or stop working or sports. The effects of prior MAD on these various outcomes were determined using Bayesian multivariate analysis.

RESULTS

The "working" group consisted of 158 patients (of which 16.5% had MAD) and the "sports" group consisted of 118 patients (of which 17.8% had MAD). In those with a history of MAD, return to work was 21±11 weeks later and the return to sports was 17±8 weeks later than in those without MAD. There was a 98% probability that return to work or return to sports was delayed by at least 4 weeks in patients with history of MAD. The likelihood that patients with prior MAD who undergo RCR will completely abandon their sport was 2.8 times higher (OR=2.8 [1; 7.8]).

CONCLUSION

We found a negative influence of prior MAD on the return to work and return to sports after RCR.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Predictors of Postoperative Patient-Reported Outcome Measure Response Rates Among Patients With Rotator Cuff Repair

BACKGROUND

Patient-reported outcome measures (PROMs) contribute to evaluating and improving the quality of patient care. Patient outcomes after rotator cuff repair (RCR) have been researched; however, the relationship between PROM response rates and individual and health care correlates has not been thoroughly investigated.

PURPOSE

To examine differences in individual and health care factors among patients who had undergone RCR based on their PROM response rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Shoulder-specific and general PROMs were solicited via email and text message of all patients who underwent RCR between 2016 and 2020. Three subgroups were classified: (1) complete responders completed all 1-year postoperative PROMs, (2) partial responders answered enough questions to produce ≥1 usable score, and (3) nonresponders did not respond to a single measure. Correlates were assessed using analysis of variance and chi-square tests. Adjusted multinomial logistic regression models identified predictors of 1-year PROM response.

RESULTS

Of 2195 patients included at the 1-year follow-up, 34% were complete responders; 11%, partial responders; and 55%, nonresponders. Patients had a mean age of 61.8 years, 63% were men, and 90% were White. Pre- and postoperative PROM scores were similar across responder groups. In stepwise selection, 1-year responses (complete or partial) were associated with older age, later year of surgery, White race, and having workers' compensation insurance. The strongest predictor of PROM response was having workers' compensation insurance.

CONCLUSION

Patients with workers' compensation insurance compared with other insurance types responded to PROMs at disproportionately higher rates. This could distort postoperative PROM scores in the population studied because there are known differences among patients with this insurance status.

Workers' Compensation Association With Clinical Outcomes After Anterior Cervical Diskectomy and Fusion

BACKGROUND

Research has suggested that workers' compensation (WC) status can result in poor outcomes after anterior cervical diskectomy and fusion (ACDF).

OBJECTIVE

To determine the influence WC status has on postoperative clinical outcomes after ACDF.

METHODS

A surgical database was reviewed for patients undergoing primary or revision single-level ACDF. Patients were grouped into WC vs Non-WC, and differences in baseline characteristics were assessed. Postoperative improvement was assessed for differences in mean scores between WC subgroups for visual analog scale (VAS) arm, VAS neck, 12-item Short Form Physical Composite Score, Patient-Reported Outcomes Measurement Information System physical function (PF), and Neck Disability Index (NDI) at preoperative and postoperative time points. Minimum clinically important difference (MCID) achievement was compared between groups.

RESULTS

The patient cohort included 44 with WC and 95 without. The cohort was 40% female with an average age of 48 years and mean body mass index of 30. Mean VAS arm, VAS neck, NDI, 12-item Short-Form Physical Composite Score, and Patient-Reported Outcomes Measurement Information System PF scores differed between groups; however, the difference was not sustained at the 1-yr time point. MCID achievement among WC subgroups was different for VAS arm (6 wk through 6 mo, P = .005), VAS neck (3 and 6 mo, P < .01), and NDI (3 and 6 mo, P < .05). No statistically significant difference was noted between cohorts for overall rates of MCID achievement for all patient-reported outcome measures collected.

CONCLUSION

WC patients reported similar preoperative and 1-yr postoperative neck and arm pain compared with non-WC patients after ACDF. One-yr MCID achievement rates were similar between cohorts for disability and PF scores.

Ineffective Communication: The Uninformed Injured Worker

BACKGROUND

Effective communication has been demonstrated to impact patient health outcomes, specifically in improving symptom resolution, safety, function, and emotional well-being, and to lower malpractice claims. I hypothesized that the communication process with patients with Workers' Compensation is inadequate.

METHODS

Prospectively, claimants presenting for an independent medical evaluation or an impairment rating were assessed concerning the education that they received with regard to their claim. Basic principles were based on the Utah Labor Commission Employee's Guide to Workers' Compensation and an employee information sheet.

RESULTS

There were 556 consecutive claimants assessed. None of the participants expressed any familiarity with the employee information sheet. Although there was a mean of 12 months since the date of claim to the evaluation, 536 participants (96.4%) were effectively unaware of the principles surrounding their claim; of these participants, 6 had attorneys and 23 had prior industrial claims. Of the 3.6% of participants who had received the State Employee Guide, 5 had a prior evaluation with the medical director of the Labor Commission, 6 had located the information online, and 9 had been provided information by their nurse-case manager. Even with this information, the context or importance of the information was not well understood. There were 16.4% of participants who were aware of the mileage compensation. Two claimants were aware that the insurer, not the employer, was responsible for managing the claim, 2 claimants were aware that their claim was open for life, and 1 claimant was aware that claimants could change physicians.

CONCLUSIONS

Workers' Compensation programs were designed to expedite care and treatment while decreasing the adversarial environment for workplace injuries. Yet delays and confrontational events continue to be experienced by the injured worker. This often results in the impression that workplace injuries have worse outcomes for the same diagnosis. The lack of effective education with regard to the rights and responsibilities of the claimant may also lead to this poorer outcome. Given studies showing the benefits of patient education in preventing malpractice claims and improving health-care outcomes, it is suggested that improved patient education for the injured worker is warranted and may lead to improved outcomes with diminished adversarial events.

Understanding Outcomes and the Ability to Return to Work After Rotator Cuff Repair in the Workers' Compensation Population

Introduction

Patients with a worker compensation claim are associated with a greater probability of continued symptoms and activity intolerance. This study aims to determine predictors of improved patient-reported outcomes in the workers’ compensation population.

Methods

Patients with workers’ compensation claims undergoing arthroscopic rotator cuff repair between 2010 and 2015 were included. Age, gender, dominant hand, occupation, and number of tendons involved were analyzed. At a minimum of two years, patients were contacted to complete American Shoulder and Elbow Surgeons (ASES) Survey, Simple Shoulder Test (SST), and return-to-work status (RTW). Preoperative characteristics and scores were then compared.

Results

Seventy patients were available for follow-up at an average of 5.4 years (range: 2.1-8.8 years). Average age was 55 years (range: 37-72); 55 (78.6%) were males, 23 (32.9%) were laborers; and 59 (84.2%) patients returned to work. The sole predictor for RTW was surgery on the non-dominant arm (96.5% versus 75.6%; p = 0.021). Laborers showed decreased RTW (p = 0.03). Patients who completed RTW had excellent outcomes with higher ASES (87 versus 50; p value < 0.001) and SST scores (10.4 versus 4.6; p < 0.001). Patients with three tendon tears had inferior ASES (p = 0.026) and SST (p = 0.023) scores than those with less.

Conclusion

Most workers’ compensation patients have excellent outcomes from rotator cuff repair. Patients with three tendon tear repairs demonstrated the worst functional outcomes. Laborers showed decreased ability to RTW with nearly one-third unable.

Patient-Reported Outcomes of Shoulder Surgery in a Community Orthopedic Practice: A 5-Year Quality Improvement Project Using the QuickDASH Questionnaire

There has been a shift in US health care to a system that emphasizes value. Patient-reported outcomes have become a critical component of that valuation. A 5-year quality improvement project at the community private practice level was undertaken to assess the authors' delivery of care and practice processes for shoulder surgery as compared with established standards. QuickDASH questionnaires were collected from 1304 consecutive shoulder surgery patients, and data were collected at 4 time points. Mean QuickDASH scores for each procedure and scores assessing biceps tenodesis, distal clavicle excision, workers' compensation status, and sex were analyzed for statistical significance. Rotator cuff repair patients who also underwent biceps tenodesis had statistically significant worse function preoperatively and at 3 and 6 months postoperatively but not at 1 year postoperatively (P<.05). Rotator cuff repair patients undergoing concomitant distal clavicle excision had statistically significantly higher pre-operative scores (P<.01). Male shoulder arthroplasty patients had statistically significant higher preoperative scores (P<.02). Non-workers' compensation patients had statistically significant higher scores at 1 year (P<.05), whereas workers' compensation patients were statistically significantly younger (P<.01). Maximum changes in scores that met minimal clinically important differences occurred between surgery and 6 months postoperatively in all procedures. Quality outcome studies can be performed in private practice by a single surgeon and yield helpful results that lead to quality improvement through practice and delivery of care processes. [Orthopedics. 2020;43(5):e383-e388.].

Do patients receiving workers' compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case-control study

PURPOSE

We compared preoperative and postoperative measures among workers' compensation board (WCB) recipients and non-recipients and determined the impact of WCB receipt on the 1- and 2-year outcomes of rotator cuff repair.

METHODS

We retrospectively reviewed patients with full-thickness rotator cuff tears who underwent arthroscopic repair between September 2011 and September 2014. Patients were divided into two groups based on WCB status: WCB recipients and non-recipients. All patients returned for follow-up functional evaluations at 1 and 2 years after the operation. Four outcome measures were evaluated: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Rating Scale of the University of California at Los Angeles (UCLA), and range of motion (ROM).

RESULTS

Seventy patients (38 males, 32 females) were evaluated, 20 of whom were WCB recipients. At 1 year after the operation, ASES, UCLA, and VAS scores as well as abduction ROM (Abd-ROM) had improved significantly in both groups. However, non-recipients showed significantly greater improvement than did WCB recipients in ASES, UCLA, and VAS scores and in forward flexion ROM and Abd-ROM ( p = 0.000, 0.009, 0.002, 0.046, and 0.020, respectively). However, at 2 years after the operation (after the end of WCB), there were no significant differences in any clinical outcome between WCB recipients and non-recipients ( p = 0.057, 0.106, 0.075, 0.724, and 0.787, respectively).

CONCLUSION

Although workers' compensation recipients who underwent arthroscopic rotator cuff repair had worse outcomes while receiving WCB benefits, the outcomes were similar after WCB benefits ended.

High prevalence of persistent pain 6 months after arthroscopic subacromial decompression and/or acromioclavicular joint resection

Purpose: The aims of this prospective study were to determine the prevalence of pain 6 months after arthroscopic subacromial decompression (ASD) and/or acromioclavicular joint resection (AC resection), to reveal causes of the pain, and to identify risk factors for persistent pain.

Methods: Preoperatively, patients were tested for their endogenous capacity to modulate pain and completed questionnaires concerning psychological vulnerability. Patients with pain 6 months after surgery were examined by an experienced orthopaedic surgeon to reveal any shoulder pathology responsible for the pain.

Results: Data from 101 patients were available for analysis 6 months after surgery. Thirty-six patients had persistent pain: 32 underwent examination by the surgeon who identified shoulder pathology in ten patients, but not in the remaining 22 in whom ongoing insurance case, unemployment, and a general tendency to worry were risk factors for persistent pain.

Conclusion: The prevalence of persistent pain 6 months after ASD and/or AC resection was 35.6% (95% CI 26.1–45.8%) and the proportion of patients with shoulder pathology was 9.9%. An association between ongoing insurance case, unemployment, general tendency to worry (t-STAI), and unexplained persistent pain 6 months after surgery was found.

Determinants of patient satisfaction following reconstructive shoulder surgery

Background

Obtaining patient satisfaction is a key goal of surgical treatment. It was the purpose of this study to identify pre-, peri- and postoperative factors determining patient satisfaction after shoulder surgery, quantify their relative importance and thereby allow the surgeon to focus on parameters, which will influence patient satisfaction.

Methods

We retrospectively reviewed 505 patients, who underwent either rotator cuff repair (n = 216) or total shoulder arthroplasty (n = 289). We examined 21 patient-specific and socio-demographic parameters as well as 31 values of the Constant-Score with regard to their impact on patient satisfaction.

Results

In the univariable analysis higher patient satisfaction was correlated with higher age, private health insurance, light physical work, retirement, primary surgery, non-smoking, absence of chronic alcohol abuse, absence of peri- or postoperative complications, operation performed by the medical director as well as various Constant Score sub-values (p < 0.05). In the multivariable analysis absence of peri- or postoperative complications (p = 0.008), little postoperative pain (p = 0.0001), a large range of postoperative active abduction (p = 0.05) and a high postoperative subjective shoulder value (p = 0.0001) were identified as independent prognostic factors for high satisfaction.

Conclusion

After reconstructive shoulder surgery particular attention should be paid to prevention of complications, excellent perioperative pain control and restoration of abduction during rehabilitation. This study is first step towards a preoperative prediction model of a subjectively successful surgery as well as a tool to exclude irrelevant parameters in clinical routine.

Ability to return to work without restrictions in workers compensation patients undergoing hip arthroscopy

The purpose of this study was to investigate the ability of worker’s compensation (WC) patients to return to work without restrictions after hip arthroscopy. Twenty-nine WC patients along with age and gender matched controls who underwent hip arthroscopy were retrospectively reviewed after achieving maximum medical improvement (MMI) status at minimum 1 year postoperatively. Patient demographic factors were evaluated, along with the Hip Outcome Score Activities of Daily Living and Sports-Specific subscales, and the modified Harris Hip Score (mHHS). The majority of WC patients were able to return to work without restrictions after reaching MMI (20/29, 69.0%). WC patients who failed to return to work without restrictions had a prolonged time from injury to surgery (3.01 ± 2.16 months versus 6.36 ± 4.16 months; P = 0.0079), more concomitant orthopedic injuries (4/20, 20.0% versus 9/9, 100%; P = 0.0001), and higher body mass index (BMI) (26.61 ± 3.52 versus 29.54 ± 3.43; P = 0.047) than those who returned to work without restrictions. WC patients had significant improvement of patient-reported outcome scores following hip arthroscopy (P < 0.0001), but WC patients who returned to work without restrictions had higher scores than those who failed to do so (HOD-ADL: P < 0.0001; HOS-SS: P = 0.004; mHHS: P = 0.009). The majority of WC patients are able to return to work without restrictions when they reach MMI status following hip arthroscopy. Factors associated with failure to return to work without restrictions include prolonged time course between injury and surgical treatment, concomitant orthopaedic injuries, and a higher BMI. Level III, retrospective case-control study

Workers' compensation claims and outcomes after reverse shoulder arthroplasty

BACKGROUND

The effect of workers' compensation claims on outcomes after reverse shoulder arthroplasty (RSA) has not been investigated. The purpose of this study was to evaluate outcomes after RSA in patients with a workers' compensation claim and to compare them with a control group without a workers' compensation claim.

METHODS

We identified 14 primary RSAs completed in patients with a workers' compensation claim and a minimum of 2 years of follow-up in a prospective shoulder arthroplasty registry. Fourteen patients without a workers' compensation claim served as the age-, gender-, and diagnosis-matched control group. The Constant score, the American Shoulder and Elbow Surgeons score, the Western Ontario Osteoarthritis of the Shoulder Index, the Single Assessment Numeric Evaluation score, mobility, and the patient's satisfaction were assessed for both groups preoperatively and at final follow-up.

RESULTS

There were no differences between the groups regarding patient demographics, duration of follow-up, complications, preoperative shoulder function scores, or preoperative mobility (P > .05). Both groups significantly improved on all shoulder function scores and for mobility from preoperative to final follow-up (all P < .001); however, the workers' compensation group had significantly worse Constant (P = .002), American Shoulder and Elbow Surgeons (P = .003), and Western Ontario Osteoarthritis of the Shoulder Index (P = .001) scores. Only 57% of the workers' compensation group reported that they were satisfied or very satisfied at final follow-up compared with 93% in the control group. The workers' compensation group had a lower return to work rate (14.2% vs 41.7%), but this did not reach statistical significance (P = .117).

CONCLUSION

Patients with a workers' compensation claim had significant improvements after RSA, but they achieved significantly worse outcomes compared with the control group.

Outcomes after hip arthroscopy in patients with workers' compensation claims

Patients with a workers' compensation claim have been shown to have inferior outcomes after various orthopedic procedures. In hip arthroscopy, good to excellent results have been shown in the athletic and prearthritic population in short-term and long-term follow-up. In the current study, the authors' hypothesis was that patients with a workers' compensation claim would have inferior outcomes after hip arthroscopy compared with patients without a workers' compensation claim. All patients with a workers' compensation claim who underwent hip arthroscopy over a 2-year period were studied. Postoperative functional outcomes were assessed with the Hip Outcome Score and modified Harris Hip Score. A cohort of 30 patients who did not have a workers' compensation claim was selected for comparison. Twenty-six patients were identified who had a workers' compensation claim and underwent hip arthroscopy performed by a single surgeon at the authors' institution with at least 6 months of follow-up. These patients were compared with 30 patients who did not have a workers' compensation claim. The workers' compensation group had a Hip Outcome Score of 66.5±28.8 and the non-workers' compensation group had a Hip Outcome Score of 89.4±12.0. This difference was statistically significant with Wilcoxon test (P=.003). The workers' compensation group had an average modified Harris Hip Score of 72.5±20.7 (mean±SD), and the non-workers' compensation group had a modified Harris Hip Score of 75.6±15.3. This difference was not significantly significant with Wilcoxon test (P=.9). At latest follow-up, 15 patients in the workers' compensation group (58%) were working. Patients returned to work an average of 6.8 months after surgery. The current study showed that postoperative functional outcomes in the workers' compensation group, as measured by Hip Outcome Score, were significantly inferior to those in the non-workers' compensation group. No statistical difference in postoperative modified Harris Hip Score was seen.

National trends and perioperative outcomes in primary and revision total shoulder arthroplasty: Trends in total shoulder arthroplasty

INTRODUCTION

Total shoulder arthroplasty (TSA) is a highly successful procedure for management of glenohumeral arthritis, fractures and rotator cuff tears. The purpose of this study was to evaluate patient demographics, perioperative outcomes and assess recent national trends in both primary and revision TSA.

METHODS

The National Hospital Discharge Survey database was searched for patients admitted to US hospitals for primary and revision TSA from 2001 to 2010.

RESULTS

A total of 1,297 patients who underwent primary TSA and 184 patients who underwent revision TSA were identified. The rates of primary TSA (r = 0.88) and revision TSA (r = 0.85) both demonstrated a strong positive correlation with time. The mean patient age of the primary group was significantly higher than the revision group. Gender was not significantly different between the groups. There was no significant difference in the racial make-up between the revision and primary groups. African Americans accounted for 3.3 % of primaries versus 4.3 % of revisions (p = 0.615). Revision TSA patients had a significantly longer average LOS (3.06 days vs 2.46 days, p < 0.01), more medical comorbidities (6.0 vs 5.1 comorbidities, p < 0.01) and a higher rate of developing a myocardial infarction (2.2 % versus 0 %, p < 0.01) than the primary TSA group.

CONCLUSIONS

This study demonstrates that the rate of TSA is rapidly increasing in the US, with over a four-fold increase in revisions and five-fold increase in primaries over the ten years studied.

General and disease-specific use of outcomes scores for the shoulder: a survey of AOSSM, AANA, and ISAKOS members

OBJECTIVE

To report on the knowledge and use of both general and disease-specific shoulder outcomes scores among orthopedic surgeons.

METHODS

A 22-question Internet survey was administered to members of the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North American, and the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine via voluntary e-mail participation. Questions targeted demographic information, preferred surgical management of shoulder conditions, and the preferred use of shoulder outcomes instruments in clinical practice.

RESULTS

Excluding defunct and duplicate e-mails among membership societies, a total of 3892 unique e-mails were sent, from which 1129 surveys were returned and were fully completed (29%). The largest number of respondents were in private practice (52%); 21% were in academia; and 26% were in a mix of settings. As for location, 74% practiced in the United States, 10% in Europe, 8% in Mexico/South America, and 6% in Asia. A total of 31% total respondents used scores all or most of the time, and 30% used scores at least some of the time. Respondents felt that the 3 most commonly utilized shoulder scores were the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) score, and the Constant score. The majority of respondents (76%) performed all-arthroscopic instability repairs. The ASES and Western Ontario Shoulder Instability Index (WOSI) scores were the most preferred measures to monitor instability patients, whether or not the scores were actually implemented in their practice. Most perform between 10 and 25 superior labrum anterior-posterior repairs per year and preferred the ASES, UCLA, and Constant scores for these repairs; rotator cuff repair preferred outcomes instruments were similar. When asked to choose 1 score for all shoulder conditions, the ASES was the clear favorite.

CONCLUSIONS

This study reports the knowledge and utilization of shoulder scores for both general and disease-specific conditions. Most respondents preferred the ASES score for most shoulder conditions; however, other scores, such as the WOSI, the Constant, and the Short-Form (SF)-36/12, were popular. This information offers insight into the current and future use of shoulder outcomes both for general and disease-specific use.

The relationship between medical malpractice litigation and parent reports of patient function following neonatal brachial plexus palsy

BACKGROUND

The increasing use of patient-reported outcome measures in clinical research and care across all medical disciplines requires an understanding of the nonclinical variables that affect these measures. Participation in medical malpractice litigation, as is common following neonatal brachial plexus palsy, may be an important confounder of parent or patient-reported outcomes.

METHODS

This multicenter, case-control study includes patients two to eighteen years of age with neonatal brachial plexus palsy seen at three tertiary brachial plexus centers from January 1990 to December 2011. Public court records were searched for litigation details. Families with and without medical malpractice litigation were matched on age and injury severity (by Raimondi scale and Mallet classification). Parent or patient-reported outcomes, measured by the Pediatric Outcomes Data Collection Instrument, were compared between litigation and non-litigation cohorts.

RESULTS

Of 334 patients from eighteen states, seventy-five (22%) were plaintiffs in medical malpractice lawsuits. When matched on patient age and injury severity, parents reported their children to have worse mobility (p = 0.04), sports or physical function (p = 0.003), and global function (p = 0.02) in the litigation cohort compared with the non-litigation cohort. Parents in active lawsuits reported their children to have greater pain (p = 0.046) compared with children of parents in closed lawsuits, when controlling for patient age and injury severity. Outcomes scores simultaneously obtained from patients and parents differed in the litigation cohort, with parents reporting their children to have worse upper-extremity function (p = 0.03) and global function (p = 0.008) than their children reported.

CONCLUSIONS

Litigation is associated with worse parent reports of children's function and pain following neonatal brachial plexus palsy, independent of age, injury severity, and the patients' own report of their function. Litigation status should be considered a confounding variable in the use of parent-reported outcomes in neonatal brachial plexus palsy research. Parents involved in litigation may benefit from additional support.

Topics and trends in research on non-clinical interventions aimed at preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs): a systematic, comprehensive literature review

PURPOSE

This study sought to provide an overview of the main topics and trends in contemporary research on successful non-clinical interventions for preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs).

METHODS

A systematic electronic search (English and French) was performed in ten scientific databases using keywords and descriptors. After screening the identified titles and abstracts using specific sets of criteria, categorical and thematic analyses were performed on the retained articles.

RESULTS

Five main topics appear to dominate the research: (1) risk factors and determinants; (2) effectiveness of interventions (programmes, specific components, strategies and policies); (3) viewpoints, experiences and perceptions of specific actors involved in the intervention process; (4) compensation issues; and (5) measurement issues. A currently widespread trend is early screening to identify risks factors for appropriate intervention and multidisciplinary, multimodal approaches. Morover, workplace-related psychosocial and ergonomic factors are considered vital to the success and sustainability of return-to-work (RTW) interventions. Finally, involving workplace actors, and more specifically, affected workers, in the RTW process appears to be a powerful force in improving the chances of moving workers away from disabled status.

CONCLUSIONS

The findings of this literature review provide with information about the main topics and trends in research on rehabilitation interventions, revealing some successful modalities of intervention aimed at preventing prolonged work disability.

IMPLICATIONS FOR REHABILITATION

Successful intervention for preventing prolonged work disability in workers compensated for WRMSDs address workplace issues: physical and psychosocial demands at work, ability of the workers to fill these demands, work organization and support of the worker, and worker' beliefs and attitudes related to work. Successful intervention promotes collaboration, coordination between all actors and stakeholders involved in the process of rehabilitation. Strategies able to mobilize the employees, employers, insurers and health care providers are still needed to be implemented.

Hip arthroscopy for labral tears in workers' compensation: a matched-pair controlled study

BACKGROUND

Workers' compensation (WC) status has been related to clinical outcomes; however, no comparative studies have been performed to assess 2-year outcomes between hip arthroscopy patients based on WC status.

PURPOSE

To evaluate 2-year outcomes of patients receiving WC who underwent hip arthroscopy for labral tears and to compare outcomes with those of a matched control group not receiving WC.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

During the study period between June 2008 and August 2010, data were collected on all patients treated with hip arthroscopy. Inclusion criteria for the study group were diagnosis of labral tear and WC status. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. A matched-pair group of patients not associated with WC was selected in a 1:1 ratio according to age within 3 years, sex, surgical procedures, and radiographic findings.

RESULTS

Twenty-one hips were included in each group. Patients with WC status had significantly lower preoperative PRO scores for all measures (P < .001). However, there was no significant difference between VAS pain scores between the groups. Of the WC patients, 86% returned to work at a median 82 days postoperatively. For the WC group, the score improvement from preoperative to 2-year follow-up was 46 to 67.7 for mHHS, 39.3 to 66 for NAHS, 39.7 to 69.5 for HOS-ADL, and 15.3 to 49.8 for HOS-SSS. For the control group, the score improvement from preoperative to 2-year follow-up was 67.9 to 85.8 for mHHS, 62.6 to 84.4 for NAHS, 69.8 to 86.9 for HOS-ADL, and 41.9 to 73.8 for HOS-SSS. Both groups demonstrated statistically significant postoperative improvement in all scores, and the average amount of change of preoperative to postoperative scores between the 2 groups was only significantly different for the HOS-ADL in the control group (P = .043). However, the WC group demonstrated greater improvement in aggregate scores in the HOS-ADL. Pain scores decreased from 7 to 3.9 in the WC group and 5.8 to 3.2 in the control group and were not significantly different between the groups. Patient satisfaction was 6.8 for the WC group and 7.7 for the control group, with no significant difference between groups.

CONCLUSION

Our study demonstrated that WC patients had significantly lower baseline PRO scores when compared with a matched-pair control group. However, both groups demonstrated statistically significant postoperative improvement in all scores. Patients with WC status started and ended with lower absolute scores but benefited from arthroscopic intervention for hip injuries. While patient and physician expectations may be adjusted accordingly, these results may reflect favorably on the use of hip arthroscopy for labral tears in the WC population.

Outcomes after distal biceps repair in patients with workers' compensation claims

BACKGROUND

Prior studies have suggested that patients with workers' compensation (WC) related injuries have less successful postsurgical outcomes compared to the general population. The purpose of this study was to determine the functional outcome and return to work for WC patients who have undergone distal biceps tendon repair (DBTR). A group of patients without a WC claim (non-WC) served as a control.

METHODS

From July 2002 to December 2009, 60 WC patients and 63 non-WC patients who underwent unilateral, acute (<6 weeks) DBTR and had a minimum of 12 months of postoperative follow-up were contacted. Data pertaining to patient age, sex, handedness, smoking status, occupation, time to return to work, and ability to return to original occupation were obtained. Functional outcomes were primarily assessed with the DASH, DASH-Work Module, and DASH Sports/Performance Arts Module questionnaires. Outcomes in the WC group were compared to the non-WC group.

RESULTS

Average length of follow-up was 3.55 years (range, 1.5-8.9) in the WC group and 3.64 years (range, 2.2-8.0) in the non-WC group. Mean DASH, DASH-Work Module, and Sports/Performance Arts Module scores were significantly greater (poorer outcome) in the WC group than in the non-WC group. Average time to return to full duty was 3.95 months in the WC group and 1.35 months in the non-WC group.

CONCLUSION

WC patients who underwent distal biceps tendon repair took longer to return to work and had worse DASH scores than non-WC patients.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study, Treatment Study.

Carpal tunnel surgery: patient preferences and predictors for satisfaction

Carpal tunnel syndrome is a debilitating disease of the upper extremity affecting patient function and quality of life. Surgical interventions have been developed that effectively treat this disease. However, there remains a subset of patients who are not fully satisfied with their outcome. Extensive investigation has been undertaken to analyze preoperative factors predictive of higher patient satisfaction. This review summarizes the role of unique patient characteristics and patient psychology, worker's compensation, patient demographics, certain clinical features, and patient preferences and expectations regarding patient satisfaction following carpal tunnel surgery. Understanding the complex nature of patient satisfaction will enable surgeons to indicate patients for surgical intervention better, provide appropriate preoperative counseling, and manage expectations postoperatively.

Occupational outcome after surgery in patients with a rotator cuff tear due to a work-related injury or occupational disease. A series of 262 cases

The goals of this study were to establish the occupational outcome after surgery in patients with a rotator cuff tear from a work-related injury (WRI) or occupational disease (OD) and determine which factors and conditions affected return to work.

HYPOTHESIS

return to work was possible for this type of patient. This questionnaire-based study comprised 262 shoulders in 254 patients with a WRI/OD who had surgery performed on their shoulder between 2000 and 2005. The average age was 50.5 ± 6.4 years. The following variables were analysed: employment status (private sector, self-employed, government employee), type of work (non-manual, manual, heavy manual labour), nature of tendon injury and surgical technique (open, mini-open and arthroscopy). Return to work occurred in 59.5% of the cases. Factors that prevented return to work (40.4% of the cases) included retirement (14.1%), an unrelated medical condition (10.3%), and the outcome of the operated shoulder (16.0%). Age had an impact on return to work (P<5 × 10(-4)). The type of work and nature of tendon injury did not affect return to work, but did affect time away from work. Employment status and surgical technique had an effect on return to work, but not on time away from work. Age was a decisive factor for return to work. Retirement seemed to be the most common choice starting at 55 years of age. Arthroscopy seemed to have reduced the impact of the WRI on the results, particularly on the time away from work. A preoperative evaluation of the patient's probability of returning to work should be done based on occupational and injury features. There may be a longer delay in returning to work for certain profiles of work (manual labour) and tendon injury. Patient management can be improved by knowing the factors and conditions that influence return to work.

LEVEL OF EVIDENCE

Level IV - Retrospective study.

Outcomes of revision arthroscopic type II superior labral anterior posterior repairs

BACKGROUND

Outcomes of arthroscopic type II superior labral anterior posterior (SLAP) repairs have been reported with success. However, published data regarding outcomes of revision arthroscopic type II SLAP repairs are lacking.

HYPOTHESIS

Outcomes of revision arthroscopic type II SLAP repairs are inferior to those of primary repairs.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective chart review was performed to identify patients who had undergone revision arthroscopic type II SLAP repairs at our institution. Patients who underwent concomitant rotator cuff repairs or labral repairs for instability were excluded. Twelve patients were contacted, and the following outcome data were prospectively gathered: American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction level, return to work, return to sports, and physical examination. Demographics and intraoperative report data were also collected from the charts.

RESULTS

The mean age at the time of revision arthroscopic type II SLAP repairs was 32.6 years (range, 19-67 years) with a mean follow-up of 50.5 months (range, 8-81 months). There were 5 workers' compensation patients and 6 overhead athletes. Pain was the chief complaint at the time of initial and revision SLAP repairs. The mean ASES score was 72.5, patient satisfaction level was 6.4 (scale of 0-10), mean return to work was at 57.8% of the previous level, and mean return to sports was at 42.2% of the previous level. In overhead athletes, mean return to sports was at 41.3% of the previous level, and none of the 4 baseball players returned to preinjury level. The mean values for all outcome data and range of motion values were lower in workers' compensation patients. There were no reported complications, but 2 patients required additional arthroscopic surgeries.

CONCLUSION

Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers' compensation patients and overhead athletes doing especially worse. A larger prospective study of this relatively rare procedure is needed to better determine which patients may benefit from this procedure.

Impact of work-related compensation claims on surgical outcome of patients with rotator cuff related pathologies: a matched case-control study

BACKGROUND

The purpose of this matched case-control study was to examine the impact of an active compensation claim following a work-related shoulder injury on reporting disability, as measured by subjective and objective outcomes at 1 year postoperatively.

METHODS

Data of 517 consecutive patients who had undergone a decompression or rotator cuff repair were reviewed. One-hundred and ten patients were on compensation related to their shoulder problems. These patients were matched with a historical control group (patients without a compensation claim) based on age, sex, and level of pathology. Outcome measures used were the Western Ontario Rotator Cuff Index, the American Shoulder and Elbow Score, and the Constant-Murley score. Nonparametric Wilcoxon and Ranked sign tests were conducted to examine the difference between and within groups.

RESULTS

Data of 220 patients were used for analysis (mean age, 48+/-10; range, 20-69). Out of 110 patients in each group, 45 patients (41%) had undergone a repair and 65 (59%) had undergone a decompression surgery (acromioplasty with or without resection of lateral clavicle). Both groups improved significantly regardless of their claim status (P < .0001). There was a significant difference between injured and noninjured workers at baseline, 1-year postoperatively, and in overall improvement with the compensation group having a significantly higher level of disability.

CONCLUSION

Our results show that although injured workers report a statistically significant higher level of disability before and after rotator cuff surgery, they still show significant improvement 1 year following decompression or repair of the rotator cuff tendon(s).

Normal shoulder outcome score values in the young, active adult

BACKGROUND

Our objective was to determine baseline, normative values for multiple shoulder outcome scores in a young, active population without shoulder symptoms.

METHODS

One hundred ninety-two volunteers completed the Single Assessment Numeric Evaluation, modified American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability index, Simple Shoulder Test, and Disabilities of the Arm, Shoulder and Hand score. Their mean age was 28.8 years (range, 17-50 years).

RESULTS

Of the participants, 59 (31%) scored no deficiencies on any of the outcome instruments, whereas 133 (69%) demonstrated some abnormal shoulder score. The mean scores were as follows: Single Assessment Numeric Evaluation, 97.7 (SD, 5.2); modified American Shoulder and Elbow Surgeons score, 98.9 (SD, 3.3); Western Ontario Shoulder Instability index, 82.7 of 2100 (SD, 153.5); Simple Shoulder Test, 11.79 (SD, 0.60); and Disabilities of the Arm, Shoulder and Hand score, 1.85 (SD, 5.99).

CONCLUSION

Our results show that the best possible shoulder score in an asymptomatic population may not be equivalent to a perfect score on the outcome scale.

Do outcomes differ after rotator cuff repair for patients receiving workers' compensation?

Comparisons of outcomes after rotator cuff repair between Worker's Compensation Board (WCB) recipients and nonrecipients generally do not consider patient, injury, and shoulder characteristics. We compared preoperative differences between WCB recipients and nonrecipients and determined the impact on their 6-month postoperative outcome. We evaluated a prospective cohort of 141 patients with full-thickness rotator cuff tears, 36 of whom (26%) were WCB recipients, preoperatively and 3 and 6 months after rotator cuff repair. Their mean age was 54.0 +/- 10.4 years (standard deviation) and 102 (72%) patients were male. Shoulder range of motion, Western Ontario Rotator Cuff (WORC) index, and American Shoulder and Elbow Surgeons' score were used to evaluate outcomes. We performed regression analyses to control for baseline differences in age, baseline scores, smoking status, symptom duration, injury type, and associated biceps disorder between WCB recipients and nonrecipients. WCB recipients were younger and more likely to smoke, have a traumatic injury, and undergo surgery within 6 months of injury. WCB recipients had lower recovery for all outcomes when these differences were not considered but when differences were accounted for, only 6-month WORC scores were lower in WCB recipients. Clinicians should consider preoperative characteristics before concluding WCB recipients experience less recovery after surgical repair.

LEVEL OF EVIDENCE

Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Factors contributing to failure of rotator cuff surgery in persons with work-related injuries

PURPOSE

Shoulder pain is a major musculoskeletal and economic concern in industrialized countries, with the rate of surgical failure reportedly higher in patients injured at work. The purposes of this study were (1) to examine the prevalence of identifiable causes of rotator cuff surgery failure and (2) to examine the relationship among the existence of these causes and outcome scores, patient expectations, and overall satisfaction.

METHODS

This was a cross-sectional study of patients who experienced continued impairments following surgical treatment for work-related injuries. The primary outcome was a disease-specific measure, the Western Ontario Rotator Cuff (WORC) index. Patients were categorized into two groups based on the existence of an identifiable reason for surgical failure vs. no reason for failure, as demonstrated by clinical and radiologic investigations and decided upon by a shoulder surgeon and a physical therapist. Analyses included a t-test for independent sample means, linear regression, non-parametric Wilcoxon test, and Fisher's exact test.

RESULTS

Thirty-eight consecutive patients were included in the study, and 24 causes of surgical failure were identified in 19 patients (50%). Overall, patients with findings of failure were more disabled according to the total WORC index and had higher levels of symptoms, emotional difficulties, and limitations in sports and recreational activities. Expectations and satisfaction levels were not significantly different between groups.

CONCLUSION

Our results indicate that 50% of patients who reported failed surgery had at least one reason to explain their ongoing symptoms, emotional difficulties, and functional limitations.

Patients with workers' compensation claims have worse outcomes after rotator cuff repair

BACKGROUND

Previous studies have demonstrated varying correlations between Workers' Compensation status and the outcome of rotator cuff repair. However, none of those studies have formally accounted for potential confounding factors with multivariable analysis. We hypothesized that patients with Workers' Compensation claims who undergo rotator cuff repair have worse outcomes, even after controlling for confounding factors.

METHODS

One hundred and twenty-five patients (including thirty-nine with Workers' Compensation claims) who underwent unilateral primary repair of a chronic rotator cuff tear by a single surgeon were studied prospectively and were evaluated one year postoperatively, prior to the settlement of any claims. Outcomes were assessed with the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) index; three visual analog scales (shoulder pain, shoulder function, and quality of life); and the Short Form-36 (SF-36).

RESULTS

Patients in the Workers' Compensation group were significantly younger, had greater work demands, and had lower marital rates, education levels, and preoperative expectations for the outcome of treatment as compared with those in the non-Workers' Compensation group (p = 0.001 to 0.016). Preoperatively, patients in the Workers' Compensation group had significantly lower scores on the SST, the SF-36 Physical Function scale, and the SF-36 Social Function scale (p = 0.01 to 0.038). One year postoperatively, those patients reported worse performance on the SST, the DASH, all three visual analog scales, and the SF-36 (p = 0.0007 to 0.05) and had worse improvement on the DASH, the visual analog scales for shoulder pain and function, and the SF-36 Bodily Pain and Role Emotional scales (p = 0.0028 to 0.038). Multivariable analysis controlling for age, sex, comorbidities, smoking, marital status, education, duration of symptoms, work demands, expectations, and tear size confirmed that Workers' Compensation status was an independent predictor of worse DASH scores.

CONCLUSIONS

Patients with Workers' Compensation claims report worse outcomes, even after controlling for confounding factors. The present study provides further evidence that the existence of a Workers' Compensation claim portends a less robust outcome following rotator cuff repair.

LEVEL OF EVIDENCE

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

Difference in outcome of shoulder surgery between workers' compensation and nonworkers' compensation populations

The purpose of this study was to review the association between compensation status and surgical outcome especially of the shoulder. Given the high prevalence of shoulder injuries in the workplace and the large proportion of workers compensation (WC) claims involving such injuries, it is worth examining the correlation between WC status and surgical outcome of the shoulder. All studies published in journals (MEDLINE and PubMed) from 1980 through 2007 on surgical interventions performed on the shoulder in which workers compensation status was documented and the postoperative functional outcome was compared according to that status were pooled for meta-analysis. This systematic review shows that compensation status of an individual receiving shoulder surgery is a consistent positive predictor of poor functional outcome. The majority of questions posed in the most commonly adopted shoulder-specific functional outcome measurement tools were subjective in nature and may account for part of the phenomenon.

Deficits in shoulder function and general health associated with sixteen common shoulder diagnoses: a study of 2674 patients

The purpose of this study is to define the self-assessed deficits in function and general health perceived by a large cohort of patients with common shoulder diagnoses. For a 10-year period, all new shoulder patients presenting to the senior author were characterized by diagnosis, age, gender, and self-assessed shoulder function and general health status. This report concerns the 2674 patients having 1 of the 16 most prevalent diagnoses. The deficits in shoulder function and health status were correlated with diagnosis, age, and gender, as well as with each other. Patient self-assessment provided a standardized method for collecting data on shoulder function and health status. These assessments revealed substantial deficits; for example, 81% of patients were unable to sleep on the affected side, and 71% were unable to wash the back of the opposite shoulder. The magnitude of these deficits correlated significantly with gender and diagnosis but not with age.

Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique

Using a patient-oriented outcome questionnaire, in addition to standard outcome measures, we sought to determine the outcome of patients who had repair of a complete rupture of the distal biceps tendon via a single anterior incision technique with suture anchors. We identified 62 patients who were treated operatively by a single surgeon over an 8-year period for a diagnosis of complete rupture of the distal biceps tendon. Of the patients, 9 could not be located for final follow-up, and 53 of 62 (85%) participated in the study. All patients were men, and their mean age was 42 years. All repairs were performed via a single anterior incision by use of 2 suture anchors in the bicipital tuberosity on an outpatient basis. There were 4 complications (4/53 [7.5%]): 1 wound infection, 2 transient paresthesias in the lateral cutaneous nerve distribution, and 1 posterior interosseous nerve palsy that resolved in 6 weeks (no reoperations). There were no reruptures, and no patient lost more than 5 degrees of elbow flexion- extension or forearm rotation. All patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The mean DASH score was 8.2 +/- 11.6 (95% CI, 5.2 to 11.9), which was similar to the mean DASH score in population controls of 6.2 (DASH User Manual). The strengths of our study include the consistent surgical technique by a single surgeon, the large number of patients, and the use of a patient-oriented outcome measure. Distal biceps tendon rupture repair via a single-incision technique with suture anchors was effective in restoring injured arms to normal, as measured by limb-specific patient-oriented measures, with minimal morbidity and a low complication rate.

Measurement of baseline shoulder function in subjects receiving workers' compensation versus noncompensated subjects

The purpose of this study was to ascertain whether a measurable difference existed in normative scores for the American Shoulder and Elbow Surgeons (ASES) questionnaire between subjects who had an active workers' compensation claim (WC) with no known shoulder injury and subjects without a compensation claim (non-WC). Subjects with non-shoulder-related orthopaedic injuries were recruited from a suburban orthopaedic sports medicine clinic and an urban occupational medicine clinic. They were asked to complete a composite questionnaire that consisted of demographic information and the ASES questionnaire. There were no significant differences in the ASES scores between subject groups. There were significant differences between subject groups with regard to work hours (P = .0001), work demands (P = .0001), and tobacco use (P = .0001). Subject group was also significantly associated with education level (P = .0001), marital status (P = .0001), work demands (P = .0001), gender (P = .0001), and sports participation (P = .0314). The ASES score was significantly affected by marital status (P = .0476), sports participation (P = .0008), and age (P = .0129).

Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty

BACKGROUND

The relationship between the characteristics of the shoulder that can be determined before humeral hemiarthroplasty and the functional improvement after surgery is not known. The goal of this study was to test the hypothesis that the functional outcome of this procedure correlated significantly with factors that are identifiable preoperatively.

METHODS

The study group included seventy-one shoulders in sixty-eight patients undergoing hemiarthroplasty, performed by the same surgeon, for diagnoses other than acute fracture. The mean age of the patients was sixty-one years (range, thirty to eighty-three years). The results were characterized in terms of the change in self-assessed shoulder function and general health status at an average of forty-nine months (range, twenty-four to 142 months) after surgery.

RESULTS

The preoperative absence of erosion of the glenoid was associated with greater improvement in shoulder function and level of comfort after hemiarthroplasty (p < 0.001). Shoulders that had not had previous surgery had greater functional improvement than did those that had previous surgery (p = 0.012). Shoulders with an intact rotator cuff showed significantly (p < 0.5) greater improvement in the ability to lift weight above shoulder level after hemiarthroplasty (p <0.5). With regard to diagnoses, shoulders with rheumatoid arthritis, capsulorrhaphy arthropathy, and cuff tear arthropathy had the least functional improvement, whereas those with osteonecrosis (p = 0.0004) and with primary (p = 0.02) and secondary degenerative joint disease (p = 0.03) had the greatest improvement. Patient age and gender did not significantly affect the outcome.

CONCLUSIONS

These results suggest that the functional improvement following humeral hemiarthroplasty is related to factors that are identifiable before surgery. These data may be of benefit in preoperative discussions with patients who have a shoulder disorder and are considering treatment with hemiarthroplasty.

The measurement of normative American Shoulder and Elbow Surgeons scores

We determined baseline scores on the American Shoulder and Elbow Surgeons (ASES) questionnaire in individuals who had no known shoulder condition and evaluated related factors that could influence the score. A modified version of the questionnaire was completed by 343 patients from an outpatient orthopaedic center being seen for conditions unrelated to the shoulder. A separate group completed the questionnaire at two different times to assess its reliability. The mean ASES score was 92.2 +/- 14.5 points. The instrument was found to be very reliable (intraclass correlation coefficient = 0.96). Only the variables of shoulder status and sports participation entered the regression model to explain the variance in scores. Subjects aged 60 years or older exhibited decreased ability to lift above shoulder level and reach behind the back when compared with younger cohorts. Previous investigators have made the assumption that a normal preinjury ASES score is 100 points. This study raises questions about this assumption. This information can serve as a basis to compare normative scores with those of patients with active shoulder disease.

The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease

So that patients with degenerative glenohumeral joint disease who wish to consider total shoulder arthroplasty will be better informed, we sought to document the magnitude and durability of the improvement in shoulder function after this procedure. The function of 124 shoulders with primary degenerative joint disease was documented by patient self-assessment with the Simple Shoulder Test before and sequentially after total shoulder arthroplasty performed with a standardized technique. Patients reported that they could perform 3.8 +/- 0.3 (SEM) of the 12 Simple Shoulder Test functions before surgery. The total number of performable functions was consistent at different follow-up intervals: 8.0 +/- 0.4 at 6 months, 9.5 +/- 0.4 at 1 year, 10.0 +/- 0.3 at 2 years, 9.2 +/- 0.4 at 3 years, 9.6 +/- 0.4 at 4 years, and 10.0 +/- 0.4 at 5 years. We conclude that total shoulder arthroplasty can provide substantial and durable improvement in shoulder function.

Improvement in comfort and function after cuff repair without acromioplasty

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.