Systematic review of rotator cuff tears in workers' compensation patients

Stem cell treatment for regeneration of the rotator cuff: study protocol for a prospective single-center randomized controlled trial (Lipo-cuff)

BACKGROUND

Rotator cuff tears (RCT) are a common musculoskeletal condition, especially in the aging population. The prevalence of rotator cuff tears varies based on factors like age, occupation, and activity level. In the general population, the prevalence of rotator cuff tears is estimated to be around 20 to 25%. Rotator cuff tears (RCT) have an impact in patients' pain level, shoulder function, sleep disturbance, and quality of life. Primary tendon surgery is in mostly cases necessary. This study aimed to examine if treatment of rotator cuff lesions with implantation of micro-fragmented adipose tissue can improve patients' reported pain and function compared to conventional surgery.

METHODS

The study is a prospective superiority parallel-group single-center randomized controlled trial including 30 patients between 40 and 69 years of age in Denmark. Patients will be allocated 1:1 ratio to reconstruction of the supraspinatus tendon with an injection of micro-fragmented adipose tissue into the related muscle (stem cell treatment) or the standard of care (SOC), which is conventional surgery. Patients, project assistants, physicians, and outcome adjudicators are not blinded to randomization due to practical constraints. The radiologist and the statistician performing the analysis will be blinded. The primary outcome will be the Oxford shoulder score at 12 months post-surgery.

DISCUSSION

This study will assess whether adding micro-fragmented adipose tissue therapy to conventional rotator cuff tear treatment can enhance recovery, accelerate return to daily activities, and improve functional outcomes. The research will also determine if this minimally invasive procedure could be standardized for routine patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06505135. Registered on July 10, 2024.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears

BACKGROUND

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

METHODS

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

RESULTS

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

CONCLUSION

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Rotator Cable Reconstruction: A Technique to Restore the Rotator Cable in the Setting of Large Cuff Tears

The rotator cable is an essential biomechanical structure in the shoulder that is commonly injured in the setting of large rotator cuff tears. Surgical techniques designed to reconstruct the cable have followed advancements in our understanding of the biomechanics and anatomic importance of this structure. Owing to its role in load sharing and stress shielding of the rotator cuff crescent, rotator cable reconstruction offers the potential to reduce retear rates and promote longevity of rotator cuff repairs. The purpose of this article is to describe a technique to augment rotator cuff repair with cable reconstruction.

Evaluation of at-home physiotherapy

An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data. The patient-specific approach with engineered features achieved the highest in-clinic performance for differentiating physiotherapy exercise from non-exercise activity (area under the receiver operating characteristic (AUROC) = 0.924). Including non-exercise data in algorithm training further improved classifier performance (random forest, AUROC = 0.985). The highest accuracy achieved for classifying individual in-clinic exercises was 0.903, using a patient-specific method with deep neural network model extracted features. Grouping exercises by motion type improved exercise classification. For at-home data, OOD detection yielded similar performance with the non-exercise data in the algorithm training (fully convolutional network AUROC = 0.919). Including non-exercise data in algorithm training improves detection of exercises. A patient-specific approach leveraging data from earlier patient-supervised sessions should be considered but is highly dependent on per-patient data quality.

Predictors of Return to Work Following Primary Arthroscopic Rotator Cuff Repair: An Analysis of 1502 Cases

BACKGROUND

It is undetermined which factors predict return to work after arthroscopic rotator cuff repair.

PURPOSE

To identify which factors predicted return to work at any level and return to preinjury levels of work 6 months after arthroscopic rotator cuff repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Multiple logistic regression analysis of prospectively collected descriptive, preinjury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work at 6 months postoperatively.

RESULTS

Six months after arthroscopic rotator cuff repair, 76% of patients had returned to work, and 40% had returned to preinjury levels of work. Return to work at 6 months was likely if patients were still working after their injuries but before surgery (Wald statistic [W] = 55, P < .0001), were stronger in internal rotation preoperatively (W = 8, P = .004), had full-thickness tears (W = 9, P = .002), and were female (W = 5, P = .030). Patients who continued working postinjury but presurgery were 1.6 times more likely to return to work at any level at 6 months compared to patients who were not working (P < .0001). Patients who had a less strenuous preinjury level of work (W = 173, P < .0001), worked at a mild to moderate level post injury but presurgery, had greater preoperative behind-the-back lift-off strength (W = 8, P = .004), and had less preoperative passive external rotation range of motion (W = 5, P = .034) were more likely to return to preinjury levels of work at 6 months postoperatively. Specifically, patients who worked at a mild to moderate level postinjury but presurgery were 2.5 times more likely to return to work than patients who were not working, or who were working strenuously postinjury but presurgery (p < 0.0001). Patients who nominated their preinjury level of work as "light" were 11 times more likely to return to preinjury levels of work at 6 months compared to those who nominated it as "strenuous" (P < .0001).

CONCLUSION

Six months after rotator cuff repair, patients who continued to work after injury but presurgery were the most likely to return to work at any level, and patients who had less strenuous preinjury levels of work were the most likely to return to their preinjury levels of work. Greater preoperative subscapularis strength independently predicted return to work at any level and to preinjury levels.

Recurrence of glenohumeral instability in patients with isolated rotator cuff repair after a traumatic shoulder dislocation

INTRODUCTION

The primary objective of this study was to assess the incidence of recurrent glenohumeral instability in patients over 40 years with isolated rotator cuff (RC) repair for traumatic shoulder dislocation. The secondary objectives were to identify risk factors for glenohumeral recurrence after RC repair and to describe the causes and incidences of re-intervention.

MATERIALS AND METHODS

In this retrospective cohort study, data of consecutive patients at a single trauma center between January 2014 and July 2019 were reviewed, and 84 patients with a mean age of 57 (range: 40-75) years and follow-up duration of 3.9 (2-6) years were included. The inclusion criteria were as follows: first traumatic anterior shoulder dislocation, reparable RC tear, primary arthroscopic RC repair, no labral or bony Bankart lesion repair, and at least 2 years of follow-up. Patients less than 40 years of age were excluded. Shoulder instability recurrences and surgical reinterventions were reviewed with medical records. Statistical analysis was performed for qualitative variables using the Chi-squared test. Statistical significance was set at P ≤ 0.05.

RESULTS

There was one patient with a redislocation episode (1.2%) at 2.5 years after surgery, who was surgically treated. Age, subscapular tears, bony Bankart injuries, humeral defects, and associated neurological injuries were not risk factors for recurrence in this study. Ten patients (11.9%) required reintervention. Nine patients (10.7%) re-tore their RCs.

CONCLUSIONS

Recurrent glenohumeral instability in active patients over 40 years with isolated RC repair after traumatic shoulder dislocation was infrequent, despite the incidence of significant Hill-Sachs defects, anterior glenoid defects, bipolar bone defects, size of the RC injury, and tendon re-tears. The incidence of re-interventions was 11.9%, with symptomatic RC retear as the main cause.

High Early-onset acromioclavicular secondary pathologies after acute arthroscopic joint reduction: a cohort study

PURPOSE

The research aim was to determine the prevalence and risk factors of early secondary acromioclavicular (AC) joint disease in patients undergoing acute arthroscopic AC joint reduction and fixation and early complications of acute surgical treatment in patients with high-grade AC joint dislocation.

METHODS

Overall, 102 patients diagnosed with Rockwood type V AC joint dislocation and undergoing arthroscopic coracoclavicular fixation were included. Early clinical and radiological complications were evaluated, as well as risk factors of secondary AC joint pathology.

RESULTS

Twenty-nine patients (28%) presented with a secondary AC joint pathology, with 24 and 5 cases of osteolysis and osteoarthritis, respectively. The main complication was a loss of reduction of ≥ 1 mm (78%). Patients aged > 55 years were more likely to develop a secondary AC joint disease (odds ratios (OR) = 10.1, 95% confidence interval (CI): 1.42 - 72.55, p = 0.021). Patients with osteolysis (OR = 3.2, 95% CI 1.16 - 9.27, p = 0.025) or loss of reduction of > 5 mm (OR = 7.4, 95% CI 2.31 - 24.08, p = 0.001) were more likely to develop AC joint pain. Patients with an initial over-reduction were less likely to develop a subluxated AC joint (OR = 0.033, 95% CI 0.0021-0.134, p = 0.001) CONCLUSION: Age > 55 years and female sex were identified as risk factors of early-onset secondary AC joint disease. Osteolysis and a loss of reduction of > 5 mm were risk factors of AC joint pain but not of revision surgery. The main early complication was a loss of reduction of ≥ 1 mm. An initial over-reduction of the distal clavicle was a protective factor to avoid AC joint subluxation.

Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing shoulder pain in Alberta, Canada

Background

Shoulder pain is a highly prevalent condition and a significant cause of morbidity and functional disability. Current data suggests that many patients presenting with shoulder pain at the primary care level are not receiving high quality care. Primary care decision-making is complex and has the potential to influence the quality of care provided and patient outcomes. The aim of this study was to develop a clinical decision-making tool that standardizes care and minimizes uncertainty in assessment, diagnosis, and management.

Methods

First a rapid review was conducted to identify existing tools and evidence that could support a comprehensive clinical decision-making tool for shoulder pain. Secondly, provincial consensus was established for the assessment, diagnosis, and management of patients presenting to primary care with shoulder pain in Alberta, Canada using a three-step modified Delphi approach. This project was a highly collaborative effort between Alberta Health Services’ Bone and Joint Health Strategic Clinical Network (BJH SCN) and the Alberta Bone and Joint Health Institute (ABJHI).

Results

A clinical decision-making tool for shoulder pain was developed and reached consensus by a province-wide expert panel representing various health disciplines and geographical regions. This tool consists of a clinical examination algorithm for assessing, diagnosis, and managing shoulder pain; recommendations for history-taking and identification of red flags or additional concerns; recommendations for physical examination and neurological screening; recommendations for the differential diagnosis; and care pathways for managing patients presenting with rotator cuff disease, biceps pathology, superior labral tear, adhesive capsulitis, osteoarthritis, and instability.

Conclusions

This clinical decision-making tool will help to standardize care, provide guidance on the diagnosis and management of shoulder pain, and assist in clinical decision-making for primary care providers in both public and private sectors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01544-3.

Return to Work After Primary Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Rotator cuff tears are a prevalent pathology in injured workers, causing significant economic ramifications and time away from work. To date, published articles on work outcomes after rotator cuff repair have not been cumulatively assessed and analyzed.

PURPOSE

To systematically review reports on return to work after rotator cuff repair and perform a meta-analysis on factors associated with improved work outcomes.

STUDY DESIGN

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

METHODS

A systematic review of return-to-work investigations was performed using PubMed, Embase, and the Cochrane Database of Systematic Reviews in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Individual studies reporting rates of return to previous work with level of evidence 1 to 4 were independently screened by 2 authors for inclusion, and study quality was assessed using the Methodologic Index for Non-randomized Studies and Newcastle-Ottawa Scale. Work outcome data were synthesized and analyzed using random effects modeling to identify differences in rates of return to previous work as a function of operative technique, work intensity, and workers' compensation status.

RESULTS

Thirteen retrospective investigations comprising 1224 patients who underwent rotator cuff repair met inclusion criteria for this investigation. Across all investigations, a weighted average of 62.3% of patients returned to previous level of work at 8.15 ± 2.7 months (mean ± SD) after surgery. Based on random effects modeling, higher rates of return to previous work were identified with decreasing work intensity (P < .001), while rates were similar between open and arthroscopic repair technique (P = .418) and between workers' compensation and non-workers' compensation cohorts (P = .089). All shoulder pain and functional outcome assessments demonstrated significant improvements at final follow-up when compared with baseline across all investigations.

CONCLUSION

The majority of injured workers undergoing rotator cuff repair return to previous work at approximately 8 months after surgery. Despite this, >35% of patients are unable to return to their previous work level after their repair procedure. Similar rates of return to work can be anticipated regardless of workers' compensation status and operative technique, while patients in occupations with higher physical intensity experience inferior work outcomes.

Operative Management of Failed Rotator Cuff Repair With Soft Tissue Release

Background We hypothesize that revision surgery that includes soft tissue releases for patients with residual pain and reduced range of motion following rotator cuff repair can provide pain relief and improvement of motion and function. Methods Patients were identified via a retrospective chart over a 10-year period who had a history of previous rotator cuff repair and had revision surgery with or without a rotator cuff repair and soft tissue release. Changes in visual analog scores (VAS) pain score on a 10-point scale and shoulder motion including forward flexion and external rotation were evaluated from the preoperative visit to the postoperative visit. Results In total, 73 patients underwent procedures to address their symptoms following failed rotator cuff repair. Patients that underwent soft tissue release with revision rotator cuff repair and those who underwent isolated soft tissue release had decreased postoperative VAS pain scores (absolute reduction of 3 and 1.6 points, respectively) and improved postoperative forward flexion (15.3° and 13.6° respectively). Patients that have had one previous surgery had decreased pain (absolute reduction of 3.2 points), increased forward flexion and external rotation (16.2° and 4.9°). Patients that underwent two or more previous surgeries had decreased pain (absolute reduction of 1.8 points) and increased forward flexion (12.7°). Patients who were filing a Worker's compensation claim also had decreased pain (absolute reduction of 2.2 points) and increased forward flexion (14.9°). Overall, there was a VAS pain scores absolute reduction of 2.6 points or 49.5% when examining the entire patient population. Conclusion Operative management by performing soft tissue release with or without concurrent revision rotator cuff repair is successful for both decreasing pain as well as improving motion. This effect was noted both in patients with commercial insurance and worker's compensation claims. Improvements of pain and motion were more significant in patients who had undergone one prior surgery compared to those who have had multiple prior procedures.

Adherence Patterns and Dose Response of Physiotherapy for Rotator Cuff Pathology: Longitudinal Cohort Study

BACKGROUND

Physiotherapy is considered to be essential for the successful operative and nonoperative management of rotator cuff pathology; however, the extent to which patients adhere to assigned physiotherapy activities and how this impacts recovery is unknown.

OBJECTIVE

The purpose of this study was to measure the rate and patterns of participation in physiotherapy for rotator cuff disorders, assess the dose response between physiotherapy activity and recovery, and explore patient factors predictive of physiotherapy participation.

METHODS

We report a prospective longitudinal study of 42 patients undergoing physiotherapy for symptomatic rotator cuff pathology. The patients were issued a smartwatch that recorded inertial sensor data while they performed physiotherapy exercises both in the clinic and in the home setting. A machine learning approach was used to assess total physiotherapy participation from smartwatch inertial data. Primary outcomes were the Disabilities of the Arm Shoulder and Hand and numeric pain rating scale assessed every 4 weeks until 12 weeks follow-up. The relationships between participation, outcomes, and clinical patient variables were assessed in univariable analyses.

RESULTS

Mean physiotherapy exercise participation in clinic and at home were 11 minutes per week and 33 minutes per week, respectively, with patients participating in physiotherapy on 41% of days assigned to treatment. Home physiotherapy participation decreased significantly over time (P=.03). There was a statistically significant and clinically meaningful relationship between cumulative physiotherapy participation and recovery demonstrated by pain scores at 8 weeks (P=.02) and 12 weeks (P=.05) and disability scores at 8 weeks (P=.04) and 12 weeks (P=.04). Low patient expectations and self-efficacy were associated with low rates of physiotherapy participation.

CONCLUSIONS

There was a low rate of participation in home shoulder physiotherapy exercise, and a statistically and clinically significant dose response of physiotherapy on treatment outcome in patients with rotator cuff pathology. The findings highlight the opportunity to develop novel methods and strategies to improve the participation in and efficacy of physiotherapy exercises for rotator cuff disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17841.

Adherence Tracking With Smart Watches for Shoulder Physiotherapy in Rotator Cuff Pathology: Protocol for a Longitudinal Cohort Study

Background

Physiotherapy is essential for the successful rehabilitation of common shoulder injuries and following shoulder surgery. Patients may receive some training and supervision for shoulder physiotherapy through private pay or private insurance, but they are typically responsible for performing most of their physiotherapy independently at home. It is unknown how often patients perform their home exercises and if these exercises are performed correctly without supervision. There are no established tools for measuring this. It is, therefore, unclear if the full benefit of shoulder physiotherapy treatments is being realized.

Objective

The proposed research will (1) validate a smartwatch and machine learning (ML) approach for evaluating adherence to shoulder exercise participation and technique in a clinical patient population with rotator cuff pathology; (2) quantify the rate of home physiotherapy adherence, determine the effects of adherence on recovery, and identify barriers to successful adherence; and (3) develop and pilot test an ethically conscious adherence-driven rehabilitation program that individualizes patient care based on their capacity to effectively participate in their home physiotherapy.

Methods

This research will be conducted in 2 phases. The first phase is a prospective longitudinal cohort study, involving 120 patients undergoing physiotherapy for rotator cuff pathology. Patients will be issued a smartwatch that will record 9-axis inertial sensor data while they perform physiotherapy exercises both in the clinic and in the home setting. The data collected in the clinic under supervision will be used to train and validate our ML algorithms that classify shoulder physiotherapy exercise. The validated algorithms will then be used to assess home physiotherapy adherence from the inertial data collected at home. Validated outcome measures, including the Disabilities of the Arm, Shoulder, and Hand questionnaire; Numeric Pain Rating Scale; range of motion; shoulder strength; and work status, will be collected pretreatment, monthly through treatment, and at a final follow-up of 12 months. We will then relate improvement in patient outcomes to measured physiotherapy adherence and patient baseline variables in univariate and multivariate analyses. The second phase of this research will involve the evaluation of a novel rehabilitation program in a cohort of 20 patients. The program will promote patient physiotherapy engagement via the developed technology and support adherence-driven care decisions.

Results

As of December 2019, 71 patients were screened for enrollment in the noninterventional validation phase of this study; 65 patients met the inclusion and exclusion criteria. Of these, 46 patients consented and 19 declined to participate in the study. Only 2 patients de-enrolled from the study and data collection is ongoing for the remaining 44.

Conclusions

This study will provide new and important insights into shoulder physiotherapy adherence, the relationship between adherence and recovery, barriers to better adherence, and methods for addressing them.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17841

Shoulder Terrible Triad: Classification, Functional Results, and Prognostic Factors

INTRODUCTION

The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT.

METHODS

Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator.

RESULTS

Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors.

CONCLUSIONS

The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores.

Outcomes of expedited rotator cuff surgery in injured workers: Impact of pathology on readiness for return to work

OBJECTIVES

The objectives of this study were to (1) examine the overall recovery and satisfaction following an expedited rotator cuff (RC) decompression or repair at 3-6 months and (2) explore group differences (repair vs. decompression) in demographics, clinical, disability, and psychosocial factors.

METHODS

This was a prospective longitudinal study of injured workers whose surgery was expedited. The outcome measures were Quick disabilities of the arm, shoulder, and hand ( QuickDASH), the Hospital Anxiety and Depression Scale (HADS), the readiness for return to work (RRTW) scale, and satisfaction with surgery and overall recovery.

RESULTS

Of 118 patients participated in the study, 106 patients, age: 51 (9), 71 males (67%) completed the study. Sixty-four (60%) patients underwent a RC repair and 42 (40%) had RC decompression. Patients improved on average in QuickDASH ( p = 0.004), anxiety ( p = 0.003), and depression scores ( p = 0.004). The majority of patients (75%) were satisfied with surgery. In the decompression group, the pre-contemplation (PC) stage of the RRTW which documents the absence of desire or planning for return to work in the non-working sample ( r = 0.81, p = 0.008) and the uncertain maintenance (UM) stage of the RRTW which explores the worker's struggle to stay at work in the working sample correlated with physical disability as measured by the QuickDASH scores ( r = 0.62, p = 0.0001). In the repair group, the above domains correlated with the depression HADS scores (PC: r = 0.64, p = 0.001 and UM: r = 0.57, p < 0.0001).

CONCLUSION

Expedited RC surgery improved physical disability and mental well-being and was associated with a relatively high satisfaction at a maximum of 6 months. The poorer report of readiness for return to work was associated with higher physical disability in the decompression group and higher report of depression in the repair group. These differential associations may emphasize the importance of physical versus psychological management in patients with different levels of pathology.

Validation of a tool to assess patient satisfaction, waiting times, healthcare utilization, and cost

AIM

Patients' experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) - a tool that collects patients' experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH).

BACKGROUND

The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH's dimensions.

METHODS

This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test-retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing).

FINDINGS

Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1-29). Only out-of-pocket utilization possessed an ICC<0.70. Patients reported that items were relevant and appropriate to measuring quality of care. No floor or ceiling effects were present. Criterion validity was reached for all items assessed. A priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient's continuum of care.

Comparison of Surgeon Performance of Rotator Cuff Repair: Risk Adjustment Toward a More Accurate Performance Measure

BACKGROUND

Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon's panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons' performance of rotator cuff repair.

METHODS

Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon.

RESULTS

The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, -13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons' rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R = 0.44), male sex, Workers' Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05).

CONCLUSIONS

Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons' rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon's relative performance based on PROs.

LEVEL OF EVIDENCE

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

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Evaluating quality of care for patients with rotator cuff disorders

Background

Measuring quality in healthcare is vital in evaluating patient outcomes and system performance. The availability of reliable and valid information about the quality of care for patients presenting with rotator cuff disorders (RCD) in Alberta, Canada is scarce. The objective of this study is to measure quality of care for patients with RCD in order to identify areas of improvement.

Methods

This study employs descriptive survey research design. Between March 2015 and November 2016, a convenience sample of patients presenting with chronic, full-thickness rotator cuff tears to two sport medicine centres in Calgary and Edmonton, Alberta completed two questionnaires: the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) and the Rotator Cuff Quality-of-Life Index (RC-QOL). Data collected using both questionnaires were used to make judgments about quality of care. Quality of care was evaluated using six dimensions of quality defined by the Alberta Quality Matrix for Health: accessibility, acceptability, efficiency, effectiveness, appropriateness, and safety. Data was also used to compare current patient clinical pathways to ideal clinical pathway algorithms and used to make judgments about the appropriateness and safety of healthcare practices.

Results

One hundred seventy-one patients participated in the study. The longest mean waiting times for medical services in Alberta were for magnetic resonance imaging (MRI) received in the public sector (103 days) and consultation by orthopaedic surgeon (172 days). Patient satisfaction with respect to quality of care was lowest for emergency room physician and highest for orthopaedic surgeon visits. Patients were treated by a mean of 2.5 physicians (SD: 0.77, range: 2–7). The total aggregate average cost per patient was $4541.19. The mean RC-QOL score for all patients was 42 (SD: 22). Only 54 patients (64%) requiring surgery were able to consult with a surgeon within benchmark timeframes. A comparison of current to ideal clinical pathway algorithms found that 38 patients (22%) experienced indirect clinical pathways, whereby care was fragmented and patients received care from multiple and often, redundant healthcare professionals.

Conclusion

There is a discrepancy between current and ideal clinical pathways whereby some patients are experiencing quality of care that is inefficient, disjointed, and less than ideal.

Abnormal Pain Response After a Compensable Shoulder Injury

Background:

The role of psychosocial factors has been established in patients with shoulder abnormalities. However, the prevalence of exaggerated pain behaviors and their association with the characteristics of injured workers have not been well studied.

Purpose:

To examine the prevalence of abnormal pain responses (APRs) in workers with active workers’ compensation claims for a shoulder injury and to examine the differences between workers with APRs versus workers without APRs.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

An analysis of electronic data files of injured workers was completed. An APR was defined as an exaggerated pain response during a clinical examination, including facial grimacing, shaking, withdrawal, nonanatomic dermatome or myotome disturbances, increased tenderness, regional symptoms, and verbal utterances such as groaning, moaning, or gasping. To control for potential confounders, patients with positive APRs (APR group) were matched with injured workers without APRs (control group) seen in the same clinic and matched for sex, age, and surgical candidacy.

Results:

Data from 1000 workers who had sustained a shoulder injury at work and who were referred for an early assessment by an orthopaedic surgeon and a physical therapist were reviewed. A total of 86 (9%) injured workers (mean age, 47 ± 11 years; 55 [64%] female) demonstrated APRs and were matched with 86 injured workers without APRs. There were no statistically significant between-group differences in the wait time, mechanism of injury, coexisting comorbidity, type of abnormality, or medication consumption. The APR group reported higher levels of disability (P < .0001) and psychological problems (P < .0001), presented with more inconsistency in range of motion (P = .04), and had more limitations at work (P = .02).

Conclusion:

The presence of an APR after a compensable shoulder injury was associated with higher reports of disability and psychological problems. Patients with positive APRs were more likely to be off work and less likely to perform full duties.

Worker's Compensation Status and Outcomes Following Anterior Lumbar Interbody Fusion: Prospective Observational Study

BACKGROUND

Anterior lumbar-interbody fusion (ALIF) is a commonly performed procedure for degenerative spinal disorders with reasonable clinical and safety outcomes, although there is limited evidence regarding the impact of ALIF in patients receiving worker's compensation (WC) compared with those without. The aim of our study is to identify whether WC status affects the clinical outcome and rates of complication following ALIF surgery in a prospective cohort.

METHODS

We followed prospectively 114 consecutive patients undergoing ALIF surgery from 2012-2014. Patients were categorized into 2 groups: those with worker's compensation (WC) (n = 24) and those without (n = 90). Patients were evaluated preoperative and postoperatively. Outcome measures included Short Form-12 (SF-12), Oswestry Disability Index (ODI), surgical complications, and subsidence.

RESULTS

In terms of baseline traits, the WC group had a significantly higher proportion of class III/IV obesity patients, who were younger (46.3 vs. 60.2 years) compared with non-WC. There were no significant differences in fusion rates or preoperative or postoperative disk height. No significant differences were found for hospital stay, blood loss, or operation duration. Similar rates of complications were found between WC versus non-WC cohorts. No significant difference was noted in clinical improvement between the 2 cohorts with SF-12 PCS, SF-12 MCS, or ODI (P = 0.232). No significant difference was found in the proportion of patients achieving minimal clinically important difference for SF-12 PCS/MCS or ODI.

CONCLUSIONS

In our prospective cohort, there were no significant differences found between WC versus non-WC patients in terms of fusion rates, complications, clinical outcomes, or proportion of patients achieving minimal clinically important difference.

Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy

BACKGROUND

This is a retrospective prognostic study on soft tissue injury following isolated greater tuberosity (GT) fractures of the proximal humerus with respect to the relationship between rotator cuff tears and GT displacement.

METHODS

Forty-three patients with isolated GT fractures were recruited and evaluated with a standardized interview and physical examination, quality of life and shoulder function questionnaires (Western Ontario Rotator Cuff Index, SF-12 Version 2, Constant, Quick-Disabilities of the Arm, Shoulder and Hand, Visual Analogue Scale), standard shoulder radiographs and an ultrasound. The main outcome measurements were: incidence of rotator cuff tears and atrophy, biceps pathology and sub-acromial impingement; superior displacement of the GT fragment; and questionnaire scores.

RESULTS

Mean age was 57 years (31 years to 90 years) with a follow-up of 2.4 years (0.8 years to 6.8 years). In total, 16% had a full rotator cuff tear and 57% showed subacromial impingement on ultrasound. Full rotator cuff tears and supraspinatus fatty atrophy significantly correlated with decreased function and abduction strength. Significant atrophy (>50%) of the supraspinatus and infraspinatus, without a rotator cuff tear, was correlated with the worst function in the presence of a residual displacement of the greater tuberosity at the last-follow-up (7 mm).

CONCLUSIONS

Residual displacement, full rotator cuff tear and muscle atrophy are associated with the worst outcomes. Soft tissue imaging could benefit patients with an unfavourable outcome after a GT fracture to treat soft tissue injury.

Sex and gender disparity in pathology, disability, referral pattern, and wait time for surgery in workers with shoulder injury

BACKGROUND

The role of sex as an important biological determinant of vulnerability to sustaining injury and gender as a social determinate of access to resources, referral for medical care and perceived disability remains conflicted in injured workers. The purpose of this study was to examine sex and gender disparity following a compensable work-related shoulder injury.

METHODS

This study involved cross-sectional analyses of data of two independent samples of workers with shoulder injury. Measures of disability and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numerical Pain Rating Scale (NPRS) for patients seen at an Early Shoulder Physician Assessment (ESPA) program and the American Shoulder and Elbow Surgeons (ASES) assessment form and Visual Analogue Scale (VAS) for the sample who underwent surgery.

RESULTS

The files of 1000 (443 females, 557 men) consecutive patients seen at an ESPA program and 150 (44 females, and 106 men) consecutive patients who underwent rotator cuff surgery (repair or decompression) were reviewed. Significant gender disparity was observed in the referral pattern of injured workers seen at the ESPA program who were referred for surgical consultation (22 vs. 78 % for females and males respectively, p < 0.0001). The independent rotator cuff surgical group had a similar gender discrepancy (29 % vs. 71 %, p < 0.0001). The timeframe from injury to surgery was longer in women in the surgical group (p = 0.01). As well, women waited longer from the date of consent to date of surgery (p = 0.04). Women had higher incidence of repetitive injuries (p = 0.01) with men reporting higher incidence of falls (p = 0.01). Women seen at the ESPA program were more disabled than men (p = 0.02). Women in both samples had a higher rate of medication consumption than men (p = 0.01 to <0.0001). Men seen at the ESPA program had a higher prevalence of full thickness rotator cuff tears (p < 0.0001) and labral pathology (p = 0.01). However, these pathologies did not explain gender disparity in the subsample of ESPA who were referred for surgical consultation or those who had surgery.

CONCLUSIONS

Sex and gender disparity exists in workers with shoulder injuries and is evident in the mechanism of injury, perceived disability, medication consumption, referral pattern, and wait time for surgery.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology

Background

Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm.

Methods

A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting.

Results

In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic.

Conclusion

This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0165-8) contains supplementary material, which is available to authorized users.

Utilization and Costs of Postoperative Physical Therapy After Rotator Cuff Repair: A Comparison of Privately Insured and Medicare Patients

PURPOSE

To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques.

METHODS

The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total.

RESULTS

A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic).

CONCLUSIONS

Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality.

LEVEL OF EVIDENCE

Level IV, economic.

Examining outcome of early physician specialist assessment in injured workers with shoulder complaints

Background

There is minimal research on demographics, type of injury and diagnosis of injured workers with shoulder problems. The purposes of this study were: 1) to document the demographics of patients with shoulder complaints referred to an Early Shoulder Physician Assessment (ESPA) Program and to describe the recommended management, and 2) to examine the relationship between patient characteristics and their subjective complaints of pain and functional difficulty.

Methods

This study involved a retrospective review of electronic files of injured workers mostly seen within the first 16 weeks of injury or recurrence. Measures of functional difficulty and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numeric Pain Scale (NPS).

Results

Files of 550 consecutive patients, 260 females (47%), 290 men (53%) were examined. The average age was 49 (SD = 11, range 22–77), with 28 (5%) patients being 65 years of age or older. Patients who were not working were the most disabled group based on Quick DASH (F = 49.93, p < 0.0001) and NPS (F = 10.24, p = 0.002). Patients who were working full time performing regular duties were the least disabled according to both measures, the QuickDASH (F = 10.24, p = 0.002) and NPS (F = 7.57, p = 0.006).

Patients waiting more than 16 weeks were slightly older (53 years of age vs. 49, p = 0.045) than those who met the criteria for early assessment with similar levels of pain and functional difficulty. Biceps pathology had the highest prevalence (37%). Full thickness tear had a prevalence of 14%. Instability, labral lesions and osteoarthritis of glenohumeral joint were uncommon conditions (3, 2 and 1% respectively). Fifty-five patients (10%) were surgical candidates and had higher scores on QuickDASH (F = 7.16, p = 0.008) and NPS (F = 4.24, p = 0.04) compared to those who did not require surgery.

Conclusions

This study provides information on characteristics and prevalence of important variables in injured workers with shoulder problems and highlights the impact of these characteristics on pain and disability.

Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear

PURPOSE

The purpose of this study was to examine the impact of distal clavicle resection (DCR) on subjective and objective outcome measures in patients with acromioclavicular (AC) joint osteoarthritis (OA) and rotator cuff tear.

METHODS

Prospectively collected data of consecutive patients with arthroscopic evidence of OA of the ACJ with complete data at 2 years were used for the data analysis. Patients with moderate-to-severe OA of the AC joint underwent a DCR in conjunction with rotator cuff repair, while patients with mild OA of the ACJ underwent surgery related to concomitant rotator cuff tear without a DCR.

RESULTS

Data of 184 (72 females, 112 males, mean age: 62) patients with rotator cuff tear and varying degrees of OA of the AC joint were used for the analysis. Of 184 patients, 144 (78 %) had a resection of distal clavicle (resection group) and 40 (22 %) did not have a resection (no-resection group). Both groups showed a statistically significant (p < 0.0001) improvement in the American Shoulder and Elbow Surgeons (ASES) scores, Constant Murley score, and strength. Multivariable analysis showed that lower pre-operative ASES scores (higher disability), having a larger tear, an active compensation claim, and not having a DCR, had a negative impact on post-operative ASES scores.

CONCLUSION

When untreated surgically, even mild arthroscopic findings of AC joint OA may lead to a poorer outcome after rotator cuff repair. Further characterisation of patients in whom mild arthroscopic findings of OA of AC joint are clinically significant and warrant resection is needed.

LEVEL OF EVIDENCE

Retrospective outcome study, Level II.

The peripheral neuronal phenotype is important in the pathogenesis of painful human tendinopathy: a systematic review

BACKGROUND

The pathogenesis of tendinopathy is complex and incompletely understood. Although significant advances have been made in terms of understanding the pathological changes in both the extracellular matrix and the cells involved, relatively little is known about the role of neuronal regulation in tendinopathy. The frequent mismatch between tendon pathology and pain may be explained, in part, by differences in the peripheral neuronal phenotype of patients.

QUESTIONS/PURPOSES

The primary purpose of this review was to determine whether evidence exists of changes in the peripheral neuronal phenotype in painful human tendinopathy and, if so, to identify the associated histological and molecular changes. The secondary purpose was to determine if any changes in the peripheral neuronal phenotype reported correlate with pain symptoms.

METHODS

We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines. The Medline and Embase databases were searched using specific search criteria. Only studies analyzing the peripheral tissue of patients with the clinical diagnosis of tendinopathy were included. Inclusion was agreed on by two independent researchers on review of abstracts or full text.

RESULTS

Overall in the 27 included studies, there was clear evidence of changes in the peripheral neuronal phenotype in painful human tendinopathy. The excitatory glutaminergic system was significantly upregulated in seven studies, there was a significant increase in sensory neuropeptide expression in four studies, and there were significant changes in the molecular morphology of tenocytes, blood vessels, and nerves. In rotator cuff tendinopathy, substance P has been shown to correlate with pain and the neural density in the subacromial bursa has been shown to correlate with rest pain.

CONCLUSIONS

The peripheral neuronal phenotype is an important factor in the pathogenesis of painful human tendinopathy. Further research in this area specifically correlating tissue changes to clinical scores has great potential in further developing our understanding of the disease process.

Workers' compensation status: does it affect orthopaedic surgery outcomes? A meta-analysis

INTRODUCTION

Previous reviews have demonstrated that patient outcomes following orthopaedic surgery are strongly influenced by the presence of Workers' Compensation. However, the variability in the reviews' methodology may have inflated the estimated strength of this association. The main objective of this meta-analysis is to evaluate the influence of Workers' Compensation on the outcomes of orthopaedic surgical procedures.

METHODS

We conducted a systematic search of the literature published in this area from 1992-2012, with no language restrictions. The following databases were used MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and Pubmed. We also hand-searched the reference sections of all selected papers. We included all prospective studies evaluating the effect of compensation status on outcomes in adult patients who had undergone surgery due to orthopaedic conditions or diseases. Outcomes of interest included disease specific, region specific and/or overall quality of life scales/questionnaires and surgeons' personal judgment of the results. We used an assessment tool to appraise the quality of all included studies. We used Review Manager to create forest plots to summarize study data and funnel plots for the assessment of publication bias.

RESULTS

Twenty studies met our eligibility criteria. The overall risk ratio for experiencing an unsatisfactory result after orthopaedic surgery for patients with compensation compared to non-compensated patients is 2.08 (95% CI 1.54-2.82). A similar association was shown for continuous data extracted from the studies using assessment scales or questionnaires (Standard Mean Difference = -0.70 95% CI -0.97- -0.43).

CONCLUSIONS

Among patients who undergo orthopaedic surgical procedures, those receiving Workers' Compensation experience a two-fold greater risk of a negative outcome. Our findings show a considerably lower estimate of risk compared to previous reviews that include retrospective data. Further research is warranted to determine the etiological explanation for the influence of compensation status on patient outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42012002121.