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

Establishing a rabbit model with massive supraspinatus tendon defect for investigating scaffold-assisted tendon repair

BACKGROUND

Shoulder pain and disability from rotator cuff tears remain challenging clinical problem despite advancements in surgical techniques and materials. To advance our understanding of injury progression and develop effective therapeutics using tissue engineering and regenerative medicine approaches, it is crucial to develop and utilize animal models that closely resemble the anatomy and display the pathophysiology of the human rotator cuff. Among various animal models, the rabbit shoulder defect model is particularly favored due to its similarity to human rotator cuff pathology. However, a standardized protocol for creating a massive rotator cuff defect in the rabbits is not well defined. Therefore, the objective of our study was to establish a robust and reproducible model of a rotator cuff defect to evaluate the regenerative efficacy of scaffolds.

RESULTS

In our study, we successfully developed a rabbit model with a massive supraspinatus tendon defect that closely resembles the common rotator cuff injuries observed in humans. This defect involved a complete transection of the tendon, spanning 10 mm in length and encompassing its full thickness and width. To ensure stable scaffolding, we employed an innovative bridging suture technique that utilized a modified Mason-Allen suture as a structural support. Moreover, to assess the therapeutic effectiveness of the model, we utilized different scaffolds, including a bovine tendon extracellular matrix (ECM) scaffold and a commercial acellular dermal matrix (ADM) scaffold. Throughout the observation period, no scaffold damage was observed. Notably, comprehensive histological analysis demonstrated that the regenerative tissue in the tendon ECM scaffold group exhibited an organized and aligned fiber structure, indicating tendon-like tissue regeneration while the tissue in the ADM group showed comparatively less organization.

CONCLUSIONS

This study presents a comprehensive description of the implemented procedures for the development of a highly reproducible animal model that induces massive segmental defects in rotator cuff tendons. This protocol can be universally implemented with alternative scaffolds to investigate extensive tendon defects and evaluate the efficacy of regenerative treatments. The application of our animal model offers a standardized and reproducible platform, enabling researchers to systematically evaluate, compare, and optimize scaffold designs. This approach holds significant importance in advancing the development of tissue engineering strategies for effectively repairing extensive tendon defects.

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.

An isolated bioinductive repair vs sutured repair for full-thickness rotator cuff tears: 2-year results of a double blinded, randomized controlled trial

BACKGROUND

Partial-thickness rotator cuff tears treated with an isolated bioinductive repair (IBR) in lieu of a completion-and-repair have shown complete healing. This treatment option is afforded by the remaining tendon's structural integrity, which is similar to that present in small/medium full-thickness tears (FTTs) when the rotator cable remains intact. This randomized controlled trial (RCT) investigated whether an IBR for small/medium full-thickness tears resulted in superior healing and patient-reported outcomes (PROs) compared with a sutured repair.

METHODS

This prospective, double blinded (patients and outcome assessors), single-center randomized controlled trial enrolled patients ≥18 years with a small/medium (≤2.5 cm) full thickness supraspinatus tear and intact rotator cable. Patients were randomized and blinded to arthroscopic transosseous-equivalent repair (control, n = 30) or IBR (n = 30). The primary outcome was tendon quality on biopsy at 6 months. Secondary outcomes were PROs (American Shoulder and Elbow Surgeons [ASES], Constant-Murley Shoulder [CMS], and pain visual analogue scale scores) and tendon thickness and healing measured via MRI at 6, 12, and 24 months; satisfaction at 12 and 24 months; and time to return to work.

RESULTS

Baseline demographic, tear, and surgical characteristics were comparable between the groups (IBR: mean age, 54.2 years, 14 male; control: mean age, 56.4 years, 16 male). Measured via a 6-month biopsy, highly organized, parallel bundles of collagen, without inflammation, were present in all IBR patients, whereas poorly organized, nonparallel collagen fibers were present in 24/30 (80%) of control patients (P < .0001), with 28/30 having minimal to mild inflammation. The increase in tendon thickness measured via MRI at 6 months from baseline was greater in the IBR group (2.0 mm) than in the control group (0.8 mm) (P < .0001). All IBR patients had 100% healing on MRI at 12 and 24 months. Compared with the control group, the IBR group had higher American Shoulder and Elbow Surgeons and Constant-Murley Shoulder scores at each evaluation, less pain at 6 and 12 months, and greater satisfaction at 12 and 24 months (P < .0003). The IBR group returned to work significantly faster (median 90 days [IQR, 25] vs. median 163.5 days [IQR, 24]; P < .0001) than the control group.

CONCLUSION

Compared with a sutured repair, the IBR treatment resulted in superior tendon quality, patient outcomes, satisfaction, and return to work. The IBR enabled a robust healing response evident through MRI and biopsy evaluation, demonstrating superior tendon quality and healing.

Worker's compensation and no-fault insurance are associated with decreased patient reported outcomes and higher rates of revision at 2 and 5 years follow-up compared to patients with commercial insurance undergoing hip arthroscopy for femoroacetabular impingement

PURPOSE

To investigate the patient reported outcomes (PROs) of patients undergoing hip arthroscopy (HA) for femeroacetabular impingement syndrome (FAIS), a condition where irregular bone growth in the hip joint leads to friction and pain during movement, who have worker's compensation (WC) or no-fault insurance (NF) versus commercial insurance (CI) at both 2 year and 5 year follow-up.

METHODS

This was a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023 of consecutive patients that underwent HA, a minimally invasive surgical procedure used to diagnose and treat problems inside the hip joint through small incisions, for FAIS. Patients were divided into two cohorts-those with WC/NF and those with commercial insurance (CI). Patient reported outcomes (PROs), which included modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS), were collected preoperatively, as well as at least 2-year postoperatively. Additionally, other clinically relevant outcomes variables including prevalence of revision surgery and conversion to total hip arthroplasty were recorded.

RESULTS

Three hundred and forty three patients met inclusion criteria. There were 32 patients in the WC/NF cohort and 311 patients in the commercial cohort. When controlling for age, sex, and Body Mass Index (BMI), WC/NF status was associated with lower mHHS at both 2 year (β = - 8.190, p < 0.01, R2 = 0.092) and 5 year follow-up (β = - 16.60, p < 0.01, R2 = 0.179) and NAHS at 5 year follow up (β = - 13.462, p = 0.03, R2 = 0.148). The WC/NF cohort had a lower rate of achieving Substantial Clinical Benefit (SCB) for mHHS at 2-years follow-up (66.7% vs. 84.1%, p = 0.02).The rate of revision hip arthroscopy was significantly higher in the worker's compensation/no fault cohort than the commercial insurance cohort (15.6% vs. 3.5%, p < 0.01). The rate of conversion to total hip arthroplasty (THA) in the WC/NF cohort was not significantly different than the rate of conversion to THA in the commercial insurance cohort (0.0% vs. 3.2%, p = 0.30).

CONCLUSION

Patients with WC/NF insurance may expect a significant improvement from baseline mHHS and NAHS following HA for FAIS at short-term follow-up. However, this improvement may not be as durable as those experienced by patients with CI. Additionally, WC/NF patients should be counseled that they have a higher risk of undergoing revision hip arthroscopy than similar CI patients.

LEVEL OF EVIDENCE

III, Retrospective Comparative Prognostic Investigation.

When is a Reverse Shoulder Arthroplasty Indicated for a Rotator Cuff Tear?

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy

INTRODUCTION

Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy.

METHODS

A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy.

RESULTS

Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results.

CONCLUSION

In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

Workers' Compensation Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement Syndrome Experience Worse Mid-Term Outcomes but Similar Return-to-Work: A Propensity-Matched Analysis at 5-Year Follow-Up

PURPOSE

To investigate mid-term patient-reported outcomes (PROs) and return-to-work for workers' compensation (WC) patients undergoing primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) versus propensity-matched, non-WC controls and to determine whether achievement rates of minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) differ between these populations.

METHODS

A retrospective cohort study was conducted on WC patients who underwent primary HA for FAIS from 2012 to 2017. WC and non-WC patients were propensity matched on a 1:4 basis by sex, age, and body mass index (BMI). PROs were compared preoperatively and at 5 years postoperatively, employing the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. MCID and PASS were calculated using published thresholds for these measures. Preoperative and postoperative radiographs and the presence and timing of return to unrestricted work were evaluated.

RESULTS

Forty-three WC patients were successfully matched to 172 non-WC controls and followed for 64.2 ± 7.7 months. WC patients demonstrated lower preoperative scores for all measures (P ≤ .031) and worse HOS-ADL, HOS-SS, and VAS pain scores at 5-year follow-up (P ≤ .021). There were no differences in MCID achievement rates or magnitude of change between preoperative and 5-year postoperative PROs (P ≥ .093); however, WC patients achieved PASS at lower rates for HOS-ADL and HOS-SS (P ≤ .009). 76.7% of WC and 84.3% of non-WC patients returned to work without restrictions (P = .302) at 7.4 ± 4.4 versus 5.0 ± 3.8 months, respectively (P < .001).

CONCLUSIONS

WC patients undergoing HA for FAIS report worse preoperative pain and function than non-WC patients and experience worse pain, function, and PASS achievement at 5-year follow-up. However, they demonstrate similar MCID achievement and magnitude improvement between preoperative and 5-year postoperative PROs, and return to work without restrictions at a similar rate to non-WC patients, although they may take longer to do so.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Rotator cuff repair in patients 50 years of age or younger: A comparative study of functional outcomes in relation to older patients

BACKGROUND

Few studies have evaluated the clinical results of surgical treatment of rotator cuff tears in young patients and most of the publications are only case series and with a small number of evaluated individuals. The aim of this study is to compare the clinical outcomes of patients undergoing arthroscopic rotator cuff repair according to age at the time of the procedure.

HYPOTHESIS

Patients with 50 years of age or younger undergoing surgical treatment of rotator cuff tear have similar clinical outcomes to older patients.

MATERIALS AND METHODS

Retrospective cohort study comparing results obtained after surgical treatment of rotator cuff tears between patients aged 50 years or younger and the older patients by the ASES and UCLA functional scales. Patients undergoing arthroscopy full-thickness rotator cuff repair were included.

RESULTS

We evaluated 390 shoulders (377 patients), 94 aged 50 years or younger (median=46.5 years) and 296 aged over 50 years (median=60 years). Both groups significantly improved with the procedure after 24 months of follow-up, according to the ASES and UCLA scales (p<0.001). The groups did not differ in the scores obtained in the preoperative assessments and at 24 months of follow-up. The score obtained on the ASES scale at 24 months of follow-up had a median of 87.2 (IQR=38) among patients aged 50 years or younger and 90 points (IQR=26.4) among older patients (p=0.253). The scores obtained by the UCLA scale were 31 points (IQR=9) and 33 points (IQR =7) respectively (p=0.156).

DISCUSSION

Our results showed that, after 24 months, the functional results of arthroscopic full-thickness rotator cuff repair did not differ between patients younger than 50 years and older patients. These results are similar to those found by other authors. Both groups of patients achieved significant improvement after the surgical procedure, achieving approximately 90 points on the ASES scale and 32 points on the UCLA scale.

LEVEL OF EVIDENCE

III Retrospective cohort study.

The impact of shoulder pathologies on job discontinuation and return to work: a pilot ultrasonographic investigation

BACKGROUND

Ultrasound imaging has emerged as one of the most useful tools for evaluating shoulder disorders. To date, the association between shoulder ultrasonography and a patient's work status has rarely been explored by antecedent studies.

AIM

This study aimed to investigate the association between sonographically diagnosed shoulder pathologies and job discontinuation and return to work.

DESIGN

A cross-sectional study.

SETTING

Outpatient clinic in the university hospital.

POPULATION

Fifty-nine patients who were older than 20 years of age and had worked in a full-time job within the past three years.

METHODS

All participants underwent clinical evaluation using the visual analog scale (for pain), Shoulder Pain and Disability Index, Pittsburgh Sleep Quality Index, and shoulder ultrasound examination. The work-related ergonomic risks, including dealing with heavy objects, repeated use and requiring forceful motion of the affected upper extremity, were assessed. The ultrasound-identified shoulder pathologies associated with job discontinuation, that is, sick leave due to painful shoulder for more than two consecutive months, were considered as the primary outcome. In the job discontinuation subgroup, we further investigated the association between return to work and the clinical/sonographic findings.

RESULTS

Univariate analysis revealed a positive association between job discontinuation and shoulder surgery or work types requiring forceful upper-limb movements. Multivariate analysis demonstrated that job discontinuation was positively associated with supraspinatus tendon full-thickness tears (risk ratio, 8.80; 95% CI, 1.77-10.56; P=0.018). Of the patients who received shoulder surgery, 46.6% had recurrent rotator cuff tears. Return to work was likely to be related to pain scores during overhead activities and shoulder function impairment but not to sonographic findings.

CONCLUSIONS

Job discontinuation is associated with shoulder surgery, work that necessitates forceful upper-extremity movements and supraspinatus tendon full-thickness tears detected by ultrasound.

CLINICAL REHABILITATION IMPACT

Sonographic findings should not be used as the only standard for evaluating the patient's work capability.

Photobiomodulation self-treatment at home after rotator cuff arthroscopic repair accelerates improvement in pain, functionality, and quality of life: A double-blind, sham-controlled, randomized clinical trial

OBJECTIVE

To determine whether self-applied photobiomodulation (PBM) therapy at home, following rotator cuff arthroscopic surgery (RCAS) can accelerate improvement in patient-reported outcomes within the first 6 months postsurgery.

METHODS

This study was a prospective, double-blind, sham-controlled, randomized clinical trial (NCT04593342). Patients (n = 50, age 55 ± 7 years, male:female 29:21) who underwent primary RCAS were randomized to receive active (n = 22) or sham (n = 28) PBM devices (B-Cure Laser Pro, Erica B-Cure LASER Ltd., Haifa, Israel) in addition to standard care. Patients self-applied the treatments (808 nm, 15 min, 16.5 J/cm2 ) at home for 3 months postsurgery. Evaluations were conducted before the surgery (baseline) and at 1-3 and 6 months post-RCAS (FU-1M, FU-3M, FU-6M), and included Constant-Murley score (CMS), range of motion (ROM), subjective pain by visual analogue scale (VAS), disability by QuickDASH, and quality of life (QOL) by SF-12. The difference from baseline to follow-up (ΔFU), %patients achieving minimal clinical important difference (MCID), and patient acceptable symptom score (PASS) were calculated. Comparisons were conducted with superiority 2-sample t test and χ2 .

RESULTS

Baseline values were not significantly different between groups. Both groups had similar improvements in CMS and ROM. However, compared to Sham, PBM significantly accelerated subjective pain reduction at 3 and 6 months (VAS mean ± SD, PBM-vs-Sham: ΔFU-3M 32 ± 33 vs. 16 ± 27, p = 0.040; ΔFU-6M: 41 ± 36 vs. 23 ± 26, p = 0.038), with a significantly higher proportion of patients achieving MCID at 3 months (76% vs. 48%, p = 0.027) and PASS at 6 months (48% vs. 23%, p = 0.044). PBM also significantly accelerated improvement in functionality and QOL at 6 months (QuickDASH ΔFU-6M: 30 ± 24 vs. 18 ± 14, p = 0.029; SF-12 physical component 6.8 ± 12.5 vs. 0.4 ± 8.6, p = 0.031; SF-12 mental component 8.5 ± 9.1 vs. 2.2 ± 12, p = 0.032).

CONCLUSIONS

Self-applied photobiomodulation following RCAS significantly accelerates decrease in pain and disability, and improves QOL. This nonpharmacologic add-on therapeutic modality is easy to use and encourages active patient involvement. Its potential use in rehabilitation following other surgeries should be considered.

LEVEL OF EVIDENCE

Level I, high-quality RCT.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictive factors of return-to-work trajectory after work-related rotator cuff syndrome: A prospective study of 96 workers

OBJECTIVE

Sustained return to work after surgery for work-related rotator cuff syndrome (WRRCS) remains quite difficult. The main purpose of the present study was to identify predictive factors of a return-to-work (RTW) trajectory.

METHODS

A total of 96 workers with WRRCS were identified by 4 surgeons. They were followed prospectively before and after the surgery, until 1 year after RTW, or for 20 months after surgery when they did not. Participants completed a series of standardized questionnaires related to working conditions, health, and beliefs, and performed functional tests at the inclusion time. During the follow-up period, they were regularly asked about their working conditions (present or not at work), activity (normal or lightened physical duties) and schedules (full- or part-time job). Statistical analysis was based on single- and multiple-factor models of prediction of the workers' trajectory.

RESULTS

Three trajectories of RTW were distinguished, considering RTW and absenteeism that occurred during the follow-up: stable, unstable, and non-RTW. The median age of the sample was 49.5 [45.0-54.0], with 67.7% of workers employed in highly physically demanding jobs. In the multiple factor model, three factors were highly predictive of the trajectory: perceived health before surgery, having had a repaired ruptured-rotator-cuff tendinopathy, and the level of physical demand of the job.

CONCLUSION

Three easy-to-collect predictive factors of RTW trajectory have been identified. They may be useful for healthcare professionals and care givers to identify vulnerable workers' risk of occupational dropout after arthroscopic surgery for rotator cuff tendinopathy.

Longitudinal Analysis of the ASES and Constant-Murley Scores, and the Internal Rotation/Shift and Jobe Tests Following Arthroscopic Repair of Supraspinatus Lesions

It is essential to investigate patients post-surgery using functional surveys like the American Shoulder and Elbow Surgeons Shoulder (ASES) and the Constant-Murley shoulder (CMS) scores, as well as clinical tests, such as the Internal Rotation and Shift (IRO/Shift) and Jobe tests. In this study, 51 out of an initial 87 patients underwent an arthroscopic supraspinatus repair (22 single-row, 16 double-row, 13 debridement). Testing occurred pre-surgery, and 3 and 6 months post-surgery. Both surveys showed significant improvements over time among all 87 patients, but there were no differences between groups (lesion/no lesion) (p > 0.815) or time × group (p > 0.895). The IRO/Shift test showed a stronger ability to distinguish between both groups (positive vs. negative) with respect to the ASES and CMS scores over time, but the Jobe test did not (p > 0.100). Improvements in the CMS scores and the Jobe test were lower following repair compared to the ASES and IRO/Shift test. Most patients returned to adequate levels of functional abilities at 6 months post-surgery. The time required to return to activities of daily living and negative clinical tests was longer for the double-row repair patients compared to the single-row and debridement groups. In conclusion, both the functional surveys and the clinical tests demonstrated improvements following surgery.

Effect of Retear After Arthroscopic Rotator Cuff Repair on Return to Work and Sports in Nonathletes: A Retrospective Cohort Study

Background

The impact of retear after arthroscopic rotator cuff repair (ARCR) on clinical outcomes of patients remains controversial.

Purpose/Hypothesis

The purpose of this study was to determine the effects of retear on strength recovery, return to previous levels of work, and return to sports participation. It was hypothesized that retears (1) would not have a significant effect on patient-reported outcome measures (PROMs) and (2) would significantly inhibit strength recovery and return to previous work and sports.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors collected data from patients who underwent ARCR between January 2015 and December 2019. All included patients had undergone magnetic resonance imaging (MRI) and strength measurements 1 year postoperatively. Minimum 2-year postoperative PROMs (Constant score, pain visual analog scale, American Shoulder and Elbow Surgeons score, and Single Assessment Numeric Evaluation) and status on work and sports participation were collected, and PROM scores, strength recovery (percentage compared with the contralateral shoulder), return to work, and return to sports were compared between patients with versus without retear on 1-year postoperative MRI. Additionally, factors related to return to work and sports were identified through multivariable regression analysis.

Results

A total of 159 patients were included, of whom 19 (11.9%) had evidence of retear. Return-to-work and return-to-sports status was evaluated in 134 (84.3%) and 93 (58.5%) patients, respectively. There were no significant differences in PROM scores between patients with and without retears; however, patients with retears exhibited significantly worse supraspinatus strength recovery (73% vs 86%; P = .018) and external rotation strength recovery (78% vs 88%; P = .030) compared with patients with intact shoulders. There were no between-group differences in return to work or sports. Active workload was associated with unsuccessful return to work, whereas preoperative participation in shoulder sports was associated with successful return to work.

Conclusion

Patients with postoperative retears had significantly worse postoperative strength recovery than patients with intact shoulders. Active workload and preoperative shoulder sports participation were factors associated with ability to return to work.

Comparison of three common shoulder injections for rotator cuff tears: a systematic review and network meta-analysis

OBJECTIVE

To compare the clinical effectiveness of three common shoulder injections mentioned in the guidelines [corticosteroid, sodium hyaluronate (SH) and platelet-rich plasma (PRP)] on rotator cuff tears.

MATERIAL AND METHODS

The PubMed, Embase and Cochrane Library databases were systematically searched up to June 1, 2022, for randomized controlled trials (RCTs) and prospective studies on the three injection therapies for rotator cuff tears. The main results were pain relief and functional improvement at 1-5 months and over 6 months, pooled using a network meta-analysis and ranked by SUCRA score. The risk of bias of the included studies was assessed using the Cochrane Collaboration tool.

RESULTS

Twelve RCTs and 4 prospective studies comprising a total of 1115 patients were included in the review. Three prospective studies were judged to be at high risk of selection bias and performance bias, and one was considered as having a high risk of detection bias. SH injection ranked first in the short term in pain relief (MD: - 2.80; 95%CI - 3.91, - 1.68) and functional improvement (MD:19.17; 95%CI 12.29, 26.05), while PRP injection obtained better results in the long term in both pain relief (MD: - 4.50; 95%CI - 4.97, - 4.03) and functional improvement (MD:11.11; 95%CI 0.53,21.68).

CONCLUSIONS

PRP injection has the potential to successfully treat rotator cuff tears as an alternative to corticosteroids in the long term, in terms of either therapeutic efficiency or adverse effects, followed by SH injection. More research is needed to make high-quality recommendations on treatment options for injection treatments of rotator cuff tears.

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.

Return to physical activities after arthroscopic rotator cuff repair: a systematic review and meta-analysis

BACKGROUND

Rotator cuff tear is one of the most common disorders in orthopedic surgery. When conservative treatment fails, arthroscopic rotator cuff repair has become the most common procedure to achieve a functional shoulder.

HYPOTHESIS/PURPOSE

The articles on return to activities following arthroscopic rotator cuff repair have not been collectively analyzed and investigated. We aimed to review systematically and perform a meta-analysis of studies on the return to activities which consist of the return to work, return to sports, and return to daily activities following arthroscopic rotator cuff repair.

STUDY DESIGN

Systematic Review and Meta-Analysis.

METHODS

Articles regarding return to activities were systematically searched using databases of PubMed, MEDLINE via EBSCO, ScienceDirect, and ProQuest. The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. The study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews. Studies with a level of evidence 1-4 that examined the rate of return to activities after arthroscopic rotator cuff repair were included and analyzed.

RESULTS

Fifteen studies published between 2005 and 2021 were included, with 1065 patients (644 male and 421 female). The patient populations are workers and athletes. The meta-analysis on the combined effect of a return to activities using the random-effects model was 88.5% (83.8% on return to work, 88.2% on return to sport, and 97.3% on return to daily activities). The mean duration for return to activities is 6.59 months.

CONCLUSION

As much as 88.5% of patients were able to return to activities after arthroscopic rotator cuff repair with a mean duration of 6.59 months. Preoperative factors (gender, workload, chronicity, tear size, and cholesterol level) may contribute to the rate and duration of return to activities.

Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears

Purpose

This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT).

Methods

We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors.

Results

The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing.

Conclusions

This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving.

Level of Evidence

Level IV, economic analysis.

Effects of sex and age on work-related upper extremity musculoskeletal disorders in Ontario, Canada

BACKGROUND

Effective targeting of workplace upper extremity musculoskeletal disorder (MSD) prevention strategies requires the identification of demographic groups most at risk. Workers' compensation data provides an effective means of surveillance of MSDs at the population level.

OBJECTIVE

The primary purpose of this study was to identify the effects of age and sex on rates of tendon injuries of the wrist and hand, carpal tunnel syndrome (CTS), epicondylitis, and soft tissue shoulder injuries in Ontario, Canada between 2000-2019 using workers' compensation data from the Association of Workers Compensation Boards of Canada (AWCBC).

METHODS

Age and sex specific rates of lost-time injury claims from the four identified injury categories as well as "non-specific" upper extremity MSDs which did not fit into the four categories were calculated by standardizing injury claim totals with "at-risk" population estimates from the Canada Labour Force Survey. A multiple regression analysis was used to analyze the effects of age and sex on rates of specific injury claims.

RESULTS

Statistically significant age and sex effects were identified for rates of claims from tendon injuries of the wrist and hand, CTS, and shoulder injuries, while only age effects were significant for epicondylitis. Between 2000-2019, rates of claims from the four injury categories studied and the magnitude of the age and sex effects declined substantially over time.

CONCLUSION

Detailed surveillance of workplace ergonomic hazards in Ontario workplaces is needed to determine what is causing rates of upper extremity claims to decline.

Rates of Return to Manual Labor After Arthroscopic Rotator Cuff Repair

BACKGROUND

Rotator cuff tears represent a significant cause of shoulder pain and dysfunction in the United States. The development of these injuries is associated with older patient age and higher levels of physical activity; however, data regarding the rate of return to work after arthroscopic rotator cuff repair in patients older than 50 years of age who have physically strenuous jobs is inconclusive.

PURPOSE/HYPOTHESIS

The purpose of this study was to report short term outcomes and return to work rates after arthroscopic rotator cuff repair in a cohort of patients aged 50 to 60 years working in manual labor jobs. It was hypothesized that arthroscopic rotator cuff repair would result in good functional outcomes for these patients and allow for return to work rates in excess of 80%.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative and final evaluations including the pain visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score were collected. A total of 73 patients were screened for inclusion. Nineteen patients were outside of the inclusion age range, 2 underwent exclusionary concomitant procedures, and 4 patients were lost to follow up, leaving a total of 48 patients with a mean follow up of 34.02 months (range, 24-67 months) available for analysis. None of the patients were involved in a workers' compensation claim. Subgroup analysis was performed to determine if arm dominance or tear size affected surgical outcomes or return to work rates.

RESULTS

After arthroscopic rotator cuff repair, 43 of 48 patients (89.6%) were able to return to manual labor positions. Tears were classified using the Southern California Orthopaedic Institute Classification at the time of repair as massive (C4) in 9 patients (18.75%), large (C3) in 13 patients (27.08%), medium (C2) in 21 patients (43.75%), and small (C1) in 5 patients (10.42%). At latest follow up, the mean VAS decreased from 8.0 ± 1.81 to 0.46 ± 1.20, the average SANE increased from 47.50 ± 18.59 to 91.88 ± 12.30, and the average ASES score improved from 39.58 ± 10.71 to 93.44 ± 11.97 (P < .0001). Outcomes did not differ between patients who underwent surgery on their dominant shoulder and those who underwent surgery on their nondominant shoulder. The overall postoperative complication rate was 8.33%.

CONCLUSION

Arthroscopic rotator cuff repair portended favorable outcomes and high rates of return to work in this cohort of manual laborers, with 89.6% of patients able to return to work.

Return to Work After Primary Hip Arthroscopy: A Systematic Review and Meta-analysis

BACKGROUND

Hip arthroscopy is a procedure commonly performed to correct various hip pathologies such as femoroacetabular impingement and labral tears. These hip pathologies commonly affect young, otherwise healthy patients. The recovery after hip arthroscopy can prevent patients from returning to work and impair performance levels, having significant economic repercussions. To date, there has been no cumulative analysis of the existing literature on return to work after hip arthroscopy.

PURPOSE

The purpose of this study was to perform a systematic review of the existing literature regarding return to work after hip arthroscopy and analysis of factors associated with the ability to return to work and time to return to work.

STUDY DESIGN

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

METHODS

A literature search of the MEDLINE, EMBASE, and Cochrane Library databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies assessing functional outcomes and return to work, including return to military duty, after hip arthroscopy were included. Patients' ability to return to work, as well as time to return, was compared between selected studies. Where available, workers' compensation status as well as type of work was compared. All statistical analysis was performed using SPSS, Version 22. P < .05 was considered statistically significant.

RESULTS

Twelve studies with 1124 patients were included. Patients were followed for an average of 17.6 months. Using weighted means, the average rate of return to work was 71.35%, while full return to previous work duties was achieved at a rate of 50.89%. Modification to work duties was required at a rate of 15.48%. On average, the time to return to work was 115 days (range, 17-219 days). Rate of return by patients with workers' compensation status was found to be 85.15% at an average of 132 days (range, 37-211 days). Rate of return to work in workers performing professions reported as strenuous vs light (ie, mostly sedentary) jobs showed a statistically higher return to work in light professions (risk ratio, 0.53; 95% CI, 0.41-0.69).

CONCLUSION

After hip arthroscopy, there is a high rate of return to work at an average of 115 days after surgery. However, full return to work was achieved by only half of patients upon final follow-up.