ARTHROSCOPIC ACROMIOPLASTY

Do Outcomes Differ After Proximal Hamstring Repair for Patients Receiving Workers' Compensation?

Background

Patients with workers' compensation (WC) insurance claims are often shown to experience inferior patient-reported outcomes (PROs) after an orthopaedic surgical intervention compared with patients without WC claims.

Purpose

To compare the postoperative PROs of patients with WC claims (WC patients) versus those without WC claims (non-WC patients) after proximal hamstring repair (PHR).

Study Design

Cohort study; Level of evidence, 3.

Methods

WC patients who underwent PHR between November 2011 and to September 2020 were propensity score matched at a 1:2 ratio to non-WC patients according to age, sex, and body mass index. Comorbidity data were collected as well as minimum 1-year postoperative PRO scores for the Lower Extremity Functional Scale (LEFS), the Hip Outcome Score (HOS), and the 12-Item Short From Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS). The type of work was characterized according to national WC insurance guidelines as light (maximum 20 lbs [9.1 kg]), medium (maximum 50 lbs [22.7 kg]), or heavy (≥50 lbs) [>/=22.7 kg].

Results

A total of 30 patients (10 WC and 20 non-WC) were included. The work type and baseline demographic characteristics of patients did not differ between groups. There were no significant between-group differences in postoperative PRO scores as measured by the LEFS (P = .488), HOS (P = .233), or SF-12 PCS (P = .521). However, the WC cohort showed inferior SF-12 MCS scores compared with the non-WC group (49.28 ± 9.97 vs 54.26 ± 9.69, respectively; P = .032). The WC status was also associated with an increased time needed for patients to return to full-duty work capacity (21 ± 9 vs 9 ± 8 weeks; P = .005).

Conclusion

Our findings suggest that WC and non-WC patients who undergo PHR have comparable outcomes. Differences in SF-12 MCS scores and return to work time for full-duty capacity warrant further investigation.

Arthroscopic treatment and subacromial decompression of calcific tendinitis without removal of the calcific deposit results in rapid resolution of symptoms and excellent clinical outcomes in commercial airline pilots and cabin crew

PURPOSE

The purpose of this study was to report the results of subacromial arthroscopic decompression (SAD) without removal of the calcific deposits in patients with calcifying tendinitis.

METHODS

All patients between 2016 and 2019 were included if they were aged between 18 and 60 years and had an isolated calcific deposit. The Constant-Murley score (CMS), Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, the Shoulder Pain and Disability Index (SPADI), the simple shoulder test (SST), and the single assessment numeric evaluation (SANE) were used for assessment. Time to return to work was recorded.

RESULTS

24 patients (13 pilots, 11 cabin crew) with a mean age of 47.1 ± 7.8 years were included. Quick Dash improved from 68.8 preoperative, to 8.4 at 3 months, and 0.1 at 24 months. CMS improved from 37.4 preoperative, to 83 at 3 months, and 94 at 24 months. SPADI improved from 73.8 preoperative, to 5.4 at 3 months, and 1 at 24 months. SST improved from 22.5 preoperative, to 94.2 at 3 months, and 100 at 24 months. SANE improved from 33.5 preoperative, to 78.7 at 3 months, and 95.6 at 24 months. MCID, SCB, and PASS reached values above 83% at 3 months and 100% at 6 months, with the exception of SANE which reached 29% at 3 months and plateaued to 96% at 6 months. The mean time to return to work was 7.1 ± 2.1 weeks. Pilots returned at a mean of 6.9 ± 1.8 weeks; cabin crew returned to work at a mean of 7.8 ± 2.5 weeks.

CONCLUSIONS

The results of this study suggest excellent short- and mid-term clinical outcomes can be achieved in patients with calcific tendinitis undergoing arthroscopic debridement and subacromial decompression without removal of calcific deposits. In this patient population, early surgical intervention was a potentially viable alternative to nonoperative treatment, and allowed early return to work.

Earlier Return to Light Duty Is Associated With Successful Return to Full Duty of Workers’ Compensation Patients Treated With Shoulder Arthroscopic Surgery

Purpose

To evaluate Workers’ Compensation (WC) patients who underwent arthroscopic shoulder surgery for workplace shoulder injuries and to determine whether there was an association between earlier return to light duty and earlier return to full duty.

Methods

After receiving institutional review board approval, we performed a retrospective chart review of all WC patients treated with shoulder arthroscopic surgery by 2 senior authors between 2011 and 2018. The patients were divided into 2 groups: Group 1 went back to light-duty work within the first 100 days after surgery, whereas group 2 performed light-duty work after 100 days or performed no light-duty work. The primary outcomes included the length of time from surgery to light-duty work and the length of time from surgery to return to the full-duty work level.

Results

A total of 59 patients met the inclusion criteria. There was a moderate correlation between the number of days at which the patients were released to light duty and the days they were able to be released to full duty (r = 0.35). In group 1 (light duty ≤ 100 days), 18 patients (75%) went back to full duty, whereas only 16 patients (46%) in group 2 were able to return to full-duty work (P = .025).

Conclusions

Earlier return to light duty is associated with earlier return to full duty after shoulder arthroscopic surgery in patients with a Workers’ Compensation claim. Additionally, WC patients who returned to early light duty in the first 100 days postoperatively had a higher rate of return to full duty than did patients who did not return to early light duty.

Level of Evidence

Level III, case-control study.

Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft

PURPOSE

To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds.

METHODS

The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement.

RESULTS

Fifty-eight patients were identified (n = 39 males; n = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively.

CONCLUSION

On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR.

LEVEL OF EVIDENCE

Level IV, case series.

Pilots After Shoulder Surgery and Rehabilitation in a Dedicated Musculoskeletal Rehabilitation Unit of a Major Airline Returned to Work Earlier When Compared to Standard Rehabilitation by External Providers

Purpose

The purpose of this study was to compare the time to return to work (RTW) for pilots who underwent shoulder surgery and underwent rehabilitation within a dedicated musculoskeletal rehabilitation (MSK) unit of a major airline to a group of pilots who had standard rehabilitation and to calculate cost savings.

Methods

The database of Emirates Airline was searched for all ICD-10 codes relating to shoulder pathology. Pilots who had shoulder surgery between January 2017 and June 2021 were included. Pilots who had previous shoulder surgery, underwent fracture surgery, joint replacement, revision surgery, or conservative treatment were excluded. The time between suspension and reinstatement of their license was defined as RTW. Cost savings were calculated on the basis of the median salary and rosterable fraction of a commercial airline pilot. RTW compared between a group undergoing rehabilitation in the MSK unit and a group receiving standard rehabilitation by external providers. Group allocation for either attending MSK unit or standard rehabilitation occurred randomly and according to the individual pilots preferences.

Results

The MSK unit treated 36 pilots (36 males/0 females, mean age 45.4 ± 9.4), and 18 pilots (17 males/1 female, mean age 50.3 ± 7.3) were treated by external physical therapist providers. Patients treated by the MSK unit returned to work at a mean of 85.3 ± 32.8 days, and patients treated by external providers returned to work at a mean of 117.9 ± 42.5days (P = .02). The cost savings for pilots treated by the MSK unit were calculated to be $27,948 USD per patient.

Conclusions

The results of this study showed that pilots’ after shoulder surgery RTW times range between 85 to 118 days. Rehabilitation in a dedicated MSK unit reduced the return to flying duties by 39%. Pilots treated by the MSK unit returned to work by a mean of 33 days earlier with cost savings of $27,948 USD per pilot.

Ineffective Communication: The Uninformed Injured Worker

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quantification of acromioplasty. Systematic review of the literature

INTRODUCTION

Acromioplasty is controversial. Technically, it consists in bone resection, but there is no gold-standard technique and resection is often not quantified. The aims of the present study were 1/to assess the methodological quality of studies of acromioplasty; 2/to identify reports in which acromioplasty was quantified; and 3/to assess any correlation between clinical results and resection quantity.

MATERIAL AND METHODS

A systematic literature review was performed on PRISMA criteria in the PubMed, Springer and Ovid databases, including all articles in French or English referring to acromioplasty. Articles were analyzed by 2 surgeons and those with complete procedural description were selected. 1/Methodology was assessed on 3 grades according to aim of acromioplasty, intraoperative assessment of resection, and postoperative radiologic assessment. 2/Results were extracted from articles with robust methodology and quantitative data. 3/Correlations were assessed between clinical results and resection quantity.

RESULTS

Out of the 250 articles retrieved, 94 were selected. 1/44 of these (47%) specified the aim of the acromioplasty, 53 (56%) included an intraoperative clinical assessment criterion, and 13 (14%) included postoperative radiographic assessment. Methodologic quality was insufficient in 33 articles (35%), poor in 23 (24%) and robust in 38 (40%). 2/Seven articles (7.5%) included quantitative results. 3/Three articles assessed correlation between clinical results and resection quantity, but only 1 used reproducible radiographic assessment by critical shoulder angle (CSA); this study reported a significant positive correlation between clinical results and decreased CSA.

CONCLUSION

Methodology in studies of acromioplasty was largely insufficient and resection was usually not quantified. Current data to assess the usefulness of the procedure are sparse. We advocate including a Checklist for Acromioplasty Studies in the methodology of future studies. There is at present no gold-standard for assessing and quantifying acromial resection. CSA seems contributive, but other methods might be worth developing.

LEVEL OF EVIDENCE

IV; systematic review of level 1-4 studies.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

High Rate of Full Duty Return to Work After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Workers Who Are Not on Workers' Compensation

BACKGROUND

Femoroacetabular impingement syndrome (FAIS) is an increasingly common diagnosis among working-age adults. Hip arthroscopy provides reliable improvements in pain and may allow patients to return to physical activities. No study to date has evaluated return to work (RTW) among a general population of adults after arthroscopic surgery for FAIS.

PURPOSE

To evaluate (1) patients' rate of RTW, (2) time required to RTW, and (3) factors correlated with time required to RTW after arthroscopic surgery for symptomatic FAIS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients aged 25 to 59 years who underwent arthroscopic surgery for FAIS between June 2018 and December 2018 were reviewed. Workers' compensation cases and patients with <1-year follow-up were excluded. The following were collected at a minimum of 1 year postoperatively: demographics, employment characteristics, Hip Outcome Score (HOS; Activities of Daily Living and Sports Specific subscales), modified Harris Hip Score, 12-Item International Hip Outcome Tool (iHOT-12), visual analog scale for pain, and RTW characteristics. Work physical activity level was classified as sedentary, light, moderate, heavy, or very heavy per established criteria.

RESULTS

A total of 97 patients were selected through inclusion and exclusion criteria. RTW surveys were collected for 79 (81.4%), and 61 were employed preoperatively. Time worked per week was 42.8 ± 12.5 hours (mean ± SD). Patients' work level was most commonly classified as sedentary (42.6%), followed by moderate (24.6%). All 61 (100%) patients returned to work at a mean 7.3 weeks (range, <1-88 weeks) postoperatively. Sixty patients (95.2%) returned to full duty. Time required to full duty RTW was strongly correlated with expected time off from work (r = 0.900; P < .0001) and moderately correlated with work classification (r = 0.640; P = .0001). All patients had significant pre- to postoperative improvements in the HOS-Activities of Daily Living (64.8 ± 15.3 to 87.1 ± 12.2; P < .001), HOS-Sports Specific (42.8 ± 18.8 to 76.7 ± 16.5; P < .001), iHOT-12 (31.3 ± 18.8 to 69.3 ± 21.1; P < .001), modified Harris Hip Score (61.8 ± 12.1 to 80.3 ± 14.1; P < .001), and visual analog scale for pain (5.19 ± 2.11 to 2.40 ± 1.96; P < .001).

CONCLUSION

Patients undergoing arthroscopic treatment for FAIS demonstrated a high rate of RTW at a mean of <2 months postoperatively. A patient's expected time off from work and the level of physical demands required for work were highly associated with time required to RTW. These results are valuable for orthopaedic surgeons, patients, and employers when establishing a timeline for expected RTW after surgery.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

Influence of workers' compensation status on postoperative outcomes in patients following biceps tenodesis: a matched-pair cohort analysis

BACKGROUND AND HYPOTHESIS

Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs).

METHODS

Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined.

RESULTS

All patients showed significant improvements in all outcome measures (P < .001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P < .001).

CONCLUSION

WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.

Return to Work Following Shoulder Surgery: An Analysis of 1,773 Cases

Background

There is limited information on patients' ability to return to work (RTW) after the majority of shoulder surgical procedures.

Methods

This study was a retrospective analysis of prospectively collected data on 1,773 consecutive patients who underwent shoulder surgery performed by a single surgeon from 2004 to 2017. A validated L'Insalata Shoulder Questionnaire was used to collect information on 32 preoperative factors, which were used for analysis. The questionnaire included the premorbid level of work and the levels preoperatively and at 6 months postoperatively.

Results

Six months following the shoulder operations, 77% of the patients returned to work (40% with full duties and 37% with light duties). Concomitant rotator cuff repair and stabilization was associated with the highest RTW rate (90%) whereas some of the lowest RTW rates were associated with reverse total shoulder arthroplasty (56%) and total shoulder arthroplasty (71%). The highest rate of RTW with full duties was associated with debridement for calcific tendinitis (62%). Capsular release provided a significant improvement in work level (on a scale ranging from none to strenuous) from preoperatively to postoperatively (p = 0.0116). Older patients with stiffer shoulders who were not working preoperatively had the lowest RTW rate at 6 months.

Conclusions

To our knowledge, this is the largest study of RTW outcomes of shoulder surgical procedures, and it showed that 4 out of 5 patients were able to RTW 6 months postoperatively with approximately half resuming full duties and half, lighter duties. Capsular release was the only procedure to result in a significant improvement in work level within 6 months. The best independent predictors of RTW were younger age, less stiffness, and working preoperatively.

Level of Evidence

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

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.

Return to work after shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

With the rising incidence of shoulder arthroplasty, there is increasing emphasis on improving functional outcomes and ability to return to work (RTW). The purpose of this study was to determine the rate of RTW after shoulder arthroplasty.

METHODS

This systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of 4 electronic databases was performed from database conception through April 2018 to identify studies reporting data on RTW after shoulder arthroplasty. The primary outcome was the rate of RTW after shoulder arthroplasty. Random-effects meta-analysis was used to pool the rate of RTW across studies.

RESULTS

Seven studies were reviewed, including 447 patients at an average follow-up of 4.4 years (range, 1.0-12.6 years). The overall rate of RTW was 63.6% (95% confidence interval, 58.8%-68.2%) at a mean 2.3 months postoperatively (range, 0.3-24.0 months). RTW was significantly lower for patients with heavy-intensity occupations vs. all intensity types (61.7% vs. 67.6%; P = .04). RTW did not differ between anatomic total shoulder arthroplasty (63.4%) and hemiarthroplasty (66.1%) or reverse total shoulder arthroplasty (61.5%; P = .53). There were no significant differences in RTW among underlying diagnoses (osteoarthritis, 64.4%; cuff tear arthropathy, 65.6%; proximal humerus fracture, 69.1%; P = .41) or by workers' compensation status (61.2% vs. 65.3%; P = .41).

CONCLUSIONS

A majority of patients return to work after shoulder arthroplasty at an average of 2.3 months postoperatively. Those with heavy-intensity occupation return at significantly lower rates, whereas no differences in RTW by arthroplasty type, underlying diagnosis, or workers' compensation were found.

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers' compensation patients

BACKGROUND

Outcomes of shoulder surgery in workers' compensation (WC) patients have generally been inferior to those in non-WC patients. The purpose of this study was to compare the complication rates and clinical outcomes after shoulder arthroplasty in WC patients and control non-WC patients.

METHODS

An institutional shoulder arthroplasty database was queried for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. WC patients were age and sex matched with non-WC patients and retrospectively evaluated for complication rates, patient-reported outcome (PRO) scores, and range of motion.

RESULTS

We matched 45 WC and 45 non-WC patients by age and sex, with the WC group having a higher rate of prior surgery (82% vs 38%, P < .001). Both groups experienced significant improvements in all PROs, forward elevation, and external rotation (P < .05 for all). The WC group had inferior 2-year outcomes for all PROs and forward elevation (P ≤ .001 for all), as well as a higher reoperation rate (16% vs 2%, P = .030) and higher rate of persistent pain at final follow-up (33% vs 11%, P = .021). On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in American Shoulder and Elbow Surgeons (P < .001), functional (P < .001), and Simple Shoulder Test (P < .001) scores, as well as a higher reoperation rate (P = .015) and higher rate of persistent pain (P = .027).

CONCLUSION

Although both WC and non-WC patients experienced significant clinical improvements after shoulder arthroplasty, WC patients had a higher reoperation rate, inferior PROs, and a higher rate of persistent pain.

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.

The effect of expedited rotator cuff surgery in injured workers: a case-control study

BACKGROUND

Expediting rotator cuff surgery is expected to facilitate recovery and return to work in injured workers. This case-control study examined the effect of expedited rotator cuff surgery on recovery and work status in injured workers.

MATERIALS AND METHODS

Injured workers who had undergone an expedited rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period. Disability was measured by the American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form score. The percentage of patients who exceeded the minimal clinically important difference of 17 points in the ASES was calculated.

RESULTS

The study group waited less time to have surgery than the control group (P < .0001), reported less disability after surgery, and had a higher number of patients whose improvement exceeded the minimal clinically important difference (119 vs. 65, P < .0001). The study group was more likely to be working at the time of the final follow-up (P < .0001). The final multivariable regressions, which adjusted for unmatched variables, such as dominant side involvement, mechanism of injury, and associated operations that were different between groups, were consistent with univariable analyses indicating superior results in the study group.

CONCLUSIONS

Injured workers who underwent expedited rotator cuff surgery reported less disability and had a more successful return to work after surgery than injured workers who waited longer for specialist assessment and surgery within the public health system.

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

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

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.

Duration of sick leave after shoulder arthroscopy in Germany: analysis of health care data

INTRODUCTION

The expected duration of incapacity after arthroscopic shoulder surgery is an important factor for therapy planning. The aim of this study was to analyze the duration of sick leave after arthroscopic shoulder surgery in Germany and to identify factors associated with a longer duration of sick leave. We hypothesized that certain patient-related factors may be associated with a longer duration of sick leave.

METHODS

Routine health care data of all patients insured by one German health insurance company who underwent inpatient arthroscopic shoulder surgery between 2010 and 2012 were included in the analysis of the duration of sick leave in this retrospective cohort study (level III evidence). Comparisons were performed for different arthroscopic surgical procedures using the log-rank test. Possible factors that might be associated with a longer duration of incapacity were analyzed.

RESULTS

Sick leave was reported in 303 of 660 cases. The median duration of sick leave was 82 days after subacromial decompression and 157 days after rotator cuff repair (p = 0.004). The duration of sick leave was longer in patients older than 50 years (p = 0.044) and in patients with sick leave that started prior to surgery (p < 0.001). Patients not receiving physiotherapy had a longer period of sick leave (p = 0.058). The median period of prescribed physiotherapy (64 days) was shorter than the period of incapacity. The duration of disability was not notably longer in female patients, patients taking opioid or antidepressant medication or diabetics.

CONCLUSIONS

The duration of sick leave after arthroscopic shoulder surgery in Germany does not exceed sick leave duration in other countries. More complex procedures, advanced age and sick leave beginning prior to surgery resulted in longer durations of sick leave. Preoperative prognosis of the necessary duration of postoperative sick leave may not always be realistic. An extended period of sick leave can be expected after more complex procedures and in patients older than 50 years of age. Future studies should investigate whether a longer period of physiotherapy may help to shorten the period of postoperative sick leave.

A comparison of opioid use between WCB recipients and other Manitobans for knee, shoulder, back and carpal tunnel release procedures

BACKGROUND

This study's objectives were to evaluate whether WCB claimants with conditions requiring certain surgical procedures are more likely to be prescribed outpatient opioids than other Manitobans and whether those prescribed opioids are more likely to still be on opioid medications 6 months post procedure.

METHODS

We compared 7,246 WCB claims for a number of surgical procedures to 65,032 similar procedures performed in other Manitobans. Logistic regression was used to explore the association between being a WCB claimant and being prescribed opioids, while controlling for type of surgical procedure and other potential confounders.

RESULTS

WCB claimants were more likely than other Manitobans to be prescribed opioids (adjusted OR 1.38; 95%CI 1.30-1.47). Amongst those prescribed opioids, the odds of being still on opioids 6 months post-procedure were not significantly elevated for WCB claimants (adjusted OR 1.09 95%CI 0.97-1.23).

CONCLUSIONS

WCB claimants are prescribed opioids more often than non-claimants for similar procedures.

Workers' compensation claims and outcomes after reverse shoulder arthroplasty

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study, Treatment Study.

Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study

BACKGROUND

Patients suffering from isolated subacromial impingement (SI) of their shoulder but who are resistant to other therapies benefit substantially from arthroscopic subacromial decompression (ASD) if they are young (<60 years). Although physical demands rise notably in the older population, it still remains unclear if surgery leads to better results in these patients. Therefore, the aim of this study was to focus on the impact of age on the functional outcome in elderly patients suffering from SI.

METHODS

In this retrospective analysis, 307 patients (age range: 42-63 years) with isolated SI were enrolled. The 165 patients were allocated to physical therapy whereas 142 underwent ASD. The patient cohort was divided into two groups according to the median age (<57 years). Functional outcome was recorded using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self -assessment of the Constant, SPADI and Dark Scores.

RESULTS

Median age was 57 (25%-75%: 48-63) years, follow-up was 55 (25%-75%: 25-87) months. In group I (age < 57 years, n = 165) no significant differences in outcome between physical therapy and ASD were detected. In contrast, in group II (age > 57 years; n = 142) the patients reported significantly better results after ASD in the overall MSQs.

CONCLUSION

Despite their higher age, elderly patients with isolated SI actually benefit significantly from ASD in comparison to physical therapy.

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.

Few insurance-based differences in upper extremity elective surgery rates after healthcare reform

BACKGROUND

Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law's enactment.

QUESTIONS/PURPOSES

We asked whether differences in rates of surgery between patients with novel government-subsidized healthcare plans and other forms of insurance, and between uninsured and insured patients, were similar after institution of the Massachusetts reform laws.

METHODS

We identified 7577 patients diagnosed with upper extremity injuries between January 1, 2007 and October 1, 2010. From an institutional administrative database, we extracted demographics, insurance status, and plan of care. Insurance categories included government-subsidized healthcare plan (Commonwealth Care), private insurance, workers compensation, military-related (TriCare), Medicare, Medicaid (MassHealth), non-Commonwealth Care, and other insured and uninsured. After adjusting for age, gender, and diagnosis, we compared the proportions of patients who underwent elective surgery.

RESULTS

Of 7577 patients, 1685 (22%) underwent elective upper extremity surgery. The adjusted rates of surgery were similar across most insurance categories, with higher rates in the workers compensation and TriCare categories compared with Commonwealth Care. Uninsured patients were as likely to undergo surgery as insured patients.

CONCLUSION

In a population with near-universal health insurance, a government-run health insurance exchange, and novel, government-subsidized, managed care plans, we found few insurance-based differences in rates of elective upper extremity orthopaedic surgery in a cohort of patients after healthcare reform.

The clinical results of arthroscopic transtendinous repair of grade III partial articular-sided supraspinatus tendon tears

PURPOSE

The purpose of this study was to evaluate the clinical results of arthroscopic transtendinous repair of deep partial articular-sided rotator cuff tears.

METHODS

We retrospectively evaluated the results of 53 patients who underwent arthroscopic transtendinous repair for Ellman grade III articular-sided rotator cuff tears (>50% of the thickness of the rotator cuff). The intact bursal side of the cuff was not detached, and all associated pathology was treated. Fifty patients available for follow-up were evaluated with the American Shoulder and Elbow Surgeons (ASES) questionnaire.

RESULTS

American Shoulder and Elbow Surgeons scores improved from a mean of 48.0 to 89.4 (+41.4) (P < .0001). Pain scores on a visual analog scale improved from 5.7 to 1.0 (P < .0001). Ninety-eight percent of patients were satisfied with the results of surgery. Results for the 50 patients available for follow-up were excellent in 32 (64%), good in 6 (12%), fair in 6 (12%), and poor in 6 (12%). Articular-sided rotator cuff tears rarely occurred in isolation but were typically found in association with coexisting pathology suggestive of the tears' etiology. Most common were impingement lesions, seen in 94% of patients, and instability lesions such as labral tears, seen in 30% of patients. Associated procedures included acromioplasty in 47, distal clavicle resection in 29, treatment of biceps pathology in 7, and instability repair in 15. One patient sustained a postoperative pulmonary embolism, which represented the only complication. Tears varied in size from 50% to 90% of the thickness of the cuff insertion. Significant differences were identified in the results of Workers' Compensation patients. Preoperative magnetic resonance imaging and magnetic resonance arthrography were accurate in identifying a partial-thickness rotator cuff tear in less than 40% of cases.

CONCLUSIONS

Arthroscopic transtendinous repair of partial articular-sided rotator cuff tears is a safe and effective treatment that allows identification of commonly associated pathology and reliable improvement in pain and function.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Optimizing the management of rotator cuff problems

Of the 31 recommendations made by the work group, 19 were determined to be inconclusive because of the absence of definitive evidence. Of the remaining recommendations, four were classified as moderate grade, six as weak, and two as consensus statements of expert opinion. The four moderate-grade recommendations include suggestions that exercise and nonsteroidal anti-inflammatory drugs be used to manage rotator cuff symptoms in the absence of a full-thickness tear, that routine acromioplasty is not required at the time of rotator cuff repair, that non-cross-linked, porcine small intestine submucosal xenograft patches not be used to manage rotator cuff tears, and that surgeons can advise patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.

Disability and satisfaction after rotator cuff decompression or repair: a sex and gender analysis

Background

Rotator-cuff pathology is the most common cause of pain and disability in the shoulder. Examining the combined effect of biological and societal factors on disability would potentially identify existing differences between men and women with rotator cuff pathology which would help to provide suggestions for better models of care. Purpose of this study was to determine the overall differences in disability between men and women and to examine the relationship between factors that represent sex (biological factors) and gender (non-biological factors) with disability and satisfaction with surgical outcome 6 months after rotator cuff surgery.

Methods

Patients with impingement syndrome and/or rotator cuff tear who underwent rotator cuff surgery completed the Western Ontario Rotator Cuff (WORC) index, the American Shoulder & Elbow Surgeons (ASES) assessment form, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measures prior to surgery and 6 months post-operatively. They also rated their satisfaction with surgery at their follow-up appointment.

Results and Discussion

One hundred and seventy patients entered into the study (85 men and 85 women). One hundred and sixty patients (94%) completed the 6-month assessment. Women reported more disability both prior to and after surgery. Disability at 6 months was associated with pain-limited range of motion, participation limitation, age and strength. Satisfaction with surgery was associated with level of reported disability, expectations for improved pain, pain-limited range of motion and strength.

Conclusions

The results of this study indicate that women with rotator cuff pathology suffer from higher levels of pre- and post-operative disability and sex and gender qualities contribute to these differences. Gender-sensitive approach will help to identify existing differences between men and women which will help to promote more effective and tailored care by health professionals.

Effect of insurance status on the rate of surgery following a meniscal tear

BACKGROUND

Uninsured and underinsured Americans face barriers to access to medical care. The objective of this study was to characterize the effect of insurance status on whether patients with a torn meniscus proceed to elective arthroscopic knee surgery.

METHODS

The records from January 2003 through April 2006 at a single academic orthopaedic surgery institution in Massachusetts were retrospectively reviewed to identify patients diagnosed with a meniscal tear and to determine whether surgery had been performed within six months after the diagnosis. Six categories of insurance were identified: private insurance, Workers' Compensation, Medicare, Medicaid, Uncompensated Care Pool, and self pay. A comparison of the proportions of insured and uninsured patients who underwent surgery was the primary outcome measure.

RESULTS

A total of 1127 patients were identified, and 446 (40%) of them underwent surgery within six months after an office visit. The patients with and without surgery had similar age and sex distributions. When patients were divided, according to their insurance status, into insured and uninsured groups, no significant difference was found in the rate of surgery (p = 0.23). However, subgroup analysis revealed significant differences among the six insurance categories. Logistic regression analysis showed that patients in the self-pay group had a lower rate of surgery than those with private insurance (odds ratio, 0.33; 95% confidence interval, 0.14 to 0.75; p = 0.008), whereas patients receiving Workers' Compensation (odds ratio, 1.93; 95% confidence interval, 1.05 to 3.55; p = 0.034) and those receiving Medicaid (odds ratio, 1.63; 95% confidence interval, 1.09 to 2.42; p = 0.016) had higher surgical rates than those with private insurance.

CONCLUSIONS

The rate of elective arthroscopic knee surgery for meniscal tears varied significantly for some insurance categories at this single academic institution in Massachusetts. Further work is necessary to clarify the patient and surgeon factors influencing these disparities in clinical decision-making.

Arthroscopic subacromial decompression: outcome comparison between outpatient and hospitalized patients with 2- to 5-year follow-up

BACKGROUND AND AIMS

The purpose of this study was to evaluate the mid-term result of the arthroscopic subacromial decompression after failed conservative treatment of shoulder pain caused by subacromial impingement, when the patients were treated as an outpatient way or by staying overnight in hospital after surgery (hospitalized patients). Our hypothesis was that the results would be equal in both groups.

MATERIAL AND METHODS

Arthroscopic subacromial decompression was performed in 80 consecutive patients, of which 40 patients were treated as an outpatient way (Outpatient Group), and 40 patients as a hospitalized way (Hospitalized Group). A prospective, comparative 2- to 5-year follow-up study including clinical examination, radiographic evaluation, isometric elevation strength measurements, as well as the University of California, Los Angeles (UCLA) and Constant shoulder scores was performed in 74 patients (93%).

RESULTS

Preoperatively, the mean UCLA score was 19 (SD 3) in the Outpatient Group, and 19 (SD 3) in the Hospitalized Group. Respectively, the mean Constant scores were 62 (SD 10) and 60 (SD 11). At the follow-up, the mean UCLA score was 32 (SD 4) in the Outpatient Group, and 32 (SD 3) in the Hospitalized Group, which both indicated good clinical outcome. Respectively, the mean Constant scores were 95 (SD 7) and 92 (SD 11), which both indicated excellent clinical outcome. At the follow-up, the UCLA and the Constant shoulder scores were significantly bet-ter than preoperatively in both groups (p < 0.01, p < 0.01), although no differences were found between the groups.The duration of the sick leaves and ability to return to work were similar in both groups. Also, the isometric elevation strengths of the operated shoulders were equally good in both groups.

CONCLUSIONS

According to this study, the results of arthroscopic subacromial decompression were equally good whether the patient was treated as an outpatient way or by staying over-night in hospital after surgery. The results were significantly better at follow-up than preoperatively in both groups. Key words: Shoulder pain; subacromial impingement; arthroscopic subacromial decompression; outpatient unit; hospitalized patient; clinical result.

Effect of anterior supraspinatus tendon partial-thickness tears on infraspinatus tendon strain through a range of joint rotation angles

BACKGROUND

Rotator cuff tears are common shoulder problems whose propagation is difficult to predict because of the structural and mechanical inhomogeneity of the supraspinatus tendon. We have previously shown that the supraspinatus and infraspinatus tendons interact mechanically when the supraspinatus tendon is intact or exhibits a full-thickness tear, so that an increase in supraspinatus tendon strain is paralleled by an increase in infraspinatus tendon strain. Such interaction is critical and suggests that an increase in infraspinatus tendon strain that accompanies an increase in supraspinatus tendon strain may shield the supraspinatus tendon from further injury, but increase the risk of injury to the infraspinatus tendon. In this study, the mechanical interactions between the supraspinatus and infraspinatus tendons were evaluated for the commonly occurring supraspinatus tendon partial-thickness tears through a range of rotation angles.

METHODS

For each joint rotation and supraspinatus tendon tear size evaluated, the supraspinatus tendon was loaded, and images corresponding to 5 N, 30 N, 60 N, and 90 N of supraspinatus tendon load were isolated for the speckle painted supraspinatus and infraspinatus tendons. A region of interest outlining the insertion site was isolated and displacements between the 5 N loaded image and each of the others were measured, from which normalized average principal strains were quantified in both tendons.

RESULTS

The observed effect on infraspinatus tendon strain paralleled that observed on strain in the supraspinatus tendon. Introducing a supraspinatus tendon partial-thickness tear and increasing load caused an increase in normalized average maximum and a decrease in normalized average minimum principal strain in the infraspinatus tendon. Increasing rotation angle from internal to external rotation caused a general decrease in normalized average maximum and increase in normalized average minimum principal strain in both tendons.

CONCLUSION

The supraspinatus and infraspinatus tendons mechanically interact for the intact and partially torn supraspinatus tendons for neutral and rotated glenohumeral joint.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep position and shoulder pain

The overuse theory for musculoskeletal joint pain cannot explain adequately the occurrence of shoulder pain in those who do not engage in activities that involve repeated and stressful use of the shoulder since the percentage of the painful right shoulders usually does not match the percentage of dominant right arms in such individuals. An alternative hypothesis is presented to propose that shoulder pain is caused by postural immobility in the decubitus or side position during sleep. Prolonged pressure on the shoulder caused by the weight of the thorax can produce enough damage to cause subsequent shoulder pain. In order to test this hypothesis, a preliminary study was carried out to compare the laterality of shoulder pain with the laterality of sleep position. The calculated laterality ratios for sleep position and shoulder pain were found to be strikingly similar, suggesting a causal relationship between the two phenomena. However, the prevalence of shoulder pain in the general population was found to be smaller than the percentage of the time people would spend sleeping in the decubitus position. This discrepancy could be explained by the idea that in order for shoulder pain to develop subjects may have to spend longer times in the same decubitus position before changing to another position than the average person would. Additional evidence from published clinical studies also supports the postural theory of shoulder pain. More studies can be done to test this hypothesis by focusing on the sleep habits of patients with shoulder pain. According to the present hypothesis shoulder pain should for the most part occur on the side that the patient preferred to sleep on before the onset of shoulder pain. The postural theory of shoulder pain provides the possibility for a new and noninvasive method to treat shoulder pain by the modification of posture during sleep.

New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears

Partial-thickness cuff tears (PTCTs) are increasingly recognized as a source of pain and athletic impairment, especially in overhead athletes. 1,2 Improvements in diagnostic imaging have enhanced the ability to detect and quantify partial cuff disease, and arthroscopic advances have led to novel techniques by which partial cuff tears can be repaired. 2-6 Despite increasing recognition and improved understanding of this condition, the natural history, clinical evaluation, and management of partial tears remain elusive. This is because of the disparity between the extent of partial cuff tearing and the wide variability in clinical impairment and the frequent overlay of concomitant labral and subacromial pathology. When should operating on an athlete with a partial cuff tear be considered? What percentage of cuff tear justifies repair rather than debridement? Does this threshold vary according to the athlete or sport? And if the partial tear is repaired, what can be expected in terms of return to activity, particularly in a high-level thrower? The purpose of this manuscript is to provide an overview of partial cuff tears and their evaluation and management.

Application for disability pension and change in use of prescribed drugs. A regional Danish cohort study

AIM

To investigate if a pending application for disability pension had an influence on the applicant's purchase of medical drugs, with a particular focus on musculoskeletal disorders and the use of painkillers.

METHODS

We performed a registry-based follow-up study including 12,020 applicants for disability pension in a Danish county from 1995 to 2000 and linked this information to a database of drug prescriptions. Purchase of drug was calculated for the 6-month period just before the decision and for the 6-month period 2 years later. Changes in a 2-year time period were estimated by differences in purchase rates. Furthermore, the proportion of applicants with an increased purchase of drugs and the proportion of applicants who ceased buying drugs were estimated. The results were stratified by diagnosis and result of application (awarded/rejected). The analyses were furthermore restricted to musculoskeletal disorders and the use of painkillers.

RESULTS AND CONCLUSIONS

At baseline 81% had a purchase and after the 2-year time period 11% ceased buying prescribed drugs. Half of all applicants increased the purchase of drugs. For musculoskeletal disorders one third had an increased purchase rate of painkillers while one fourth ceased purchase of drugs with variations in different diagnostic subgroups. The major changes of drug purchase after a pending application for disability pension are probably ascribed to characteristics of the diseases underlying the disability.

Long-term Effect of the Use of a Pain Pump After Arthroscopic Subacromial Decompression

PURPOSE

The aim of the study was to evaluate the long-term effect of the use of a pain pump after arthroscopic subacromial decompression.

METHODS

This prospective, randomized study included 50 patients: 25 patients had a 24-hour pain pump with 0.375% ropivacaine infusion and a continuous rate of 5 mL/h in the subacromial space after arthroscopic subacromial decompression, and 25 patients did not. Rehabilitation was similar in both groups. Evaluation methods were clinical examination, radiographic evaluation, and isometric elevation strength measurements, as well as the University of California, Los Angeles and Constant shoulder scores. All the operations were done by 1 experienced orthopaedic surgeon, and all the evaluations at follow-up were done by 1 independent, blinded examiner. There were no differences between the study groups preoperatively. Of the patients, 47 (94%) were available at a minimum follow-up of 2 years (range, 24 to 32 months).

RESULTS

Concerning the duration of sick leave (P = .053) and ability to return to work (P = .321), the group differences were not statistically significant. At follow-up, the shoulder scores (University of California, Los Angeles and Constant) were significantly better than preoperatively (P < .001) in both groups, although no differences were found between the groups. The isometric elevation strengths of the operated shoulders were equally good in both groups (P = .976) as well, and no significant differences were observed between the operated shoulders and nonoperated shoulders at follow-up.

CONCLUSIONS

According to this study, the use of a pain pump after arthroscopic subacromial decompression did not have any long-term effects on the patients' recovery, return to work, or final result at the minimum 2-year follow-up. The results were significantly better at follow-up than preoperatively in both groups.

LEVEL OF EVIDENCE

Level II, prospective, randomized therapeutic study lacking statistical significance and narrow confidence intervals.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

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

Revision arthroscopic shoulder instability repair

PURPOSE

The purpose of this study was to report on a difficult patient population and to critically evaluate the role of revision arthroscopic stabilization surgery.

METHODS

Eighteen patients with failed traumatic instability repairs were treated with revision arthroscopic labral fixation and plication with a mean follow-up of 29.7 months (range, 24 to 48 months). There were 15 male patients and 3 female patients with a mean age of 28.6 years (range, 15 to 50 years). Of the 18 patients, 9 were Workers' Compensation cases. The 18 patients had a mean of 1.55 surgeries before our revision surgery, with 9 having a component of thermocapsular shrinkage. The patients' characteristics, operative techniques, and findings were recorded, and their clinical outcome was critically evaluated (via physical examination, visual analog pain scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and Short Form 12).

RESULTS

The revision surgery incorporated a 4-portal technique via a mean of 4.6 suture anchors and 3 plication stitches, and 15 patients received a rotator interval closure. At the follow-up evaluation, 13 patients had satisfactory results whereas 5 cases were considered clinical failures (with recurrent instability in 3 and pain in 2). There was clinically significant improvement in pain score (6 preoperatively v 2 postoperatively, P = .0001), Simple Shoulder Test score (6 preoperatively v 10 postoperatively, P = .001), and American Shoulder and Elbow Surgeons score (50 preoperatively v 76 postoperatively, P = .001). Of the 9 Workers' Compensation patients, 5 were able to return to their original work.

CONCLUSIONS

Arthroscopic revision instability repair by use of a combination of suture anchors, plication stitches, and rotator interval closure can result in a satisfactory outcome in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic versus open acromioplasty: a systematic review

Prior to 1972, a variety of operations were performed to treat rotator cuff pain. Neer in 1972 recommended an anterior acromioplasty, which quickly became the standard of care based on Level IV and Level V evidence. In 1987, Ellman offered an arthroscopic approach to performing the acromioplasty; since then Level I studies have been conducted to assess the success of the arthroscopic approach. The purpose of our systematic review was to whether an arthroscopic approach to acromioplasty produces different outcomes (primary outcome pain relief) when compared to traditional open techniques. We performed a systematic literature review. We identified four Level I and one Level II randomized controlled prospective studies of four patient cohorts. While these studies had substantial flaws which could introduce bias, we found no differences between arthroscopic and open approaches for pain. Other outcomes that showed no difference in technique included UCLA shoulder scores, range of motion and strength. The data for the time required to perform surgery and the time to return to work for patients could not be used to recommend one approach over the other. Therefore, with the data available from four Level I and one Level II randomized controlled trials, we could not find appreciable differences between arthroscopic and open acromioplasty.

Payer type has little effect on operative rate and surgeons' work intensity

Does health-care payer type affect the rate of operative treatment and surgeons' work intensity for patients with orthopaedic conditions? We analyzed the clinical and financial data collected during 6 consecutive years (1999-2004) for a group practice of 40 orthopaedic surgeons. We examined the rate of operative treatment and surgeons' work intensity (total physician's work Resource-based Relative Value System units) by diagnosis, patient age, and payer type. The eight payer types were: capitation health maintenance organization, health maintenance organization, preferred provider organization, indemnity, self-pay, Workers' Compensation, Medicaid, and Medicare. There were 230,306 patients with 526 unique primary diagnoses. Diagnosis accounted for most of the variability in operative rates and surgeons' work intensity. After adjusting for differences attributable to diagnosis, payer type had little effect on the rate of operative treatment and surgeons' work intensity.

Surgical treatment of os acromiale with and without associated rotator cuff tears

Nineteen consecutive patients treated surgically for meso-os acromiale and subacromial pathology were reviewed retrospectively, with a mean length of follow-up of 40 months (range, 24-94 months). Of the patients, 11 (58%) were treated with acromioplasty in the presence of a stable os acromiale; 8 patients (42%) underwent open reduction-internal fixation for an unstable and painful os fragment. Of the 19 patients, 8 (42%) with an os acromiale had an associated full-thickness rotator cuff tear. Overall, only 10 of 19 patients (53%) achieved a satisfactory result. All 8 patients (100%) treated with open reduction-internal fixation achieved union of the os fragment, although only 3 (37.5%) achieved a satisfactory result. Of the 11 patients who underwent acromioplasty, only 7 (64%) achieved a satisfactory result. The outcome of surgical management of symptomatic meso-os acromiale with concomitant rotator cuff pathology was satisfactory in 4 of 8 patients in our study group. The rate of satisfactory results was similar in patients with (50%) and without (55%) associated rotator cuff tears. When we analyzed our results to exclude workers' compensation patients, 80% achieved satisfactory results (compared with only 22% in our workers' compensation group).

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

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

Partial-thickness rotator cuff tears

Partial-thickness tears of the rotator cuff have been diagnosed with increased frequency because of a heightened awareness of the condition by clinicians and improved diagnostic methods. Research into the causes, natural history, and optimal treatment of this condition lags behind that of full-thickness tears. However, despite the limitations in the existing literature, there has emerged a consensus among shoulder experts that partial-thickness rotator cuff tears should be aggressively treated in the active athlete because of the unfavorable natural history of these lesions and success of accepted surgical algorithms. This review will provide an overview of the theories regarding the origins of partial-thickness rotator cuff tears, discuss the relative accuracy of accepted diagnostic techniques, and summarize the indications and methods of operative repair with an emphasis on the results of various treatment approaches.