Friday, February 3, 2017

Rotator cuff surgery in workers - effect of timing

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

These authors examined the effect of ‘expedited’ surgery on recovery and work status in injured workers.

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.

The patients in the ‘expedited’ group waited less time to have surgery than the control group, reported less disability after surgery, had a higher number of patients whose improvement exceeded the minimal clinically important improvement in the ASES score, and were more likely to be working at the time of the final follow-up.

Comment: The duration of symptoms was <18 months in 77% of the ‘expedited’ group and in 41% of the control group. In the ‘expedited’ group symptoms had been present for 16±18 months and for 38±51 months in the control group. It is not clear whether the workers were off work for the duration of symptoms. It well known that the longer a worker is off work the more difficulty it is to get them back to work. Thus it is not surprising that only 36% of the ‘expedited’ group was back to regular work at followup and only 19% of the control group was back to regular work at followup.

While the title of this study indicates that it is about ‘rotator cuff surgery’, only 45% of the cases in either group had rotator cuff repairs. Other surgeries included acromioplasty, distal clavicle resection, and biceps surgery. This is not a study of the value of acute repairs of traumatic cuff tears.

It is noted that patients in the ‘expedited’ group had an orthopedic evaluation at a specialty shoulder and elbow clinic and an expedited arthroscopic rotator cuff decompression or repair, or both. In contrast, patients in the control group had an active compensable injury that had undergone a publicly funded operation for rotator cuff decompression or repairs. Who winds up being covered by ‘parallel-pay insurance’ and who winds up being covered by public health insurance? We are not informed if these surgeries were performed at a ‘specialty shoulder and elbow clinic’ or not. Thus it is unclear whether selection bias may have tipped the results in favor of the ‘expedited’ group.

The management of injured workers is complex. Our approach is to do our best at the initial visit to determine whether the patient is likely to return to work without or with surgery. If return to work is likely, we expedite non-operative or operative treatment to minimize the detrimental off work time.


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