Symptomatic re-tears after arthroscopic cuff repair - association with subacromial steroid injections and depression.

 Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears

These authors analyzed consecutive patients having full-thickness tears of the supraspinatus repaired arthroscopically.

They identified symptomatic re-tears, defined as "Sugaya type IV and V on magnetic resonance imaging that were associated with intensive pain and/or functional impairment."

These patients were compared to those without symptomatic re-tears with respect to potential risk factors for symptomatic re-tears.

Corticosteroid injection (CSI) was defined when the patient received 1 or more preoperative injections.

Depression was defined when the patient had a medical diagnosis of depression at the time of the surgical assessment and/or was receiving antidepressant treatment because of depression. 

The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration.

On multivariate analysis, corticosteroid injections were associated with a 7 fold increase and depression was associated with an 8 fold increase in symptomatic re-tear risk.

Comment:  It is well recognized that a high percentage of rotator cuff repair attempts fail to durably re-establish a secure connection between the torn tendon and bone, even for repairs of tears confined to the supraspinatus. It is also recognized that a high percentage of anatomically failed repair attempts yield improved postoperative shoulder comfort and function in spite of having a Sugaya 4 or 5 re-tear. 

Patients with re-tears but without substantial symptoms would have been assigned to the "control" group in this study: asymptomatic patients were not routinely examined by MRI. Thus the "symptomatic retear rate" of 9.5% (15 of 158 patients) in this study is likely to be substantially lower than the actual anatomic failure rate. Only 25 postoperative MRIs were obtained in 158 patients.

Most of the findings of this study are consistent with prior publications regarding the risks factors for rotator cuff repair failure. The observation that depression was associated with post operative intensive pain and/or functional impairment and Sugaya types IV and V on magnetic resonance imaging may be due to the fact that patients with depression are more likely to have "intensive pain and/or functional impairment" after surgery and thus to meet the criteria for a "symptomatic re-tear".

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Steroid injections - the risk of infections

Preoperative corticosteroid joint injections within 2 weeks of shoulder arthroscopies increase postoperative infection risk

These authors assessed the relationship between preoperative corticosteroid injection timing and shoulder arthroscopy infectious outcomes using an insurance database to identify and sort all shoulder arthroscopy patients by corticosteroid shoulder injection history within 6 months before surgery.

They identified 50,478 shoulder arthroscopy patients, of whom 4115 received injections in the 6-month preoperative period. They found a significant increase in both the overall infection rate (P < .0001) and severe infection rate (P < .0001) in patients who received injections within 2 weeks before surgery (n = 79; 8.86% and 6.33%, respectively) compared with those who received no injections in the 6-month preoperative period (n = 46,363; 1.56% and 0.55%, respectively). 

Comment: The risk of infection with shoulder arthroscopy should be low. Here we see a dramatic increase in the rate of infection in those patients having steroid injections within two weeks of the procedure. 

It is reasonable to suspect a similar increase in risk of infections in shoulder arthroplasties performed within 2 weeks of an injection.

It would have been interesting to know what bacteria caused these injections, but those data are not available.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff repair - does injection increase the risk of infection?

The Timing of Injections Prior to Arthroscopic Rotator Cuff Repair Impacts the Risk of Surgical Site Infection


These authors sought to determine if there is a temporal relationship between corticosteroid injections and the risk of surgical site infection after arthroscopic rotator cuff repair.

They reviewed the PearlDiver database for patients undergoing arthroscopic rotator cuff repair from 2007 to 2016. Patients were stratified into 2 cohorts: those undergoing arthroscopic rotator cuff repair within 1 year of injection (n = 12,060), and those undergoing arthroscopic rotator cuff repair without prior injection (n = 48,763). Patients with preoperative injections were further stratified by the duration in months that the injection was performed prior to the surgical procedure.

There was no significant difference in the incidence of surgical site infection in patients receiving a shoulder injection at 0.7% compared with the control cohort at 0.8% (odds ratio [OR], 0.9 [95% confidence interval (CI), 0.7 to 1.1]; p = 0.2). However, patients receiving an injection within 1 month prior to operative management had a significantly higher rate of surgical site infection overall at 1.3% compared with the control group at 0.8% (OR, 1.7 [95% CI, 1.0 to 2.9]; p = 0.04). On multivariate analysis, male sex (OR, 1.7 [95% CI, 1.4 to 1.9]; p = 0.001), obesity (OR, 1.4 [95% CI, 1.2 to 1.6]; p < 0.001), diabetes (OR, 1.3 [95% CI, 1.1 to 1.5]; p < 0.001), smoking status (OR, 1.7 [95% CI, 1.4 to 1.9], p < 0.001), and preoperative corticosteroid injections within 1 month of the surgical procedure (OR, 2.1 [95% CI, 1.5 to 2.7]; p < 0.001) were independent risk factors for development of a surgical site infection.

The authors concluded that injections within 1 month of arthroscopic rotator cuff repair significantly increases the risk of surgical site infection. However, there is no increased risk of infection if the surgical procedure is delayed by 1 month following an injection.

Comment: This is an important study pointing to recent steroid injections as a risk factor for infection after arthroscopic cuff repair. It would be of interest to know the organisms responsible for these infections. As the authors point out, infections with Cutibacterium may not have been recorded in the database because of their subtle presentation (pain and stiffness).

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Injection can increase the risk of infection in rotator cuff repairs

The Timing of Injections Prior to Arthroscopic Rotator Cuff Repair Impacts the Risk of Surgical Site Infection

These authors investigated the temporal relationship between corticosteroid injections and the risk of surgical site infection after arthroscopic rotator cuff repair. 

Using the PearlDiver database they identified 12,060 patients undergoing arthroscopic rotator cuff repair within 1 year of injection 48,763 undergoing arthroscopic rotator cuff repair without prior injection. Patients with preoperative injections were further stratified by the duration in months that the injection was performed prior to the surgical procedure. Surgical site infection within 6 months of the surgical procedure was recorded. 

They no significant difference in the overall incidence of surgical site infection in patients receiving a shoulder injection. However, patients receiving an injection within 1 month prior to operative management had a significantly higher rate of surgical site infection overall at 1.3% compared with the control group at 0.8%.  On multivariate analysis, male sex, obesity, diabetes, smoking, and preoperative corticosteroid injections within 1 month of the surgical procedure were independent risk factors for development of a surgical site infection.

Comment: This study provides a useful guideline for the timing of cuff surgery after a prior injection. 

It would have been of interest to know the types of bacteria causing the infections noted in this study - were they Cutibacterium or the more aggressive types of Staph, Strep or gram negative bacteria? This gets to the question of how injection within one month increases the risk of infection. If the infections were by Cutibactium (commonly residing in the sebaceous glands of normal skin), one might wonder whether the bacteria were carried from the skin into the shoulder by the needle. If the infections were by bacteria not usually found in the skin, one might wonder if the corticosteroid rendered the joint more susceptible to transient bacteremia. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Can steroid injections accelerate arthritis?

Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee OsteoarthritisA Randomized Clinical Trial

These authors asked, "What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain in patients with osteoarthritis?".

In a randomized clinical trial of 140 patients with symptomatic knee osteoarthritis they used annual knee magnetic resonance imaging for the quantitative evaluation of cartilage volume. They found that the use of intra-articular triamcinolone compared with intra-articular saline resulted in greater cartilage volume loss (i.e. worsening of the arthritis). There was no significant difference on knee pain severity between treatment groups.

They concluded that among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.


Comment: Many physicians try to delay the need for arthroplasty through the use of injections (steroids, PRP, hylaluronic acid) The safety and efficacy of these injections is unclear (see this link, this link, this link, this link, this link, and this link). Laboratory investigations, such as Lidocaine Potentiates the Chondrotoxicity of Methylprednisolone (see this link), may be of relevance.

Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis.

Here's a recent example.

A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:

His current shoulder radiographs are shown here:

While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.

For comparison, the x-rays below show the more typical appearance of osteoarthritis.

Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:

Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. 

Here is an interesting recent post about platelet rich plasma (see this link).

The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.

The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.

===
Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Is there such a thing as injection arthropathy?

We often see patients whose physicians have tried to delay the need for arthroplasty through the use of injections (steroids, PRP, hylaluronic acid) The safety and efficacy of these injections is unclear (see this link, this link, this link, this link, this link, and this link). Laboratory investigations, such as Lidocaine Potentiates the Chondrotoxicity of Methylprednisolone (see this link), may be of relevance.
Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis. This is not intended to imply a cause/effect relationship.

Here's a recent example.

A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:

His current shoulder radiographs are shown here:

While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.

For comparison, the x-rays below show the more typical appearance of osteoarthritis.

Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:

Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. 

Here is an interesting recent post about platelet rich plasma (see this link).

The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.

The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.

===
Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.