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Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery

Published:November 22, 2018DOI:https://doi.org/10.1016/j.arthro.2018.07.043

      Purpose

      To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery.

      Methods

      Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders.

      Results

      A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations.

      Conclusions

      A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears.

      Level of Evidence

      Level III, retrospective cohort study.
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      References

        • Colvin A.C.
        • Egorova N.
        • Harrison A.K.
        • Moskowitz A.
        • Flatow E.L.
        National trends in rotator cuff repair.
        J Bone Joint Surg Am. 2012; 94: 227-233
        • Nielsen T.G.
        • Miller L.L.
        • Lund B.
        • Christiansen S.E.
        • Lind M.
        Outcome of arthroscopic treatment for symptomatic femoroacetabular impingement.
        BMC Musculoskel Disord. 2014; 15: 394
        • Minagawa H.
        • Yamamoto N.
        • Abe H.
        • et al.
        Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village.
        J Orthop. 2013; 10: 8-12
        • Northover J.R.
        • Lunn P.
        • Clark D.I.
        • Phillipson M.
        Risk factors for the development of rotator cuff disease.
        Int J Shoulder Surg. 2007; 1: 82-86
        • Wendelboe A.M.
        • Hegmann K.T.
        • Gren L.H.
        • Alder S.C.
        • White G.L.
        • Lyon J.L.
        Associations between body-mass index and surgery for rotator cuff tendinitis.
        J Bone Joint Surg Am. 2004; 86: 743-747
        • Mall N.A.
        • Lee A.S.
        • Chahal J.
        • et al.
        An evidenced-based examination of the epidemiology and outcomes of traumatic rotator cuff tears.
        Arthroscopy. 2013; 29: 366-376
        • Kang L.
        • Henn R.F.
        • Tashjian R.Z.
        • Green A.
        Early outcome of arthroscopic rotator cuff repair: A matched comparison with mini-open rotator cuff repair.
        Arthroscopy. 2007; 23 (582.e1-2): 573-582
        • Lindley K.
        • Jones G.L.
        Outcomes of arthroscopic versus open rotator cuff repair: A systematic review of the literature.
        Am J Orthop (Belle Mead NJ). 2010; 39: 592-600
        • Henry P.
        • Wasserstein D.
        • Park S.
        • et al.
        Arthroscopic repair for chronic massive rotator cuff tears: A systematic review.
        Arthroscopy. 2015; 31: 2472-2480
        • Motamedi A.R.
        • Urrea L.H.
        • Hancock R.E.
        • Hawkins R.J.
        • Ho C.
        Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears.
        J Shoulder Elbow Surg. 2002; 11: 6-10
        • Kluger R.
        • Bock P.
        • Mittlbock M.
        • Krampla W.
        • Engel A.
        Long-term survivorship of rotator cuff repairs using ultrasound and magnetic resonance imaging analysis.
        Am J Sports Med. 2011; 39: 2071-2081
        • Le B.T.
        • Wu X.L.
        • Lam P.H.
        • Murrell G.A.
        Factors predicting rotator cuff retears: An analysis of 1000 consecutive rotator cuff repairs.
        Am J Sports Med. 2014; 42: 1134-1142
        • von Wehren L.
        • Blanke F.
        • Todorov A.
        • Heisterbach P.
        • Sailer J.
        • Majewski M.
        The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3787-3792
        • Mei-Dan O.
        • Carmont M.R.
        The role of platelet-rich plasma in rotator cuff repair.
        Sports Med Arthrosc. 2011; 19: 244-250
        • Gialanella B.
        • Prometti P.
        Effects of corticosteroids injection in rotator cuff tears.
        Pain Med. 2011; 12: 1559-1565
        • Buchbinder R.
        • Green S.
        • Youd J.M.
        Corticosteroid injections for shoulder pain.
        Cochrane Database Syst Rev. 2003; : Cd004016
        • Maman E.
        • Yehuda C.
        • Pritsch T.
        • et al.
        Detrimental effect of repeated and single subacromial corticosteroid injections on the intact and injured rotator cuff: A biomechanical and imaging study in rats.
        Am J Sports Med. 2016; 44: 177-182
        • Dean B.J.
        • Franklin S.L.
        • Murphy R.J.
        • Javaid M.K.
        • Carr A.J.
        Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: A mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy?.
        Br J Sports Med. 2014; 48: 1620-1626
        • Lee H.J.
        • Kim Y.S.
        • Ok J.H.
        • Lee Y.K.
        • Ha M.Y.
        Effect of a single subacromial prednisolone injection in acute rotator cuff tears in a rat model.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 555-561
        • Papaspiliopoulos A.
        • Papadopoulou E.
        • Papalois A.
        • Papaparaskeva K.
        • Feroussis J.
        • Zoubos A.
        The effect of local use of nandrolone decanoate on rotator cuff repair in rabbits.
        J Invest Surg. 2010; 23: 204-207
        • Mikolyzk D.K.
        • Wei A.S.
        • Tonino P.
        • et al.
        Effect of corticosteroids on the biomechanical strength of rat rotator cuff tendon.
        J Bone Joint Surg Am. 2009; 91: 1172-1180
        • Werner B.C.
        • Cancienne J.M.
        • Burrus M.T.
        • Griffin J.W.
        • Gwathmey F.W.
        • Brockmeier S.F.
        The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients.
        J Shoulder Elbow Surg. 2016; 25: 390-397
        • Coombes B.K.
        • Bisset L.
        • Vicenzino B.
        Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials.
        Lancet. 2010; 376: 1751-1767
        • Tillander B.
        • Franzen L.E.
        • Karlsson M.H.
        • Norlin R.
        Effect of steroid injections on the rotator cuff: an experimental study in rats.
        J Shoulder Elbow Surg. 1999; 8: 271-274
        • Nichols A.W.
        Complications associated with the use of corticosteroids in the treatment of athletic injuries.
        Clin J Sport Med. 2005; 15: 370-375
        • Gaujoux-Viala C.
        • Dougados M.
        • Gossec L.
        Efficacy and safety of steroid injections for shoulder and elbow tendonitis: A meta-analysis of randomised controlled trials.
        Ann Rheum Dis. 2009; 68: 1843-1849
        • Baverel L.
        • Boutsiadis A.
        • Reynolds R.J.
        • Saffarini M.
        • Barthélémy R.
        • Barth J.
        Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?.
        JSES Open Access. 2018; 2: 54-59
        • Parada S.A.
        • Dilisio M.F.
        • Kennedy C.D.
        Management of complications after rotator cuff surgery.
        Curr Rev Musculoskel Med. 2015; 8: 40-52
        • Duquin T.R.
        • Buyea C.
        • Bisson L.J.
        Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review.
        Am J Sports Med. 2010; 38: 835-841
        • Bishop J.
        • Klepps S.
        • Lo I.K.
        • Bird J.
        • Gladstone J.N.
        • Flatow E.L.
        Cuff integrity after arthroscopic versus open rotator cuff repair: A prospective study.
        J Shoulder Elbow Surg. 2006; 15: 290-299
        • Cooper J.
        • Mirzayan R.
        Acellular dermal matrix in rotator cuff surgery.
        Am J Orthop (Belle Mead, NJ). 2016; 45: 301-305
        • Montgomery S.R.
        • Petrigliano F.A.
        • Gamradt S.C.
        Failed rotator cuff surgery, evaluation and decision making.
        Clin Sports Med. 2012; 31: 693-712
        • Iannotti J.P.
        • Deutsch A.
        • Green A.
        • et al.
        Time to failure after rotator cuff repair: A prospective imaging study.
        J Bone Joint Surg Am. 2013; 95: 965-971
        • Barth J.
        • Andrieu K.
        • Fotiadis E.
        • Hannink G.
        • Barthelemy R.
        • Saffarini M.
        Critical period and risk factors for retear following arthroscopic repair of the rotator cuff.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2196-2204
      1. Centers for Medicare and Medicaid Services. Medicare Fee-for-Service 2012 Improper Payments Report. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Downloads/MedicareFeeforService2012ImproperPaymentsReport.pdf.

        • Hughes J.D.
        • Hughes J.L.
        • Bartley J.H.
        • Hamilton W.P.
        • Brennan K.L.
        Infection rates in arthroscopic versus open rotator cuff repair.
        Orthop J Sports Med. 2017; 5 (2325967117715416)

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