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Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair—Is It Time to Rethink a Conservative Treatment Paradigm?

      Abstract

      The standard of care for most rotator cuff conditions over the past half century or longer has been a trial of nonoperative treatment including nonsteroidal anti-inflammatory agents, physiotherapy, and steroid injections prior to surgery. There is compelling basic science data to suggest a negative effect of corticosteroids on tissue quality. Chronicity of the tear is a risk factor for unsuccessful repair, but other factors including use of tobacco products, repair technique, and postoperative management all have an impact. Evidence either in favor of or against use of steroid injections as a treatment option is limited or weak at best. Given advances in rotator cuff repair techniques and successful long-term outcomes, treating surgeons should be mindful of how injections might affect surgical outcomes owing to either delayed surgical intervention or a direct effect on tissue quality.
      As early as the 1950s, orthopaedic surgeons and other clinicians have used corticosteroid injections as a nonoperative treatment option for symptomatic rotator cuff disease, including bursitis, tendinosis, and tears.
      • Crisp E.J.
      • Kendall P.H.
      Treatment of periarthritis of the shoulder with hydrocortisone.
      • Hollander J.L.
      Intra-articular hydrocortisone in arthritis and allied conditions; a summary of two years' clinical experience.
      In 1988, Bjorkenheim et al.
      • Bjorkenheim J.M.
      • Paavolainen P.
      • Ahovuo J.
      • Slatis P.
      Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results.
      reported higher repair failure rates after open rotator cuff repairs among patients who had received 3 or more injections preoperatively. However, investigation of the impact shoulder injections might have on the healing of rotator cuff repairs is limited. In their article entitled “Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair,” Traven, Brinton, Simpson, Adkins, Althoff, Palsis, and Slone
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      conclude that injections of corticosteroids in shoulders within 6 months of arthroscopic rotator cuff repair increase the risk of revision rotator cuff surgery. In their study, the revision risk was found to be higher even when a repair was completed within 3 months of injection. The data for this study were derived from a private medical insurance claims database over the years 2010 to 2014 and included nearly 5,000 subjects. The authors aptly cited limitations of database studies including the quality of the baseline data; the private insurer subset their database queried; exclusion of the Medicare population (age >64 years); and lack of information about tear size, repair technique, and perioperative care. The sheer number of subjects considered in this comparison, however, lends balance to the large database comparison. It is important to note that, although such large database studies cannot be used to generate conclusions about causation, they can provide clinicians and researchers insight regarding correlation, which opens up the potential to reconsider long-held clinical paradigms.
      The effects of steroid injections on tissue biomechanics are concerning. In a recent study, Maman et al.
      • 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.
      showed even a single steroid injection could significantly weaken rotator cuff tissue in a rat model and negatively affect bone quality in addition to causing deterioration of the osteotendinous junction. Traven et al.
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      cited evidence of this in other published rat studies. Conversely, negative effects of steroid injections on human rotator cuff integrity have been refuted.
      • Bhatia M.
      • Singh B.
      • Nicolaou N.
      • Ravikumar K.J.
      Correlation between rotator cuff tears and repeated subacromial steroid injections: A case-controlled study.
      Another human study showed significant improvement in the clinical symptoms of rotator cuff tendinopathy but a 17% incidence of new rotator cuff tears 3 months after steroid injections.
      • Ramirez J.
      • Pomes I.
      • Cabrera S.
      • Pomes J.
      • Sanmarti R.
      • Canete J.D.
      Incidence of full-thickness rotator cuff tear after subacromial corticosteroid injection: A 12-week prospective study.
      More clinical research is needed to firmly establish the effect of injections on human cuffs.
      For the shoulder surgeon, steroid injections have long been accepted as an option for managing painful rotator cuff pathology. Patients sometimes present requesting an injection for their pain. Many degenerative tears still permit function, and pain can be the factor most impacting quality of life. It is interesting to note that data on the utility of steroid injections for cuff disease have not shown favorable long-term results and injections likely do not stop the course of disease progression.
      • Mohamadi A.
      • Chan J.J.
      • Claessen F.M.
      • Ring D.
      • Chen N.C.
      Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: A meta-analysis.
      • Alvarez C.M.
      • Litchfield R.
      • Jackowski D.
      • Griffin S.
      • Kirkley A.
      A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis.
      For the chronic, degenerative tear population, favorable long-term surgical outcomes have been reported—perhaps slightly diminished when complete healing is not achieved.
      • Elia F.
      • Azoulay V.
      • Lebon J.
      • Faraud A.
      • Bonnevialle N.
      • Mansat P.
      Clinical and anatomic results of surgical repair of chronic rotator cuff tears at ten-year minimum follow-up.
      Chronicity of the tear is a known risk factor for tear reparability. It would follow that delaying repair while the patient responds to steroid injections may be delaying the best treatment option in some instances, particularly if a trial of nonsteroidal agents and physiotherapy has already failed to improve function and reduce pain. Another important factor in the study by Traven et al.
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      is that the mean patient age was around 50 years, so applying their findings to clinical practice might also favor a more aggressive approach with earlier surgery to optimize the potential for successful repair compared with the treatment approach in an older patient population.
      An interesting collateral finding that was not addressed by the authors is the impact their study has shown concerning smoking and the incidence of additional rotator cuff surgery. Prior research has shown the negative impact smoking has on rotator cuff healing, and recent studies have strengthened the link between smoking and repair failure.
      • Jenssen K.K.
      • Lundgreen K.
      • Madsen J.E.
      • Kvakestad R.
      • Dimmen S.
      Prognostic factors for functional outcome after rotator cuff repair: A prospective cohort study with 2-year follow-up.
      • Park J.H.
      • Oh K.S.
      • Kim T.M.
      • et al.
      Effect of smoking on healing failure after rotator cuff repair.
      With an odds ratio indicating a 2.5 times greater risk of repeated surgery for smokers compared with nonsmokers, the study by Traven et al.
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      adds to the body of data supporting tobacco abuse counseling and even postponement of surgery until the patient has ceased use of tobacco products.
      This article suggests that the use of corticosteroid injections to treat symptomatic rotator cuff tears is correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure, presumably because of an increased risk of repair failure. Although the injection itself may not be the cause of repair failure, the connection is interesting and concerning. I do not interpret the authors' data as a mandate to avoid steroid injections altogether in rotator cuff tear patients. Surely there are cases in which nonoperative treatment is most appropriate, and a steroid injection provides an alternative method of managing the painful shoulder, especially in older patients.
      A substantial, unavoidable deficit in the data of Traven et al.
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      is the lack of comparative clinical functional outcomes for the study population overall. The results of this study can only suggest a connection between injections and additional rotator cuff surgery but cannot be used to compare patient satisfaction or clinical outcomes. Although repair failure is not equivalent to clinical failure, successful healing tends toward better strength and functional outcomes than incomplete healing. One might surmise that the decision to pursue injections instead of surgery should be considered carefully and surgery perhaps should be delayed when injections have been selected as a conservative treatment approach. Yet, delaying surgery furthers the chronicity of the tear, perhaps detrimentally.
      In summary, the study by Traven et al.
      • Traven S.A.
      • Brinton D.
      • Simpson K.N.
      • et al.
      Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair.
      provides the clinician with important considerations when counseling patients about surgery and the timing thereof, particularly when the topic of steroid injections comes up. The historical treatment paradigm of steroid injections for painful rotator cuff conditions warrants reconsideration. As we strive to optimize results after rotator cuff surgery, details and timing matter.

      Supplementary Data

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