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Timing Is Everything

Commentary on an article by Brian Forsythe, MD, et al.: “The Timing of Injections Prior to Arthroscopic Rotator Cuff Repair Impacts the Risk of Surgical Site Infection”

Hasan, Samer S., MD, PhD

doi: 10.2106/JBJS.19.00173
Commentary and Perspective
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MercyHealth-Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, Ohio

E-mail: sshasan@zoomtown.com

Disclosure: There was no source of external funding for this work. On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F220).

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Commentary

Arthroscopic rotator cuff repair is performed with ever-increasing frequency1 because of refinements in technique, excellent clinical outcomes, and improving repair durability. Nevertheless, nonoperative treatment is still offered initially to many patients, especially older patients with symptomatic chronic rotator cuff tears. These patients often have multiple comorbidities and tear variations involving features such as tendon retraction, muscle atrophy, and fibro-fatty muscle changes that collectively pose a barrier to successful tendon healing.

Corticosteroid injections are potent anti-inflammatory agents that have been commonly used to ameliorate the pain and inflammation associated with rotator cuff tears and remain a cornerstone of nonoperative treatment2,3. Corticosteroid injections are used to improve patient compliance with physical therapy and exercise during nonoperative treatment of rotator cuff tears and have been shown to be an effective adjunct in treating adhesive capsulitis4,5 and partial-thickness rotator cuff tears6. However, the catabolic effects of corticosteroids have also raised concerns over their potentially deleterious effects on tendon and hyaline cartilage7. Some have advocated the use of image guidance to ensure accurate placement of corticosteroid injections to mitigate those potential harmful effects8.

In their article, Forsythe et al. demonstrate that corticosteroid injections may also increase the risk of postoperative surgical site infection following arthroscopic rotator cuff repair. They queried the 2007 to 2016 Humana database within PearlDiver (www.pearldiverinc.com) for patients undergoing arthroscopic rotator cuff repair. Patient data were stratified into 2 cohorts: those undergoing arthroscopic rotator cuff repair within 1 year of ipsilateral corticosteroid injection, and those undergoing arthroscopic rotator cuff repair without prior corticosteroid injections. Patients who received a preoperative corticosteroid injection were further stratified by the duration prior to the surgical procedure that the corticosteroid injection was performed, and postoperative surgical site infections within 6 months were recorded. Although the authors found no difference in the overall incidence of surgical site infection in patients receiving a corticosteroid injection compared with the control cohort, patients receiving a corticosteroid injection within 1 month prior to arthroscopic rotator cuff repair had a 65% to 75% higher rate of surgical site infection. In addition to preoperative corticosteroid injections, male sex, obesity, diabetes, and smoking status were independent risk factors for the development of a surgical site infection.

This study follows several recent large-scale database studies that have raised concerns about the detrimental effects of preoperative corticosteroid injections in patients undergoing an arthroscopic shoulder surgical procedure. A recent study by Werner et al.9 employing the Medicare database within PearlDiver revealed that ipsilateral intra-articular corticosteroid injections within 3 months prior to an arthroscopic shoulder surgical procedure increased the risk of surgical site infection at 3 months and 6 months postoperatively9; the authors could not demonstrate an increased risk of surgical site infection when the corticosteroid injections were performed 3 to 12 months prior to the surgical procedure9. However, their study included a heterogeneous population of patients who underwent surgical procedures other than arthroscopic rotator cuff repair, such as labral repair, distal clavicle excision, subacromial decompression, or isolated biceps tenodesis.

Another recently published study by Desai et al.10 explored the dose-related impact of corticosteroid injection prior to arthroscopic rotator cuff repair on the risk of a subsequent revision surgical procedure. The authors analyzed separately the patients in both Humana and Medicare databases within PearlDiver and employed multivariate logistic regression analysis controlling for various demographic factors. The authors found that patients in both databases undergoing ≥2 corticosteroid injections within the 12 months prior to arthroscopic rotator cuff repair had a greater than twofold higher risk of a revision surgical procedure within the first 2 years postoperatively than patients who did not receive an injection10. In contrast, patients undergoing a single corticosteroid injection within the 12 months prior to arthroscopic rotator cuff repair did not have a higher revision risk. That study did not specifically examine the causes, surgical site infection or other, for a revision surgical procedure.

Along with the other large database-mining studies discussed here, the study by Forsythe et al. has several limitations that must be acknowledged. The authors point out that the quality of the available data in the Humana database is dependent on accurate coding from each provider; studies evaluating the accuracy of coding are lacking. Furthermore, the database does not include information on tear size and chronicity or provide any information on injection technique, accuracy, and concentration and volume of injectate. Although the authors controlled for demographic factors such as age, sex, obesity, diabetes, and smoking status, the study may still have selection bias. It may be that patients receiving a corticosteroid injection preoperatively differ from those who do not with respect to shoulder stiffness, the severity of their comorbidities, treatment environment, their socioeconomic circumstance, or other factors that may influence surgical site infection risk after arthroscopic rotator cuff repair.

Additionally, the Humana database may not accurately represent the breadth of patients undergoing arthroscopic rotator cuff repair. According to the article by Forsythe et al., nearly 70% of patients were between 60 and 80 years of age, so the study results may not generalize to arthroscopic rotator cuff repair in younger patients. Finally, the study examined only those surgical site infections arising within 6 months of the surgical procedure, thereby missing potential indolent or stealthy infections that may not become clinically relevant for many years.

In summary, observational studies cannot shed light on the cause-and-effect relationship between corticosteroid injections and infection. However, this study, coupled with other recently published studies, raises questions about the role of corticosteroid injections in the treatment of rotator cuff tears. These studies caution that corticosteroid injections should not be performed routinely in patients with reparable rotator cuff tears. Rather, a single corticosteroid injection may be considered in select patients who cannot undergo timely repair or participate in physical therapy and home exercises because of pain and stiffness, but whenever practical subsequent repair should be delayed by ≥1 month to minimize risk of postoperative infection.

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References

1. Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Analysis of rotator cuff repair trends in a large private insurance population. Arthroscopy. 2013 Apr;29(4):623-9. Epub 2013 Feb 1.
2. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;1:CD004016.
3. Gialanella B, Prometti P. Effects of corticosteroids injection in rotator cuff tears. Pain Med. 2011 Oct;12(10):1559-65. Epub 2011 Sep 23.
4. Ranalletta M, Rossi LA, Bongiovanni SL, Tanoira I, Elizondo CM, Maignon GD. Corticosteroid injections accelerate pain relief and recovery of function compared with oral NSAIDs in patients with adhesive capsulitis: a randomized controlled trial. Am J Sports Med. 2016 Feb;44(2):474-81. Epub 2015 Dec 9.
5. Griesser MJ, Harris JD, Campbell JE, Jones GL. Adhesive capsulitis of the shoulder: a systematic review of the effectiveness of intra-articular corticosteroid injections. J Bone Joint Surg Am. 2011 Sep 21;93(18):1727-33.
6. Donohue NK, Prisco AR, Grindel SI. Pre-operative corticosteroid injections improve functional outcomes in patients undergoing arthroscopic repair of high-grade partial-thickness rotator cuff tears. Muscles Ligaments Tendons J. 2017 May 10;7(1):34-9.
7. Freire V, Bureau NJ. Injectable corticosteroids: take precautions and use caution. Semin Musculoskelet Radiol. 2016 Nov;20(5):401-8. Epub 2016 Dec 21.
8. Saffarini M. Editorial commentary: “Doctor, are you sure the steroid injection won’t harm my shoulder?” Perhaps we should stop injecting corticosteroids and just repair those rotator cuffs. Arthroscopy. 2019 Jan;35(1):51-3.
9. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 Mar;25(3):390-7. Epub 2015 Nov 30.
10. Desai VS, Camp CL, Boddapati V, Dines JS, Brockmeier SF, Werner BC. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy. 2019 Jan;35(1):45-50. Epub 2018 Nov 22.

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