No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study.

PURPOSE: Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years. METHODS: In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma. RESULTS: Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups. CONCLUSION: In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic. LEVEL OF EVIDENCE: III.

No Increased Risk of Venous Thromboembolism in High-Risk Patients Continuing Their Dose of 75 mg Aspirin Compared to Healthier Patients Given Low-Molecular-Weight Heparin.

BACKGROUND: Optimum venous thromboembolism (VTE) prophylaxis for patients undergoing total hip or knee arthroplasty remains undefined. The purpose of this study is to compare complication rates among total joint arthroplasty patients using either low-dose aspirin (75 mg once daily) or low-molecular-weight heparin (LMWH; Fragmin/dalteparin 5000 U) for VTE prophylaxis. METHODS: This is a prospective observational study. All total hip or knee arthroplasties from 2014 to 2020 were included. One thousand eighty-four patients already taking aspirin 75 mg as primary or secondary prophylaxis for cardiovascular disease continued their daily aspirin dose throughout their hospital stay and after discharge without any other kind of thromboprophylaxis. Five thousand ten patients not already taking aspirin were given LMWH for 12-14 days starting the day of surgery. Both groups consisted of patients undergoing either primary or revision total hip or knee arthroplasty. The aspirin group was older (73 ± 7.8 vs 66 ± 10.2 years, P < .01, 95% CI -7.6, -6.3) with more comorbidities but otherwise did not differ from the LMWH group. Outcome measures were recorded at 3-month follow-up and included the following complications: clinically deep venous thrombosis (DVT), pulmonary embolism (PE), deep infection, blood transfusion, and death. RESULTS: The aspirin group had 0.28% DVT and 0.28% PE, and the LMWH group had 0.24% DVT and 0.16% PE (P = .42 and .74, respectively). No difference in deep infection, allogenic blood transfusion, or mortality was found. CONCLUSION: No statistically significant difference in complication rates was found between aspirin 75 mg and LMWH used for VTE prophylaxis. Aspirin 75 mg daily is safe for VTE prophylaxis after total hip or knee arthroplasty.

No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial.

PURPOSE: The aim of this study was to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff (RC) repair in a prospective randomized controlled non-inferiority trial. METHODS: One hundred twenty patients were included after RC surgery for a small- to medium-sized tear of supraspinatus and upper infraspinatus tendons. Group A was immobilized in a simple sling for 3 weeks, and group B had a brace with a small abduction pillow with the arm in neutral position for 6 weeks. All patients started active range of motion when they removed the sling/brace. One hundred eighteen (98%) patients were assessed at 1-year follow-up. They underwent magnetic resonance imaging (MRI) of the shoulder, filled out the Western Ontario Rotator Cuff (WORC) index, and were evaluated with a Constant Murley (CM) score. RESULTS: Statistical non-inferiority was demonstrated for the 2 groups on the basis of the WORC index, the primary endpoint at 1 year. The objective for the non-inferiority test was to determine whether the expected mean WORC index for group A was at most 13% worse than standard treatment (Group B). The WORC index at 1 year was similar in both groups, with mean percent scores of 83% in group A and 87% in group B (mean difference = -4; 95% one-sided CI -9, -4). Age-adjusted CM scores were also similar, with means of 86 in group A and 90 in group B (mean difference = -4; 95% CI -13, 5; P = .37). MRI after 1 year showed 50 (89%) patients in each group with healed RC repair. Four patients in group A had complications: 1 acute postoperative infection, 2 cases of postoperative capsulitis treated with corticosteroid injections, and 1 repeat operation because of a loose anchor and subacromial pain. No patients in group B had complications. CONCLUSION: RC repair resulted in improved postoperative shoulder function, regardless of whether the shoulder was immobilized for 3 or 6 weeks. Three weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace with regard to the WORC index at 12 months' follow-up. MRI indicated similar degrees of healing between the groups. Based on these findings, it is safe to immobilize patients in a simple sling for 3 to 6 weeks after repair of small to medium RC tears. LEVEL OF EVIDENCE: Level I, high-quality randomized controlled trial with statistically significant differences.

Targeted intervention of acute postoperative infection after rotator cuff repair results in good functional outcomes.

PURPOSE: The primary goal of this retrospective review of a prospective database was to document the functional results after acute postoperative deep infection following rotator cuff repair in a single orthopaedic unit over a period of 5 years. Secondary goals were to document the effect of infection on healing of the cuff repair and to describe its incidence, diagnostic challenges, pathogens and management. METHODS: Patients undergoing arthroscopic rotator cuff repair were prospectively registered from 2010 to 2014. Eleven out of 1072 repairs developed an acute postoperative infection. The patients were examined with an MRI scan, Constant-Murley (CM) score and the Western Ontario Rotator Cuff Index (WORC) at final follow-up (median of 22 months). RESULTS: All 11 patients who developed acute postoperative deep infections were males. Median age was 56 years (range 41-68). All patients underwent arthroscopic debridement and biopsies were collected at a median of 26 days (range 14-50) after primary surgery. In ten patients, Propionibacterium acnes was cultured, six of these patients also had positive cultures for coagulase-negative staphylococci. In the remaining patient, only coagulase-negative staphylococcus was cultured. Five patients were treated with one arthroscopic debridement, five had two arthroscopic debridements and one required arthroscopic debridement four times before the infection was eradicated. Two patients had their implants removed due to loosening of the suture anchors. All patients were treated with parenteral antibiotics for 1-4 weeks, followed by oral treatment for 1-5 weeks. At median 22 months (range 11-28) follow-up the median CM score was 84 and median WORC index was 81%. Ten patients had a postoperative MRI scan after a median of 23 months (range 3-49), with eight presenting a healed cuff repair. CONCLUSION: The findings of this study support the rapid, targeted intervention of acute postoperative infection after RC repair with immediate arthroscopic debridement, irrigation and biopsies for bacteriological diagnostics followed by parenteral antibiotics. Furthermore, repeated arthroscopic debridement and irrigation are recommended if signs of infection persist. Removal of the implant is rarely needed. Despite the postoperative acute infection, these patients presented good functional results at final follow-up. LEVEL OF EVIDENCE: Level III.

Peroneal Nerve Palsy After Total Knee Arthroplasty.

Background: Common peroneal nerve palsy (CPNP) is a rare complication of total knee arthroplasty (TKA). It may lead to impaired function and pain. The purpose of this study was to determine the frequency and outcome of CPNP in a single orthopedic unit and to identify potential risk factors. Methods: This is a single-center study using the hospital's prospectively collected quality registry. All TKAs from 2002 to 2022 were included and followed up from 3 to 24 months with a follow-up rate of 98.4%. The local joint register was reviewed to identify patients with CPNP and used to extract data regarding the operation and the patients with and without CPNP. The groups were compared to identify possible risk factors for nerve injury. The medical records of the patients with CPNP were reviewed to determine the CPNPs' severity and outcome, and their preoperative radiographs were analyzed and compared to a control group with no nerve injury. Results: A total of 7704 TKAs were included, and 25 CPNPs were identified (0.32%). Complete palsies occurred in 18 cases, and partial palsies in 7. Postoperative epidural anesthesia, preoperative excessive valgus, and female sex were significant risk factors. Body mass index and age were not associated with CPNP. Two-thirds of the complete palsies had complete recovery, and four-fifths of the partial palsies recovered. Conclusions: The incidence of CPNP was 0.32%, and risk factors were epidural anesthesia, excessive valgus, and female sex. Most patients with CPNP recovered completely. Partial palsies had better outcomes than complete palsies in our cohort.

Prognostic Factors for Functional Outcome After Rotator Cuff Repair: A Prospective Cohort Study With 2-Year Follow-up.

BACKGROUND: Although shoulder function is reported to be generally good after rotator cuff repair, limited knowledge exists regarding which prognostic factors predict functional outcomes. PURPOSE: To identify pre- and perioperative predictors of functional outcomes after arthroscopic rotator cuff repair. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A cohort of 733 consecutive patients treated with rotator cuff repair between 2010 and 2014 in a single orthopaedics unit was included. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariable linear regression analyses were used to predict shoulder function at 2-year follow-up, as measured by the Western Ontario Rotator Cuff Index (WORC). RESULTS: In total, 647 (88%) patients were followed for 25 ± 5 months (mean ± SD; range, 17-66 months). In the multivariable regression model, the adjusted R2 was 0.360, indicating that 36% of the variation in the WORC at final follow-up could be explained by this statistical model. The multivariable linear regression analysis revealed that the strongest positive independent predictors of shoulder function at 2 years were preoperative WORC and Constant-Murley score in the contralateral shoulder. The model also indicated that activities of daily living, age, subacromial decompression, and biceps surgery had independent positive associations with better shoulder function at 2 years. In addition, previous surgery in the ipsilateral or contralateral shoulder, smoking, partial rotator cuff repair, preoperative pain, and atrophy in the infraspinatus were all independent factors negatively associated with shoulder function after 2 years. The overall healing rate of complete repairs per magnetic resonance imaging was 80%. CONCLUSION: The most important finding of the present study was that the strongest prognostic factors for better WORC at 2-year follow-up were better preoperative WORC and Constant-Murley score in the contralateral shoulder. Although not all the prognostic factors identified in this study are modifiable, they can still be useful for guiding patients in shared decision making with the surgeon. This cohort study shows that if selection of patients is performed properly, it is possible to obtain a successful outcome.