Puzzitiello, Richard N.

Purpose To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects. Methods A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications. Results Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month. Conclusions Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow‐up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events. Level of Evidence Systematic review of level I‐IV studies.

Background There is increased emphasis on properly allocating healthcare resources to optimize value within orthopedic surgery. Establishing time to maximal medical improvement (MMI) can inform clinical decision-making and practice guidelines. Purpose We sought (1) to evaluate the time to MMI as predicted by commonly used patient-reported outcome measures (PROMs) for evaluation of shoulder stabilization and (2) to evaluate typical time to return to sports and employment following surgery. Methods A systematic review of the Medline database was conducted to identify outcome studies reporting sequential follow-up at multiple time points, up to a minimum of 2 years after shoulder stabilization surgery. The included studies examined the outcomes of arthroscopic or open surgical techniques on anterior instability. Clinically significant improvements were evaluated utilizing the minimal clinically important difference specific to each PROM. Secondary outcomes included range of motion, return to sport/work, and recurrent instability. Results Ten studies comprising 590 surgically managed cases of anterior shoulder instability were included (78% arthroscopic, 22% open). Clinically significant improvements in PROMs were achieved up to 1 year post-operatively for Rowe, Western Ontario Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. For the three most utilized tools (Rowe, WOSI, ASES), the majority of improvement occurred in the first 6 post-operative months. Clinically significant improvements in Constant Score and Oxford Shoulder Instability Score (OSIS) were achieved up to 6 months and 2 years after surgery, respectively. No clinically significant improvements were achieved on the Disabilities of the Arm, Shoulder, and Hand (DASH) tool. Conclusion Maximal medical improvement as determined by commonly utilized PROMs occurs by 1 year after operative management of anterior shoulder instability. The DASH tool does not appear to demonstrate a reliable time frame for clinically significant outcome improvement.