by Tyler Tice, PT, DPT, MS, ATC
Background:
The utilization of multimodal analgesia (MMA) injections during arthroscopic rotator cuff repairs has gained popularity after commonly being utilized in hip and knee surgeries. MMA injections are a mixture of analgesic (pain relieving) agents of various classes with the intention of reducing pain and improving post-operative function. One of the agents included in this MMA injection is corticosteroids due to their local anti-inflammatory effect and ability to reduce the stress response to surgery. Previous research has demonstrated utilization of an MMA injection combined with corticosteroid significantly reduced pain and patients utilized fewer opioid medications in the first 24 hours following rotator cuff surgery. In the acute stage, the utilization of corticosteroid injections to the rotator cuff are highly effective, but concern regarding infection, risk for tendon re-tear, and general long-term tendon health remains. The goal of this study was to investigate the impact of corticosteroid injections on tendon health 1 year after arthroscopic rotator cuff repair.
Methods:
This study investigated 50 patients who were undergoing arthroscopic rotator cuff repair surgery. Patients were randomized into either the study group or control group. There were 25 patients in the study group and 25 patients in the control group. Inclusion and exclusion criteria for both groups can be found in the original article. Prior to surgery, all patients completed the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder score (ASES), and Simple Shoulder Test (SST) and pain levels were recorded. The study group received a periarticular injection that consisted of ropivacaine, morphine, and methylprednisolone (corticosteroid) while the control group received a saline injection. Both groups followed the same post-operative rehabilitation regime. The day after surgery patients completed passive movements and pendulum exercises. Additionally, patients wore a splint that kept the affected arm in internal rotation for the first 4 weeks post-operatively. A standardized outpatient rehab program was supervised by a physical therapist where active motion was initiated at 6 weeks and strengthening exercises were initiated at 12 weeks. Patients were able to return to heavy manual work and sports 3 months after surgery. At 12-months post-op, pain levels and functional scores were remeasured, and an MRI was completed to determine tendon integrity.
Results:
Pain levels were significantly reduced in both groups 12-months following surgery.
CMS, ASES, and SST scores significantly improved within both groups 12-months following surgery. There were no significant differences in scores between groups 12-months following surgery.
MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group.
There were no significant differences between groups in retear rates at 12-months following surgery.
Factors negatively impacting healing were determined to be advanced age, diabetes, and posterior extension of the tear. Receiving a corticosteroid injection was determined to not negatively impact healing.
Discussion:
Building on their previous study, the researchers of this study determined that MMA injections that included corticosteroids have no harmful effect on tendon healing and functional outcomes 1 year after surgery. However, the authors of this study noted that the potential harmful effects of corticosteroids must be balanced out when included in MMA injections as laboratory and animal studies continue to demonstrate harmful effects on tendons. Currently, there is mixed research regarding the impact of corticosteroids on tendon healing and integrity following rotator cuff surgery. Another finding from this study was that there was no significant difference between groups in functional scores at 1-year post-op. A similar result was found in a study where patients received a corticosteroid injection preoperatively or 1-month post-surgery. There were also no instances of infection in this study following the corticosteroid injection. The overall re-tear rate in this study was 14%, which is similar to re-tear rates observed in other research.
This study had a number of limitations that should be noted such as small sample size in both the study and control groups. Also, the MMA injection was a mixture of analgesics so it’s impossible to determine the sole effect of corticosteroids on tendon healing within the study, and the hyperglycemic effect of corticosteroids was no observed due to the controversial results related to type of corticosteroid, dosage, and injection site.
Take Home Messages:
While the results of this study may not appear drastically different compared to the control group, this can actually be interpreted as a good thing as the whole concern regarding the inclusion of corticosteroids in anesthetic injections is its negative impact on tendon healing. This study demonstrated virtually no differences between groups, which can be interpreted as there is no difference between receiving an MMA injection intra-operatively with or without corticosteroids. While this study did not explicitly demonstrate the effect of just corticosteroids on tendon healing when utilized intra-operatively, the results demonstrating little to no difference when it’s included in an MMA injection is positive. More research needs to be conducted regarding the effect of corticosteroids on tendon healing when individually utilized intra-operatively, but for the time being these research can put people’s minds at ease regarding the potential negative impact if received intra-operatively for rotator cuff repair surgery.
Reference:
Perdreau, A., Duysens, C., & Joudet, T. (2020). How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthopaedics & traumatology, surgery & research : OTSR, 106(6), 1159–1166. https://doi.org/10.1016/j.otsr.2020.05.009