Prognostic blood biomarkers in shoulder surgery. Dr Simon Jenkin Sport & Exercise Medicine Registrar Sport Exercise Movement, Perth WA

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1 Prognostic blood biomarkers in shoulder surgery Dr Simon Jenkin Sport & Exercise Medicine Registrar Sport Exercise Movement, Perth WA

2 Fellow Researchers Anne Smith (Curtin University) Alison Thorpe (Curtin University & Body Logic Physiotherapy)

3 Ethics Approval Curtin University Human Research Ethics Committee Bethesda Hospital Medical Advisory Committee

4 Shoulder Pain Shoulder pain and dysfunction is common Significant burden to patient, society and healthcare system 1 Frequently attributed to rotator cuff disease or impingement Prevalence increases with age 2

6 Rotator Cuff Disease (RCD) Exact aetiopathogenesis unknown; likely multifactorial Intrinsic 3,4 v Extrinsic model 5

7 Rotator Cuff Disease (RCD) Conservative v Surgical management Much debate over the efficacy of surgery in RCD 6,7 Treatment for should be individualised How do we decide which patient with RCD will have a better outcome from surgery? Cochrane review We need a better understanding of aetiopathogenesis and prognostic factors 8

8 Tendon Disease Failed healing response is a hallmark of tendinopathy 9 Well demonstrated link between these markers and lower limb tendinopathy 10 Emerging evidence of adiposity and poor glycaemic control as a risk factor for RCD Diabetics have poorer outcomes following shoulder surgery 16,17 These tendon risk factors could affect healing and outcomes of surgery for rotator cuff disease

9 Do serum markers of adiposity and glycaemic control have a prognostic effect on surgical outcomes in RCD?

10 Methodology Prospective cohort study 53 patients recruited over 6 months 6 Orthopaedic surgeons involved at Bethesda Hospital 12 month follow-up

11 Pre-operative Measures Demographics age, gender, BMI, smoking status, occupational tasks, duration of symptoms Intra-operative Subacromial decompression +/- rotator cuff repair Arthroscopic, mini-open or open Disability of the Arm, Shoulder and Hand (DASH) questionnaire 18 Fasting blood test Lipid profile (total chol, LDL, HDL, Tg) Apolipoprotein A & B Glucose HbA1c Insulin

12 Outcome Measures DASH questionnaire 30 item, self-report questionnaire Validated & reliable Score Ultrasound examination Senior MSK Radiologist Tendon quality & integrity

14 Study Cohort 48 patients (90.6%) completed follow-up DASH questionnaire 30 male, 18 female Mean age = 55 (31 78) 7 smokers, 41 non-smokers Procedure Number Arthroscopic acromioplasty only 22 plus arthroscopic rotator cuff repair 14 plus mini-open rotator cuff repair 7 plus open rotator cuff repair 5

15 Results Demographic factors did not correlate with outcome Baseline DASH mean = 38/100 ( ) Post-operative DASH mean = 9.18/100 ( ) Baseline DASH score predicted for outcome Beta coefficient 0.66 (95% CI , P = 0.011) A high pre-operative score was more likely to result in a high post-operative score

16 Correlation between pre-operative serum markers and post-operative DASH score Predictor variable Beta Coefficient 95% CI P-value Total Cholesterol Triglycerides LDL Cholesterol HDL Cholesterol Cardiac Risk Ratio Apolipoprotein A Apolipoprotein B Glucose Insulin Glycated Haemoglobin

17 Correlation between pre-operative serum markers and post-operative DASH score Predictor variable Beta Coefficient 95% CI P-value Total Cholesterol Triglycerides LDL Cholesterol HDL Cholesterol Cardiac Risk Ratio Apolipoprotein A Apolipoprotein B Glucose Insulin Glycated Haemoglobin

18 Correlation between pre-operative serum markers and post-operative DASH score (adjusted for baseline DASH) Predictor variable Beta Coefficient 95% CI P-value Total Cholesterol Triglycerides LDL Cholesterol HDL Cholesterol Cardiac Risk Ratio Apolipoprotein A Apolipoprotein B Glucose Insulin Glycated Haemoglobin

19 Results No correlation between serum markers and outcomes of pain and function following surgery for RCD Patients with higher serum insulin and glycated haemoglobin had more pain and poorer function

20 Ultrasound Findings 35 (66%) patients underwent follow-up ultrasound 32 were intact and normal thickness 3 were predominantly intact with small area of partial thickness tearing Significant number lost to follow-up Geographical considerations

21 Discussion Strengths High follow-up rate Consistent data collection Minimal participation bias Heterogenous sample population Multiple surgeons Weaknesses Small sample size (limited power) Possible confounding surgical factors Non-standardised postoperative treatment Ceiling effect of DASH

22 Summary This is the first study to examine serum markers as prognostic factors for shoulder surgery Treatment of RCD remains a complicated process with no clear guidelines or conclusions on best practice More research required to: Confirm or establish an association between markers of adiposity or poor glycaemic control, and tendon disease in the shoulder Better identify prognostic factors for surgery in RCD so that we can make more individualised decisions on patient treatment 7,20

23 Acknowledgements Bethesda Hospital Western Diagnostic Pathology Dr Bill Breidahl (Perth Radiological Clinic) Surgeons Dr Grant Booth, Dr Sven Goebel, Dr Jonathan Spencer, Dr Paul Khoo, Dr Mark Hurworth, Dr Aaron Tay

24 References 1. Meislin RJ, Sperling JW, Stitik TP. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. Am J Orthop (Belle Mead NJ). 2005;34(12 Suppl): Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8): Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med. 1991;10(4): Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med. 2003;22(4): Nho SJ, Yadav H, Shindle MK, Macgillivray JD. Rotator cuff degeneration: etiology and pathogenesis. Am J Sports Med. 2008;36(5): Dorrestijn O, Stevens M, Winters JC, van der Meer K, Diercks RL. Conservative or surgical treatment for subacromial impingement syndrome? A systematic review. J Shoulder Elbow Surg. 2009;18(4): Seida J, Schouten J, Mousavi S, Tjosvold L, Vandermeer B, Milne A, et al. Comparative effectiveness of nonoperative and operative treatment for rotator cuff tears. Comparative Effectiveness Review No 22 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No ). Rockville, MD: Agency for Healthcare Research and Quality; Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease (Review). Cochrane Database of Systematic Reviews (Internet). 2008;1 9. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009;43(6):

25 References 10.Gaida JE, Ashe MC, Bass SL, Cook JL. Is adiposity an under-recognised risk factor for tendinopathy? A systematic review. Arthritis Care Res. 2009;61: Abboud JA, Kim JS. The effect of hypercholesterolaemia on rotator cuff disease. Clin Orthop Relat Res. 2010;468(6): Longo UG, Franceschi F, Spiezia F, Forriol F, Maffulli N, Denaro V. Triglycerides and total serum cholesterol in rotator cuff tears: do they matter? Br J Sports Med. 2010;44: Wendelboe AM, Hegmann KT, Gren LH, Alder SC, White GL, Jr., Lyon JL. Associations between body-mass index and surgery for rotator cuff tendinitis. J Bone Joint Surg Am. 2004: Longo UG, Franceschi F, Ruzzini L, Spiezia F, Maffulli N, Denaro V. Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears. Br J Sports Med. 2009;43: Chen AL, Shapiro JA, Ahn AK, Zuckerman JD, Cuomo F. Rotator cuff repair in patients with type I diabetes mellitus. J Shoulder Elbow Surg. 2003;12(5): Clement ND, Hallett A, MacDonald D, Howie C, McBirnie J. Does diabetes affect outcome after arthroscopic repair of the rotator cuff? J Bone Joint Surg (Br). 2010;92-B(8): Longo UG, Franceschi F, Ruzzini L, Rabitti C, Morini S, Maffulli N, et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med. 2008;36(3): Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6): Fermont AJ, Wolterbeek N, Wessel RN, Baeyens JP, de Bie RA. Prognostic factors for recovery after arthroscopic rotator cuff repair: a prognostic study. Journal of Shoulder & Elbow Surgery. 2015;24(8):

26 Thank you

Adress correspondence and reprint requests to Hyun Seok Song, M.D. Department of Orthopedic Surgery, St.Paul s Hospital, The Catholic University of

Adress correspondence and reprint requests to Hyun Seok Song, M.D. Department of Orthopedic Surgery, St.Paul s Hospital, The Catholic University of Korea 620-56 Jeonnong-dong, Dongdaemun-gu, Seoul, Korea