Trenton T. Stevens, MD1 Jacob T. Hartline, MD2 Tyler J. Brolin, MD1 David L. Bernholt, MD1 Daniel T. Dibaba, PhD MPH3 Frederick M. Azar, MD1 Thomas W. Throckmorton, MD1 1
University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee
2
University of Maryland, College of Medicine Orthopaedic Department Baltimore, Maryland
3
Tennessee Clinical and Transitional Science Institute University of Tennessee Health Science Center Memphis, Tennessee
The Importance of Surgeon Judgment in Obtaining Early Magnetic Resonance Imaging to Prevent Delays in Care for Acute Subacromial Injury INTRODUCTION Shoulder pain accounts for up to one-third of orthopaedic complaints in the United States. Payors often dictate a minimum duration of conservative treatment for patients with shoulder pain emanating from the subacromial space before authorizing advanced imaging studies. This study evaluated the role of initial assessment by an orthopaedic surgeon to identify potential surgical lesions benefitting from early imaging in the setting of acute subacromial injury. We compared 1) the incidence of full and partial-thickness rotator cuff tears between patients undergoing acute magnetic resonance imaging (MRI) and those initially managed conservatively, and 2) the time between initial treatment and surgery for those with surgical lesions in each group.
METHODS A retrospective analysis identified patients between the age of 18 and 65 who presented to an outpatient orthopaedic clinic between 2015 and 2018 with the initial diagnosis of subacromial injury that began within 3 months from presentation. These initial diagnoses included partial or full-thickness rotator cuff tear, subacromial bursitis, rotator cuff strain, and subacromial impingement. All patients were initially evaluated by a board certified orthopaedic surgeon. Patients with fractures, those receiving prior physical therapy, MRI, other advanced imaging, or other targeted treatments such as corticosteroid and/or biologic injections were excluded. The study group included patients who had an acute MRI ordered at their initial visit after being judged by the treating physician as having a high likelihood of a surgical lesion. The control group of remaining patients were treated conservatively without obtaining an acute MRI. Data abstracted from the electronic medical record included an MRI order at initial or subsequent visits, duration of time to MRI completion, surgical intervention, and duration from initial visit to surgery. When obtained, MRIs were reviewed to determine the presence of full-thickness or high-grade partial thickness rotator cuff tears. Dependent sample t-test compared the patient characteristics between the control group and the acute MRI group. Analysis of variance and simple and multivariate linear regression were used to evaluate the amount of time to MRI and to surgery based on injury type.
RESULTS Corresponding Author Thomas W. Throckmorton, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3110 F: 901-759-3195 tthrockmorton@campbellclinic.com
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A total of 367 patients were included in the retrospective analysis; 298 had initial conservative treatment, while 69 had an MRI ordered at their initial visit. In the MRI-first group, 32 patients (46.4%) had surgery at an average time of 85 days from presentation compared to 38 patients (12.8%) in the conservatively treated group at an average time of 140 days from presentation (p=0.019). The average time to scan for the MRI-first group was 20 days compared to 89 days in the conservatively treated cohort (p<0.001). After a trial of conservative therapy, 84 of the 298 (28.1%) patients had an MRI subsequently completed. Review of MRI scans revealed that 41/69 (59.4%) patients who had an MRI ordered at the initial visit had a full-thickness rotator cuff tear and 8/69 (11.6%) had a partial-thickness tear. Of the patients in whom initial conservative treatment failed,
CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021
