Prevent Delays in Care for Acute Subacromial Injury

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

Corresponding Author

Thomas W. Throckmorton, MD

1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3110 F: 901-759-3195 tthrockmorton@campbellclinic.com

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 benefi tting from early imaging in the setting of acute subacromial injury. We compared 1) the incidence of full and partial-thickness rotator cu 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 identifi ed 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 cu tear, subacromial bursitis, rotator cu strain, and subacromial impingement. All patients were initially evaluated by a board certifi ed 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 cu 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

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-fi rst 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-fi rst 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 cu tear and 8/69 (11.6%) had a partial-thickness tear. Of the patients in whom initial conservative treatment failed,

33/84 scans (39.3%) revealed a full-thickness tear and 17/84 (20.2%) a partial thickness tear. Chi square analysis demonstrated a signifi cant di erence in the presence of a full-thickness rotator cu tear with MRI ordered at fi rst visit, 59.4%, versus diagnosis of full-thickness tear after trial of conservative treatment, 39.3% (p=0.020).

DISCUSSION

A minimal period of non-operative treatment often is dictated by payors for patients presenting with suspected acute subacromial injury; however, these data suggest that acute MRI is warranted in patients who are judged by a board-certifi ed orthopaedic surgeon to have a potential surgical lesion. Specifi cally, almost 60% of patients who had acute MRIs had a full-thickness rotator cu tear, signifi cantly more than patients treated non-operatively upon initial evaluation. Further, patients who fi rst have a trial of conservative treatment for suspected acute subacromial injury experience a signifi cant delay both to MRI and surgical intervention, if indicated. Because delays in surgical treatment of rotator cu tears have been shown to have compromised functional outcomes, we conclude surgeon judgment is an important factor in the decision to obtain MRI in the setting of acute subacromial injury to prevent these delays in care.

TRENTON T. STEVENS, MD

Hometown: Johnson City, Tennessee Undergraduate Institution: University of North Carolina - Chapel Hill Medical School: University of Tennessee Health Science Center College of Medicine Dr. Stevens is the middle child, with an older sister and a younger brother. He is the fi rst in his family to pursue a career in medicine.

Dr. Stevens met his wife Jeanne-Marie, a CRNA, at college in Chapel Hill. They were married in 2019, and their daughter Eleanor Louise will be one year old in June. When asked why he chose medicine as a career: I pursued a career in medicine for reasons too many to list, but primarily for the challenge of staying ahead in a continually evolving complex fi eld, the ability to take care of patients both healthy and severely traumatized, and the opportunity to use my education and training to positively impact patients on a daily basis. And why he chose orthopaedics as a specialty: I chose orthopaedics after my rotation in the emergency department when I witnessed trauma admits with severe injuries and the amount of planning, expertise, passion and commitment by the trauma team and staff to successfully care for and treat these patients. Plans After Campbell: Dr. Stevens will complete an Orthopaedic Trauma Fellowship at Hospital for Special Surgery in New York.

Dr. Stevens adds: I would like to thank all of the Campbell Clinic faculty and staff for their dedication and commitment to resident training and education. I am exceptionally thankful for the mentorship of Dr. Rudloff , Dr. Weinlein and Dr. Beebe. I aspire to carry on the same passion they have for orthopaedic trauma and education throughout my own career. I am beyond grateful for the companionship and support of my fellow residents, before and after me, who push me to be a better person and physician.