prognostic blood biomarkers in shoulder surgery conf preso's/updated 201… · •surgeons...
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Prognostic blood biomarkers in shoulder surgery
Dr Simon Jenkin
Sport & Exercise Medicine Registrar
Sport Exercise Movement, Perth WA
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Fellow Researchers
• Anne Smith (Curtin University)
• Alison Thorpe (Curtin University & Body Logic Physiotherapy)
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Ethics Approval
• Curtin University Human Research Ethics Committee
• Bethesda Hospital Medical Advisory Committee
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Shoulder Pain
• Shoulder pain and dysfunction is common
• Significant burden to patient, society and healthcare system1
• Frequently attributed to rotator cuff disease or ‘impingement’
• Prevalence increases with age2
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Rotator Cuff Disease (RCD)
• Exact aetiopathogenesis unknown; likely multifactorial
• Intrinsic3,4 v Extrinsic model5
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Rotator Cuff Disease (RCD)
• Conservative v Surgical management
• Much debate over the efficacy of surgery in RCD6,7
• Treatment for should be individualised
• How do we decide which patient with RCD will have a better outcome from surgery?
• Cochrane review 2008 - We need a better understanding of aetiopathogenesis and prognostic factors8
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Tendon Disease
• Failed healing response is a hallmark of tendinopathy9
• Well demonstrated link between these markers and lower limb tendinopathy10
• Emerging evidence of adiposity and poor glycaemic control as a risk factor for RCD11-15
• Diabetics have poorer outcomes following shoulder surgery16,17
• These tendon risk factors could affect healing and outcomes of surgery for rotator cuff disease
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Do serum markers of adiposity and glycaemic control
have a prognostic effect on surgical outcomes in RCD?
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Methodology
• Prospective cohort study
• 53 patients recruited over 6 months
• 6 Orthopaedic surgeons involved at Bethesda Hospital
• 12 month follow-up
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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) questionnaire18
• Fasting blood test• Lipid profile (total chol, LDL, HDL, Tg)
• Apolipoprotein A & B
• Glucose
• HbA1c
• Insulin
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Outcome Measures
• DASH questionnaire• 30 item, self-report questionnaire
• Validated & reliable
• Score 0-100
• Ultrasound examination• Senior MSK Radiologist
• Tendon quality & integrity
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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
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Results
• Demographic factors did not correlate with outcome
• Baseline DASH mean = 38/100 (5 – 81.25)
• Post-operative DASH mean = 9.18/100 (0-40.83)
• Baseline DASH score predicted for outcome• Beta coefficient 0.66 (95% CI 0.16 – 1.16, P = 0.011)
• A high pre-operative score was more likely to result in a high post-operative score
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Correlation between pre-operative serum markers and post-operative DASH score
Predictor variable Beta Coefficient 95% CI P-value
Total Cholesterol 0.07 -0.22 – 0.37 0.620
Triglycerides 0.28 -0.25 – 0.82 0.295
LDL Cholesterol 0.03 -0.32 – 0.38 0.849
HDL Cholesterol -0.07 -0.81 – 0.67 0.852
Cardiac Risk Ratio 0.13 -0.13 – 0.38 0.330
Apolipoprotein A 0.18 -0.70 – 1.07 0.681
Apolipoprotein B 0.29 -0.88 – 1.46 0.619
Glucose 0.05 -0.07 – 0.16 0.404
Insulin 0.52 0.03 – 1.01 0.038
Glycated Haemoglobin 0.10 0.00 – 0.20 0.061
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Correlation between pre-operative serum markers and post-operative DASH score
Predictor variable Beta Coefficient 95% CI P-value
Total Cholesterol 0.07 -0.22 – 0.37 0.620
Triglycerides 0.28 -0.25 – 0.82 0.295
LDL Cholesterol 0.03 -0.32 – 0.38 0.849
HDL Cholesterol -0.07 -0.81 – 0.67 0.852
Cardiac Risk Ratio 0.13 -0.13 – 0.38 0.330
Apolipoprotein A 0.18 -0.70 – 1.07 0.681
Apolipoprotein B 0.29 -0.88 – 1.46 0.619
Glucose 0.05 -0.07 – 0.16 0.404
Insulin 0.52 0.03 – 1.01 0.038
Glycated Haemoglobin 0.10 0.00 – 0.20 0.061
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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 0.03 -0.25 – 0.32 0.805
Triglycerides 0.09 -0.45 – 0.62 0.750
LDL Cholesterol 0.00 -0.33 – 0.34 0.979
HDL Cholesterol 0.10 -0.61 – 0.81 0.787
Cardiac Risk Ratio 0.03 -0.23 – 0.29 0.818
Apolipoprotein A 0.30 -0.54 – 1.15 0.477
Apolipoprotein B 0.08 -1.05 – 1.21 0.889
Glucose 0.02 -0.09 – 0.17 0.670
Insulin 0.32 -0.19 – 0.84 0.213
Glycated Haemoglobin 0.04 -0.07 – 0.16 0.456
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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
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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
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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 post-operative treatment
• Ceiling effect of DASH
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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 treatment7,20
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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
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Thank you