Patient-reported outcomes for arthroscopic resection of the distal clavicle with concomitant arthroscopic subacromial decompression at a 2-year follow-up: a prospective study of 131 consecutive patients.

Background: Arthroscopic distal clavicle resection (DCR) can be offered to patients with persistent acromioclavicular (AC) joint pain who do not benefit from conservative treatment. The aim of this study was to evaluate the outcome of combined arthroscopic DCR and concomitant arthroscopic subacromial decompression in a large consecutive and prospective cohort using patient-reported outcomes. Methods: Consecutive patients were identified from our online database and included based on their primary treatment code. All patients had a diagnosis of shoulder impingement syndrome and persistent AC joint pain resistant to at least six months of conservative treatment. The outcomes from the combined intervention were evaluated by patients through the Oxford Shoulder Score (OSS) questionnaire and EuroQol 5-Dimension 3-Level questionnaire, including a EuroQol visual analog scale score collected preoperatively and at a 2-year follow-up. Patient-reported satisfaction with the procedure was reported at the follow-up. Subgroups were formed to further evaluate outcome based on preoperative OSS (low, moderate, high) and age. Results: 131 patients (75%) were available for analysis at the 2-year follow-up. Sixty seven patients (51%) were female and the mean age was 51 years (range 19-82). A mean OSS change of 12.1 (95% confidence interval, 10.3-14.0; P < .001) was observed within the entire study group. In both the low and moderate preoperative-OSS (pre-OSS) groups, a mean change of 14 was found with no difference between groups (P = .971). A mean change of 7 was found in the high pre-OSS group, which differed from both the moderate (P < .001) and low (P = .036) pre-OSS groups. A significant change in EuroQol 5-Dimension and EuroQol visual analog scale was observed within all the pre-OSS groups, and 107 patients (82%) replied that they were satisfied or very satisfied with their outcome of surgery at the follow-up. Conclusions: Patients who suffer from persistent AC joint pain largely benefit from arthroscopic DCR with arthroscopic subacromial decompression through relief of symptoms and improved quality of life, including those with a high self-reported and preoperative level of shoulder function.

Minimal Pain Decrease Between 2 and 4 Weeks After Nonoperative Management of a Displaced Midshaft Clavicle Fracture Is Associated with a High Risk of Symptomatic Nonunion.

BACKGROUND: The main long-term benefit of operative treatment of displaced midshaft clavicular fractures is the reduction in nonunion risk, and as this risk is generally low, the ideal approach would be to operate only patients at high risk of nonunion. However, most current surgical decision models use baseline variables to estimate the nonunion risk, and the value of these models remains unclear. Pain in the early weeks after fracture could be potentially be an indirect measurement of fracture healing, and so it is a potential proxy variable that could lead to simpler prediction models. QUESTIONS/PURPOSES: (1) Is pain a possible proxy variable for the development of symptomatic nonunion after nonoperative treatment of midshaft clavicular fractures? (2) How reliable is the model we created that uses pain as a proxy variable for symptomatic nonunion of nonoperatively treated clavicle fractures? METHODS: In this secondary retrospective analysis of an earlier randomized trial, we studied prospectively collected data from 64 nonoperatively treated patients aged 18 years to 60 years. In the original randomized trial, we compared operative and nonoperative treatment of displaced midshaft clavicular fractures. In all, 150 patients were included in the study, of whom 71 received nonoperative treatment. Patients were predominantly males (75%, 48 of 64) with a mean age of 38 ± SD 12 years; most fractures were comminuted and shortened more than 1 cm. All 71 patients who were nonoperatively treated were potentially eligible for this secondary analysis; of those, 11% (8 of 71) were lost to follow-up, leaving 63 patients from the nonoperative treatment arm and one patient from the operative treatment arm (who declined surgical treatment after randomization but was followed in this group according to the intention-to-treat principle) for analysis here. Nonunion was defined as lack of callus formation, persistent fracture lines and/or sclerotic edges of the bones at the fracture site on plain radiographs at 6 months follow-up. Nonunions were regarded as symptomatic if pain, tenderness, and local crepitation were present at the fracture site. Seventeen percent (11 of 64) of patients had symptomatic nonunions. After investigating differences in early pain scores between the union and nonunion groups, we defined the VASratio as the VAS pain score at 4 weeks divided by the VAS pain score at 2 weeks. Week 2 VAS pain score was chosen as baseline after visual inspection of a linear mixed model that showed increased divergence in pain scores between union and nonunion group at 2 weeks after fracture. Week 4 was chosen as the cutoff because we wanted a reasonable time frame for the detection of pain reduction and did not want to delay surgical treatment more than necessary. Odds ratios for various risk factors were calculated using logistic regression analyses. We used a receiver operating characteristic curve analysis to identify cutoff values for the VASratio. RESULTS: An increase in absolute pain score at 4 weeks after fracture (odds ratio 1.8 per 1 point increase [95% confidence interval 1.1 to 3.4]) was associated with an increased risk of nonunion 6 months after fracture. Likewise, we found that an increasing VASratio (OR 1.02 per 0.01 point increase [95% CI 1.002 to 1.06]) was also associated with nonunion. Receiver operating curve analysis found that the best cutoff value of VASratio was about 0.6. Patients with a VASratio above 0.6 had a relative risk of developing nonunion of 18 (95% CI 2 to 130) compared with patients with a VASratio below 0.6. Sparse-data bias could be present, as is evident from this wide confidence interval, though even at the low end of the confidence interval, the relative risk was 2, which may still improve surgical decision-making. CONCLUSION: A pain score that exhibits no or minimal change from 2 to 4 weeks after nonoperative treatment of a displaced midshaft fracture of the clavicle is associated with a high risk that symptomatic nonunion will develop. Patients with no or minimal change in pain in the early weeks may be candidates for surgery to reduce the risk of symptomatic nonunion. As this was a retrospective study, with a risk of sparse-data bias, the predictive value of the VASratio needs to be further investigated in large prospective studies before clinical use. LEVEL OF EVIDENCE: Level III, diagnostic study.

Diabetic and non-diabetic patients report equal symptom relief after arthroscopic capsular release of frozen shoulder.

BACKGROUND: Frozen shoulder is a painful joint disease. Patients with diabetes seem to have worse clinical symptoms and surgery in this patient population is believed to be more common.The objective postoperative evaluation indicates inferior results when surgically treating diabetics, but no previous studies have investigated exclusively the subjective patient satisfaction with arthroscopic capsular release. MATERIALS AND METHODS: A total of 93 patients were included. All had persistent symptoms despite conservative treatment for at least six months. The patients were retrospectively divided into two groups based on diabetes status: Group 1 consisted of patients with type 1 or type 2 diabetes (18) and group 2 consisted of the remaining patients (75). Evaluation was performed prior to arthroscopic capsular release and at six months follow-up. The web-based questionnaire consisted of two different evaluation forms: The Oxford Shoulder Score (OSS) and a visual quality scale (VQS). RESULTS: Both groups reported a statistically significant improvement in both evaluations. OSS in group 1 improved by 11.5 [95% CI: 6.2 ; 16.4] and by 15.8 [95% CI: 13.6 ; 17.9] in group 2. The improvement was more pronounced in group 2, though not statistically significant (p = 0.09). The VQS improved 39.6 in group 1 and 44.5 in group 2, (p = 0.50). CONCLUSION: Diabetic and non-diabetic patients reported equal symptom relief after arthroscopic capsular release of frozen shoulder when selected for operation without considering diabetic status. We will continue to select patients for arthroscopic release without differences in preoperative counseling between diabetics and non-diabetics.

Acromioplasty in patients selected for operation by national guidelines.

BACKGROUND: Shoulder impingement syndrome is the most common shoulder disorder. Even though conservative treatment is the primary treatment of choice, surgery has increased substantially in several countries during the last 20 years. This has resulted in recommended clinical guidelines for treatment of shoulder impingement syndrome in countries such as The Netherlands and Denmark during recent years. The aim of this study was to investigate the effectiveness of an arthroscopic subacromial decompression in 244 patients selected for surgery according to national clinical guidelines. MATERIALS AND METHODS: Patients were included from an Internet-based shoulder and elbow database. They were asked to complete 2 questionnaires consisting of the Oxford Shoulder Score (OSS) and the EuroQol 5-Dimension 3-Level and visual analog scale preoperatively and at 6-month follow-up. All patients were carefully selected for surgery according to the national guidelines, with symptoms persisting for at least 6 months. Furthermore, subgroups related to the OSS were formed to assess the clinical outcome according to preoperative status and age. RESULTS: For the complete study group, an OSS change of 10 (8.8-11.2; P = .0001) was found at 6-month follow-up. No significant difference was found between the genders (P = .17). The largest clinical effect from the intervention was found in the low preoperative OSS (pre-OSS) group, in which a mean change of 17 was found. The moderate and high pre-OSS groups had mean changes of 13 and 5, respectively. Similarly, according to the EuroQol 5-Dimension 3-Level and visual analog scale, the largest improvements were seen in the low and moderate pre-OSS groups. CONCLUSION: Arthroscopic subacromial decompression is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish national guidelines.