Estimating the minimal clinically important difference of shoulder functional scores after arthroscopic rotator cuff repair: a prospective study.

INTRODUCTION: The minimal clinically important difference (MCID) is a valuable tool for patient-based outcome analysis, for which limited data is available in the literature, especially after arthroscopic rotator cuff repair (ARCR). Although several studies have reported MCID after ARCR, few have studied the impact of various clinical factors such as Diabetes, pseudoparalysis, type of cuff repair, and retear over MCID. This study attempts to determine the MCID in shoulder functional scores after ARCR and the impact of various factors on MCID. METHODS: 144 patients undergoing ARCR were prospectively evaluated at six and 12 months by ASES and UCLA scores. MCID for American Shoulder and Elbow Surgeons (ASES) and the University of California and Los Angeles (UCLA) scores were calculated using an anchor-based and distribution-based approach. MCID was also calculated for diabetic and non-diabetic patients, smokers vs. non-smokers, presence or absence of pseudoparalysis, type of cuff repair (single row vs. suture bridge), and presence of retears. Uni- and multivariate analysis was performed to identify factors affecting the MCID of both scores. RESULTS: Mean MCID for ASES score was 13.3 and 16.6 using an anchor-based and distribution-based approach, respectively. For the UCLA score, the mean MCID was 10.0 and 12.6 by anchor-based and 12.6 by distribution-based approach, respectively. Patients with higher pre-operative ASES scores demonstrated lower MCID values. No significant difference was observed in MCID scores of diabetic vs. non-diabetic patients, smoker vs. non-smoker, patients with or without pseudoparalysis, and type of cuff repair. The age, gender, and presence of retear did not affect MCID values. CONCLUSION: This study establishes the MCID values of ASES and UCLA scores for rotator cuff repair by anchor and distribution methods. No patient or surgical factors appear to affect the MCID except pre-operative ASES scores. STUDY DESIGN: Prospective cohort, Level II.

Exploring global changes in nitrogen and phosphorus cycles in agriculture induced by livestock production over the 1900-2050 period.

Crop-livestock production systems are the largest cause of human alteration of the global nitrogen (N) and phosphorus (P) cycles. Our comprehensive spatially explicit inventory of N and P budgets in livestock and crop production systems shows that in the beginning of the 20th century, nutrient budgets were either balanced or surpluses were small; between 1900 and 1950, global soil N surplus almost doubled to 36 trillion grams (Tg) · y(-1) and P surplus increased by a factor of 8 to 2 Tg · y(-1). Between 1950 and 2000, the global surplus increased to 138 Tg · y(-1) of N and 11 Tg · y(-1) of P. Most surplus N is an environmental loss; surplus P is lost by runoff or accumulates as residual soil P. The International Assessment of Agricultural Knowledge, Science, and Technology for Development scenario portrays a world with a further increasing global crop (+82% for 2000-2050) and livestock production (+115%); despite rapidly increasing recovery in crop (+35% N recovery and +6% P recovery) and livestock (+35% N and P recovery) production, global nutrient surpluses continue to increase (+23% N and +54% P), and in this period, surpluses also increase in Africa (+49% N and +236% P) and Latin America (+75% N and +120% P). Alternative management of livestock production systems shows that combinations of intensification, better integration of animal manure in crop production, and matching N and P supply to livestock requirements can effectively reduce nutrient flows. A shift in human diets, with poultry or pork replacing beef, can reduce nutrient flows in countries with intensive ruminant production.

Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association.

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting.

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Five Year Follow up of Retrospective Cohort Comparing Structural and Functional Outcome of Arthroscopic Single-row ersus Double-row Suture Bridge Repair of Large Posterosuperior Rotator Cuff Tear in Patients Less than or Equal to 70 Years.

BACKGROUND: High re-tear rates after repairing large-sized posterosuperior rotator cuff tears remain a significant concern which may affect the clinical outcome. The most optimal type of repair (single versus double-row suture bridge) suited for large size tear remains debatable. METHODS: In a retrospective cohort study with a minimum of five years follow up, the structural and functional outcome of 103 patients with large size cuff tear repaired with single row (SR) or double row suture bridge (DRSB) were evaluated. The structural outcome was assessed with ultrasonography whereas functional outcome was evaluated with Constant Murley (CM) and American shoulder elbow score (ASES). RESULTS: There were 55 patients in the SR group and 48 patients in the DRSB group with a mean follow-up of 74.2 months (range, 60-96 months). While comparing the structural integrity in two groups, we found significantly lower re-tear rates in the DRSB group as compared to the SR group (10.4% vs. 32.7%; P=0.006). Also, there were more focal defects in the SR group (25.4%) than the DRSB group (8.3%). Overall, there was no significant difference in CM and ASES scores when the SR group was compared to DRSB. However, subgroup analysis between those with intact and retorn tendon revealed significant difference (P=0.0001) in the clinical scores. CONCLUSION: At a minimum of five years follow-up, the DRSB repair of large posterosuperior cuff tear resulted in superior structural healing over SR repair. Nevertheless, overall there was no significant functional difference between both the techniques. However, the functional outcome of the healed tendon subgroup was superior to retear tendon subgroup.

Validation of the Dutch version of the Oxford Shoulder Score.

BACKGROUND: The Oxford Shoulder Score (OSS) is an internationally-used patient-based outcome score. Up to now, it was not validated in Dutch. The purpose of this study was to produce a Dutch translation of the OSS and to test this version in terms of reliability and validity. METHODS: Translation of the OSS was done according to the guidelines in literature. One hundred and three patients completed the Dutch version of the OSS. Additionally, the Constant-Murley shoulder score, the (Dutch) Simple Shoulder Test (DSST) score, and SF-36 were included into the validation process. Feasibility and patient-burden parameters were also tested. RESULTS: One-hundred and three patients with general shoulder problems age 55 years (min-max: 21-81 +/- 13 yrs), sex ratio 2/3 (f/m) completed the Dutch version of the OSS and the SF-36. Internal consistency tested by the Cronbach's alpha (0.921) was high. Intra-class correlation coefficient was R = .981 (95% confidence interval: .961 - .993) and the mean difference between both tests was 2.7 points (0-8). Construct validity was also tested by the Pearson correlation coefficient and showed a significant correlation (P < .01) between the Dutch version of the OSS and the other scores (DSST 0.61; the Constant-Murley score 0.64 and with most of the SF-36 sub-scores, except for 2 psychometric subscales, namely, mental health (0.15 [P = .123]) and general health (0.10 [P = .316]) CONCLUSION: The instrument proved to be valid by demonstrating significant correlations predicted by standard clinical assessments (DSST and Constant-Murley scores) and a generic patient-based instrument (SF-36). Application and evaluation in clinical trial proved feasible and understandable.

Adolescent responses toward a new technology: first associations, information seeking and affective responses to ecogenomics.

This paper reports on an exploratory study among adolescents (N = 752) who were introduced to the emerging technology of ecogenomics for the first time. An online survey focused on their associations with the term ecogenomics, their planned information seeking behaviors if they were to acquire information about the new technology, and their first affective responses toward ecogenomics after having read some introductory information about it. Adolescents were found to associate ecogenomics most frequently with economy. Although the Internet was the most popular medium to be used in their planned information seeking behaviors, books and science communication professionals were judged as the most trustworthy information sources. After having read the introductory information about ecogenomics most adolescents reported positive affective responses toward the new technology.

Additional surgery after anterior cruciate ligament reconstruction: can we improve technical aspects of the initial procedure?

PURPOSE: To determine factors that cause reoperation after anterior cruciate ligament (ACL) reconstruction and determine which cause of reoperation can be addressed to help to improve technical aspects of the initial procedure. METHODS: Between 1988 and 1998, 436 patients underwent an ACL reconstruction by a single surgeon. We analyzed all 207 patients who had a bone-patellar tendon-bone reconstruction (BPTB). The same technique was used in all operations, which consisted of the 1-incision endoscopic approach with autologous central third patellar-tendon graft. Of these patients, 196 were available for full evaluation. Evaluation included: a detailed history, physical examination, functional knee ligament testing, KT-1000 arthrometer testing, One-leg-hop testing, Lysholm score, Tegner score, and the International Knee Documentation Committee standard evaluation form. All technical surgical aspects concerning the index operation and the reoperations were collected and evaluated in detail to detect predictors for failure or improvement. Position of the graft was measured radiographically using the Amis circle and Taylor score. RESULTS: The average age of the 196 patients at the time of the operation was 34 years, and the mean duration of follow-up was 7.4 years. Seventy-seven reoperations were performed in 54 (27.6%) patients during a period of 83 months postsurgery. Reoperations were done between day 22 and 83 months post-ACL reconstruction. Indications for reoperations were: pain caused by fixation material (n = 25); meniscal lesions (n = 24); cyclops lesion (n = 16); donor site morbidity (n = 5); re-rupture of the ACL (n = 5); posterior cruciate ligament rupture (n = 1); and a medial collateral ligament lesion (n = 1). A more ventral position of the graft on the femur (Amis <60%) was correlated with a higher frequency of meniscal lesions and cyclops lesions (P < .01). Patients who had a meniscal lesion after an ACL reconstruction had significantly lower Lysholm (P < .05) and Tegner scores (P < .01). CONCLUSIONS: A large percentage of the patients (27.6%) required additional surgical procedures after patellar tendon autograft ACL reconstruction. A poor position of the graft resulted in cyclops and meniscal lesions. Analyzing the reasons for reoperations gives information about how to improve our surgical technique. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The shape of the inferior part of the glenoid: a cadaveric study.

Previously, the shape of the inferior glenoid has been described as a circle with a bare spot being the center of that circle. This cadaveric study was done to test that statement. Forty cadaveric scapulae were used in this study. Two researchers used a digital image analysis program to assess the shape of the inferior glenoid and measured the distances from the bare spot to the anterior, inferior, and posterior cartilage and the bone rim. In 39 of 40 scapulae, the inferior glenoid had the shape of a true circle. Statistical analysis showed that the center of the bare spot is not the mathematical center of the inferior glenoid, but the differences in distances to the anterior, inferior, and posterior rims were very small (1.16-2.41 mm). Both observations can be used for further development of methods for measuring glenoid bone loss in patients with anterior glenohumeral instability.