Editorial Commentary: At Least 2 out of 3 Adolescent Athletes Can Return to Preinjury Sports After Marrow Stimulation for Osteochondritis Dissecans of the Elbow.

Osteochondritis dissecans (OCD) of the capitellum is a common cause of elbow pain in young throwers and gymnasts, symptoms of which can rob these young athletes of valuable time participating in sporting activities. The optimal treatment of adolescent capitellar OCD lesions is dependent on a variety of patient- and lesion-specific factors, including, but not limited to, lesion size, lesion location, physeal status, and lesion chronicity. Promisingly, marrow stimulation with or without debridement appears to confer high return-to-sport rates coupled with a low complication rate for young athletes suffering from this condition. Furthermore, these outcomes appear to remain consistent across the spectrum of OCD lesions typically encountered. There is concern, however, with the inconsistent reporting of patient- and lesion-specific factors across the literature, which greatly interferes with our ability to synthesize knowledge from multiple published studies and may lead surgeons astray when deciding on the optimal treatment for their patients. It is clear that no two OCD lesions are the same, and each patient requires a thorough history and physical exam, a complete radiographic workup, and a surgeon comfortable with a variety of surgical interventions if outcomes are to be maximized.

An Innovative Seven-year Physician Scientist Residency Training Program That Addresses the Shortage of Academic Surgeons.

Due to the declining number of scientifically trained physicians and increasing demand for high-quality literature, our institution pioneered a seven-year Physician Scientist Training Program (PSTP) to provide research-oriented residents the knowledge and skills for a successful academic career. The present study sought to identify orthopaedic surgeons with MD/PhD degrees, residency programs with dedicated research tracks, and to assess the effectiveness of the novel seven-year program in training prospective academic orthopaedic surgeons. Surgeons with MD/PhD degrees account for 2.3% of all 3,408 orthopaedic faculty positions in U.S. residency programs. During the last 23 years, our PSTP residents produced 752 peer-reviewed publications and received $349,354 from 23 resident-authored extramural grants. Eleven of our seven-year alumni practice orthopaedic surgery in an academic setting. The seven-year PSTP successfully develops clinically trained surgeon scientists with refined skills in basic science and clinical experimental design, grant proposals, scientific presentations, and manuscript preparation. (Journal of Surgical Orthopaedic Advances 31(3):144-149, 2022).

Editorial Commentary: Déjà Vu: Double-Bundle Anterior Cruciate Ligament Reconstruction Revisited.

Regardless of the technique utilized, tunnel expansion following anterior cruciate ligament reconstruction remains a mystery and a clinical challenge. No procedure seems to be immune to this, even anatomic double-bundle reconstruction. This technique was introduced more than 20 years ago and showed great promise while also contributing significantly to our current knowledge of anterior cruciate ligament anatomy and biomechanics. However, we must remember that new techniques do carry with them new side effects that we must document and acknowledge if we hope to improve our surgical outcomes.

Peripheral Nerve Injury After Elbow Arthroscopy: An Analysis of Risk Factors.

PURPOSE: To identify risk factors associated with peripheral nerve injury after elbow arthroscopy and provide an updated incidence of those complications. METHODS: The elbow arthroscopies that were performed at our institution between 2006 and 2016 were identified. Over a 10-year period, 253 elbow arthroscopies were performed at our institution. Two hundred twenty-seven cases had a minimum follow-up of 4 weeks, and were included in our analysis. Minor and major nerve-related complications were recorded. The surgeon's experience and training, body max index of the patients, surgical tourniquet time, type of anesthesia or surgery, radiographic appearance of the elbow, diagnosis at the time of surgery, and presence of diabetes were analyzed. RESULTS: There were 12 reported peripheral nerve injuries, 10 minor (4.4%) and 2 major complications (0.9%). The risk factors examined in this study were not correlated with a higher rate of complications. CONCLUSIONS: The minor nerve-related complication rate was 4.4%, with a 0.9% incidence of major peripheral nerve injury. Based on these findings, we conclude that elbow arthroscopy is a relatively safe procedure. The risk factors examined in this study had no association with the rate of complications. This finding could be potentially related to type II or beta error in the analysis of risk factors for nerve injury. The exact reasons for nerve injury are not known from this study. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Decreased Time to Return to Work Using Robotic-Assisted Unicompartmental Knee Arthroplasty Compared to Conventional Techniques.

INTRODUCTION: Unicompartmental knee arthroplasty (UKA) is a commonly used procedure for patients suffering from debilitating unicompartmental knee arthritis. For UKA recipients, robotic-assisted surgery has served as an aid in improving surgical accuracy and precision. While studies exist detailing outcomes of robotic UKA, to our knowledge, there are no studies assessing time to return to work using robotic-assisted UKA. Thus, the purpose of this study was to prospectively assess the time to return to work and to achieve the level of work activity following robotic-assisted UKA to create recommendations for patients preoperatively. We hypothesized that the return to work time would be shorter for robotic-assisted UKAs compared with TKAs and manual UKAs, due to more accurate ligament balancing and precise implementation of the operative plan. MATERIALS AND METHODS: Thirty consecutive patients scheduled to undergo a robotic-assisted UKA at an academic teaching hospital were prospectively enrolled in the study. Inclusion criteria included employment at the time of surgery, with the intent on returning to the same occupation following surgery and having end-stage knee degenerative joint disease (DJD) limited to the medial compartment. Patients were contacted via email, letter, or phone at two, four, six, and 12 weeks following surgery until they returned to work. The Baecke physical activity questionnaire (BQ) was administered to assess patients' level of activity at work pre- and postoperatively. Statistical analysis was performed using SAS Enterprise Guide (SAS Institute Inc., Cary, North Carolina) and Excel® (Microsoft Corporation, Redmond, Washington). Descriptive statistics were calculated to assess the demographics of the patient population. Boxplots were generated using an Excel® spreadsheet to visualize the BQ scores and a two-tailed t-test was used to assess for differences between pre- and postoperative scores with alpha 0.05. RESULTS: The mean time to return to work was 6.4 weeks (SD=3.4, range 2-12 weeks), with a median time of six weeks. There was no difference seen in the mean pre- and postoperative BQ scores (2.70 vs. 2.69, respectively; p=0.87). CONCLUSION: The findings of the current study suggest that most patients can return to work six weeks following robotic-assisted UKA which appears to be shorter than conventional UKA and TKA. Future level I studies are needed to verify our study findings.

Editorial Commentary: Elbow Lateral Epicondylitis (Tennis Elbow) Surgery Works, but Is Not Often Indicated.

In the small percentage of patients who do not respond to nonoperative approaches to tennis elbow, surgery-whether it is open, arthroscopic, or percutaneous-provides near 90% satisfaction rates.

The Development of a Xenograft-Derived Scaffold for Tendon and Ligament Reconstruction Using a Decellularization and Oxidation Protocol.

PURPOSE: To evaluate the biological, immunological, and biomechanical properties of a scaffold derived by architectural modification of a fresh-frozen porcine patella tendon using a decellularization protocol that combines physical, chemical, and enzymatic modalities. METHODS: Porcine patellar tendons were processed using a decellularization and oxidation protocol that combines physical, chemical, and enzymatic modalities. Scaffolds (n = 88) were compared with native tendons (n = 70) using histologic, structural (scanning electron microscopy, porosimetry, and tensile testing), biochemical (mass spectrometry, peracetic acid reduction, DNA quantification, alpha-galactosidase [α-gal] content), as well as in vitro immunologic (cytocompatibility, cytokine induction) and in vivo immunologic nonhuman primate analyses. RESULTS: A decrease in cellularity based on histology and a significant decrease in DNA content were observed in the scaffolds compared with the native tendon (P < .001). Porosity and pore size were increased significantly (P < .001). Scaffolds were cytocompatible in vitro. There was no difference between native tendons and scaffolds when comparing ultimate tensile load, stiffness, and elastic modulus. The α-gal xenoantigen level was significantly lower in the decellularized scaffold group compared with fresh-frozen, nondecellularized tissue (P < .001). The in vivo immunological response to implanted scaffolds measured by tumor necrosis factor-α and interleukin-6 levels was significantly (P < .001) reduced compared with untreated controls in vitro. These results were confirmed by an attenuated response to scaffolds in vivo after implantation in a nonhuman primate model. CONCLUSIONS: Porcine tendon was processed via a method of decellularization and oxidation to produce a scaffold that possessed significantly less inflammatory potential than a native tendon, was biocompatible in vitro, of increased porosity, and with significantly reduced amounts of α-gal epitope while retaining tensile properties. CLINICAL RELEVANCE: Porcine-derived scaffolds may provide a readily available source of material for musculoskeletal reconstruction and repair while eliminating concerns regarding disease transmission and the morbidity of autologous harvest.

Obesity has no effect on outcomes following unicompartmental knee arthroplasty.

PURPOSE: Although obesity has historically been described as a contraindication to UKA, improved outcomes with modern UKA implant designs have challenged this perception. The purpose of this study was to assess the influence of obesity on the outcomes of UKA with a robotic-assisted system at a minimum follow-up of 24 months with the hypothesis that obesity has no effect on robotic-assisted UKA outcomes. METHODS: There were 746 medial robotic-assisted UKAs (672 patients) with a mean age of 64 years (SD 11) and a mean follow-up time of 34.6 months (SD 7.8). Mean overall body mass index (BMI) was 32.1 kg/m2 (SD 6.5), and patients were stratified into seven weight categories according to the World Health Organization classification. RESULTS: Patient BMI did not influence the rate of revision surgery to TKA (5.8 %) or conversion from InLay to OnLay design (1.7 %, n.s.). Mean postoperative Oxford knee score was 37 (SD 11) without correlation with BMI (n.s.). The type of prosthesis (InLay/OnLay) regardless of BMI had no influence on revision rate (n.s.). BMI did not influence 90-day readmissions (4.4 %, n.s.), but showed significant correlation with higher opioid medication requirements and a higher number of physical therapy session needed to reach discharge goals (p = 0.031). CONCLUSION: These findings suggest that BMI does not influence clinical outcomes and readmission rates of robotic-assisted UKA at mid-term. The classic contraindication of BMI >30 kg/m2 may not be justified with the use of modern UKA designs or techniques. LEVEL OF EVIDENCE: IV.

Shoulder Strength Requirements for Upper Limb Functional Tasks: Do Age and Rotator Cuff Tear Status Matter?

Understanding upper limb strength requirements for daily tasks is imperative for early detection of strength loss that may progress to disability due to age or rotator cuff tear. We quantified shoulder strength requirements for 5 upper limb tasks performed by 3 groups: uninjured young adults and older adults, and older adults with a degenerative supraspinatus tear prior to repair. Musculoskeletal models were developed for each group representing age, sex, and tear-related strength losses. Percentage of available strength used was quantified for the subset of tasks requiring the largest amount of shoulder strength. Significant differences in strength requirements existed across tasks: upward reach 105° required the largest average strength; axilla wash required the largest peak strength. However, there were limited differences across participant groups. Older adults with and without a tear used a larger percentage of their shoulder elevation (p < .001, p < .001) and external rotation (p < .001, p = .017) strength than the young adults, respectively. Presence of a tear significantly increased percentage of internal rotation strength compared to young (p < .001) and uninjured older adults (p = .008). Marked differences in strength demand across tasks indicate the need for evaluating a diversity of functional tasks to effectively detect early strength loss, which may lead to disability.

Assessments of Fatty Infiltration and Muscle Atrophy From a Single Magnetic Resonance Image Slice Are Not Predictive of 3-Dimensional Measurements.

PURPOSE: To (1) determine whether standard clinical muscle fatty infiltration and atrophy assessment techniques using a single image slice for patients with a rotator cuff tear (RCT) are correlated with 3-dimensional measures in older individuals (60+ years) and (2) to determine whether age-associated changes to muscle morphology and strength are compounded by an RCT. METHODS: Twenty older individuals were studied: 10 with an RCT of the supraspinatus (5 men and 5 women) and 10 matched controls. Clinical imaging assessments (Goutallier and Fuchs scores and cross-sectional area ratio) were performed for participants with RCTs. Three-dimensional measurements of rotator cuff muscle and fat tissues were obtained for all participants using magnetic resonance imaging (MRI). Isometric joint moment was measured at the shoulder. RESULTS: There were no significant associations between single-image assessments and 3-dimensional measurements of fatty infiltration for the supraspinatus and infraspinatus muscles. Compared with controls, participants with RCTs had significantly increased percentages of fatty infiltration for each rotator cuff muscle (all P ≤ .023); reduced whole muscle volume for the supraspinatus, infraspinatus, and subscapularis muscles (all P ≤ .038); and reduced fat-free muscle volume for the supraspinatus, infraspinatus, and subscapularis muscles (all P ≤ .027). Only the teres minor (P = .017) fatty infiltration volume was significantly greater for participants with RCTs. Adduction, flexion, and external rotation strength (all P ≤ .021) were significantly reduced for participants with RCTs, and muscle volume was a significant predictor of strength for all comparisons. CONCLUSIONS: Clinical scores using a single image slice do not represent 3-dimensional muscle measurements. Efficient methods are needed to more effectively capture 3-dimensional information for clinical applications. Participants with RCTs had increased fatty infiltration percentages that were likely driven by muscle atrophy rather than increased fat volume. The significant association of muscle volume with strength production suggests that treatments to preserve muscle volume should be pursued for older patients with RCTs. LEVEL OF EVIDENCE: Level II, diagnostic study, with development of diagnostic criteria on the basis of consecutive patients with universally applied reference gold standard.

Short-term outcomes of robotically assisted patello-femoral arthroplasty.

PURPOSE: The purpose of this study was to determine the outcomes in patients treated with robotically assisted patello-femoral arthroplasty (PFA). METHODS: This technique offers a safe, reliable, and reproducible way of obtaining correct implant positioning in patello-femoral arthroplasty, and as a result, reduces revision surgery due to implant malalignment. We evaluated 30 knees in 29 patients who underwent robotically assisted patello-femoral arthroplasty between June 2009 and May 2011. Mean follow-up was 15.9 months. This was a retrospective study that involved chart reviews and radiographic analysis. Radiographic analysis included pre-operative and postoperative plain films for implant positioning. Functional outcomes were evaluated using the Oxford Knee Score (OKS), range of motion, University of California at Los Angeles (UCLA) patient activity-level ratings, visual analog pain scale (VAS), and the Knee Society Score (KSS). RESULTS: The patients had an average OKS of 21.7 pre-operatively and reached an average of 33.5 postoperatively (p = 0.0033). Pre-operative UCLA patient activity-level ratings was 3.1, compared with 4.8 postoperatively. Average VAS pre-operatively was 8 and postoperatively it decreased to 2.1 (p = 0.0033). The average KSS final score pre-operatively was 56 and postoperatively it increased to 68.3 while the functional score pre-operatively was 47.2 compared to 68.1 postoperatively (p = 0.011). As a result, patello-femoral arthroplasty is an emerging knee resurfacing technique that is an alternative to the total knee arthroplasty. CONCLUSIONS: The early retrospective data for robotically-assisted PFA show encouraging results. Advantages of this technique include a smaller incision, faster rehabilitation, preservation of bone stock, and implantation without malalignment.

A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies.

INTRODUCTION: Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies. METHODS: One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment. RESULTS: The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005). CONCLUSIONS: Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.

Change is a Constant.

In 2015, Henry P. Hackett, Managing Editor, Arthroscopy, retires, and Edward A. Goss, Executive Director, Arthroscopy Association of North America (AANA), retires. Association is a positive constant, in a time of change. With change comes a need for continuing education, research, and sharing of ideas. While the quality of education at AANA and ISAKOS is superior and most relevant, the unique reason to travel and meet is the opportunity to interact with innovative colleagues. Personal interaction best stimulates new ideas to improve patient care, research, and teaching. Through our network, we best create innovation.

Assessment of accuracy of robotically assisted unicompartmental arthroplasty.

PURPOSE: The purpose of this study was to analyse the accuracy of component placement during unicompartmental knee arthroplasty (UKA) using a robotic-assisted system. METHODS: Two hundred and six patients (232 knees) who underwent medial robotic-assisted UKA were retrospectively studied. Femoral and tibial sagittal and coronal alignments were measured in the post-operative radiographs and were compared with the equivalent measurements collected during the intra-operative period by the robotic system. Mismatch between pre-planning and post-operative radiography was assessed against accuracy of the prosthesis insertion. RESULTS: Robotic-assisted surgery for medial UKA resulted in an average difference of 2.2° ± 1.7° to 3.6° ± 3.3° depending on the component and radiographic view between the intra-operatively planned and post-operative measurements. Mismatch between pre-planning and post-operative radiography (inaccuracy) was related to improper cementing technique of the prosthesis in all measurements (except for tibial sagittal axis) rather than wrong bony cuts performed by the robotic arm. CONCLUSION: Robotic-assisted medial UKA results in accurate prosthesis position. Inaccuracy may be attributed to suboptimal cementing technique.

Effect of arthritis in other compartment after unicompartmental arthroplasty.

The purpose of this study is to evaluate the outcome of robotic-assisted (MAKO Surgical Corp.) unicondylar replacement in the treatment for knee osteoarthritis after the initial surgical insult is worn off to evaluate the impact of residual patellofemoral and lateral osteoarthritis on the outcome of medial unicompartmental knee replacement. One hundred and thirty-four patients who underwent uncomplicated 144 robotic-assisted medial unicondylar replacements for knee arthritis were identified and studied. Original radiographs were used to classify severity of patellofemoral and lateral compartmental osteoarthritis in these patients. Severity of patellofemoral and lateral compartmental osteoarthritis was analyzed against Oxford and Knee Society scores and amount of ipsilateral residual knee symptoms at 6 months postoperative period. Preoperative Oxford and Knee Society scores, other comorbidities and long-term disability were studied as confounding variables. We found significant improvement in symptoms and scores in spite of other compartment diseases. Poorer outcome was seen in association with comorbidities and long-term disability but not when radiographic signs of arthritis in the other compartments were present. Six patients required revision of which three had (lateral facet) patellofemoral disease in the original X-rays. In conclusion, there is a higher amount of postoperative retained symptoms, but similar outcome when there is radiographic disease in the other compartments. However, when symptoms are severe enough to necessitate revision, this is due to the lateral facet of patellofemoral compartment and not lateral compartment disease.

Effect of cyclic strain on tensile properties of a naturally derived, decellularized tendon scaffold seeded with allogeneic tenocytes and associated messenger RNA expression.

Naturally derived tendon scaffolds have the potential to improve the treatment of flexor tendon injuries. Seeded and unseeded tendon scaffolds were maintained in the presence or absence of physiologic strain for 7 days. After 7 days, the tensile properties and associated messenger RNA expression were compared. Seeded scaffolds maintained in the absence of strain had significantly lower tensile properties than unseeded tendons and fresh-frozen tendons. The loss of tensile properties was associated with elevated matrix metalloproteinase-2 and collagen III expression. Tensile properties of seeded scaffolds maintained in the presence of strain for 7 days after seeding did not differ from those of fresh-frozen tendons. This study demonstrates that the tensile properties of seeded, naturally derived tendon scaffolds will degrade rapidly in the absence of cyclic strain. Seeded scaffolds used for tendon reconstruction should be maintained under cyclic strain to maintain essential tensile properties.

Favourable mid-term outcomes following unicompartmental knee arthroplasty with wider patient selection: A single-centre experience.

OBJECTIVE: The purpose of this study was to determine surgical outcomes of robotic-assisted UKAs utilizing a wider set of indications than traditionally utilized. Additionally, we seek to determine alternate predictive factors as potential surgical indications and contraindications. METHODS: A prospectively maintained institutional joint registry was queried at a single academic centre for all patients that underwent robotic-assisted UKA between January 2010-December 2016. Surgical indication included isolated medial or lateral compartment degenerative disease with a stable knee based on physical exam. In 2013, haemoglobin A1C levels over 7.5% were considered contraindications, which was lowered to 7.0% in 2015. Preoperative alignment, age, activity level and degree of pain were not contraindications for surgery. Preoperative demographics, Oxford scores, radiographic (joint space), comorbidities and operative data were collected and reviewed to determine factors related to conversion to TKA and survivorship of the primary implant. RESULTS: In total, 1878 cases were performed; however, excluding multi-joint knees, there were a total of 1186 knees in 1014 patients with a minimum 4-year follow-up. The mean age was 63.4 â€‹± â€‹10.7 years and mean follow-up was 76.4 â€‹± â€‹17.4 months. Mean BMI was 32.3 â€‹± â€‹6.5 â€‹kg/m2. (52.9% females, 47.1% males). There were 901 patients undergoing medial UKA, 122 patients undergoing lateral UKA and 69 patients undergoing patellofemoral UKA. In total, 85 (7.2%) knees underwent conversion to TKA. Preoperative factors such as the degree of preoperative valgus deformity (p â€‹= â€‹0.01), greater operative joint space (p â€‹= â€‹0.04), previous surgery (p â€‹= â€‹0.01), inlay implant (p â€‹= â€‹0.04) and pain syndrome (p â€‹= â€‹0.01) were associated with increased risk of revision surgery. Factors associated with decreased implant survivorship included patients with history of previous surgery (p â€‹< â€‹0.01), history of pain syndrome (p â€‹< â€‹0.01) and greater preoperative joint space (>2 â€‹mm) (p â€‹< â€‹0.01). There was no association of BMI to conversion to TKA. CONCLUSION: Robotic-assisted UKA with wider patient selection demonstrated favourable outcomes at 4 years with survivorship greater than 92%. The present series agree with emerging indications that do not exclude patients based on age, BMI, or degree of deformity. However, increased operative joint space, inlay design, history of surgery and coexistence of pain syndrome are factors that increase risk of conversion to TKA. LEVEL OF EVIDENCE: Level III.

History of Wrist Arthroscopy.

Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.

Use of intraoperative computed tomography scanning in determining the magnitude of arthroscopic osteochondroplasty.

Femoroacetabular impingement has recently become a recognized cause of disability and hip arthritis. Hip arthroscopy and femoroacetabular reshaping have been performed to treat this condition. Quantification of the excess femoral and acetabular bone requiring resection has been challenging with the less invasive arthroscopic technique. We describe the use of intraoperative computed tomography assessing osteochondroplasty during arthroscopic surgery to treat cam- and pincer-type femoroacetabular impingement. We also describe the technical steps and present the important radiologic findings we have been able to visualize. We found intraoperative computed tomography scanning to be a reliable and reproducible method of assessing the quality of femoroacetabular impingement surgery. We believe that femoroacetabular impingement surgery can be assessed intraoperatively by use of computed tomography scanning where corrections can be made if necessary.

Consensus statement on shoulder instability.

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patient's age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeon's preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.