Patterns of proximal humeral bone resorption after total shoulder arthroplasty with an uncemented rectangular stem.

BACKGROUND: The aim of this study was to assess the timing and location of cortical bone resorption after total shoulder arthroplasty with an uncemented rectangular stem and investigate its effect on shoulder function up to 5 years after implantation. METHODS: Between June 2003 and September 2006, 183 consecutive total shoulder arthroplasties were performed, 133 of which received a cementless rectangular stem as indicated by primary or post-traumatic osteoarthritis (OA). The 5-year postoperative follow-up rate was 80%. Standardized radiographic controls and clinical assessments were performed at 6 weeks, 6 months, and 1, 2, and 5 years. RESULTS: Twenty-two patients (17%) showed full-thickness cortical bone resorption, 21 of whom were diagnosed with Sperling zone 2 resorption. The maximum craniocaudal distance of full resorption averaged 19.1 mm (range, 5.6-46.7 mm). The median distance progressed significantly from 9.6 mm to 13.8 mm between 6 and 12 months (P = .005). The risk of bone resorption was 3.1 times higher for post-traumatic OA patients than for those with primary OA. The occurrence of bone resorption increased significantly with increasing stem diameters relative to the humeral diameter. There was no significant effect of bone resorption on functional outcome. CONCLUSION: Full-thickness cortical bone resorption in the proximal posterolateral humerus after receipt of a cementless rectangular stem has a prevalence of 17%, mostly occurring within the first year after surgery. Risk factors include age, post-traumatic conditions, and larger stem sizes relative to the humerus. This is a radiographic phenomenon without significant impairment of function or need for revision within 5 years after surgery.

Long-term survival of GSB III elbow prostheses and risk factors for revisions.

INTRODUCTION: Although replacement of the elbow joint is a complex procedure there is not much clinical evidence that contributes to surgical decision-making, mainly due to small clinical samples and short follow-up. Therefore, we performed a long-term analysis up to 30 years after implantation of a GSB III total elbow prosthesis to quantify long-term outcome and to identify possible risk factors for implant revision. MATERIALS AND METHODS: All patients who received a primary GSB III total elbow prosthesis between 1978 and 1998 were included. Information about patient characteristics, the latest known implant status and possible risk factors were collected, Kaplan-Meier survival curves plotted, and 10- and 20-year survival calculated. The cohort was stratified for known risk factors such as diagnosis, age, or gender and included in a Cox regression analysis. RESULTS: A total of 253 patients [mean age at operation 56.9 years (range from 17.5 to 84 years)] with 293 GSB III prostheses were included. The median follow-up was 9.1 years (0 months to 29.3 years). Whereas 81 prostheses did not need revision during the observation period, 76 had been implanted in patients who died before any revision was required, and 75 had not been revised by the last known follow-up. 61 prostheses were revised. This corresponds to a 10-year survival rate of 0.8 (95 % CI 0.74-0.85) and a 20-year rate of 0.67 (95 % CI 0.57-0.76). Prostheses in patients with post-traumatic conditions survived significantly shorter than those in patients with rheumatoid arthritis; previous operations lead to a 2.8 times greater risk of revision (p = 0.004). Neither age at implantation nor gender had a significant influence on prosthesis survival. CONCLUSIONS: The results indicate a good long-term prognosis for this design. The prognosis has to be adjusted for the underlying disease. Previous operations such as joint reconstruction significantly increase the risk of revision.

Treatment strategies for periprosthetic infections after primary elbow arthroplasty.

BACKGROUND: The goal of this study was to investigate the outcome of different surgical procedures (debridement and retention vs 1- or 2-stage exchange) together with a well-defined antimicrobial regimen. MATERIALS AND METHODS: A total of 236 consecutive patients underwent 262 primary elbow arthroplasties between January 1994 and December 2007. We observed 20 episodes of periprosthetic infections in 19 patients and placed them into 3 groups according to the occurrence of infection after index surgery. A total of 9 early infections (<3 months), 1 delayed infection (3-24 months), and 10 late infections (>24 months) were observed. The treatment among those 3 groups was compared, and the outcome was assessed with a mean follow-up of 60.2 months. RESULTS: In the group with early infections (n = 9), 8 cases were treated by irrigation and debridement and 1 case was treated by a 2-stage exchange without recurrence of infection. The mean Mayo Elbow Performance Score improved from 48.3 points (range, 30-75 points) to 91.7 points (range, 85-100 points). The delayed infection was treated by 1-stage exchange without recurrence of infection. For late infections (n = 10), 3 cases presented recurrence of infection after debridement and irrigation, and the mean Mayo Elbow Performance Score remained nearly unchanged, from 60 points (range, 45-80 points) to 65 points (range, 50-80 points). Eradication of infection could be achieved by staged revision and in 3 cases by debridement. CONCLUSION: Both debridement with retention and staged reimplantation are highly successful for appropriate indications. Staged revisions are successful even against biofilm-active microorganisms, but a prosthesis-free interval of at least 3 months is recommended.

Packaging--a problem for patients with hand disorders? A cross-sectional study on the forces applied to packaging tear tabs.

INTRODUCTION: Patients with hand disorders frequently experience difficulties opening peelable packaging. PURPOSE: To investigate the forces patients can apply to tear tabs and to compare the results with normative data to make recommendations for the industry and clinical practice. STUDY DESIGN: Descriptive, cross-sectional. METHODS: One hundred patients with hand disorders were studied. The pinch pull force (PPF) applied to tear tabs of different lengths and materials (aluminum, plastic) was measured with a specially designed device. Key pinch was measured with a pinch gauge. Normative data were taken from another study on 402 healthy adults. RESULTS: Patients were able to apply most force to the longest aluminum tab, using the key grip, but this was only 53% of the force exerted by healthy people. Key pinch determines PPF (R(2)=0.548, p≤0.001). CONCLUSIONS: Manufacturers should provide long aluminum tear tabs. Health professionals are encouraged to measure key pinch to detect difficulties in opening packages. LEVEL OF EVIDENCE: Level IV.

Reverse shoulder arthroplasty as a salvage procedure for failed conventional shoulder replacement due to cuff failure--midterm results.

Our goal was to evaluate the objective and subjective midterm outcome after revision of a failed shoulder arthroplasty with a reverse design prosthesis. Twenty consecutive patients with 21 revisions of a primary shoulder arthroplasty using reverse shoulder prosthesis Delta III(®) were followed up postoperatively for a mean of 46 months including clinical and radiological examination. Complications were recorded and Constant score, DASH and SF36 were assessed. With the numbers given a significant reduction of pain was achieved from 8.7 to 3.0 (p < 0.001). There was a significant improvement of active flexion from 43° to 97° (p < 0.001) and active abduction from 44° to 90° (p < 0.001). However, at the same time, active external rotation with an adducted humerus decreased significantly from 26° to 12° (p = 0.012). The constant score improved significantly from 16.7 to 55.9 (p < 0.001). Sixteen patients (84%) rated their shoulder better or much better than before. In 43% an intraoperative and in 38% a postoperative complication occurred including two late stage infections which required prosthesis removal. Our results support the use of the reverse prosthesis as revision prosthesis. The reverse design helps to compensate functional deficits due to severe soft-tissue damage except active external rotation. Nevertheless, the revision is a technically demanding procedure reflected in a high rate of intraoperative complications. The rate of secondary infections of 10% remains a special concern.

Determinants of patient satisfaction after orthopedic interventions to the hand: a review of the literature.

UNLABELLED: Treatment effectiveness is increasingly evaluated from the patients' perspective. However, the interpretation of satisfaction is complex because the patient's perception of a satisfactory outcome is influenced by numerous factors. The objective of this study was to identify which factors are associated with patient satisfaction after orthopedic interventions to the hand. A literature review was conducted, including studies on determinants of satisfaction with treatment outcome or unspecified overall satisfaction of patients with hand problems. The results indicate that patient satisfaction is determined by multiple factors. There is moderate evidence that pain/symptoms, activities of daily living/function, aesthetics, and embodiment influence patient satisfaction. Furthermore, data indicate a correlation of strength, range of motion, fulfillment of expectations, deformity, workers' compensation, and length of follow-up with satisfaction. Knowledge about these determinants may lead to a more detailed decision-making process, thus contributing to improved treatment outcomes and cost-effectiveness. LEVEL OF EVIDENCE: V.

Prediction of grip and key pinch strength in 978 healthy subjects.

BACKGROUND: Hand strength is an important independent surrogate parameter to assess outcome and risk of morbidity and mortality. This study aimed to determine the predictive power of cofactors and to predict population-based normative grip and pinch strength. METHODS: A representative population survey was used as the basis for prediction analyses (n = 978). Bivariate relationships between grip/pinch strengths of the dominate hand were explored by means of all relevant mathematical functions to maximize prediction. The resulting best functions were combined into a multivariate regression. RESULTS: Polynoms (up to the third degree) were the best predictive functions. On the bivariate level, height was best correlated to grip (46.2% explained variance) and pinch strength (37.7% explained variance) in a linear relationship, followed by sex, age, weight, and occupational demand on the hand. Multivariate regression provided predicted values close to the empirical ones explaining 76.6% of the variance for grip strength and 67.7% for pinch strength. CONCLUSION: The five easy-to-measure cofactors sex, age, body height, categorized occupational demand on the hand, and body weight provide a highly accurate prediction of normative grip and pinch strength.

Deltoid flap reconstruction for massive rotator cuff tears: mid- and long-term functional and structural results.

BACKGROUND: Various open and arthroscopic techniques for irreparable massive rotator cuff tears have been described. Muscle-tendon transfers may be considered in order to improve range of motion and strength. MATERIALS AND METHODS: We assessed retrospectively the functional and structural results of 31 deltoid flap transfers for massive postero-superior rotator cuff tears at 2 time points: Mid- and long-term follow-up exams were performed after a mean of 53 and 175 months, respectively. RESULTS: Functional gains were minor, but improvement in pain and patient satisfaction was high. The mean Constant score improved from 31 preoperatively to 46 points at mid-term follow-up. At long-term follow-up, 16 shoulders were still available for exam and presented with a mean Constant score of 66 points. Survival rates of the deltoid flap, confirmed by ultrasound, were 16.5% at mid-term and 12.5% at long-term follow-up, and correlated with better clinical outcome. Cranial migration of the humeral head progressed in all cases and could not be prevented by the interposition of a deltoid flap. CONCLUSION: Based on the results of this series, we no longer use nor recommend this technique.

Extended overview of the longitudinal pain-depression association: A comparison of six cohorts treated for specific chronic pain conditions.

BACKGROUND: The aim was to quantify and to compare the associations between longitudinal changes in pain and depression in different chronic pain conditions. METHODS: Data were retrieved from 6 observational cohort studies. From baseline to the 6-month follow-up, the score changes on the Short Form (36) Health Survey (SF-36) bodily pain (pain) and the SF-36 mental health (depression) scales (0=worst, 100=best) were quantified, using partial correlations obtained by multiple regression. Adjustment was performed by age, living alone/with partner, education level, number of comorbidities, baseline pain and baseline depression. RESULTS: Stronger associations were found between changes in levels of pain and depression for neck pain after whiplash (n = 103, mean baseline pain=21.4, mean baseline depression=52.5, adjusted correlation r = 0.515), knee osteoarthritis (n = 177, 25.4, 64.2, r = 0.502), low back pain (n = 134, 19.0, 49.4, r = 0.495), and fibromyalgia (n = 125, 16.8, 43.2, r = 0.467) than for lower limb lipedema (n = 68, 40.2, 62.6, r = 0.452) and shoulder arthroplasty (n = 153, 35.0, 76.4, r = 0.292). Those correlations were somewhat correlated to baseline pain (rank r=-0.429) and baseline depression (rank r=-0.314). LIMITATIONS: The construct of the full range of depressive symptoms is not explicitly covered by the SF-36. CONCLUSIONS: Moderate associations between changes in pain and depression levels were demonstrated across 5 of 6 different chronic pain conditions. The worse the pain and depression scores at baseline, the stronger those associations tended to be. Both findings indicate a certain dose-response relationship - an important characteristic of causal interference. Relieving pain by treatment may lead to the relief of depression and vice versa.

How sharp is the short QuickDASH? A refined content and validity analysis of the short form of the disabilities of the shoulder, arm and hand questionnaire in the strata of symptoms and function and specific joint conditions.

PURPOSE: To assess and compare content, validity, and specificity of the QuickDASH (Disability of the arm, shoulder and hand questionnaire) as compared to the full-length DASH and other instruments to give a recommendation for its use depending on a specific clinical situation. METHODS: Data of three large cohorts of patients with shoulder (n = 138), elbow (n = 79), and carpo-metacarpal I (n = 103) arthroplasties were analyzed. The item content of both instruments was compared within the subdomains function and symptoms. Scores and correlations to other instruments were compared in all strata to assess construct convergence. Specificity was quantified and compared using receiver operating characteristics curves (ROC) and effect sizes (in shoulder only). RESULTS: The QuickDASH underestimates symptoms (e.g., 71.1 vs. DASH 66.1 in elbow, 100 = no symptoms, P < 0.001) but overestimates disability (e.g., 72.8 vs. DASH 78.5 in wrist, 100 = full function, P < 0.001). It does not measure the same content as the DASH although the total score levels of both instruments are similar. Furthermore, the QuickDASH is less specific than the DASH in the subdomains, especially in symptoms: for example, area under ROC 0.65 vs. DASH 0.68 in elbow (P = 0.015); effect size in shoulder 1.42 vs. DASH 1.65 (P < 0.001). CONCLUSION: The short QuickDASH can be recommended for a summary assessment of arm symptoms and function based on the total score in the daily clinical rush. For differentiated assessment of symptoms and function, e.g. for clinical studies, the full-length DASH provides more specific and sophisticated results.

A concept for comprehensively measuring health, function and quality of life following orthopaedic interventions of the upper extremity.

The view that subjective complaints rather than "objective" measurements decide on whether to consult the doctor or allow for an intervention to be carried out, should contribute to the decision-making process. This is especially true in diseases with multiple joint impairments. Although a variety of patient self-assessment scores exists, no gold standard is available to measure function and quality of life (QoL) after interventions at the upper extremity. The goal of our concept is to establish a comprehensive score set where patients should rate their generic health resp. quality of life (QoL), function of the upper extremity and specific joint function including activities of daily living, function and pain. A comparison with normative data should be possible in order to estimate how the subjective results of the patient when compared to "healthy" people in the general population. Score sets for measuring intervention effect at the shoulder, elbow and the hand were established after previous methodological testing within an interdisciplinary research project. The provisional sets were defined following a systematic literature search. Each set received a score of measuring the quality of life (SF-36), the whole function of the arm (DASH) and the specific joint function (SPADI/ASES for shoulder, PREE/mASES for the elbow and PRWE/custom for the hand). Individual scores were translated, if necessary according to AAOS-guidelines, and tested for reliability and construct validity. All three score sets were then systematically tested in cross-sectional studies. In addition, characteristic values such as minimal detectable difference and effect size could already be determined in the shoulder set in a long-term study. Definite score sets were defined, which allow quantification of the intervention effect at the upper extremity on function and quality of life after.

[In situ assembly of a modular noncemented total shoulder prosthesis for the reconstruction of complex joint pathology]. / In-situ-Montage einer modularen, nichtzementierten Schulterprothese zur Wiederherstellung komplexer Schulteranatomie.

OBJECTIVE: Exact restoration of the glenohumeral joint, especially in the case of complex pathologies, due to high prosthesis modularity and in situ assembly; later conversion to inverse design with same shaft possible. INDICATIONS: Primary shoulder osteoarthritis, secondary joint destruction after previous fracture or its treatment, humeral head necrosis, or inflammatory processes, revisions of defect situations such as hemiprostheses. CONTRAINDICATIONS: General contraindications of total shoulder arthroplasty, additionally, functional loss of the rotator cuff, advanced osteoporosis, narrow medullary canal, e.g., in patients with juvenile rheumatoid arthritis. SURGICAL TECHNIQUE: After deltopectoral approach free resection of the humeral head along landmarks, stepwise rasping of the humeral medullary canal, insertion of the rectangled stem, realignment of humeral height with the body, realignment of inclination and possible retroversion with the inclination set. The asymmetric head ensures exact restoration of the joint center. Implantation of the cemented glenoid, test of range of motion and soft-tissue tension, and exchange of components in situ, if necessary. RESULTS: A prospective evaluation of the first 146 consecutive patients with 1-year follow-up revealed significant improvements of about 151% regarding pain and of about 98% in function without significant differences between different indications. Four shaft fissures were observed and treated with intraoperative cerclages during the learning period. No further fissures were noted after adaptation of the surgical procedure and subsequent guidelines. One traumatic and one atraumatic head rotation were observed but should be prevented with a new torque wrench. Similar functional results can be achieved even in complex shoulder pathologies due to the high modularity of the prosthesis.

Arthroscopic and open options for surgical treatment of chondromatosis of the elbow.

PURPOSE: The purpose of this study was to evaluate the treatment-specific outcome of surgical therapy of chondromatosis of the elbow with special attention on the complication and recurrence rate as well as induction of secondary osteoarthritis. METHODS: A consecutive patient group from 1989 to 2003 was evaluated retrospectively and followed up clinically and radiologically. Special attention was paid to locking and catching, swelling, pain, loose bodies, and signs of osteoarthritis. In the case of a causal pathology, mostly osteoarthritis, the condition was classified as secondary; otherwise, it was classified as primary. The following scores were calculated: modified American Shoulder and Elbow Surgeons questionnaire for elbows; Disabilities of the Arm, Shoulder and Hand questionnaire; and Short Form 36. RESULTS: Of 24 patients operated on, 19 (79%) were followed up after 56 months (range, 11 to 177 months). Of these, 10 were primary types and 9 secondary types. The extension deficit of 12 degrees preoperatively decreased to -9 degrees , and pain was significantly (P = .001) reduced. Postoperatively, 1 patient still reported occasional locking and 1 patient had swelling. In both patients no loose bodies could be identified by radiography. Comparison of the arthroscopic and open techniques showed a trend toward a shorter rehabilitation time of 2.4 months after arthroscopic intervention, in contrast to 4.6 months for an open procedure, and a trend toward higher patient satisfaction after arthroscopy. Comparison of the primary and secondary forms showed significantly (P = .042) better pain reduction for primary chondromatosis. Of the patients with distinct preoperative osteoarthritis, 44% showed ongoing osteophytic growth; there were no cases of new osteoarthritis. CONCLUSIONS: Both open and arthroscopic approaches give satisfactory results with a trend toward shorter rehabilitation and higher patient satisfaction for the arthroscopic approach. Osteoarthritis is not induced and there is no danger of recurrence in the medium term. LEVEL OF EVIDENCE: Level III, therapeutic, retrospective comparative study.

Lessons learned during the cross-cultural adaptation of the American Shoulder and Elbow Surgeons shoulder form into German.

Cross-cultural adaptation and testing of reliability and validity were performed by use of a sample of 118 patients after shoulder arthroplasty. They completed a questionnaire booklet containing the American Shoulder and Elbow Surgeons (ASES) questionnaire, Shoulder Pain and Disability Index (SPADI), Short Form 36, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 1 week later, they completed the ASES questionnaire again. The cross-cultural adaptation procedure revealed no major problems. The intraclass correlation coefficients (ICCs) for the subscales for pain and function and for the total score were very high (>0.84); the ICC for the subscale instability was unacceptably low. Function of the contralateral side was consistently better for all items (P < .01). Reliability for both function scales was similar (ICC >0). The ASES scores showed moderate correlation of 0.57 to 0.67 with the various scales of the SF-36 and higher correlation with the DASH (0.84) and SPADI (0.92). The German ASES showed good reliability and validity and can be used for shoulder-specific patient self-assessment in comparison to the contralateral (unaffected) side and provides additional information to objective parameters. The instability domain does not provide any additional clinical information.

Usefulness of concomitant biceps tenodesis in total shoulder arthroplasty: a prospective cohort study.

The purpose of this report is to assess the association of concomitant biceps tenodesis in total shoulder arthroplasty with treatment success 1 year after total shoulder arthroplasty. Of 136 consecutive shoulders (124 patients) undergoing primary total shoulder arthroplasty between 2003 and 2006, 54 (39.7%) underwent biceps tenodesis. For each patient, we obtained potential preoperative confounding data, such as age; gender; presence of rheumatoid arthritis; Short Form 36; number of previous shoulder operations; Disabilities of the Arm, Shoulder and Hand score; Shoulder Pain and Disability Index score; and insurance status. At the 1-year follow-up, we calculated the Constant score of all patients (ranging from 0 [worst] to 100 [best]). We first determined the crude association of concomitant biceps tenodesis with 1-year treatment success (Constant score > or =80) and then fitted a multivariate model correcting for potential confounders to assess the adjusted association of the biceps tenodesis on treatment success. The total number of treatment successes was 46 of 136 shoulders (33.8% of all prosthesis implantations). The crude association (odds ratio) of a concomitant biceps tenodesis with treatment success was 2.38 (95% confidence interval [CI] 1.15 to 4.93; P = .02). When adjusting for potential confounders, we found that this association slightly increased to 2.97 (95% CI 1.00 to 8.85; P = .05). Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty.

Surgery Insight: orthopedic treatment options in rheumatoid arthritis.

Longstanding rheumatoid arthritis (RA) leads to disability, caused mainly by joint destruction. The current goals of surgical intervention are to restore function and quality of life, prevent joint deterioration, relieve pain, and correct deformity. A number of different surgical treatment options are available to patients with RA, including synovectomy, arthrodesis, joint replacement, and soft tissue and special hand surgery; nonoperative management is also important. Decision-making and timing for orthopedic intervention are complex issues because of polyarticular involvement. Functional impairment, pain, and the subsequent loss of quality of life and inability to work have become the main considerations for surgical reconstruction. Early referral for orthopedic treatment can lead to improved functional benefit for patients with RA. The decision for orthopedic intervention should be established by an interdisciplinary team that includes rheumatologists and orthopedic surgeons experienced in the surgery of RA. Priority should be given to the joint that causes the greatest disability and pain. Disease progression and pharmaceutical treatment options should be taken into consideration when establishing an orthopedic intervention protocol.

Does Weber's rotation osteotomy induce degenerative joint disease at the shoulder in the long term?

Weber's internal rotation osteotomy of the humeral head is recommended for the treatment of anteroinferior shoulder instability with a large Hill-Sachs defect. The observation of severe joint degeneration in the course of long-term follow-up provided the motivation for this study. An osteotomy was performed in 42 patients from 1984 to 1990. Thirty-four patients were available for clinical and radiological follow-up after 14.5 years. Our own CT-based classification was applied to categorize the degree of osteoarthritis. A shoulder prosthesis was implanted in 9 patients (26%). Only 3 patients (9%) did not show any signs of degeneration. A statistically significant relationship was found between increased internal rotation of the humeral head and disease severity (P = .03). A lower incidence of joint degeneration (P = .02) was found for patients with generalized ligamentous laxity. We therefore recommend this osteotomy only as a salvage procedure whereby the internal rotation of the humeral head should not exceed 20 degrees .

Evaluation of wrist and hand handicap and postoperative outcome in rheumatoid arthritis.

Functional instruments in rheumatology should use standardized procedures and should be quantifiable, valid, reliable, and responsive/sensitive to change. For most assessment tools, these aspects have been considered and tested. One of the most important questions in assessing hand involvement in patients with RA is what the single assessment should be used for. There could be a substantial difference should hand assessment be done in a routine way in a hand practice or should it be performed within scientific studies on disease progression or the effect of operative interventions. Among other points, answering this question has a significant impact on the time the patient has to spend with the tests and on the time the hand therapist or hand surgeon is involved with it. In addition to aspects such as accuracy, reliability, and validity, therefore, in some evaluation tools the time needed to perform the clinical examination and assessment of hand function has also been considered to be of importance. In addition, it has to be considered that description of the anatomic status, measurements of impairment, and assessment of disability cannot simply be replaced by each other, and even measurements of single aspects often are not sufficient. It has been stated, therefore, that the combination of different discrete hand-function assessment methods provides a more complete picture of hand ability. Moreover, although better responsiveness of disability outcome measures over impairment measures has been demonstrated previously (eg, in patients treated for Colle fracture), the relationship between disability and impairment measures is not clearly established. Although some studies reported significant correlations between impairment and disability tests, other studies showed only poor or moderate correlations between disability scores, impairment, and disease activity measures when rheumatoid hands were assessed. It has been concluded that the relationship between impairment and disability is not straightforward. The new ICF-model addresses these two levels of health-related quality of life by different concepts of assessment. Because impairment reflects the consequences of the disease at the organ level, whereas disability reflects the consequences of the disease for functional performance and activity, for comprehensive assessment of hand handicap, measurement of disability is more comprehensive and closer to the patient's needs for performing ADLs.

Responsiveness of five outcome measurement instruments in total elbow arthroplasty.

OBJECTIVE: To quantify and compare the sensitivity to change of 5 outcome instruments for the elbow joint. METHODS: In a prospective cohort study (n = 65), outcome was measured by the Short Form 36 (SF-36), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), the modified American Shoulder and Elbow Surgeons questionnaire for the elbow, patient part (pmASES) and examiner/clinical part (cmASES), and the Patient-Rated Elbow Evaluation form (PREE). Responsiveness was quantified by the effect size (ES) and standardized response mean (SRM) before and 6 months after total elbow arthroplasty. Receiver operating characteristic (ROC) curves were used to determine the instruments' ability to classify effects into global health change assessment categories. RESULTS: For the total scores, the ES were 1.50 for the PREE, 1.32 for the pmASES, 0.86 for the cmASES, 0.56 for the DASH, and 0.11 for the SF-36 (P ≤ 0.002 for all differences, except the cmASES and DASH). The same order was found within the subdomains of pain/symptoms and function and remained consistent when using the SRM and in ROC curve analysis. PREE total (area under the ROC curve 0.68), DASH function, and pmASES total and pain (area under the ROC curve range 0.64-0.67) discriminated best between "much better" and the other categories. CONCLUSION: The PREE was the most responsive instrument and can be recommended for every set of measures for elbow joint disorders. The pmASES was slightly less responsive but is a valid alternative. The examiner-assessed cmASES is affected by concerns regarding validity and was relatively less responsive. The DASH for comprehensive measurement of the entire upper extremity and the SF-36 for chronic pain conditions complete the assessment set.