High variability in what is considered important to report following instability surgery: a Delphi study among Dutch shoulder specialists.

Background: Standardized reporting leads to high-quality data and can reduce administration time. The aim of this study was to (1) get an insight into the variability of what is considered important to report in the surgical report following shoulder instability surgery and (2) determine which elements should be included in the surgical report following shoulder instability surgery according to Dutch surgeons using a Delphi method. Methods: Dutch orthopedic shoulder surgeons were included in a panel for a Delphi study consisting of 3 rounds. Importance of the elements was rated on a 9-point Likert scale. High variability was defined as an element that received at least 1 score between 1 and 3 and 1 score between 7 and 9 in round 3. Consensus was defined as ≥80% of the panel giving a score of 7 or more. Results: Seventeen shoulder specialists completed all 3 rounds and identified a total of 82 elements for the arthroscopic Bankart repair and 60 for the open Latarjet. High variability was observed in 57 (70%) and 52 (87%) of the elements, respectively. After round 3, the panel reached consensus on 27 and 11 elements that should be mentioned in the surgical report following arthroscopic Bankart repair and open Latarjet. Conclusion: There is high variability in what shoulder specialists regard essential to report. Consensus was reached on 27 and 11 elements to be reported following arthroscopic Bankart repair and open Latarjet, respectively. Future studies on an international scale can further improve data collection and communication between specialists.

Interobserver agreement for detecting Hill-Sachs lesions on magnetic resonance imaging.

BACKGROUND: Our aim is to determine the interobserver reliability for surgeons to detect Hill-Sachs lesions on magnetic resonance imaging (MRI), the certainty of judgement, and the effects of surgeon characteristics on agreement. METHODS: Twenty-nine patients with Hill-Sachs lesions or other lesions with a similar appearance on MRIs were presented to 20 surgeons without any patient characteristics. The surgeons answered questions on the presence of Hill-Sachs lesions and the certainty of diagnosis. Interobserver agreement was assessed using the Fleiss' kappa (κ) and percentage of agreement. Agreement between surgeons was compared using a technique similar to the pairwise t-test for means, based on large-sample linear approximation of Fleiss' kappa, with Bonferroni correction. RESULTS: The agreement between surgeons in detecting Hill-Sachs lesions on MRI was fair (69% agreement; κ, 0.304; p<0.001). In 84% of the cases, surgeons were certain or highly certain about the presence of a Hill-Sachs lesion. CONCLUSIONS: Although surgeons reported high levels of certainty for their ability to detect Hill-Sachs lesions, there was only a fair amount of agreement between surgeons in detecting Hill-Sachs lesions on MRI. This indicates that clear criteria for defining Hill-Sachs lesions are lacking, which hampers accurate diagnosis and can compromise treatment.

Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients.

BACKGROUND: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. METHODS: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. RESULTS: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €-1969, 95%CI= -3680 to -939) and third (mean difference €-2298, 95%CI= -4092 to -1288) compared to the first dislocation. CONCLUSIONS: Nonoperative treatment of shoulder instability has substantial societal costs. LEVEL OF EVIDENCE: III, economic analysis.

[A woman with shoulder pain after surgery abroad]. / Een vrouw met schouderpijn na operatie in buitenland.

A 58-year-old woman came to the outpatient clinic with exacerbation of chronic shoulder pain following a shoulder accident two week before. After the accident, she had been treated abroad with percutaneous K-wire fixation following the diagnosis of a displaced greater tuberosity fracture. X-ray images of the shoulder, however, showed calcification of the supraspinatus tendon fixed to the humerus, rather than a greater tuberosity fracture. After removal of the K-wires, the patient made a good recovery.

Does bone cement influence soft tissue balancing in total knee arthroplasty?

BACKGROUND: Soft tissue tension significantly affects the function of total knee arthroplasties. This study aims to evaluate if there is a difference in soft tissue tension, comparing trails to cemented definitive components in TKA. METHODS: We prospectively compared femorotibial compartment pressures before and after cement fixation of the components in 40 primary TKA. Femorotibial pressures were measured in the medial and lateral compartment with the knee in 10°, 45°, and 90° of flexion (six measurements per TKA), and the difference in pressure between both compartments was calculated in the three positions. RESULTS: The median femorotibial pressures were not significantly different following cement fixation. There was, however, a change in the difference between medial and lateral compartment pressures after cement fixation. The difference between both compartment pressures decreases after cement fixation. This difference is statistically significant only with the knee in 10° of flexion; mean (IQR) pressures change from 8.5 (five to 14) pounds to six (2.25-10) pounds (P = 0.01). CONCLUSION: Compartment pressures in TKA do not significantly change after cement fixation. The number of TKA that qualifies as 'balanced' increases after cement fixation, predominantly because the differences between the medial and lateral compartment pressures decrease.

An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score.

BACKGROUND: The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability. METHODS: A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors. RESULTS: We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors. CONCLUSIONS: RCTs reporting on shoulder instability surgery are well performed but poorly reported.

The Reliability of Sensor-Assisted Soft Tissue Measurements in Primary Total Knee Arthroplasty.

BACKGROUND: In pursuit to improve soft tissue balancing in total knee arthroplasties (TKAs), a wireless device was introduced to assess femorotibial pressures. The aim of this study was to evaluate the reliability of this device. METHODS: After 33 TKAs were balanced by conventional techniques, contact pressures were measured using a wireless sensor 3 times in a row; twice while the examiner was blinded for the result (n = 29); and once while the examiner was able to see the result as visual feedback (n = 32). Femorotibial pressures were measured in the medial and lateral compartments with the knee in 10°, 45°, and 90° of flexion (6 measurements per TKA). Furthermore, both the combined pressure and the difference in pressure between the compartments was calculated throughout the 3 positions (together another 6 measurements per TKA). RESULTS: The intraclass correlation coefficient between the blind measurements was poor in 2 of the 12 (17%), moderate in 4 of 12 (33%), and good in 6 of 12 (50%) measurements. The intraclass correlation coefficient between the blind and observing measurement was poor in 2 of the 12 (17%), moderate in 6 of 12 (50%), and good in 4 of 12 (33%) measurements. Especially measurements in 10° of flexion are associated with poorer reliability. CONCLUSION: The wireless sensor has a moderate to good reliability in 83% of the measurements.

Are collision athletes at a higher risk of re-dislocation after an open Bristow-Latarjet procedure? A systematic review and meta-analysis.

BACKGROUND: The primary aim of the present study was to review, summarize and compare the redislocation risk for collision athletes and noncollision athletes after an open Bristow-Latarjet procedure. Our secondary aim was to summarize return to sport, satisfaction, pain and complications. METHODS: We conducted a systematic review in PubMed and EMBASE of articles until 1 July 2016. We included all studies describing Bristow-Latarjet like procedures as a result of glenohumeral instability, mentioning redislocation rates in collision athletes with >2 years of follow-up. We pooled the data using random-effects meta-analysis for redislocation risk-differences (RD) between collision and noncollision athletes, and assessed heterogeneity with I2 and Tau2 tests. RESULTS: From 475 titles and abstracts, 11 studies were included and eight studies were meta-analyzed. The pooled RD to develop a postoperative redislocation between collision athletes and noncollision athletes was -0.00 (95% confidence interval: -0.03 to 0.03, p = 0.370). Return to sports rates were high (67-100%), and patients reported high satisfaction scores (93-100% satisfied) and low pain scores (mean visual analogue scale score of 1.6); however, postoperative complication rates varied from 0.8% to 19.2%. CONCLUSIONS: Collision athletes are not more at risk for redislocation rates after an open Bristow-Latarjet procedure compared to noncollision athletes. Overall postoperative outcomes were good, although numerous complications occurred.

The Responsiveness and Minimal Important Change of the Western Ontario Shoulder Instability Index and Oxford Shoulder Instability Score.

Study Design Prospective cohort study. Background Patient-reported outcome measurements (PROMs) are widely used to evaluate functional limitations. Considering PROMs for shoulder instability, information is lacking with regard to what constitutes a relevant change from baseline scores. Objectives To evaluate the responsiveness of the Western Ontario Shoulder Instability Index (WOSI) and the Oxford Shoulder Instability Score (OSIS) and estimate their minimal important change (MIC). Methods One hundred five consecutive patients with shoulder instability completed 5 PROMs at baseline and at 6-month follow-up. The PROMs included the WOSI and OSIS, the Simple Shoulder Test, the Oxford Shoulder Score, and the Disabilities of the Arm, Shoulder and Hand assessment. Patients also rated their functional change on an anchor question at follow-up. Responsiveness was evaluated by testing 9 hypotheses regarding predefined correlations between the changes in PROM scores, by calculating the area under the receiver operating characteristic curve and by calculating the standardized response mean and effect size statistics. The MIC was determined by identifying the optimal cutoff on the receiver operating characteristic curve. Results Seven out of 9 hypotheses (78%) were confirmed; as expected, a high correlation (0.77) was found between change scores of the WOSI and OSIS, whereas the correlations of the change scores of the WOSI and OSIS with those of general shoulder PROMs were slightly lower (0.61-0.75). The area under the curve was 0.83 (95% confidence interval: 0.75, 0.91) for the OSIS and 0.82 (95% confidence interval: 0.74, 0.90) for the WOSI. The MIC was about 6 points for the OSIS and about 14 points for the WOSI. Conclusion Both the WOSI and OSIS are able to measure change in shoulder function in patients with shoulder instability. The estimated MIC is 6 points for the OSIS (on a scale from 0 to 48) and 14 points for the WOSI (on a scale from 0 to 100). J Orthop Sports Phys Ther 2017;47(6):402-410. doi:10.2519/jospt.2017.6548.

Redislocation risk after an arthroscopic Bankart procedure in collision athletes: a systematic review.

BACKGROUND: The purpose of this review was to determine the redislocation risk for collision athletes after an arthroscopic Bankart repair and to compare the redislocation rate between collision athletes and noncollision athletes after an arthroscopic Bankart repair. METHODS: A PubMed and Embase query was performed, screening all relevant literature of arthroscopic Bankart procedures mentioning redislocation rates in collision athletes. Studies with a follow-up <2 years or lacking information on redislocation rates in collision athletes were excluded. We used the modified Coleman Methodology Score to assess the quality of included studies. Finally, the data in all the studies were combined and analyzed. RESULTS: There were 1012 studies screened on title and abstract, of which 111 studies were full-text screened, and finally 20 studies were included. Four studies reported on collision athletes only, whereas 16 compared collision with noncollision athletes. Fourteen studies reported increased redislocation rates for collision athletes in comparison to noncollision athletes (absolute risk difference varying from 0.4% to 28.6%), whereas 2 studies reported decreased rates (absolute risk differences of -6% and -2.4%). A combined analysis revealed that collision athletes have an increased absolute risk of 8.09 with 95% CI from 3.61 to 12.57% for development of postoperative instability in comparison to noncollision athletes (P = .001). CONCLUSION: Collision athletes have an increased risk for redislocation in comparison to noncollision athletes after an arthroscopic Bankart repair, although there were no differences in return to sport.

Surgical Versus Nonoperative Treatment in Patients Up to 18 Years Old With Traumatic Shoulder Instability: A Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: To compare the outcome of surgical and nonoperative treatment in patients aged 18 years or younger with traumatic shoulder instability. METHODS: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A complete search of PubMed, Medline, Cochrane, CINAHL, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "instability," "glenohumeral instability," "pediatric," "adolescent," "skeletally immature," "young," "open physis," "children," "management," "treatment," "surgical," "stabilization," and "recurrence." There was no time restriction. RESULTS: Fifteen articles met our inclusion criteria, including a total of 693 patients with 705 shoulders aged 18 years or younger. Of 411 shoulders, 293 (71.3%) treated with a nonoperative approach experienced a redislocation compared with 55 of 314 shoulders (17.5%) that received surgical treatment. The results of the quantitative synthesis showed that the recurrence rate was significantly lower in the surgical group compared with the nonoperative group. CONCLUSIONS: The recurrence rate is lower in patients undergoing surgical treatment. Further studies are necessary to clarify several points in the treatment of skeletally immature patients with traumatic shoulder instability. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies and 1 case series.

The Oxford Shoulder Instability Score; validation in Dutch and first-time assessment of its smallest detectable change.

BACKGROUND: The Oxford Shoulder Instability Score (OSIS) is a short, self-reported outcome measurement for patients with shoulder instability. In this study, the OSIS was validated in Dutch by testing the internal consistency, reliability, measurement error, validity and the floor and ceiling effects, and its smallest detectable change (SDC) was calculated. METHODS: A total of 138 patients were included. Internal consistency was calculated with Cronbach's α. Reliability (test-retest) was calculated with the intraclass correlation coefficient (ICC). The measurement error was calculated (SEM), and the SDC was estimated in a subgroup of 99 patients that completed the re-test after a mean of 13 days (5-30 days). Construct validity was evaluated by comparing the OSIS with the Western Ontario Shoulder Instability index (WOSI), the Simple Shoulder Test (SST), the Oxford Shoulder Score (OSS), the Disability of the Arm, Shoulder, and Hand assessment (DASH), and the Short Form-36 (SF-36). RESULTS: Internal consistency was good, with a Cronbach's α of 0.88. The reliability was excellent, with an ICC of 0.87. The SEM was 3.3 and the SDC was 9 points (on a scale of 0-48). Regarding the construct validity, 80% of the results were in accordance with the hypotheses, including a high correlation (0.82) with the WOSI. No floor or ceiling effects were found. CONCLUSIONS: The Dutch version of the OSIS showed good reliability and validity in a cohort of patients with shoulder instability.

Measurement properties of the Western Ontario Shoulder Instability index in Dutch patients with shoulder instability.

BACKGROUND: The Western Ontario Shoulder Instability index (WOSI) is a patient-reported outcome measure for patients with shoulder instability. The purpose of this study was to validate the WOSI in a Dutch population by evaluating its structural validity, internal consistency, measurement error, reliability, and construct validity. Floor and ceiling effects were also addressed. METHODS: Two cohorts were recruited, including a total of 138 patients with shoulder instability. Confirmatory factor analysis was used to assess the structural validity and Cronbach's α to assess internal consistency. The measurement error was calculated as the smallest detectable change (SDC). Reliability (test-retest) was estimated in a subgroup of 99 patients who completed the re-test after a mean of 13 days (5-30 days). Reliability was calculated with the intraclass correlation coefficient (ICC). Construct validity was evaluated by comparing the WOSI with the Oxford Shoulder Instability Score (OSIS), the Simple Shoulder Test, the Oxford Shoulder Score, the Disability of the Arm, Shoulder, and Hand assessment (DASH), and the Short Form-36 Health Survey. Measurement properties were evaluated for both the total WOSI score and its four domains. RESULTS: Factor analysis did not confirm the validity of the four domains. Best results were found for a one-factor model. Internal consistency was good, with Cronbach's α ranging from 0.93 to 0.96. Reliability was excellent (ICC 0.88-0.92 for all subscales). The measurement error (SDC) was 23.0% for the total WOSI and 23% to 28% for the subscales (on a scale of 0-100). Regarding the construct validity, 76% of the results were in accordance with the hypotheses, including a high correlation with the OSIS (0.82) and DASH (0.81) assessments. No floor or ceiling effects were found. CONCLUSION: The Dutch version of WOSI showed good reliability and validity in a cohort of patients with shoulder instability, although the factor structure remains unclear.

Long-term results after arthroscopic shoulder stabilization using suture anchors: an 8- to 10-year follow-up.

BACKGROUND: Arthroscopic stabilization using suture anchors is widely used to restore stability after anterior shoulder dislocations and is associated with low recurrence rates in short-term follow-up studies. PURPOSE: To evaluate the long-term follow-up after arthroscopic stabilization for traumatic recurrent anterior instability using suture anchors with emphasis on both redislocations and subjective shoulder function. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We included 67 consecutive patients with 70 affected shoulders. After 8 to 10 years, patients were asked to report the presence and course of their redislocations. Subjective shoulder function was addressed using the Oxford Instability Score (OIS), the Western Ontario Shoulder Instability Index (WOSI), and the Simple Shoulder Test (SST). Patients rated their health status using the Short Form-36 (SF-36). RESULTS: Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up; 35% reported a redislocation. Median shoulder function scores were 16 of 12 to 60, 22 of 0 to 210, and 12 of 0 to 12 for the OIS, WOSI, and SST, respectively. There was a significant difference in subjective function between patients with and without recurrent instability, respectively, 16 versus 24 for the OIS (P = .004), and 16 versus 47 for the WOSI (P = .05). We found a trend for an inverse relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (P = .06). Another trend was found with the presence of a Hill-Sachs defect slightly increasing the risk of a redislocation (P = .07). CONCLUSION: With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. The presence of a Hill-Sachs defect and the use of less than 3 suture anchors might increase the chance of a redislocation. Patients without a redislocation have a significantly better shoulder function compared with patients with a redislocation.