Clinical Assessment of Physical Examination Maneuvers for Superior Labral Anterior to Posterior Lesions.

Purpose Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study. Methods We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis ("certain the diagnosis is absent/present," or "uncertain requires further testing"). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions. Results Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I-V) as disease positive, none of the tests was sensitive (10.3-33.3) although they were moderately specific (61.3-92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5-38.7) and specificity (70.6-93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%). Conclusion Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.

Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee.

OBJECTIVE: To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA). DESIGN, SETTING AND PARTICIPANTS: We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2). INTERVENTIONS: Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only. MAIN OUTCOME MEASURES: Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups. RESULTS: 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only. CONCLUSIONS: Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. TRIAL REGISTRATION NUMBER: NCT00158431.

Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions.

BACKGROUND: Shoulder pain and disability pose a diagnostic challenge for clinicians owing to the numerous causes that exist. Unfortunately, the evidence in support of most clinical tests is weak or absent. PURPOSE: To determine the diagnostic validity of physical examination maneuvers for rotator cuff lesions. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Consecutive shoulder patients recruited for this study were referred to 2 tertiary orthopaedic clinics. A surgeon took a thorough history and indicated his or her certainty about each possible diagnosis. A clinician performed the physical examination for diagnoses where uncertainty remained. Arthroscopy was considered the reference standard for patients who underwent surgery, and MRI with arthrogram was considered the reference for patients who did not. The sensitivity, specificity, and likelihood ratios were calculated to investigate whether combinations of the top tests provided stronger predictions of the presence or absence of disease. RESULTS: There were 139 participants. None of the tests were highly sensitive for diagnosing rotator cuff tears or tendinosis. Tests for subscapularis tears were all highly specific. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears. Closer analysis revealed the internal rotation and lateral rotation lag sign did not improve the ability to diagnose subscapularis or supraspinatus tears, respectively, although the lateral rotation lag sign demonstrated a discriminatory ability for tear size. CONCLUSION: No test in isolation is sufficient to diagnose a patient with rotator cuff damage. A combination of tests improves the ability to diagnose damage to the rotator cuff. It is recommended that the internal rotation and lateral rotation lag signs be removed from the gamut of physical examination tests for supraspinatus and subscapularis tears.

A biomechanical assessment of superior shoulder translation after reconstruction of anterior glenoid bone defects: The Latarjet procedure versus allograft reconstruction.

BACKGROUND: The coracoacromial ligament (CAL) is an important restraint to superior shoulder translation. The effect of CAL release on superior stability following the Latarjet is unknown; therefore, our purpose was to compare the effect of two Latarjet techniques and allograft reconstruction on superior instability. MATERIALS AND METHODS: Eight cadaveric specimens were tested on a simulator. Superior translation was monitored following an axial force in various glenohumeral rotations (neutral, internal, and external) with and without muscle loading. Three intact CAL states were tested (intact specimen, 30% glenoid bone defect, and allograft reconstruction) and two CAL deficient states (classic Latarjet (classicLAT) and congruent-arc Latarjet (congruentLAT)). RESULTS: In neutral without muscle loading, a significant increase in superior translation occurred with the classicLAT as compared to 30% defect (P = 0.046) and allograft conditions (P = 0.041). With muscle loading, the classicLAT (P = 0.005, 0.002) and the congruentLAT (P = 0.018, 0.021) had significantly greater superior translation compared to intact and allograft, respectively. In internal rotation, only loaded tests produced significant results; specifically, classicLAT increased translation compared to all intact CAL states (P < 0.05). In external rotation, only unloaded tests produced significant results with classicLAT and congruentLAT allowing greater translations than intact (P ≤ 0.028). For all simulations, the allograft was not significantly different than intact (P > 0.05) and no differences (P = 1.0) were found between classicLAT and congruentLAT. DISCUSSION: In most simulations, CAL release with the Latarjet lead to increased superior humeral translation. CONCLUSION: The choice of technique for glenoid bone loss reconstruction has implications on the magnitude of superior humeral translation. This previously unknown effect requires further study to determine its clinical and kinematic outcomes.

Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial.

BACKGROUND: Both total shoulder arthroplasty and hemiarthroplasty have been used commonly to treat severe osteoarthritis of the shoulder; however, their effect on disease-specific quality-of-life outcome is unknown. The purpose of this study was to compare the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty in patients with osteoarthritis of the shoulder. METHODS: Forty-two patients with a diagnosis of osteoarthritis of the shoulder were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she "crossed over" was used for the analysis. RESULTS: Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty (90.6 +/- 13.2 and 81.5 +/- 24.1 points, respectively; p = 0.18). The other outcome measures demonstrated similar findings. Two patients in the hemiarthroplasty group crossed over to the other group by undergoing a revision to a total shoulder arthroplasty because of glenoid arthrosis. CONCLUSIONS: Both total shoulder arthroplasty and hemiarthroplasty improve disease-specific and general quality-of-life measurements. With the small number of patients in our study, we found no significant differences in these measurements between the two treatment groups. LEVEL OF EVIDENCE: Therapeutic Level I.