Ultrasound in the assessment of musculoskeletal involvement in systemic lupus erythematosus: state of the art and perspectives.

Musculoskeletal manifestations are extremely common in patients with systemic lupus erythematosus. Transient and migratory arthralgia is frequently reported even without clinical signs of joint or tendon inflammation. In less than 15% of patients, joints may be more severely affected by deforming (Jaccoud's arthropathy) and/or erosive arthropathy (Rhupus syndrome). In recent years, ultrasound has emerged as a promising imaging technique for the assessment of musculoskeletal involvement in systemic lupus erythematosus, having demonstrated the ability to detect inflammation and structural damage both at articular and periarticular level. Recent ultrasound studies have also revealed new insights into musculoskeletal involvement in patients with systemic lupus erythematosus, some of them questioning the traditional concepts of systemic lupus erythematosus arthropathy, with potential clinical, prognostic and therapeutic implications. In daily clinical practice, the use of ultrasound in the assessment of joint and tendon involvement in patients with systemic lupus erythematosus is still limited. Several methodological issues encountered in ultrasound studies evaluating musculoskeletal involvement in systemic lupus erythematosus patients need to be addressed in order to improve both the reliability and clinical usefulness of ultrasound findings. This paper reviews ultrasound studies assessing musculoskeletal involvement in patients with systemic lupus erythematosus, highlighting certainty, limits, potential applications and future perspectives of ultrasound use in systemic lupus erythematosus patients.

Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck.

BACKGROUND: Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking. OBJECTIVE: The objective of this study was to evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States. METHODS: A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18-64 years with non-surgically managed cervical or lumbar degenerative spine disease during 2015-6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications. RESULTS: Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care. CONCLUSIONS: The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.

In-Office Diagnostic Needle Arthroscopy: Understanding the Potential Value for the US Healthcare System.

In-office diagnostic needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients. Significant value was realized in this 200-patient retrospective review. Minimum savings of $418 and $554.62 were realized for noncontrast knee and shoulder magnetic resonance imaging (MRI) scans, respectively, in independent MRI facilities. Those savings more than doubled in hospital-based facilities: $961.08 and $1097.62, respectively, for knee and shoulder noncontrast MRI scans.

Radiographic assessment of humeroulnar congruity in a medium and a large breed of dog.

Elbow joint incongruity is recognized as an important factor in the development, treatment, and prognosis of canine elbow dysplasia. Elbow incongruity has been measured based on radiographic joint space widths, however these values can be affected by the degree of elbow joint flexion. Recent studies have reported radiographic curvature radii as more precise measures of humeroulnar congruity in dogs. The aim of this prospective observational study was to describe radiographic curvature radii measured from flexed and extended elbow radiographs for a sample of dogs representing a medium breed (Portuguese Pointing Dog) and a large breed (Estrela Mountain Dog). The curvature radii from the ulnar trochlear notch and humeral trochlea were measured in 114 mediolateral elbow extended radiographic views (30 Portuguese Pointing Dog and 27 Estrela Mountain Dog), and 84 mediolateral flexed views (22 Portuguese Pointing Dog and 20 Estrela Mountain Dog). The sampled animals' ages ranged from 12 to 84 months (34.6 ± 17.8 months). Good agreement was observed between curvature radii measurements for flexed vs. extended views in both breed groups. Ulnar trochlear notch curvature radii measurements were greater than humeral trochlea curvature radii measurements in both breed groups. Both curvature radii were greater in the large-breed dog group vs. the medium-breed dog group. Both breed groups had ulnar and humeral curves with similar typology. However, the large breed group had greater intermediate differences between the humeroulnar surface curvature radii. Results from this study supported the use of curvature radii as measures of humeroulnar congruity in mediolateral flexed elbow radiographs of medium and large breed dogs.

Arthrofibrosis Associated With Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS: In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS: Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION: Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth.

PURPOSE: To determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth. METHODS: Eighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6 weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations. RESULTS: The interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade. CONCLUSIONS: The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system. CLINICAL RELEVANCE: As cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.

Appropriateness of knee MRI prescriptions: clinical, economic and technical issues.

OBJECTIVES: Many studies show that a large portion of medical prescriptions for diagnostic examinations may be not useful for patient's management or unnecessary. Rapid technological advancement has made it possible for magnetic resonance imaging (MRI) to be increasingly used all over the world, particularly for musculoskeletal disorders. The aim of this study was to assess the appropriateness of the knee MRI prescriptions. MATERIALS AND METHODS: A panel of experts found standard clinical practice guidelines in the management of knee disorders. Secondly, the finalized set of guidelines chosen was compared with the data of 400 patients who underwent previous knee MRIs, which were then reported in a specific questionnaire prepared by the authors. The rate of appropriateness of knee MRI prescriptions was then calculated. RESULTS: Almost 21% of prescriptions were totally inappropriate, 18.8% were uncertain, and 60.2% could be considered totally appropriate. The most frequent prescription indication was for meniscal disorders that account for 26.8% of the total indications. CONCLUSIONS: Our results demonstrate that approximately 40% of the total prescriptions were totally inappropriate or uncertain and that most of these were made by general practitioners. In light of these results, the economic impact of inappropriate prescriptions on the Italian healthcare system has to be seriously considered.

Radiographic and computed tomographic assessment of the development of the antebrachia and elbow joints in Labrador Retrievers with and without medial coronoid disease.

OBJECTIVES: To compare the development, monitored by radiography and computed tomography, of the antebrachia and elbow joints in seven Labrador Retrievers with healthy elbow joints and in seven Labrador Retrievers that developed medial coronoid disease (MCD), in order to determine whether disturbances in the development of the antebrachia and elbow joints, between the age of six and 17 weeks may lead to medial coronoid disease. METHODS: A prospective study of 14 Labrador Retrievers in their active growth stage was performed. The development of the antebrachia and elbow joints was assessed between six and 17 weeks of age using radiography and computed tomography determining the development of secondary ossification centres, radioulnar length ratio, radial angulation, and inter-relationship between the humerus, ulna and radius. RESULTS: For the parameters of ossification of secondary ossification centres, radioulnar length ratio, radial angulation, and joint congruence evaluation, there was no significant difference in the development of the antebrachia and elbow joints of seven Labrador Retrievers positive and seven Labrador Retrievers negative for MCD at the age of six to 17 weeks. CLINICAL SIGNIFICANCE: These findings demonstrate that the development of MCD in the Labrador Retrievers in our study was not related to any disturbance in the development of the antebrachia and elbow joints during the rapid growth phase.

Diagnostic accuracy of ultrasound for assessment of hemophilic arthropathy: MRI correlation.

OBJECTIVE. The purpose of this article is to assess the reliability of interpretation of ultrasound findings according to data blinding in maturing hemophilic joints and to determine the diagnostic accuracy of ultrasound compared with MRI for assessing joint components. SUBJECTS AND METHODS. Ankles (n = 34) or knees (n = 25) of boys with hemophilia or von Willebrand disease (median age, 13 years; range, 5-17 years) were imaged by ultrasound, MRI, and radiography in two centers (Toronto, Canada, and Vellore, India). Ultrasound scans were performed by two operators (one blinded and one unblinded to MRI data) and were reviewed by four reviewers who were unblinded to corresponding MRI findings according to a proposed 0- to 14-item scale that matches 14 of 17 items of the corresponding MRI scale. MRI examinations were independently reviewed by two readers. RESULTS. When data were acquired by radiologists, ultrasound was highly reliable for assessing soft-tissue changes (intraclass correlation coefficient [ICC], 0.98 for ankles and 0.97 for knees) and substantially to highly reliable for assessing osteochondral changes (ICC, 0.61 for ankles and 0.89 for knees). Ultrasound was highly sensitive (> 92%) for assessing synovial hypertrophy and hemosiderin in both ankles and knees but had borderline sensitivity for detecting small amounts of fluid in ankles (70%) in contrast to knees (93%) and variable sensitivity for evaluating osteochondral abnormalities (sensitivity range, 86-100% for ankles and 12-100% for knees). CONCLUSION. If it is performed by experienced radiologists using a standardized protocol, ultrasound is highly reliable for assessing soft-tissue abnormalities of ankles and knees and substantially to highly reliable for assessing osteochondral changes in these joints.

Comparison of clinical and histologic diagnoses in 16,587 total joint arthroplasties: implications for orthopedic and pathologic practices.

OBJECTIVES: To confirm how often histologic diagnoses correspond to reported clinical diagnoses in patients undergoing total joint arthroplasties. METHODS: We compared the submitting operative diagnosis with the pathologic diagnosis in 16,587 total joint arthroplasties for the seven most common diagnoses. RESULTS: The discrepancy rates between the submitted operative and histologic diagnosis were 18.8% for 7,968 total hip replacements and 9.4% for 8,619 total knee replacements. In addition, 5.4% of hip joints and 1.4% of knee joints demonstrated discordant histologic findings that had not been suspected clinically and should have affected clinical management and patient outcomes. CONCLUSIONS: Our findings demonstrated significantly more diagnostic discrepancies and discordance than has been suggested by the previously published literature. A large part of the difference may be due to more careful diagnostic analyses of orthopedic specimens than in other institutions. These analyses include some diagnoses that are not often made elsewhere but may have important future implications for patients.

Low income and rural county of residence increase mortality from bone and joint sarcomas.

BACKGROUND: This is a part of a larger effort to characterize the effects on socio-economic factors (SEFs) on cancer outcome. Surveillance, Epidemiology and End Result (SEER) bone and joint sarcoma (BJS) data were used to identify potential disparities in cause specific survival (CSS). MATERIALS AND METHODS: This study analyzed SEFs in conjunction with biologic and treatment factors. Absolute BJS specific risks were calculated and the areas under the receiver operating characteristic (ROC) curve were computed for predictors. Actuarial survival analysis was performed with Kaplan-Meier method. Kolmogorov-Smirnov's 2-sample test was used to for comparing two survival curves. Cox proportional hazard model was used for multivariate analysis. RESULTS: There were 13501 patients diagnosed BJS from 1973 to 2009. The mean follow up time (SD) was 75.6 (90.1) months. Staging was the highest predictive factor of outcome (ROC area of 0.68). SEER stage, histology, primary site and sex were highly significant pre-treatment predictors of CSS. Under multivariate analysis, patients living in low income neighborhoods and rural areas had a 2% and 5% disadvantage in cause specific survival respectively. CONCLUSIONS: This study has found 2-5% decrement of CSS of BJS due to SEFs. These data may be used to generate testable hypothesis for future clinical trials to eliminate BJS outcome disparities.

Assessment of articular cartilage and subchondral bone using EPIC-microCT in Labrador retrievers with incipient medial coronoid disease.

The aetiopathogenesis of medial coronoid disease (MCD) remains obscure, despite its high prevalence. The role of changes to subchondral bone or articular cartilage is much debated. Although there is evidence of micro-damage to subchondral bone, it is not known whether this is a cause or a consequence of MCD, nor is it known whether articular cartilage is modified in the early stages of the disease. The aim of the present study was to use equilibrium partitioning of an ionic contrast agent with micro-computed tomography (microCT) to investigate changes to both the articular cartilage and the subchondral bone of the medial coronoid processes (MCP) of growing Labrador retrievers at an early stage of the disease and at different bodyweights. Of 14 purpose-bred Labrador retrievers (15-27 weeks), six were diagnosed with bilateral MCD and one was diagnosed with unilateral MCD on the basis of microCT studies. The mean X-ray attenuation of articular cartilage was significantly higher in dogs with MCD than in dogs without MCD (P<0.01). In all dogs, the mean X-ray attenuation of articular cartilage was significantly higher at the lateral (P<0.001) than at the proximal aspect of the MCP, indicating decreased glycosaminoglycan content. Changes in parameters of subchondral bone micro-architecture, namely the ratio of bone volume to tissue volume (BV/TV), bone surface density (BS/TV), bone surface to volume ratio (BS/BV), trabecular thickness (Tb.Th; mm), size of marrow cavities described by trabecular spacing (Tb.Sp; mm), and structural model index (SMI), differed significantly by litter (P<0.05) due to the difference in age and weight, but not by the presence/absence of MCD (P>0.05), indicating that subchondral bone density is not affected in early MCD. This study demonstrated that cartilage matrix and not subchondral bone density is affected in the early stages of MCD.

Bi-oblique dynamic proximal ulnar osteotomy in dogs: reconstructed computed tomographic assessment of radioulnar congruence over 12 weeks.

OBJECTIVE: To evaluate radioulnar joint modification using computed tomography (CT) after bi-oblique dynamic proximal ulnar osteotomy (BODPUO). STUDY DESIGN: Clinical study. ANIMALS: Dogs (n = 18, 26 elbows) with elbow incongruence treated by a single surgeon with BODPUO. METHODS: Radioulnar space measurements were performed on transverse, frontal, and sagittal CT projections preoperatively and after radiographically determined osteotomy healing. RESULTS: Three transverse plane measurements were statistically different than preoperatively at 12 weeks after the surgery demonstrating divergence of the lateral coronoid region of the radial incisure of the ulna from the radial head. None of the other measurements within the elbow were statistically different, but measurements of the radioulnar space at the level of the osteotomy site documented a statistically significant caudal tipping of the distal extent of the proximal ulnar segment. CONCLUSION: CT measurements documented a significant increase in radioulnar joint space at the mid-coronoid level, at the level of the base of the medial coronoid process, and at the level of the lateral coronoid process. This corresponds to cranially directed rotation of the medial coronoid process around the proximal radial epiphysis. A tendency for cranial tilting of the medial coronoid process was observed, which was confirmed by statistically significant caudal tipping of the distal extent of the proximal ulnar segment.

The diagnostic accuracy of unenhanced MRI in the assessment of joint abnormalities in juvenile idiopathic arthritis.

OBJECTIVES: To assess the diagnostic accuracy and reliability of MRI without contrast enhancement in the evaluation of JIA knee joint abnormalities. METHODS: JIA patients with clinically active knee involvement were prospectively studied using an 1-T open-bore magnet. MRI features were independently evaluated by two readers using the JAMRIS system. The first reading included unenhanced images, whereas complete image sets were available for the second reading. RESULTS: Imaging findings from 73 patients were analysed. Agreement between Gd-enhanced (+Gd) and Gd-unenhanced (-Gd) MRI scores of bone marrow changes, cartilage lesions and bone erosions was good concerning sensitivity, specificity, negative predictive value and positive predictive value. Inter-observer agreement was good for both -Gd and +Gd scores (ICC = 0.91-1.00, 0.93-1.00, respectively). Regarding the assessment of synovial hypertrophy, specificity of -Gd was high (0.97), but the sensitivity of unenhanced MRI was only 0.62. Inter-reader agreement for +Gd MRI was ICC = 0.94; however, omitting post-Gd acquisitions increased inter-reader variation (ICC = 0.86). CONCLUSIONS: If Gd-enhanced MRI is the reference standard, omitting Gd contrast medium is irrelevant for the assessment of bone marrow changes, cartilage lesions and bone erosions as joint abnormalities in JIA. Omitting intravenous Gd in the MRI assessment of joints in JIA is inadvisable, because it decreases the reliability of detecting synovial disease. KEY POINTS: • Magnetic resonance imaging is increasingly used to assess juvenile idiopathic arthritis. • Synovial hypertrophy, a marker of JIA activity, is well shown by MRI. • Omitting intravenous contrast medium decreases the reliability of synovial hypertrophy scores. • Bone marrow, cartilage and erosions can be reliably evaluated without contrast enhancement. • In the evaluation of JIA disease activity, unenhanced MRI is inadvisable.

Is there a valid and reliable assessment of diagnostic knee arthroscopy skill?

BACKGROUND: The Basic Arthroscopic Knee Skill Scoring System (BAKSSS) has construct validity as an objective measure of arthroscopic proficiency when used to assess the task of performing arthroscopic meniscectomies on cadaver knees. The reliability of this instrument is unknown. QUESTIONS/PURPOSE: We asked whether (1) a simple modification of the BAKSSS would show construct validity similar to that in the initial BAKSSS study, (2) this assessment would be reliable, and (3) this assessment could be used as a high-stakes pass or fail test. METHODS: Twenty-three orthopaedic residents performed diagnostic knee arthroscopies on cadaveric knee specimens. Their competency was assessed by three live raters using the modified BAKSSS. Interrater reliability was assessed by comparing the scores given by each rater to each subject. RESULTS: The modified BAKSSS showed construct validity with junior residents achieving lower scores (mean score, 20) than senior residents (mean score, 33). The modified BAKSSS had an interrater reliability of kappa = 0.685-0.852. The modified BAKSSS had a kappa = 0.543 when used as a proficiency test for diagnostic arthroscopy. CONCLUSIONS: The modified BAKSSS is useful for assessing diagnostic knee arthroscopy proficiency. Future scoring systems should be designed to be generalizable so they can be applied to multiple procedures without the need for modification, allow for video-based assessment, and must be rigorously tested for reliability and other types of validity (eg, face validity, content validity, and criterion-related validity). CLINICAL RELEVANCE: Having a valid and reliable assessment of basic arthroscopic procedures may allow educators to more adequately evaluate individual residents and the effectiveness of various training modalities.

Sociodemographic differences in the severity and duration of disease amongst patients undergoing hip or knee replacement surgery.

BACKGROUND: Differences in the use of hip and knee replacement by sex, age, ethnicity or socioeconomic status may lead to differences in disease severity between those who have surgery. METHODS: Analyses used data collected from 117,736 patients in 2009-10 via the Patient Reported Outcome Measures (PROMs) programme in England. Adjusted differences were estimated in the Oxford Hip Score (OHS) or the Oxford Knee Score (OKS), both expressed on a scale from 0 to 48, and the proportion with longstanding problems (>5 years), expressed as odds ratios (ORs). RESULTS: Women had more severe pain and disability than men on average (difference OHS 2.3 and OKS 3.3), but less often longstanding problems. Compared with white patients, average severity was higher in South Asian patients (difference OHS 2.7 and OKS 3.0) and in black patients (difference OHS 0.9 and OKS 1.6), who also more often had longstanding problems (OR 1.40 for hip and 1.54 for knee). Patients from deprived areas had more severe disease (difference OHS 3.6 and OKS 3.3 between least and most deprived quintile). CONCLUSIONS: There is evidence that non-white and deprived patients tend to have hip and knee replacement surgery at a later stage in the course of their disease.

Economic evaluations in shoulder pathologies: a systematic review of the literature.

BACKGROUND: Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies. MATERIALS AND METHOD: A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature. RESULTS: The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality. CONCLUSION: Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.

A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks.

BACKGROUND: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). METHODS: Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. RESULTS: In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). CONCLUSIONS: Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.