Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial.

PURPOSE: To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). METHODS: Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. RESULTS: The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. CONCLUSIONS: The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Management of Failed SLAP Repair: A Systematic Review.

BACKGROUND: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature. QUESTIONS/PURPOSES: The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair. METHODS: The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included. RESULTS: A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery. CONCLUSION: The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.

Performance Assessment of Arthroscopic Rotator Cuff Repair and Labral Repair in a Dry Shoulder Simulator.

PURPOSE: To evaluate the use of dry models to assess performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). METHODS: Residents, fellows, and sports medicine staff performed an arthroscopic RCR and LR on a dry model. Any prior RCR and LR experience was noted. Staff surgeons assessed participants by use of task-specific checklists, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), and a final overall global rating. All procedures were video recorded and were scored by a fellow blinded to the year of training of each participant. RESULTS: A total of 51 participants and 46 participants performed arthroscopic RCR and LR, respectively, on dry models. The internal consistency or reliability (Cronbach α) using the total ASSET score for the RCR and LR was high (>0.9). One-way analysis of variance for the total ASSET score showed a difference between participants based on year of training (P < .001) for both procedures. The inter-rater reliability for the ASSET score was excellent (>0.9) for both procedures. A good correlation was seen between the ASSET score and the year of training, as well as the previous number of sports rotations. CONCLUSIONS: The results of this study show evidence of construct validity when using dry models to assess performance of arthroscopic RCR and LR by residents. CLINICAL RELEVANCE: The results of this study support the use of arthroscopic simulation in the training of residents and fellows learning arthroscopic shoulder surgery.

How to assess communication, professionalism, collaboration and the other intrinsic CanMEDS roles in orthopedic residents: use of an objective structured clinical examination (OSCE).

BACKGROUND: Assessing residents' understanding and application of the 6 intrinsic CanMEDS roles (communicator, professional, manager, collaborator, health advocate, scholar) is challenging for postgraduate medical educators. We hypothesized that an objective structured clinical examination (OSCE) designed to assess multiple intrinsic CanMEDS roles would be sufficiently reliable and valid. METHODS: The OSCE comprised 6 10-minute stations, each testing 2 intrinsic roles using case-based scenarios (with or without the use of standardized patients). Residents were evaluated using 5-point scales and an overall performance rating at each station. Concurrent validity was sought by correlation with in-training evaluation reports (ITERs) from the last 12 months and an ordinal ranking created by program directors (PDs). RESULTS: Twenty-five residents from postgraduate years (PGY) 0, 3 and 5 participated. The interstation reliability for total test scores (percent) was 0.87, while reliability for each of the communicator, collaborator, manager and professional roles was greater than 0.8. Total test scores, individual station scores and individual CanMEDS role scores all showed a significant effect by PGY level. Analysis of the PD rankings of intrinsic roles demonstrated a high correlation with the OSCE role scores. A correlation was seen between ITER and OSCE for the communicator role, while the ITER medical expert and total scores highly correlated with the communicator, manager and professional OSCE scores. CONCLUSION: An OSCE designed to assess the intrinsic CanMEDS roles was sufficiently valid and reliable for regular use in an orthopedic residency program.

CONTEXTE: Évaluer la compréhension et l'application des 6 rôles intrinsèques CanMEDS (communicateur, professionnel, gestionnaire, collaborateur, promoteur de la santé, érudit) chez les résidents pose un défi pour les responsables de la formation médicale postdoctorale. Nous avons émis l'hypothèse selon laquelle un examen clinique objectif structuré (ECOS) conçu pour évaluer plusieurs rôles CanMEDS intrinsèques serait suffisamment fiable et valide. MÉTHODES: L'ECOS comportait 6 stations de 10 minutes, permettant chacune d'évaluer 2 rôles intrinsèques à l'aide de scénarios basés sur des cas (avec ou sans recours à des patients standardisés). Les résidents ont été notés au moyen d'échelles en 5 points et d'une évaluation globale de leur rendement à chacune des stations. La validité convergente a été vérifiée par corrélation avec les rapports d'évaluation en cours de formation (RÉF) des 12 mois précédents et un classement chiffré créé par les directeurs du programme (DP). RÉSULTATS: Vingt-cinq résidents des années 0, 3 et 5 y ont participé. La fiabilité interstation pour les scores totaux aux tests (en pourcentage) a été de 0,87, tandis que la fiabilité pour chacun des rôles de communicateur, collaborateur, gestionnaire et professionnel, a été supérieure à 0,8. Les scores totaux aux tests, les scores aux stations individuelles et les scores pour les rôles CanMEDS individuels ont tous fait état d'un effet significatif selon le niveau des résidents. L'analyse des classements établis par les DP quant aux rôles intrinsèques a révélé une forte corrélation avec les scores au test ECOS pour les rôles. On a observé une corrélation entre les RÉF et l'ECOS pour le rôle de communicateur, tandis que les RÉF pour le rôle d'expert médical et les scores totaux ont été en forte corrélation avec les scores de l'ECOS pour les rôles de communicateur, de gestionnaire et de professionnel. CONCLUSION: Un ECOS conçu pour évaluer les rôles CanMEDS intrinsèques s'est révélé suffisamment valide et fiable pour un usage régulier dans un programme de résidence en orthopédie.