High frequency of posterior and combined shoulder instability in young active patients.

OBJECTIVE: The purpose of this study was to describe the epidemiology and demographics of surgically treated shoulder instability stratified by direction. We hypothesized that there would be an increased frequency of posterior and combined shoulder instability in our population compared with published literature. Secondarily, we assessed preoperative magnetic resonance imaging (MRI) reports to determine how accurately they detected the pathology addressed at surgery. MATERIALS AND METHODS: A retrospective review was conducted at a single facility during a 46-month period. The study included all patients who underwent an operative intervention for shoulder instability. The instability in each case was characterized as isolated anterior, isolated posterior, or combined, according to pathologic findings confirmed at arthroscopy. The findings were retrospectively compared with official MRI reports to determine the accuracy of MRI in characterizing the clinically and operatively confirmed diagnosis. RESULTS: A consecutive series of 231 patients (221 men, 10 women) underwent stabilization for shoulder instability over 46 months. Patients were a mean age of 26.0 years. There were 132 patients (57.1%) with isolated anterior instability, 56 (24.2%) with isolated posterior instability, and 43 (18.6%) with combined instability. Overall, MRI findings completely characterized the clinical diagnosis and arthroscopic pathology in 149 of 219 patients (68.0%). CONCLUSION: The rate of posterior and combined instability in an active population is more common than has been previously reported, making up more than 40% of operatively treated instability, including a previously unreported incidence of 19% for combined instabilities. In addition, MRI was often incomplete or inaccurate in detecting the pathology eventually treated at surgery.

Utility of computed tomography arthrograms in evaluating osteochondral allograft transplants of the distal femur.

Postsurgical evaluation of osteochondral allograft transplant surgery (OATS) of the distal femur most commonly utilizes radiographs or magnetic resonance imaging. This article proposes the utilization of computed tomography (CT) arthrography as an additional option, which allows clear assessment of articular congruity and osseous integration. A retrospective review was performed of 18 patients who underwent an OATS for distal femoral chondral lesions and obtained CT arthrograms postoperatively. CT arthrograms were evaluated for osseous integration and articular congruity. The average age and follow-up were 30.9 years and 4.3 years, respectively. Only 60% of patients were able to remain in the military postoperatively. The articular cartilage was smooth in eight (44.4%); complete bony integration was noted in eight (44.4%) patients. Neither articular congruity nor bony integration was associated with duty status at final follow-up. Although it allows excellent evaluation, similar to other modalities, CT arthrogram does not appear predictive of functional outcome.

Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Outcomes in Arthroscopic Treatment.

BACKGROUND: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported. PURPOSE: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized "perfect circle" technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability. RESULTS: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts. CONCLUSION: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different.

The Growing Gap in Electronic Medical Record Satisfaction Between Clinicians and Information Technology Professionals: Issues of Most Concern and Suggested Remediations.

BACKGROUND: With the alarming statistics concerning the quality of national health care, it is hoped that electronic health records (EHRs) will reduce inefficiencies associated with medical delivery and improve patient safety. This study reports the results of a survey that demonstrates a pattern in EHR system implementation that indicates that health-care information technology decisions are based more on the preferences of information technology professionals (ITPs) and hospital administrators than clinicians. METHODS: We present survey data highlighting the growing discrepancy in EHR-related satisfaction between clinicians and ITPs. We conducted a literature search to identify major barriers that must be overcome to achieve optimal EHR benefits. We summarize our recommendations in order to maximize the favorable impact of EHRs on the health-care system. RESULTS: The existing gap in postimplementation EHR satisfaction ratings between ITPs and clinicians reveals an underlying systematic problem. Electronic medical record vendors perceive administrators and ITPs as the "buyers" for many EHR systems, and their needs are given higher priority than those of clinicians. This possibly may lead to the lack of clinically optimized EHRs, with systems often presenting as rigid and standardized with a limited exchange of health information. CONCLUSIONS: EHRs have the potential to become a powerful tool that may improve many processes related to health care, including quality, safety, and economical aspects. The involvement of physicians in every step of the process, from electronic medical record selection to acquisition, implementation, and ongoing optimization, is crucial for enabling the achievement of the medical organization's mission.