A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Choosing patient-reported outcome measures for shoulder pathology.

This study was designed to identify the most frequent shoulder patient-reported outcome measures (PROMs) reported in high-quality literature.A systematic review was performed to identify shoulder PROMs, and their diffusion within the scientific literature was tested with a subsequent dedicated search in MEDLINE.506 studies were included in the final data analysis, for a total number of 36,553 patients.The Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the American Shoulder, Elbow Surgeons Score (ASES) and the Shoulder Pain and Disability Index (SPADI) were the most frequently reported PROMs in the analysed publications, with disease-specific PROMs being used with increasing frequency.A core set of outcome measures for future studies on patients with shoulder pathologies, based on the international acceptance and diffusion of each PROM, is needed.A combination of the DASH score for shoulder outcome assessment with more specific PROMs, such as the ASES for rotator cuff pathology and osteoarthritis and the SPADI for shoulder stiffness and shoulder pain of unspecified origin, is proposed as a recommended set of PROMs. Cite this article: EFORT Open Rev 2021;6:779-787. DOI: 10.1302/2058-5241.6.200109.

Stem Cells in Orthopedic Web Information: An Assessment with the DISCERN Tool.

OBJECTIVE: Regenerative medicine is experiencing a strong expansion worldwide, including the treatment of some common orthopedic pathologies, with an increase in physicians adopting these technologies. This growing interest has been associated with an equally significant spread of websites dedicated to public information on this topic, often lacking scientific bases. This study aims to evaluate the quality of information on the World Wide Web about stem cells for cartilage disorders in orthopedic practice. DESIGN: On February 19, 2021 we performed a search on Google using as keywords "cartilage stem cells," considering only the freely accessible sites in Italian, English, French, and Spanish. We selected the first 50 valid results for each language and evaluated them using the DISCERN scale. RESULTS: A total of 249 sites were observed, of which 49 were discarded as duplicates (8) or not relevant to the topic (41). Of the 200 sites surveyed, 47 were affiliated to a singular surgeon (23.5%), 31 to private stakeholders (15.5%), 73 to information sites (36.5%), 8 to public hospitals (4%), 13 to universities (6.5%), and 28 referred to international scientific journals (14%). Only 76 sites (38%) were rated as fair or better, while the remaining 124 (62%) were classified as poor or very poor. CONCLUSIONS: The quality of the information promoted for stem cells in orthopedics is generally low, although a significant minority of the sites offers good quality information. A greater commitment on the part of surgeons and other stakeholders is desirable to promote information on regenerative medicine through scientific criteria supported by adequate literature.

[Orthopedics between reason and passion. Guidelines and shadow lines.] / Ortopedia tra ragione e passione. Linee guida e linee d'ombra.

For over 20 years the Evidence-Based Orthopaedics Working Group (GLOBE) has been promoting evidence-based medicine (EBM) in orthopaedics and traumatology. However, despite a constant and wide-ranging editorial production and fruitful collaborations with colleagues and institutions at national and international level, the orthopaedic scientific community finds it difficult to recognize the EBM model as a solid reference: there are few guidelines available, there is little awareness of their usefulness, and the complexity of the methodology of production and adaptation of documents widens the gap between the orthopaedic real world and that of clinical epidemiology. After a quick analysis of the causes of this contrast, the authors reflect on the possible solutions to the problem, and propose to collaborate for a simplification of the guidelines production methodology, using innovative models of literature review, which have proved to be effective to make the best knowledge available quickly during the CoViD-19 pandemic.

Cross-cultural adaptation, reliability, and validity of the Italian version of the Shoulder Disability Questionnaire.

BACKGROUND: The Shoulder Disability Questionnaire (SDQ) demonstrated promising psychometric properties, but currently there is no evidence of an Italian version. OBJECTIVE: To cross-culturally adapt the Italian version of the SDQ (SDQ-I) and to explore its psychometric properties in patients with non-specific shoulder pain (SP). METHODS: The SDQ-I was translated according to international guidelines and administered to 105 patients with SP. The SDQ-I scores were compared with Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), Numerical Pain Rating Scale (NPRS), and 36-item Short Form Health Survey (SF-36). Structural validity (Exploratory Factor Analysis [EFA]), internal consistency (Cronbach's alpha), test-retest reliability (Intraclass Correlation Coefficient [ICC]), measurement error (Standard Error of the Measurement [SEM], Minimal Detectable Change [MDC]), and construct validity (hypothesis testing with correlation of the DASH, NPRS, and SF-36) were explored. RESULTS: The EFA identified two subscales (activity and participation-psychosocial factors). The internal consistency was supported for activity (α = 0.78), but not for participation-psychosocial subscales (α = 0.45). Both subscales demonstrated high test-retest reliability (ICC = 0.97 [95%CI = 0.96-0.98] and ICC = 0.95 [95%CI = 0.93-0.97]), a SEM of 5.8% and 7.0%, and a MDC of 15% and 19% for the first and second subscale, respectively. Construct validity was satisfactory, as >75% of the expected correlations were met for each subscale. CONCLUSIONS: The SDQ-I was successfully cross-cultural adapted into Italian and proved to be valid for patients with non-specific SP, but its reliability should be further assessed, as internal consistency of the participation-psychosocial subscale showed some psychometric flaws. Further research is needed to refine the instrument.

Femoral Tunnel Positioning in Anterior Cruciate Ligament Reconstruction: Anteromedial Portal versus Transtibial Technique-A Randomized Clinical Trial.

Purpose The purpose of this study was to investigate, through three-dimensional computed tomography (3D-CT), the accuracy of femoral tunnel positioning in patients undergoing anterior cruciate ligament (ACL) reconstruction, comparing transtibial (TT) and anteromedial (AM) techniques. Methods We evaluated postoperative 3D-CT scans of 26 patients treated with ACL reconstruction with hamstrings autograft using a low accessory AM portal technique and 26 treated with the TT technique. The position of the femoral tunnel center was measured with the quadrant method. Results Using quadrant method on CT scans, femoral tunnels were measured at a mean of 32.2 and 28.1% from the proximal condylar surface (parallel to Blumensaat line) and at a mean of 31.2 and 15.1% from the notch roof (perpendicular to Blumensaat line) for the AM and TT techniques, respectively. Conclusion The AM portal technique provides more anatomical graft placement than TT techniques. Level of Evidence Level I, randomized clinical study.

Achilles Tendon Open Surgical Treatment With Platelet-Rich Fibrin Matrix Augmentation: Biomechanical Evaluation.

The relationship between surgical technique and ankle biomechanical properties after surgery for acute rupture of the Achilles tendon (ATR) has not yet been fully investigated. Platelet-rich fibrin (PRF) matrices seem to play a central role in the complex processes of tendon healing. Our aim was to analyze the biomechanical characteristics, stiffness, and mechanical work of the ankle during walking in patients who had undergone surgery after ATR with and without PRF augmentation. We performed a retrospective review of all consecutive patients who had been treated with surgical repair after ATR. Of the 20 male subjects enrolled, 9 (45%) had undergone conventional open repair of the Achilles tendon using the Krackow technique (no-PRF) and 11 (55%) had undergone surgery with PRF augmentation. An additional 8 healthy subjects were included as a control group. A gait analysis evaluation was performed at 6 months after surgery. The percentage of the stance time of the operated leg, double-support time of the healthy leg, and net work of the ankle during the gait cycle showed statistically significant differences between the no-PRF and the healthy group (p < .005). No differences were found between the PRF and healthy groups. Treatment with suture and PRF augmentation could result in significant functional improvements in term of efficiency of motion.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical, but optimal management remains controversial. This is an update of a review first published in 2010 and previously updated in 2012. OBJECTIVES: To determine the effectiveness and safety of conservative and surgical treatment in ulnar neuropathy at the elbow (UNE). We intended to test whether:- surgical treatment is effective in reducing symptoms and signs and in increasing nerve function;- conservative treatment is effective in reducing symptoms and signs and in increasing nerve function;- it is possible to identify the best treatment on the basis of clinical, neurophysiological, or nerve imaging assessment. SEARCH METHODS: On 31 May 2016 we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL Plus, and LILACS. We also searched PEDro (14 October 2016), and the papers cited in relevant reviews. On 4 July 2016 we searched trials registries for ongoing or unpublished trials. SELECTION CRITERIA: The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of UNE. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of UNE with or without neurophysiological evidence of entrapment. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The review authors independently extracted data from included trials and assessed trial quality. We contacted trial investigators for any missing information. MAIN RESULTS: We identified nine RCTs (587 participants) for inclusion in the review, of which three studies were found at this update. The sequence generation was inadequate in one study and not described in three studies. We performed two meta-analyses to evaluate the clinical (3 trials, 261 participants) and neurophysiological (2 trials, 101 participants) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition; four trials in total examined this comparison.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08; moderate-quality evidence) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). The number of participants to clinically improve was 91 out of 131 in the simple decompression group and 97 out of 130 in the transposition group. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85; moderate-quality evidence).In one trial (47 participants), the authors compared medial epicondylectomy with anterior transposition and found no difference in clinical and neurophysiological outcomes.In one trial (48 participants), the investigators compared subcutaneous transposition with submuscular transposition and found no difference in clinical outcomes.In one trial (54 participants for 56 nerves treated), the authors found no difference between endoscopic and open decompression in improving clinical function.One trial (51 participants) assessed conservative treatment in clinically mild or moderate UNE. Based on low-quality evidence, the trial authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to information provision did not result in further improvement.One trial (55 participants) assessed the effectiveness of corticosteroid injection and found no difference versus placebo in improving symptoms at three months' follow-up. AUTHORS' CONCLUSIONS: We found only two studies of treatment of ulnar neuropathy using conservative treatment as the comparator. The available comparative treatment evidence is not sufficient to support a multiple treatment meta-analysis to identify the best treatment for idiopathic UNE on the basis of clinical, neurophysiological, and imaging characteristics. We do not know when to treat a person with this condition conservatively or surgically. Moderate-quality evidence indicates that simple decompression and decompression with transposition are equally effective in idiopathic UNE, including when the nerve impairment is severe. Decompression with transposition is associated with more deep and superficial wound infections than simple decompression, also based on moderate-quality evidence. People undergoing endoscopic surgery were more likely to have a haematoma. Evidence from one small RCT of conservative treatment showed that in mild cases, information on movements or positions to avoid may reduce subjective discomfort.

The influence of graft placement on clinical outcome in anterior cruciate ligament reconstruction.

PURPOSE: the aim of the present study was to investigate the influence of graft tunnel position on both clinical outcome and instrumental knee stability in patients submitted to arthroscopic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft. METHODS: thirty patients (24 men and 6 women) who underwent ACL reconstruction performed using an autologous bone-patellar tendon-bone graft were studied at a mean follow-up of 18 months. Clinical outcome was assessed on the basis of the Lysholm score, Tegner activity level, International Knee Documentation Committee (IKDC) subjective form and the Short Form-36. Clinical outcomes were correlated with both femoral and tibial tunnel placement measured on standard anteroposterior and lateral knee radiographs, in accordance with established guidelines. RESULTS: tibial tunnel position on the lateral view correlated significantly with both the IKDC subjective form (r = -0.72; p<0.05) and the Lysholm score (r=-0.73; p<0.05). Tibial tunnel position on the lateral view also correlated with stability measured using a KT-1000 arthrometer at 30N of force (r=0.57; p<0.05). No correlation was found between α angle and anteroposterior (AP) laxity measured by KT-1000 arthrometer. No significant correlation was found between femoral tunnel position (on either view) and Lysholm score, IKDC score and Tegner activity level. Similarly, no correlation was found between AP laxity measured by KT-1000 arthrometer and femoral tunnel position. CONCLUSIONS: these results suggest that the more anterior the placement of the tibial tunnel, the better the clinical outcome will be. On the basis of literature data and our findings, we discuss the hypothesis that there exists a "correct area" for tunnel placement, making it possible to obtain the best results. LEVEL OF EVIDENCE: Level IV, case series.

Reliability of forced internal rotation and active internal rotation to assess lateral instability of the biceps pulley.

PURPOSE: the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR). METHODS: a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed. RESULTS: the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears. CONCLUSIONS: painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion. LEVEL OF EVIDENCE: level I, validating cohort study with good reference standards.

Deep partial rotator cuff tear: transtendon repair or tear completion and repair? A randomized clinical trial.

PURPOSE: The purpose of this study is to compare the clinical and subjective difference between transtendon repair or complete/repair in two homogeneous groups of patients affected by deep partial articular supraspinatus tear. METHODS: Seventy-four patients were randomized in two groups of 37 patients each. The first group (A) was treated with arthroscopic transtendon repair while the second group (B) was treated with an arthroscopic completion of the tear and formal repair. All the patients were revaluated at a minimum 2 years of follow-up with Constant score and Visual Analogic Scale (VAS). RESULTS: Constant score improved by a mean value of 25 (95 % CI 21-28) (p < 0.0001) and of 29 (95 % CI 26-31) (p < 0.0001), respectively; VAS score decreased by a mean value of 3.4 (95 % CI 2.9-3.9) (p < 0.0001) and of 3.6 (95 % CI 3.3-4.0) (p < 0.0001), respectively. The improvement was higher in both groups for the ADL, and in Group B, the improvement in strength was higher than in Group A. There were no statistical differences between the two different techniques. CONCLUSION: Both repairing techniques of deep partial supraspinatus tear provide good results in terms of function and pain. There were no statistically significant differences between the two techniques. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical but optimal management remains controversial. This is an update of a review first published in 2010. OBJECTIVES: To determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 February 2012), CENTRAL (2012, Issue 2), MEDLINE (January 1966 to February 2012), EMBASE (January 1980 to February 2012), AMED (January 1985 to February 2012), CINAHL Plus (January 1937 to February 2012), LILACS (January 1982 to Feburary 2012), PEDro (January 1980 to February 2012), and the papers cited in relevant reviews. SELECTION CRITERIA: The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of ulnar neuropathy at the elbow. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of ulnar neuropathy at the elbow with or without neurophysiological evidence of entrapment. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The authors extracted data from included trials and assessed trial quality independently. They contacted trial investigators for missing information. MAIN RESULTS: We identified six RCTs (430 participants), with moderate quality evidence, for inclusion in the review. When the searches were updated in 2012 we found no further studies. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical (three trials, 261 participants included) and neurophysiological (two trials, 101 participants included) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). In the simple decompression group 91 out 131 patients clinically improved; in the transposition group 97 out 130 patients improved. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85).In one trial (47 participants) the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.One trial (51 participants) assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement. AUTHORS' CONCLUSIONS: The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small RCT of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.

Cross-cultural adaptation and measurement properties of an Italian version of the Western Ontario Shoulder Instability Index (WOSI).

STUDY DESIGN: Clinical measurement study. OBJECTIVES: To translate and cross-culturally adapt the Western Ontario Shoulder Instability Index (WOSI) into Italian, and to evaluate its measurement properties in patients with shoulder instability secondary to a first-time traumatic anterior dislocation. BACKGROUND: The WOSI was developed for English-speaking patients. To date, no Italian version of the WOSI exists. METHODS: The WOSI was cross-culturally adapted to Italian according to established guidelines. Sixty-four (16 women, 48 men) patients with unilateral shoulder anterior instability were prospectively recruited for the purposes of this study. Internal consistency, test-retest reliability, construct validity, and responsiveness of the WOSI were evaluated. RESULTS: The Italian version of the WOSI showed a high degree of internal consistency, with a Cronbach alpha of .93 (95% confidence interval [CI]: 0.91, 0.96). The test-retest reliability was high for both short-term (3 days, 64 patients) and medium-term (14 weeks, 20 patients) test-retest, with intraclass correlation coefficients of 0.95 (95% CI: 0.90, 0.97) and 0.92 (95% CI: 0.89, 0.95), respectively. The WOSI was more closely correlated to the Disabilities of the Arm, Shoulder and Hand questionnaire than to the Medical Outcomes Study 36-Item Short-Form Health Survey (r = 0.794 and 0.113, respectively). The receiver-operating-characteristic curve analysis revealed that the WOSI was more responsive than the Disabilities of the Arm, Shoulder and Hand questionnaire (P = .03), with an area under the curve of 0.90 (95% CI: 0.78, 0.97) for the WOSI and 0.76 (95% CI: 0.61, 0.88) for the Disabilities of the Arm, Shoulder and Hand questionnaire. CONCLUSION: The Italian version of the WOSI is a valid, reliable, and responsive tool that can be used to measure function in Italian-speaking patients with shoulder instability due to a first-time traumatic anterior dislocation.

Position of shoulder arthroplasty and clinical outcome in proximal humerus fractures.

Four-part proximal humeral fractures are frequently treated with shoulder replacement. Outcome of this procedure has not been standardized, and there are controversy data on range of motion (ROM) and active function of the shoulder. The aim of this study is to compare shoulder prosthesis position (SPP) in terms of version of humeral head and height of stem with clinical subjective and objective outcome. Fifty patients were treated with shoulder hemiarthroplasty for four-part proximal humeral fracture or fracture-dislocation of the humeral head. Radiological examination and CT-scan were performed preoperatively and at follow-up. Clinical outcome evaluation included active and passive ROM, and subjective perspective collected through SF-36, OSQ, ASES, and DASH. No significant correlation between stem height and clinical outcome were found. The prosthesis version correlates with all subjective questionnaires. The ROM was not correlated with stem height and prosthesis version. SPP involves clinical outcome, with great relevance of implant version.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical but optimal management remains controversial. OBJECTIVES: The objectives of this systematic review were to determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Specialized Register (16 February 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (January 1966 to February 2010), EMBASE (January 1980 to February 2010), AMED (January 1985 to February 2010), CINAHL Plus (January 1937 to February 2010), LILACS (January 1982 to Feburary 2010), PEDro (January 1980 to February 2010), and the papers cited in relevant reviews. SELECTION CRITERIA: The review included only randomised controlled clinical trials. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The authors extracted data from included trials and assessed trial quality independently. They contacted trial investigators for missing information. MAIN RESULTS: We identified 1461 papers and selected six randomised controlled clinical trials with moderate quality evidence. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical and neurophysiological outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% CI 0.80 to 1.08) and neurophysiological improvement (RR 1.47, 95% CI -0.94 to 3.87). Transposition showed a higher number of wound infections (RR 3.10, 95% CI 1.18 to 8.15).In one trial the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.One trial assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement. AUTHORS' CONCLUSIONS: The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small randomised controlled trial of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.

Health-related quality of life and subjective outcome after shoulder replacement for proximal humeral fractures.

Shoulder replacement has increased exponentially in recent decades, and previous studies have documented the effectiveness of this procedure. Pain relief, physical functional level, and health-related quality of life, however, were often not assessed. To our knowledge, no published articles have assessed quality of life in shoulder replacement for fracture. The main purpose of this study was to assess the patient-relevant outcomes in patients who underwent shoulder replacement for proximal humeral fractures. Standardized quality of life and shoulder-specific, self-administered questionnaires were used. On the Medical Outcomes Study Short Form 36 Health Survey, as expected, we observed a lower score in the domain compared with healthy Italian subjects. A surprising finding was that in the General Health and Role-Emotional domains, our sample had a better picture than the healthy one, probably because patients had experienced severe trauma and major surgery previously. These data represent the first step toward the definition of outcome for this procedure. This study does not address the necessity of therapy, but if this were included in future publications, it might provide useful data for therapeutic recommendations.