Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial.

BACKGROUND: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored. PURPOSE: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed. RESULTS: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios. CONCLUSION: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage. REGISTRATION: NCT01324531 (ClinicalTrials.gov identifier).

Orthopaedic Sport Medicine Surgeons and Fellows Value Immersive Virtual Reality for Improving Surgical Training, Procedural Planning, and Distance Learning.

BACKGROUND: Overall, the potential utility of iVR technology in orthopaedic surgery is promising. The attitudes of medical students and surgical trainees on VR simulated surgical training have been overwhelmingly positive. However, further research and understanding of the attitudes of practicing orthopaedic surgeons and Fellows are needed to appreciate its benefits for clinical practice. PURPOSE: The purpose of this study was to assess the attitudes of Canadian orthopaedic surgeons and Fellows on the value of iVR for surgical training, clinical practice, and distance learning. METHODS: Forty-three orthopedic surgeons and Fellows attended a VRthrscopy™ Knee Module (Conmed Corporation, Largo, USA) demonstration. The view and audio from the lead headset were cast to a large screen so the audience could follow the procedure in real-time. Immediately after the presentation, the audience members were given a paper questionnaire assessing their perceptions and attitudes toward iVR or use in orthopaedic learning, clinical practice and distance education and mentoring. RESULTS: iVR was perceived to be valuable for the field of orthopaedic surgery. All 13 questions were rated with mean Likert scores of five or greater indicating observed value for all 13 questions. The respondents indicated that iVR had value (score of 5 or greater) in each questionnaire domain, with agreement ranging from 78-98% for teaching and learning, 66-97% for clinical practice, and 88-100% for distance education and mentoring questions. CONCLUSION: This study has demonstrated that a group of Canadian sport medicine orthopedic surgeons and Fellows had favourable attitudes towards, and perceived that iVR has value in, orthopaedic surgical training, clinical practice, and distance learning and mentorship. The potential for utilizing iVR technology for distance learning, mentorship and global education appears promising.

Palpation and fluoroscopy are valid but unreliable for the assessment of femoral tunnel position after medial patellofemoral ligament reconstruction.

OBJECTIVES: The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. METHODS: Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment. RESULTS: The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. CONCLUSION: This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. LEVEL OF EVIDENCE: Level 2.

Inter-rater Reliability of the Classification of the J-Sign Is Inadequate Among Experts.

OBJECTIVE: The purpose of this study was to determine the inter-rater and intra-rater reliability of the symmetry, classification, and underlying pathoanatomy associated with the J-sign in patients with recurrent lateral patellofemoral instability. STUDY DESIGN: Blinded, inter-rater reliability study. SETTING: N/A. PARTICIPANTS: Thirty patellofemoral joint experts. INTERVENTIONS: Thirty clinicians independently assessed 30 video recordings of patients with recurrent lateral patellofemoral instability performing the J-sign test. MAIN OUTCOME MEASURES: Raters documented J-sign symmetry and graded it according to the quadrant and Donell classifications. Raters indicated the most significant underlying pathoanatomy and presence of sagittal plane maltracking. Intra-rater reliability was assessed by 4 raters repeating the assessments. Mean pairwise simple and/or weighted Cohen's kappa were performed to measure inter-rater and intra-rater reliability, as well as calculation of percent agreement. RESULTS: J-sign symmetry demonstrated fair inter-rater reliability (k = 0.26), whereas intra-rater reliability was moderate (k = 0.48). Inter-rater reliability for the quadrant and Donell classifications indicated moderate agreement, k = 0.51 and k = 0.49, respectively, whereas intra-rater reliability was k = 0.79 and k = 0.72, indicating substantial agreement. Inter-rater reliability of the foremost underlying pathoanatomy produced only slight agreement (k = 0.20); however, intra-rater reliability was substantial (k = 0.68). Sagittal plane maltracking demonstrated slight inter-rater agreement (k = 0.23) but substantial intra-rater agreement (k = 0.64). CONCLUSIONS: The symmetry, classification, and underlying pathoanatomy of the J-sign demonstrated fair to moderate inter-rater reliability and moderate to substantial intra-rater reliability among expert reviewers using video recordings of patients with recurrent lateral patellofemoral instability. These findings suggest individual raters have a consistent standard for assessing the J-sign, but that these standards are not reliable between assessors. LEVEL OF EVIDENCE: III.

Two-year results of a multi-centre, randomized controlled trial comparing a second-generation uncemented trabecular metal-backed versus cemented polyethylene glenoid component in total shoulder arthroplasty.

AIMS: To report early (two-year) postoperative findings from a randomized controlled trial (RCT) investigating disease-specific quality of life (QOL), clinical, patient-reported, and radiological outcomes in patients undergoing a total shoulder arthroplasty (TSA) with a second-generation uncemented trabecular metal (TM) glenoid versus a cemented polyethylene glenoid (POLY) component. METHODS: Five fellowship-trained surgeons from three centres participated. Patients aged between 18 and 79 years with a primary diagnosis of glenohumeral osteoarthritis were screened for eligibility. Patients were randomized intraoperatively to either a TM or POLY glenoid component. Study intervals were: baseline, six weeks, six-, 12-, and 24 months postoperatively. The primary outcome was the Western Ontario Osteoarthritis Shoulder QOL score. Radiological images were reviewed for metal debris. Mixed effects repeated measures analysis of variance for within and between group comparisons were performed. RESULTS: A total of 93 patients were randomized (46 TM; 47 POLY). No significant or clinically important differences were found with patient-reported outcomes at 24-month follow-up. Regarding the glenoid components, there were no complications or revision surgeries in either group. Grade 1 metal debris was observed in three (6.5%) patients with TM glenoids at 24 months but outcomes were not negatively impacted. CONCLUSION: Early results from this RCT showed no differences in disease-specific QOL, radiographs, complication rates, or shoulder function between uncemented second-generation TM and cemented POLY glenoids at 24 months postoperatively. Revision surgeries and reoperations were reported in both groups, but none attributed to glenoid implant failure. At 24 months postoperatively, Grade 1 metal debris was found in 6.5% of patients with a TM glenoid but did not negatively influence patient-reported outcomes. Longer-term follow-up is needed and is underway. Cite this article: Bone Jt Open 2021;2(9):728-736.

Perceived vs. true glenoid anchor placement: a cadaveric comparison of the beach chair and lateral position.

PURPOSE: To explore whether patient position influences a surgeon's ability to accurately judge anchor position on the glenoid. MATERIALS AND METHODS: Two anchors were inserted into the glenoid of 8 shoulders. Arthroscopic videos were taken from 3 views (posterior beach chair [pBC], posterior lateral decubitus [pLD], and anterosuperolateral decubitus [asLD]). The shoulders were disarticulated to identify "true" anchor position. Seventeen shoulder surgeons reviewed the videos and indicated anchor positions using the "clock face" method. Accuracy was measured within tolerances, ranging from zero (exact), 0.5 (half-hour), 1.0, and 1.5 hours of "true" position. Intra- and inter-rater agreement was calculated. Post hoc analyses explored for bias dependent on surgical side. RESULTS: The overall accuracy was 34.0%. At tolerances of 0.5, 1.0, and 1.5 hours, accuracy increased to 82.4%, 95.4%, and 98.0%. With a 30° scope, identification of exact position was more accurate in pBC than pLD (odds ratio [OR] = 1.397; P = .029) but not asLD (OR =1.341; P = .197). At a tolerance of 0.5 hour, the 30° scope was more accurate in pBC than both pLD (OR = 1.444; P = .011) and asLD (OR = 1.728; P = .009). In left shoulders, anchors were perceived as more inferior than true position in asLD and pLD. In right shoulders, anchors were perceived as more superior than true position from pBC and pLD. Inter- and intrarater agreement were highest in pBC with a 30° scope (30° scope weighted kappa = 0.783 and 70° scope weighted kappa = 0.853, respectively). CONCLUSION: Judgment of anchor position on video is most accurate in a pBC view. Inter- and intrarater reliability were also highest from a pBC view.

Electrothermal arthroscopic capsulorrhaphy: old technology, new evidence. A multicenter randomized clinical trial.

BACKGROUND: Radiofrequency technology for shoulder instability was rapidly adopted despite limited clinical evidence and a poor understanding of its indications. Reports of serious adverse events followed, leading to its abandonment. This paper presents findings from a multicenter randomized clinical trial evaluating the safety and efficacy of electrothermal arthroscopic capsulorrhaphy (ETAC) compared with open inferior capsular shift (ICS) and reviews the role of randomized trials in adopting new technology. METHODS: Patients (>14 years) diagnosed with multidirectional instability or multidirectional laxity with anteroinferior instability and failed nonoperative treatment were enrolled. Patients with bone lesions or labral, biceps anchor, or full-thickness rotator cuff tears were excluded intraoperatively. Outcomes included Western Ontario Shoulder Instability Index, function and recurrent instability at 2 years postoperatively, and surgical times. RESULTS: Fifty-four subjects (mean age, 23 years; 37 women) were randomized to ETAC (n = 28) or open ICS (n = 26). The groups were comparable at baseline, except for external rotation at the side. At 2 years postoperatively, there were no statistically or clinically significant differences between groups for the Western Ontario Shoulder Instability Index (P = .71), American Shoulder and Elbow Surgeons score (P = .43), Constant score (P = .43), and active range of motion. Recurrent instability was not statistically different (ETAC, 2; open, 4; P = .41). ETAC (23 minutes) was significantly shorter than open ICS (59 minutes) (P < .01) surgery. Three subjects (1 ETAC, 2 open) had stiff shoulders. CONCLUSIONS: At 2 years postoperatively, quality of life and functional outcomes between groups were not clinically different. ETAC had fewer complications and episodes of recurrence compared with open surgery. This evidence reinforces the need to critically evaluate new technology before widespread clinical use.

A comparison of pain scores and medication use in patients undergoing single-bundle or double-bundle anterior cruciate ligament reconstruction.

BACKGROUND: No gold standard exists for the management of postoperative pain following anterior cruciate ligament reconstruction (ACLR). We compared the pain scores and medication use of patients undergoing single-bundle (SB) or double-bundle (DB) ACLR in the acute postoperative period. Pain and medication use was also analyzed for spinal versus general anesthesia approaches within both surgery types. METHODS: We assessed 2 separate cohorts of primary ACLR patients, SB and DB, for 14 days postoperatively. We used a standard logbook to record self-reported pain scores and medication use. Pain was assessed using a 100 mm visual analogue scale (VAS). Medications were divided into 3 categories: oral opioids, oral nonsteroidal anti-inflammatories and acetaminophen. RESULTS: A total of 88 patients undergoing SB and 41 undergoing DB ACLR were included in the study. We found no significant difference in VAS pain scores between the cohorts. Despite similar VAS pain scores, the DB cohort consumed significantly more opioid and analgesia medication (p = 0.011). Patients who underwent DB with spinal anesthesia experienced significantly less pain over the initial 14-day postoperative period than those who received general anesthesia (p < 0.001). CONCLUSION: Adequate pain relief was provided to all ACLR patients in the initial postoperative period. Patients in the DB cohort experienced more pain, as evidenced by the significant diffrence in consumption of opioids and acetaminophen, than the SB cohort. Patients who underwent spinal anesthesia experienced less pain in the acute postoperative period than those who received general anesthesia.

CONTEXTE: Il n'existe pas de norme établie pour la prise en charge de la douleur postopératoire après la reconstruction du ligament croisé antérieur (RLCA). Nous avons comparé les scores de douleur et le recours aux analgésiques chez des patients soumis à une RLCA simple faisceau (SF) ou double faisceau (DF) durant la période postopératoire immédiate. La douleur et l'utilisation des analgésiques ont aussi été analysées en rapport avec l'anesthésie utilisée, rachidienne ou générale, dans les 2 types de chirurgie. MÉTHODES: Nous avons évalué 2 cohortes distinctes de patients soumis à une RLCA primaire, SF et DF, pendant les 14 premiers jours postopératoires. Les patients ont consigné leurs scores de douleur et leur utilisation d'analgésiques dans des carnets de bord standard. La douleur était évaluée au moyen d'une échelle analogique visuelle (ÉAV) de 100 mm. Les analgésiques étaient regroupés sous 3 catégories, soit opiacés oraux, antiinflammatoires non stéroïdiens oraux et acétaminophène. RÉSULTATS: En tout, 88 patients soumis à une RLCA SF et 41 à une RLCA DF ont été inclus dans l'étude. Nous n'avons observé aucune différence significative quant au score de douleur à l'ÉAV entre les cohortes. Malgré des scores de douleur similaires à l'ÉAV, la cohorte soumise à l'intervention DF a utilisé significativement plus d'opiacés et autres analgésiques (p = 0.011). Comparativement aux patients sous anesthésie générale, les patients soumis à l'intervention DF sous anesthésie rachidienne ont éprouvé significativement moins de douleur au cours des 14 premiers jours postopératoires (p < 0.001). CONCLUSION: Tous les patients qui ont subi une RLCA ont obtenu un soulagement adéquat de leur douleur durant la période postopératoire initiale. Les patients de la cohorte DF ont éprouvé davantage de douleur, comme en témoigne la différence significative de consommation d'opiacés et d'acétaminophène comparativement à la cohorte SF. Les patients qui ont subi une anesthésie rachidienne ont éprouvé moins de douleur pendant la période postopératoire immédiate, comparativement aux patients sous anesthésie générale.

A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes.

BACKGROUND: The literature comparing open and arthroscopic repair for glenohumeral instability is conflicting. We performed a prospective, expertise-based, randomized clinical trial to compare open shoulder stabilization with arthroscopic shoulder stabilization by measuring quality-of-life outcomes and recurrence rates at two years among patients treated for traumatic anterior shoulder instability. METHODS: Computer-generated, variable-block-size, concealed randomization allocated 196 patients to either the open-repair group (n = 98) or the arthroscopic-repair group (n = 98). An expertise-based randomization design was employed to avoid a differential bias in terms of physician experience. Outcomes were measured at baseline, at three and six months postoperatively, and at one and two years postoperatively with use of the Western Ontario Shoulder Instability Index (WOSI) and the American Shoulder and Elbow Surgeons (ASES) functional outcome scale. Recurrent instability was also analyzed. RESULTS: There were no significant differences in outcome scores at baseline. At two years, seventy-nine patients in the open group and eighty-three patients in the arthroscopic group were available for follow-up. There was no significant difference in mean WOSI scores between the groups; the mean WOSI score (and standard deviation) for the open group was 85.2 ± 20.4 (95% confidence interval [CI] = 80.5 to 89.8), and for the arthroscopic group, 81.9 ± 19.8 (95% CI = 77.4 to 86.4); p = 0.31. There was also no significant difference in mean ASES scores: 91.4 ± 12.7 (95% CI = 88.5 to 94.4) for the open group and 88.2 ± 15.9 (95% CI = 84.6 to 91.8) for the arthroscopic group; p = 0.17. Recurrence rates at two years were significantly different: 11% in the open group and 23% in the arthroscopic group (p = 0.05). Recurrent instability was more likely in patients with a preoperative Hill-Sachs lesion and in male patients who were twenty-five years old and younger. There was no significant difference in shoulder motion between the groups at two years. CONCLUSIONS: There was no difference between open and arthroscopic repair in terms of patient quality of life. Open repair resulted in a significantly lower risk of recurrence. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion.

Knee immobilization for pain control after a hamstring tendon anterior cruciate ligament reconstruction: a randomized clinical trial.

BACKGROUND: This study will attempt to evaluate the efficacy of knee immobilization on patient pain levels after an anterior cruciate ligament reconstruction. HYPOTHESIS: There is no difference in visual analog scale pain scores 2 days after anterior cruciate ligament reconstruction between patients who wear a knee immobilizer and those who do not wear a knee immobilizer. STUDY DESIGN: Randomized clinical trial; Level of evidence, 1. METHODS: Patients aged 18 to 40 years who met study inclusion criteria were eligible. Patients meeting intraoperative inclusion criteria were randomized (immobilizer or no immobilizer) after wound closure. The immobilizer used was a soft, unhinged brace with Velcro straps. Preoperative, intraoperative, and postoperative protocols were standardized. The primary outcome was patient self-assessed pain using a 0-to-100-mm visual analog scale at day 2 after surgery. Secondary outcomes included pain and analgesic use in the first 14 days after surgery, complications, and range of motion (approximately 3 weeks postoperatively). A sample size estimate was calculated and resulted in the need for 44 patients per group. RESULTS: A total of 102 patients were enrolled; 88 patients were randomized, and 14 were excluded intraoperatively. There was no difference in mean visual analog scale pain scores at 2 days after surgery between immobilized and nonimmobilized patients (32.6 and 35.2, respectively; P = .59; difference, -2.6; 95% confidence interval, -12.2 to 6.9). There were no differences between groups in medication consumed, range of motion, or complications. Pain and analgesic use were the same for both groups at 7 and 14 days postoperatively. CONCLUSION: No differences in pain or any of the secondary outcomes were detected between immobilized and nonimmobilized patients at any point during the first 14 days after anterior cruciate ligament reconstruction.

A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: disease-specific quality of life outcome at an average 2-year follow-up.

BACKGROUND: Rotator cuff tears affect patients' quality of life. The evolution toward less invasive operative techniques for rotator cuff repair requires appropriate comparisons with the standard open procedure, using validated outcomes in a randomized fashion. HYPOTHESIS: There is no difference in disease-specific quality of life outcomes at 2 years between an open surgical repair (open) versus an arthroscopic acromioplasty with mini-open (scope mini-open) repair for patients with full-thickness rotator cuff tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with unremitting pain, failed nonoperative treatment, and imaging indicating full-thickness rotator cuff tears were included in the study. Massive irreparable cuff tears were excluded. Patients were assessed using the disease-specific Rotator Cuff-Quality of Life index, which produces a maximum score of 100, representing a high quality of life. Secondary shoulder-specific outcomes (American Shoulder and Elbow Society, Shoulder Rating Questionnaire, and Functional Shoulder Elevation Test) were also measured at baseline, 3 and 6 months, and 1 and 2 years. RESULTS: The mean Rotator Cuff-Quality of Life scores at an average follow-up of 28 months were not statistically different: open, 86.9 (95% confidence interval: 81.8-92.0); and scope mini-open, 87.2 (95% confidence interval: 80.6-93.8). At 3 months, the patients who underwent scope mini-open showed statistically significantly better outcomes (55.6 vs 71.3; P = .005). The baseline to 3-month difference in Rotator Cuff-Quality of Life scores between the scope mini-open and open groups was also statistically significant. CONCLUSION: Patient outcomes improved from baseline to all postoperative measurement intervals. There was no difference in outcome at 1 and 2 years after surgery between the scope mini-open and open procedures. The quality of life of patients undergoing the arthroscopic acromioplasty with mini-open rotator cuff repair improved statistically significantly and clinically at 3 months compared with the open group.

Shoulder strength after open versus arthroscopic stabilization.

BACKGROUND: With current techniques, the main difference between arthroscopic and open shoulder stabilization is the violation of the subscapularis tendon. No studies have looked at strength differences of internal and external rotation between these groups. HYPOTHESIS: Internal rotation strength deficits will exist in patients having undergone an open shoulder stabilization procedure compared with an arthroscopic one. STUDY DESIGN: Piggy-back randomized controlled trial; Level of evidence, 1. METHODS: Forty-eight patients (38 men, 10 women), average age, 30.6 years (range, 18-59 years), were randomized to either open (n = 24) or arthroscopic (n = 24) shoulder stabilization. Rehabilitation protocols were standardized. At a mean follow-up of 19.4 months (range, 12-36 months) from surgery, patients underwent isokinetic strength testing (concentric and eccentric peak moments at 60 deg/s and 180 deg/s). Measurements were body-mass normalized. Primary outcome was internal rotation strength at 60 deg/s. RESULTS: There were no significant differences between groups with respect to age, gender, or operative limb. There were no statistical differences between operative groups for the primary outcome of internal concentric strength at 60 deg/s (mean difference, 0.011 N.m/kg; 95% confidence interval, -0.043 to 0.066; P = .677) or secondary strength measures. When compared with the contralateral limb, strength deficits existed for both surgical groups for both internal and external rotation. Regression analysis demonstrated that arm dominance is a factor in strength deficits. CONCLUSION: The results of this trial suggest there are no side-to-side isokinetic strength deficits between patients having an open stabilization using a subscapularis splitting approach versus arthroscopic stabilization for anterior traumatic shoulder instability at 1 year after surgery. Strength deficits exist in both groups when compared with the contralateral limb.

The inter-rater reliability of shoulder arthroscopy.

PURPOSE: The purpose of this study was to determine the inter-rater reliability of orthopaedic shoulder surgeons in evaluating the intra-articular structures involved in real-time diagnostic shoulder arthroscopy by use of a videotape model. METHODS: Twenty patients (nineteen male patients and one female patient) diagnosed with recurrent anterior shoulder instability with a mean age of 27.9 years (range, 15 to 44 years) consented to participate in the study. Standardized diagnostic shoulder arthroscopies (modified Snyder protocol) were done by a single experienced surgeon, and the procedures were videotaped. The patients' clinical information, radiographs, and videotape of the arthroscopy were sent to 6 experienced shoulder surgeons. The surgeons reviewed the clinical information, assessed the intra-articular structures shown on the videotape, and recorded their diagnoses on a standardized data collection form. The primary outcome was the median overall percent agreement for the video review surgeons by structure evaluated. RESULTS: The median values for overall agreement for the video review surgeons were as follows: anterior labrum, 90%; inferior labrum, 75%; superior labrum, 60%; posterior labrum, 65%; superior glenohumeral ligament, 50%; middle glenohumeral ligament, 50%; anterior inferior glenohumeral ligament, 25%; glenoid surface, 35%; detection of Hill-Sachs lesion, 85%; biceps tendon, 70%; supraspinatus tendon, 85%; infraspinatus tendon, 70%; and subscapularis tendon, 80%. CONCLUSIONS: The inter-rater reliability for orthopaedic shoulder surgeons' arthroscopic assessment of intra-articular anatomy in patients with anterior shoulder instability varied by structure examined. It was very good (>80%) for the anterior labrum and supraspinatus tendon and in detecting a Hill-Sachs lesion, poor (<40%) for the glenoid and anterior inferior glenohumeral ligament, and intermediate for all other structures examined. LEVEL OF EVIDENCE: Level V, diagnostic study, expert opinion.

Patient satisfaction with inpatient versus outpatient reconstruction of the anterior cruciate ligament: a randomized clinical trial.

OBJECTIVE: To compare satisfaction levels after reconstruction of the anterior cruciate ligament (ACL) between inpatients and outpatients by means of a valid and comprehensive outcome tool. METHODS: Fifty patients examined at a tertiary clinic who met the study's inclusion criteria (15-50 yr old, no previous ACL reconstruction, > 6 h after injury, living < 1 h from hospital, assigned a caregiver for outpatient management within 48 h of injury, no serious health condition, no known hypersensitivity to ASA/NSAIDs, bleeding disorder or gastric ulcer, ability to cope at home after operation) were recruited and randomized into either the inpatient or outpatient groups. Inpatients stayed overnight in hospital after their ACL reconstruction and were discharged home the next day. Outpatients were discharged home on the day of the procedure. All patients attended a preoperative educational session and were required to meet the same discharge criteria (able to bear weight using crutches and to void, to be reasonably pain free, no nausea or vomiting, no excess bleeding or drainage, be alert, be given take-home medications and be in the company of a caregiver). Standardized anesthetic and postoperative analgesic protocols were used. One week after ACL reconstruction, patient satisfaction was quantified with a previously validated visual analogue questionnaire (maximum score of 100). RESULTS: We collected data on 21 inpatients and 19 outpatients. The mean overall-satisfaction score of the outpatient group was higher than that of the inpatient group (85.1 v. 78.2, p = 0.015). Between-group differences in postoperative pain, nausea, rate of readmission and complications were not significant. CONCLUSION: As determined by a comprehensive, population-specific, validated outcome, patient satisfaction is higher when ACL reconstruction is done on an outpatient basis.

Arthroscopic versus open repair for traumatic anterior shoulder instability: a meta-analysis.

PURPOSE: The purpose of this study was to critically evaluate the literature to determine whether open or arthroscopic surgical repair for traumatic recurrent anterior shoulder instability results in a better outcome. TYPE OF STUDY: Meta-analysis. METHODS: The search involved clinical studies in all languages in the MEDLINE database from 1966 to October 31, 2003. The following key words were used: (1) anterior shoulder instability, (2) Bankart lesion, (3) traumatic recurrent anterior shoulder instability, and (4) arthroscopic and open Bankart repair. All abstracts were reviewed and articles were included if there was a direct clinical comparison between arthroscopic and open repair for traumatic recurrent anterior shoulder instability. These articles were manually cross-referenced for additional abstracts. The final group of articles was independently critically appraised and the following outcomes were extracted: recurrent instability, return to activity, reoperation rate, and cause of recurrence. RESULTS: The search terms resulted in 677, 183, 68, and 51 hits respectively. From these, 18 articles were determined to be eligible for full review including 2 foreign-language articles. Cross-referencing identified 2 unpublished studies. Eleven studies were included in the final analysis: 1 randomized trial, 2 pseudo-experimental designs, 4 prospective cohorts, 3 retrospective studies, and 1 case control study. Pooled Mantel-Haenszel odds ratio for recurrent instability and return to activity were 2.04 ( P = .003; 95% confidence interval, 1.27, 3.29) and 2.85 ( P = .004; 95% confidence interval, 1.40, 5.78), respectively, in favor of the open repair. CONCLUSIONS: Based on this meta-analysis, open repair has a more favorable outcome with respect to recurrence and return to activity. LEVEL OF EVIDENCE: Level III, Systematic Review of Level III (and II/I) Studies.

The reliability between surgeons comparing arthroscopic and video evaluation of patients with shoulder impingement syndrome.

PURPOSE: To assess interobserver reliability between 2 surgeons, for real-time diagnostic arthroscopy and the corresponding videotape of shoulder pathology in patients with a clinical symptom complex consistent with shoulder impingement syndrome. TYPE OF STUDY: Prospective cohort. METHODS: Fifty-three patients with shoulder impingement syndrome underwent arthroscopic surgery by 1 of 2 experienced orthopaedic shoulder surgeons. All operations were videotaped. The surgeon who did not perform the surgery reviewed the videotaped procedure. The findings in the shoulder were independently documented by each surgeon on standardized shoulder information sheets. The video-review surgeon was blinded to the results of the arthroscopy and all preoperative workup information. The percentage agreement, kappa statistics, and correlations were calculated to assess the inter-rater reliability. RESULTS: The percentage agreement ranged from 100% for tendon ruptures to 39% when identifying acromion type. Interobserver kappa statistics were significant for all relevant structures with the exception of acromion type and coracoacromial ligament. CONCLUSIONS: There was satisfactory reliability between video and real-time arthroscopy. However, better objective definitions of pathology and standardization of arthroscopic techniques would improve these results. Videotaping of arthroscopy can be considered a useful educational tool, a way to improve communication between surgeons, and possibly a medicolegal tool when defining pathology in the shoulder. LEVEL OF EVIDENCE: Level II.

A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain.

The purpose of this study was to determine the diagnostic ability of magnetic resonance imaging (MRI) compared with a reference standard, arthroscopy, in patients presenting with shoulder pain consistent with the signs and symptoms of shoulder impingement. Fifty-eight patients in whom conservative management failed underwent standardized MRI with intravenous gadolinium enhancement and arthroscopic evaluation. The prevalence of supraspinatus tendon, long head of the biceps tendon, and acromioclavicular joint pathology in this population was high: 79.3%, 66%, and 56%, respectively. MRI was highly accurate in detecting full-thickness supraspinatus tears and acromioclavicular joint pathology. However, it had poor concordance with arthroscopy in diagnosing pathology in the biceps tendon and in classifying the curvature of the acromion. A smaller number of other abnormal structures were identified in this population of patients, including labral abnormalities (superior labral anterior-posterior and Bankart tears), Hill-Sachs lesions, and articular surface damage. Concordance between MRI and arthroscopy would increase with improved radiologist-surgeon communication, a more reliable classification of pathology, and possibly the use of intraarticular contrast. This study demonstrates that patients presenting with the clinical findings of shoulder impingement syndrome represent a heterogeneous population. Overall, MRI is a useful tool in the identification of shoulder pathology; however, the clinical correlation of this information and the assessment of outcomes remains unknown.