General and disease-specific use of outcomes scores for the shoulder: a survey of AOSSM, AANA, and ISAKOS members.

OBJECTIVE: To report on the knowledge and use of both general and disease-specific shoulder outcomes scores among orthopedic surgeons. METHODS: A 22-question Internet survey was administered to members of the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North American, and the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine via voluntary e-mail participation. Questions targeted demographic information, preferred surgical management of shoulder conditions, and the preferred use of shoulder outcomes instruments in clinical practice. RESULTS: Excluding defunct and duplicate e-mails among membership societies, a total of 3892 unique e-mails were sent, from which 1129 surveys were returned and were fully completed (29%). The largest number of respondents were in private practice (52%); 21% were in academia; and 26% were in a mix of settings. As for location, 74% practiced in the United States, 10% in Europe, 8% in Mexico/South America, and 6% in Asia. A total of 31% total respondents used scores all or most of the time, and 30% used scores at least some of the time. Respondents felt that the 3 most commonly utilized shoulder scores were the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) score, and the Constant score. The majority of respondents (76%) performed all-arthroscopic instability repairs. The ASES and Western Ontario Shoulder Instability Index (WOSI) scores were the most preferred measures to monitor instability patients, whether or not the scores were actually implemented in their practice. Most perform between 10 and 25 superior labrum anterior-posterior repairs per year and preferred the ASES, UCLA, and Constant scores for these repairs; rotator cuff repair preferred outcomes instruments were similar. When asked to choose 1 score for all shoulder conditions, the ASES was the clear favorite. CONCLUSIONS: This study reports the knowledge and utilization of shoulder scores for both general and disease-specific conditions. Most respondents preferred the ASES score for most shoulder conditions; however, other scores, such as the WOSI, the Constant, and the Short-Form (SF)-36/12, were popular. This information offers insight into the current and future use of shoulder outcomes both for general and disease-specific use.

The outcomes and surgical techniques of the latarjet procedure.

PURPOSE: To determine the optimal position and orientation of the coracoid bone graft for the Latarjet procedure for recurrent instability in patients with recurrent anterior instability and high degrees of glenoid bone loss. METHODS: A systematic review of the literature including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2012), and Medline (1980-2012) was conducted. The following search teams were used: glenoid bone graft, coracoid transfer, glenoid rim fracture, osseous glenoid defect, and Latarjet. Studies deemed appropriate for inclusion were then analyzed. Study data collected included level of evidence, patient demographic characteristics, preoperative variables, intraoperative findings, technique details, and postoperative recovery and complications where available. RESULTS: The original search provided a total of 344 studies. A total of 334 studies were subsequently excluded because they were on an irrelevant topic, used an arthroscopic technique, or were not published in English or because they were review articles, leaving 10 studies eligible for inclusion. Given the different methods used in each of the studies included in the review, descriptive analysis was performed. The duration of follow-up ranged from 6 months to 14.3 years postoperatively. With the exception of 2 studies, all authors reported on recurrent shoulder instability after Latarjet reconstruction; the rate of recurrent anterior shoulder instability ranged from 0% to 8%. Overall patient satisfaction was listed in 4 studies, each of which reported good to excellent satisfaction rates of more than 90% at final follow-up. CONCLUSIONS: As noted in this review, the current literature on Latarjet outcomes consists mostly of retrospective Level IV case series. Although promising outcomes with regard to a low rate of recurrent instability have been seen with these reports, it should be noted that subtle variations in surgical technique, among other factors, may drastically impact the likelihood of glenohumeral degenerative changes arising in these patients. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

An analysis of shoulder outcomes scores in 275 consecutive patients: disease-specific correlation across multiple shoulder conditions.

OBJECTIVES: To determine the outcomes scores of military patients who initially present with a variety of shoulder conditions, identify which scores demonstrate the highest correlation per diagnosis, and determine if a difference exists for patients who went onto surgery. METHODS: Two-hundred and seventy five consecutive patients with mean age of 36.5 +/- 12.9 at presentation completed baseline outcomes assessments that included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) Score, Western Ontario Shoulder Instability Index (WOSI), Western Ontario Rotator Cuff Index (WORC), the Simple Shoulder Test (SST), and the Disabilities of the Arm, Shoulder, and Hand Index (DASH). The patients were grouped by clinical, radiographic, and surgical findings into 10 diagnostic categories. OUTCOMES: The initial mean outcomes scores were SANE 48.8, ASES 50.1, WOSI 1279 (40% normal), WORC 1122.4 (47% normal), SST 6.7, and DASH 33.1. Patients with superior labrum anterior-posterior tears demonstrated the lowest mean scores, followed by instability and rotator cuff tear patients. For all conditions, scores were lower for patients who went onto surgery compared with those managed nonoperatively (p = 0.008). CONCLUSIONS: Our findings may be utilized as a baseline to compare and track patient-derived disability across multiple shoulder conditions and serve to define mean diagnosis-specific shoulder patient preoperative scores.

Interval arthrometric comparison of anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft versus allograft: do grafts attenuate within the first year postoperatively?

BACKGROUND: There is little information regarding the incremental changes in the postoperative laxity of patellar tendon (PT) autografts versus allografts in anterior cruciate ligament (ACL) reconstruction. HYPOTHESES: (1) There would be no significant increase in laxity between 6 weeks and 1 year postoperatively with PT autografts or allografts, (2) there would be no significant difference in laxity between PT autografts and allografts, (3) there would not be a significant difference in laxity between nonirradiated and low dose-irradiated PT allograft tissues, and (4) the physical examination findings would correlate with the instrumented laxity outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of 238 ACL-deficient patients who underwent single-incision endoscopic ACL reconstruction with a PT autograft (n = 132) or allograft (n = 106; 58 irradiated and 48 nonirradiated) from a single surgeon was made looking at data from preoperatively and from 6 weeks to 1 year postoperatively. The objective measurements of ligament integrity included range of motion, Lachman test, pivot-shift test, and KT-1000 arthrometer instrumented laxity examination. Failure was defined as arthrometric side-to-side differences (maximum manual difference) ≥3 mm or a positive pivot shift. Statistical significance was defined as P < .05. RESULTS: There were no differences in postoperative examination findings or instrumented laxity between PT autografts and allografts (irradiated or nonirradiated) in either subgroup. The postoperative improvement based on the Lachman examination, pivot-shift test, and arthrometric data in all study groups was significant (P < .001) in 98% (autograft: n = 130; allograft: n = 104) of patients, and arthrometric failure correlated with failure by physical examination. There was no significant change in graft laxity, as measured by KT-1000 arthrometer, from 6 weeks to 1 year postoperatively for 98% of patients. Finally, there was no statistical correlation in instrumented laxity results for either the autograft or allograft group with reference to age, gender, concurrent meniscectomy, meniscal repairs, interval to surgery, postoperative patellar pain, time to surgery, or irradiated versus nonirradiated allograft. CONCLUSION: Laxity is not increased after the initial 6 weeks for either PT allograft or autograft constructs during the first postoperative year. There was no correlation between age, gender, concomitant injury, interval to surgery, or radiation of the graft with instrumented laxity results. Furthermore, our arthrometric data paralleled our clinical findings of stability at follow-up.

Basic science and surgical treatment options for articular cartilage injuries of the knee.

The complex structure of articular cartilage allows for diverse knee function throughout range of motion and weight bearing. However, disruption to the structural integrity of the articular surface can cause significant morbidity. Due to an inherently poor regenerative capacity, articular cartilage defects present a treatment challenge for physicians and therapists. For many patients, a trial of nonsurgical treatment options is paramount prior to surgical intervention. In instances of failed conservative treatment, patients can undergo an array of palliative, restorative, or reparative surgical procedures to treat these lesions. Palliative methods include debridement and lavage, while restorative techniques include marrow stimulation. For larger lesions involving subchondral bone, reparative procedures such as osteochondral grafting or autologous chondrocyte implantation are considered. Clinical success not only depends on the surgical techniques but also requires strict adherence to rehabilitation guidelines. The purpose of this article is to review the basic science of articular cartilage and to provide an overview of the procedures currently performed at our institution for patients presenting with symptomatic cartilage lesions.

Posterior instability of the shoulder: diagnosis and management.

Recurrent posterior instability of the shoulder can be difficult to diagnose and technically challenging to treat. Although not as common as anterior instability, recurrent posterior shoulder instability is prevalent among certain demographic and sporting groups, and may be overlooked if one is not aware of the typical examination and radiographic findings. The diagnosis itself can be difficult as patients typically present with vague or confusing symptoms, and treatment has evolved from open to arthroscopic surgical techniques. This article is intended to review the anatomy and biomechanics associated with posterior shoulder instability, to discuss the pathogenesis and presentation of posterior instability, and to describe the variety of treatment options and clinical results.

Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results.

HYPOTHESIS: There are significant differences in incidence of cosmetic deformity and load to tendon failure between biceps tenotomy versus tenodesis for the treatment of long head of the biceps brachii (LHB) tendon lesions which are supported by the evidence-based strengths and weaknesses of each procedure in the literature. MATERIALS AND METHODS: PubMed, Embase, and Cochrane databases were searched for eligible clinical and biomechanical articles relating to biceps tenotomy or tenodesis from 1966 to 2010. Keywords were biceps tenotomy, biceps tenodesis, long head of the biceps brachii, and Popeye sign. All relevant studies were included based on study objectives, and excluded studies consisted of abstracts, case reports, letters to the editor, and articles without outcome measures. RESULTS: All articles reviewed were of level IV evidence. Combined results from reviewed papers on the differences between LHB tenotomy vs tenodesis demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy. Complications were similar for each treatment, with a higher likelihood of bicipital pain associated with tenodesis. Lack of high levels of evidence from prospective randomized trials limits our ability to recommend one technique over another. DISCUSSION: This review demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy compared with tenodesis, with an associated lower load to tendon failure. However, there was no consensus in the literature regarding the use of tenotomy vs. tenodesis for LHB tendon lesions due to variable results and methodology of published studies. Individual patient factors and needs should guide surgeons on whether to use tenotomy or tenodesis. CONCLUSIONS: There is a great need for future studies with high levels of evidence, control, randomization, and power, with well-defined study variables, to compare biceps tenotomy and tenodesis for the treatment of LHB tendon lesions.

The importance of the recognition and treatment of glenoid bone loss in an athletic population.

CONTEXT: Osseous injury to the glenoid is increasingly being recognized as one of the most important aspects in the successful management of recurrent shoulder instability. Proper early recognition of glenoid bone injury in the setting of recurrent instability will lead to successful nonoperative and operative decision making, particularly in the athletic patient. EVIDENCE ACQUISITION: We conducted a MEDLINE search on shoulder instability from 2000 to 2010. The emphasis was placed on patient-oriented Level 1 literature from 2000 to 2010. RESULTS: After a traumatic anterior dislocation of the shoulder, the most common structural injury is an avulsion of the anteroinferior capsulolabrum, which is also known as a Bankart lesion. If this specific injury is accompanied by an associated fracture in the glenoid rim, the term bony Bankart lesion is more applicable. With diminished articular constraints, the glenohumeral joint is subject to recurrent instability, thereby potentiating the bony injury cycle. Additionally, patients with osseous defects usually complain of instability within the midranges of motion, or they recall a progression of instability. If glenoid bone loss is present, the humeral head often easily subluxates over the glenoid in the midranges of abduction (30°-90°) and lower levels of external rotation. Imaging workup should begin with plain radiographs, but advanced imaging should be obtained if there is any suspicion of bone loss. Treatment includes both nonoperative and operative interventions. CONCLUSIONS: Estimation of the amount of glenoid bone loss and the failure of nonoperative care is essential for guiding management, patient expectations, and surgical decision making.

Arthroscopic suprascapular nerve decompression: indications and surgical technique.

BACKGROUND: Although entrapment of the suprascapular nerve (SSN) is an infrequent presentation of shoulder pain, proper diagnosis and treatment are critical to prevent chronic supraspinatus and infraspinatus atrophy. MATERIALS AND METHODS: We present a technique that allows SSN decompression at the spinoglenoid notch or suprascapular notch through the subacromial space. RESULTS AND CONCLUSIONS: This method allows for facile decompression of the SSN after repair of concomitant shoulder pathology and allows direct visualization of the medial neck of the glenoid to avoid complications of iatrogenic SSN nerve injury from aggressive medial capsule dissection. The purpose of this article is to provide surgeons with a safe, reliable method to decompress the SSN at the suprascapular or spinoglenoid notch.

Patellofemoral kinematics after limited resurfacing of the trochlea.

Patellofemoral kinematics after a limited resurfacing of the trochlea was investigated. Patellofemoral contact pressure, area, and force were measured for intact state; after creation of a 20-mm full-thickness trochlear defect; and after trochlear resurfacing implant (Arthrosurface) in serial flexion positions (45 degrees, 60 degrees, 75 degrees). In the defect state, edge loading and peak contact forces were highest at the periphery. The chondral defect increased peak contact force (13 to 18 N, P < .01) and peak contact pressure (23 to 31 kg/cm2, P < .02) compared with the intact state. Peak contact pressure and force were restored to 90% (P < .01) and 88% (P < .01). Implantation of the device restored contact area to 85% of the intact state. Limited resurfacing of the trochlea restores contact area, peak pressure, and peak force to the intact state. These findings highlight the potential clinical use of limited patellofemoral resurfacing in trochlear chondral defects.

Complications associated with anterior shoulder instability repair.

Anterior shoulder instability is a common orthopaedic problem, and the surgical treatment, both open and arthroscopic, has been shown to effectively restore stability and prevent recurrence. However, despite success with these surgical techniques, there are several clinically relevant complications associated with both open and arthroscopic techniques for anterior shoulder stabilization. These complications can be subdivided into preoperative, intraoperative, and postoperative and include entities such as nerve injury, chondrolysis, incomplete treatment of associated lesions, and subscapularis dysfunction. When they occur, complications may significantly impact patient outcomes and function. Therefore, surgeon awareness and identification of the factors associated with these complications may help prevent occurrence. Although failure of instability repair can be classified as a complication of surgery, it requires an entirely separate discussion and is therefore not addressed in this article. Because most of the previously published studies on anterior shoulder instability have emphasized surgical technique and clinical outcomes, the purpose of this article is to define the complications associated with anterior instability repair and provide recommendations on techniques that may be used to help avoid them.

Open, mini-open, and all-arthroscopic rotator cuff repair surgery: indications and implications for rehabilitation.

UNLABELLED: Rotator cuff tears lead to debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. The clinical outcomes of the surgical methods of rotator cuff repair (open, mini-open, and all-arthroscopic cuff repair) vary, as each method provides an array of advantages and disadvantages. Although the open surgical technique has long been considered the gold standard of rotator cuff repair, surgeons are becoming more adept at decreasing patient morbidity through decreased surgical trauma from an all-arthroscopic approach. In addition to a surgery-specific rotator cuff rehabilitation program, effective communication, and coordination of care by the physical therapist and surgeon are essential in optimal patient education and outcomes. In the ideal situation, a very well-educated therapist who has great communication with the treating surgeon can mobilize the shoulder early, re-establish scapulothoracic function safely and minimize the risk of stiffness and retear, while facilitating return to function. Treatment options can be individualized according to patient age, size and chronicity of tear, surgical approach, and fixation method. We recommend that patients who have undergone an all-arthroscopic rotator cuff repair undergo an accelerated postoperative rehabilitation program. A rational approach to therapy involves early, safe motion to allow optimal tendon healing, yet maintenance of joint mobility with minimal stress. As the field of orthopedics and, particularly, rotator cuff repair continues to develop with new technologies, the patient, physical therapist, and doctor need to work together to ensure optimal outcomes and patient satisfaction. LEVEL OF EVIDENCE: Therapy, Level 5.