Is It Time to Rethink the Relationship Between Subscapularis Tears and the Long Head of Biceps Tendon?

Introduction Pre-operative diagnosis of subscapularis tears remains a difficult challenge. Ultrasound has been shown to be ineffective at directly detecting subscapularis tears. It has been widely accepted that medial subluxation of the long head of biceps tendon (LHBT) is associated with full-thickness subscapularis tears. The aims of this study are to assess whether LHBT subluxation on ultrasound scanning has any predictive value for subscapularis tears and to determine the relationship between LHBT subluxation and subscapularis tears at arthroscopy. Methods Pre-operative ultrasound and arthroscopic findings for patients undergoing arthroscopic rotator cuff repair at our institution between March 2011 and January 2016 were analysed. The accuracy of LHBT subluxation on ultrasound and at arthroscopy as a predictor of subscapularis tears at arthroscopy was calculated. The correlation between LHBT subluxation and subscapularis tears was determined. A standardised technique was used for ultrasound scans, and the grade of the sonographer was recorded. Results Three hundred fifty-nine rotator cuff repairs were performed. Twenty-four patients had a subluxed LHBT. Ultrasound was poorly sensitive (50%), and a subluxed LHBT on ultrasound only correlated very weakly with subscapularis tears at arthroscopy (R = 0.268, p<0.001). At arthroscopy, 92 patients had full-thickness subscapularis tears. Of these, only 16 patients (17%) had a subluxed/dislocated LHBT. Of the 24 patients with a subluxed LHBT, eight had no subscapularis tears. Thus, LHBT subluxation/dislocation only correlated weakly with full-thickness subscapularis tears (R=0.252, p<0.001). Conclusion Due to their close anatomical relationship, traditional teaching suggests subscapularis tears are associated with medial LHBT subluxation. Our data indicate that, contrary to popular belief, the two are only weakly correlated. In our series, the majority of patients with subscapularis tears (83%) had their LHBT in-groove. The authors therefore recommend high vigilance during arthroscopy for the diagnosis and repair of subscapularis tears, regardless of pre-operative ultrasound findings and the intra-operative position of the LHBT.

Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial.

OBJECTIVE: To assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy. DESIGN: Pragmatic, multicentre, randomised controlled trial (ARTISAN). SETTING AND PARTICIPANTS: Trauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management. INTERVENTIONS: One session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses. MAIN OUTCOME MEASURES: The primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications. RESULTS: 482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval -0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05). CONCLUSIONS: An additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63184243.

Luminous Insights: Harnessing Carbon Nanodots from Black Seed Powder via Pyrolysis for Bioimaging and Antifungal Investigations.

This study delves into the fabrication of carbon nanodots (CNDs) through a bottom-up approach, utilizing black seed powder as the precursor material and employing the pyrolysis method. CNDs were synthesized across four distinct temperature settings. The investigation encompasses an extensive characterization of the CNDs, including optical and structural attributes. UV-visible and fluorescence spectroscopy were utilized to assess their optical properties, while FT-IR and XRD analyses confirmed their structural integrity. To elucidate size, shape, and nature, HR-TEM imaging was employed. Furthermore, the functional applications of the synthesized CNDs were explored. The material's antifungal potential was evaluated, and its viability for bioimaging was demonstrated by successfully labeling yeast cells with CNDs. This study underscores the multifaceted nature of CNDs, serving as a bridge between synthesis, comprehensive characterization, and practical applications. In summary, the investigation provides insights into the versatile applications of CNDs derived from black seed powder through pyrolysis. The study contributes to the understanding of their fundamental properties and establishes their potential for both antifungal treatments and cellular bioimaging.

DFT stimulation and experimental insights of chiral Cu(II)-salen scaffold within the pocket of MWW-zeolite and its catalytic study.

A Cu(II)-salen complex encapsulated in MWW-framework as an efficient chiral organocatalyst was developed for the synthesis of 3,4-dihydropyrimidin-2-(1H)-one (DHPMs) derivatives via an asymmetric pathway. In order to confirm its structural properties, single-crystal X-ray diffraction, powder XRD, BET, XPS, FE-SEM, EDX, UV-Vis, and FTIR spectra were used. Using computer-assisted DFT calculations, the Cu(II)-salen complex has been fine-tuned to fit into the pocket of the porous MWW support while keeping its chirality. This organocatalyst was shown to be a potent catalyst for the formation of the desired DHPMs product under short reaction times. Furthermore, this green protocol allows rapid and simple isolation of active MWW-trapped Cu(II)-salen scaffolds and its reusability in at least five consecutive runs without losing much of its activity.

Development of a single-session physiotherapy and self-management intervention for the treatment of primary traumatic anterior shoulder dislocation for the 'Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN)' multi centre RCT.

OBJECTIVE: Optimum physiotherapy management for people with a conservatively managed primary traumatic anterior shoulder dislocation is not known. The purpose of the ARTISAN trial is to compare the clinical and cost-effectiveness of a course of usual care physiotherapy with a single session of physiotherapy and self-management, the ARTISAN intervention. ARTISAN is a UK multi-centre, two-arm, parallel group, randomised controlled trial with 1:1 treatment allocation. DESIGN: The intervention was developed following the Medical Research Council framework for developing and evaluating complex interventions and will be reported in line with the template for intervention description and replication checklist (TIDieR) and the Consensus on Exercise Reporting Template (CERT). It was informed by published research, national clinical guidelines, current clinical practice and patient and public involvement. RESULTS: The ARTISAN intervention comprises education (Phase 1), progressive exercise (Phase 2 and Phase 3) and an optional return to sport component (Phase 4). Behaviour change strategies are embedded throughout intervention. The single session of physiotherapy is delivered by a chartered physiotherapist, within the first six weeks of injury, in an NHS outpatient setting. At the end of the initial session, paper-based booklets and/or a patient website with the same content are provided to participants to aid self-management and progression though the four phases of the trial intervention. CONCLUSION: The ARTISAN intervention was successfully implemented throughout the internal pilot and is suitable for testing in the subsequent definitive RCT ARTISAN trial. Trial Registration Number ISRCTN63184243.

Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN): protocol for a multicentre randomised controlled trial.

INTRODUCTION: First-time traumatic anterior shoulder dislocation (TASD) is predominantly managed non-operatively. People sustaining TASD have ongoing pain, disability and future risk of redislocation. There are no published randomised controlled trials (RCTs) comparing different non-operative rehabilitation strategies to ascertain the optimum clinically effective approach after TASD. METHODS AND ANALYSIS: In this multicentre adaptive RCT, with internal pilot, adults with a radiologically confirmed first time TASD treated non-surgically will be screened at a minimum of 30 sites. People with neurovascular complications, bilateral dislocations or are unable to attend physiotherapy will be excluded.Randomisation will be on a 1:1 treatment allocation, stratified by age, hand dominance and site. Participants will receive a single session of advice; or a single session of advice plus offer of further physiotherapy (maximum 4 months). The primary analysis will be the difference in Oxford Shoulder Instability Score at 6 months. A sample size of a minimum of 478 participants will allow us to show a four point difference with 90% power.An embedded qualitative study will explore the participants' experiences of the trial interventions. ETHICS, REGISTRATION AND DISSEMINATION: Funded by NIHR HTA (16/167/56), 1 June 2018; National Research Ethic Committee approved (18/WA/0236), 26 July 2018. First site opened 5 November 2018 and final results will be updated on trial registries and submitted to a peer-reviewed journal and will inform rehabilitation strategies after a TASD. Study Within A Trial (SWAT) funded by MRC (MR/R013748/1), 1 May 2019; registered on the MRC-HTMR All-Ireland Hub (reference number SWAT 121). TRIAL REGISTRATION NUMBER: ISRCTN63184243. (Trial stage: Pre-results).

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review.

INTRODUCTION: Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis. HYPOTHESIS: Different aetiological groups yield variable outcomes following arthroscopic capsular release. MATERIALS AND METHODS: A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines. RESULTS: Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases. LEVEL OF EVIDENCE: IV, systematic review.

The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis.

BACKGROUND: Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known. PURPOSE: To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores. RESULTS: A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms. CONCLUSION: Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.

Distal Biceps and Triceps Injuries.

BACKGROUND: Rupture of the distal biceps and triceps tendons are relatively uncommon injuries typically occurring in middle-aged males as a result of eccentric loading of the tendon. METHODS: A literature search was performed and the authors' personal experiences reported. RESULTS: This review discusses the diagnosis, indications and guidelines for management of these injuries and provides a description of the authors' preferred operative techniques. CONCLUSION: Whilst non-operative treatment may be appropriate for patients with low functional demands, surgical management is the preferred option for the majority of patients. We have described a cortical button technique and osseous tunnel technique utilised at our institution for distal biceps and triceps tendon fixation respectively. For biceps or triceps tendon injuries, those receiving an early diagnosis and undergoing surgical intervention, an excellent functional outcome can be expected.

Distal Humeral Fractures-Current Concepts.

BACKGROUND: Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation. METHODS: A literature search was performed and the authors' personal experiences are reported. RESULTS: This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty. CONCLUSION: Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.

Current concepts in the management of recurrent anterior gleno-humeral joint instability with bone loss.

The management of recurrent anterior gleno-humeral joint instability is challenging in the presence of bone loss. It is often seen in young athletic patients and dislocations related to epileptic seizures and may involve glenoid bone deficiency, humeral bone deficiency or combined bipolar lesions. It is critical to accurately identify and assess the amount and position of bone loss in order to select the most appropriate treatment and reduce the risk of recurrent instability after surgery. The current literature suggests that coracoid and iliac crest bone block transfers are reliable for treating glenoid defects. The treatment of humeral defects is more controversial, however, although good early results have been reported after arthroscopic Remplissage for small defects. Larger humeral defects may require complex reconstruction or partial resurfacing. There is currently very limited evidence to support treatment strategies when dealing with bipolar lesions. The aim of this review is to summarise the current evidence regarding the best imaging modalities and treatment strategies in managing this complex problem relating particularly to contact athletes and dislocations related to epileptic seizures.

Microvascular blood flow in normal and pathologic rotator cuffs.

BACKGROUND: Microvascular blood flow in the tendon plays an important role in the pathogenesis of rotator cuff abnormalities. There are conflicting views about the presence of a hypovascular zone in the supraspinatus tendon. Besides, no studies have looked at the pattern of blood flow around a partial-thickness tear. Our aim was to measure microvascular blood flow in normal and a range of pathologic rotator cuff tendons using laser doppler flowmetry. METHODS: A total of 120 patients having arthroscopic shoulder surgery were divided into 4 equal groups on the basis of their intraoperative diagnosis: normal rotator cuff, subacromial impingement syndrome, and partial-thickness or full-thickness rotator cuff tear. Microvascular blood flow was measured at 5 different regions of each cuff using a laser doppler probe. The values were compared to assess variability within and between individuals. RESULTS: Total blood flow was greater in the normal rotator cuff group compared with the groups with pathologic rotator cuffs, with the largest difference seen in the subacromial impingement group. Within individuals, blood flow was highest at the musculotendinous junction and lowest at the lateral insertional part of the tendon. Among groups, the blood flow was significantly lower at the anteromedial and posteromedial cuff in the groups with impingement and full-thickness tears compared with the group with normal cuff. CONCLUSION: Real-time in vivo laser doppler analysis has shown that microvascular blood flow is not uniform throughout the supraspinatus tendon. Blood flow in the pathologic supraspinatus tendon was significantly lower compared with the normal tendon.

The frequency and risk factors for subsequent surgery after a simple elbow dislocation.

INTRODUCTION: Simple elbow dislocations treated by closed reduction are thought to result in a satisfactory return of function in most patients. Little, however, is known about how many patients ultimately proceed to subsequent surgical treatment due to the low patient numbers and significant loss to follow-up in the current literature. The purpose of this study was to establish the rate of and risk factors for subsequent surgical treatment after closed reduction of a simple elbow dislocation at a population level. PATIENTS AND METHODS: All patients aged 16 years or older who underwent closed reduction of a simple elbow dislocation between 1994 and 2010 were identified using a population database. Subsequent procedures performed for joint contractures, instability or arthritis were recorded. Outcomes were modelled as a function of age, sex, income quintile, co-morbidity, urban/rural status, physician speciality performing the initial reduction and whether orthopaedic consultation and/or post-reduction radiograph was performed within 28 days of the injury, in a time-to-event analysis. RESULTS: We identified 4878 elbow dislocations with a minimum 2-year follow-up: stabilisation surgery was performed in 112 (2.3%) at a median time of 1 month, contracture release in 59 (1.2%) at median 9 months and arthroplasty in seven (0.1%) at median 25 months. Admission to hospital for the initial reduction was associated with an increased risk of undergoing stabilisation (hazard ratio (HR), 2.50; 95% confidence interval (CI), 1.67-3.74) and contracture release (HR, 1.93; CI, 1.08-3.44). Multiple reduction attempts increased the risk of requiring contracture release (HR, 3.71; CI, 1.22-11.29). Survival analysis demonstrated that all subsequent procedures had taken place by 4-5 years. CONCLUSION: Few patients with simple elbow dislocations develop complications requiring surgery, but those that do most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury. Contrary to current thinking, surgery for instability is performed more often than joint contracture release, albeit with slightly different time patterns.

Synthesis, spectral investigation and catalytic aspects of entrapped VO(IV) and Cu(II) complexes into the supercages of zeolite-Y.

VO(IV) and Cu(II) complexes with Schiff base ligand derived from 1-phenyl-3-methyl-4-formyl-2-pyrazolin-5-one (PMFP) and 2-amino phenol have been synthesized as their neat and entrapped complexes into the supercages of zeolite-Y. The compounds were characterized by chemical analysis (ICP-OES and elemental), electronic and/or UV reflectance spectra, FTIR spectroscopy, X-ray powder diffraction patterns, SEMs, BET and thermogravimetric (TG) analysis. All the prepared catalysts were tested on the liquid phase limonene oxidation reaction, using 30% H2O2 as an oxidant. Limonene glycol, carveol, carvone and limonene 1,2-epoxide were the main products obtained. It was observed that zeolite-Y entrapped complexes exhibited higher catalytic activity than neat complexes. The catalysts undergo no metal leaching and can be easily recovered and reused. The use of inexpensive catalyst and oxidant are significant practical advantages of this environmentally friendly process.

The epidemiology of closed reduction for simple elbow dislocations and the incidence of early subsequent open reduction.

BACKGROUND: Simple elbow dislocations are often treated with closed reduction (CR); however, the rate of CR failure and factors that may predict failure have been largely underinvestigated. The objectives of this study were (1) to determine the incidence of elbow dislocations treated by CR in a universal health care system and (2) to identify patient characteristics associated with failed CR, defined as the subsequent need for open reduction. METHODS: Patients ≥16 years old who underwent elbow CR by a physician between 1994 and 2010 were identified from administrative databases. Concurrent elbow fractures were excluded. The incidence density rate (IDR) of CR per 100,000 eligible person-years among the general population was calculated. Failed CR was defined as subsequent open reduction with or without ligament repair or reconstruction within 90 days. Patient and provider characteristics were modeled in a multivariate logistic regression for failure. RESULTS: The cohort consisted of 4878 patients (median age, 41 years) who underwent CR (IDR, 2.65 per 100,000 person-years), and 75 (1.5%) underwent subsequent open reduction with or without ligament repair or reconstruction (median time, 15 days). Young men (≤20 years) had the highest IDR (7.45 per 100,000 person-years), twice that of young women (P = .005). Patient characteristics associated with failed CR included older age (P = .001), admission to the hospital (P < .0001), >1 attempted CR (P = .001), and new orthopedic consultation in the 4 weeks after the CR (P = .02). CONCLUSION: Young men are at highest risk for CR for simple elbow dislocations; however, older patients are more likely to require open intervention, as are those with markers of a difficult reduction signifying potentially greater soft tissue damage. A comprehensive understanding of the epidemiology of simple elbow dislocation will aid management decisions.

A review of management options for proximal humeral fractures.

Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.

Mid-term results of Copeland shoulder cementless surface replacement arthroplasty from an independent centre.

BACKGROUND: The present study reports our experience of Copeland shoulder cementless surface replacement arthroplasty (CSRA) and whether glenoid microfracture influences the progression of glenoid erosion. METHODS: One-hundred-and-twelve CSRAs were performed in 101 patients between 2002 and 2007. Eighty-three patients were alive at the median follow-up time of 72 months (range 9 to 121 months; interquartile range 46 to 93 months). Assessment included an Oxford shoulder score (OSS), patient satisfaction score and plain radiographs. RESULTS: The mean (range) OSS was 27 (7 to 48) and 64 of 73 (87.7%) patients were 'very satisfied' or 'satisfied' with their shoulder. Twenty-three (20.5%) shoulders had over 2 mm of glenoid erosion. Microfracture was performed in 43 of 112 shoulders (38.4%) and did not influence the progression of glenoid erosion. Further surgery was performed in 27 (24.1%) shoulders, including 15 revisions, eight arthrolyses and four subacromial decompressions. Revision to total shoulder arthroplasty was performed in 14 : 10 for glenoid erosion; one each for loosening, periprosthetic fracture, deep infection, and chronic pain. One was revised to reverse arthroplasty for chronic pain. CONCLUSIONS: CSRA performed in an independent centre reproduces the functional outcomes reported by the designer. Glenoid erosion, however, was a common occurrence and the main cause of revision - microfracture did not influence its progression.

Factors that influence the choice to undergo surgery for shoulder and elbow conditions.

BACKGROUND: Knowledge of the factors that influence the willingness of patients considering elective orthopaedic surgery is essential for patient-centered care. To date, however, these factors remain undefined in the orthopaedic population with shoulder and elbow disorders. QUESTIONS/PURPOSES: In a cohort of patients seeking surgical consultation for shoulder or elbow conditions, we sought to identify factors that influenced the willingness and decision to undergo surgery. METHODS: In this prospective study, 384 patients completed a questionnaire collecting socioeconomic and health status data before consultation from June 2009 to December 2010. An additional 120 patients who were offered surgery after consultation completed a second questionnaire on their perceptions and concerns regarding surgery. Logistic regression analyses were used to identify factors influencing the willingness and decision to undergo surgery. RESULTS: Lower income (odds ratio [OR], 0.02; CI, 0.02-0.08; p < 0.001) and living alone (OR, 0.25; CI, 0.08-0.77; p = 0.015) were negative predictors of willingness to consider surgery. Physical functioning did not influence willingness (p = 0.994). A greater perceived level of the likelihood of surgical success by the patient (OR, 41.84; CI, 5.24-333.82; p < 0.001) and greater fluency in the English language (OR, 28.39; CI, 3.49-230.88; p = 0.002) were positive predictors of willingness. Willingness to consider surgery as a possible treatment option before the consultation was a predictor of patients' ultimate decisions to undergo surgery (OR, 4.56; CI, 1.05-19.76; p = 0.042). Patients expressing concern about surgery being an inconvenience to daily life, however, were less likely to decide to proceed with surgery (OR, 0.12; CI, 0.02-0.68; p = 0.017). CONCLUSIONS: Many of the identified factors may act as barriers to potentially beneficial surgical interventions. Although most are not modifiable, an awareness of the influence of individual demographics and possible perceptions of patients' choices may show that more in-depth questioning and provisions for cultural differences may be required during the consultation to enable patients to make fully informed decisions. Future studies using qualitative methods would provide a greater in-depth understanding of patients' perceptions regarding surgery and their decision to proceed. Larger or more homogeneous cohorts also would enable additional identification of these factors for different shoulder and elbow conditions. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Accuracy of abduction-external rotation MRA versus standard MRA in the diagnosis of intra-articular shoulder pathology.

The goal of this study was to compare the accuracy of abduction-external rotation magnetic resonance arthrography (ABERMRA) with standard MRA in the diagnosis of intra-articular shoulder pathology.One hundred three consecutive patients undergoing preoperative direct MRA and subsequent arthroscopic examination were included in the study. Seventy-eight patients underwent standard MRA and 25 underwent ABERMRA. Specialist-trained musculoskeletal radiologists reported all scans, and attending shoulder surgeons performed all arthroscopies. Arthroscopic assessment revealed 11 partial-thickness rotator cuff tears, 3 full-thickness tears, 64 labral lesions (48 soft tissue and 16 significant bony), and 17 superior labrum anterior-posterior (SLAP) tears. The sensitivity/specificity for standard MRA was 0.56/0.99 for partial-thickness rotator cuff tears, 1.00/1.00 for full-thickness rotator cuff tears, 0.75/0.91 for soft tissue labral tears, 0.58/1.00 for significant bony glenoid lesions, and 0.50/0.91 for SLAP tears. Abduction-external rotation magnetic resonance arthrography increased the sensitivity/specificity to 1.00/0.85 for soft tissue labral tears, 0.75/1.00 for significant bony glenoid lesions, and 1.00/1.00 for SLAP tears, although it missed 2 of 2 partial-thickness rotator cuff tears.This study suggests that standard MRA is a valuable investigation tool for instability, SLAP tears, and rotator cuff tears, although limitations exist. Additional ABERMRA sequences appear to improve the diagnostic accuracy of soft tissue anterior and posterior labral tears, SLAP tears, and significant bony glenoid lesions and should be routinely requested by shoulder surgeons when ordering MRAs to obtain the maximum benefit from this invasive investigation.