Shoulder-specific Outcome Research Articles

High rate of clinically relevant improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis.

The minimal clinically important difference (MCID) is defined as the smallest meaningful change in a health domain that a patient would identify as important. Thus, an improvement that exceeds the MCID can be used to define a successful treatment for the individual patient. To quantify the rate of clinical improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis. Patients were treated with the Global Unite total shoulder platform arthroplasty between March 2017 and February 2019 at Herlev and Gentofte Hospital, Denmark. The patients were evaluated preoperatively and 3 months, 6 months, 12 months, and 24 months postoperatively using the Western Ontario Osteoarthritis of the Shoulder index (WOOS), Oxford Shoulder Score (OSS) and Constant-Murley Score (CMS). The rate of clinically relevant improvement was defined as the proportion of patients who had an improvement 24 months postoperatively that exceeded the MCID. Based on previous literature, MCID for WOOS, OSS, and CMS were defined as 12.3, 4.3, and 12.8 respectively. Forty-nine patients with a Global Unite total shoulder platform arthroplasty were included for the final analysis. Mean age at the time of surgery was 66 years (range 49.0-79.0, SD: 8.3) and 65% were women. One patient was revised within the two years follow-up. The mean improvement from the preoperative assessment to the two-year follow-up was 46.1 points [95% confidence interval (95%CI): 39.7-53.3, P < 0.005] for WOOS, 18.2 points (95%CI: 15.5-21.0, P < 0.005) for OSS and 37.8 points (95%CI: 31.5-44.0, P < 0.005) for CMS. Two years postoperatively, 41 patients (87%) had an improvement in WOOS that exceeded the MCID, 45 patients (94%) had an improvement in OSS that exceeded the MCID, and 42 patients (88%) had an improvement in CMS that exceeded the MCID. Based on three shoulder-specific outcome measures we find that approximately 90% of patients has a clinically relevant improvement. This is a clear message when informing patients about their prognosis.

Non-steroidal Anti-inflammatory Drugs and Cyclooxygenase-2 Inhibitors Do Not Affect Healing After Rotator Cuff Repair: A Systematic Review and Meta-analysis

To determine whether non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors affect healing rate, functional outcomes, and patient satisfaction after rotator cuff repair. Medline, EMBASE, PsychINFO and the Cochrane Library were searched for randomized controlled trials (RCTs) investigating the use of NSAIDs and COX-2 inhibitors after arthroscopic rotator cuff repair. Primary outcomes included healing and retear rate, determined by radiological imaging. Secondary outcomes included shoulder-specific outcome measures and the visual analog scale (VAS). Risk of bias was graded using the Cochrane risk-of-bias v2.0 tool. The GRADE framework was used to assess certainty of findings. Seven RCTs with a total of 507 patients were included (298 randomized to NSAID/COX-2 vs 209 randomized to control). NSAIDs use did not yield a difference in retear rate (P= .77). NSAIDs were shown to significantly reduce pain in the perioperative period (P= .01); however, no significant difference was present at a minimum of 6 months (P= .11). COX-2 inhibitors did not significantly reduce pain (P= .15). Quantitative analysis of ASES and UCLA scores showed NSAIDs significantly improved functional outcomes versus control (P= .004). COX-2 inhibitors did not significantly improve functional outcomes (P= .15). Two trials were deemed "low" risk of bias, four trials were graded to have "some concerns", and one trial was graded to have "high" risk of bias. Retear rate and functional PROMs were deemed to have "low" certainty. VAS pain scale was graded to have "moderate" certainty. This systematic review and meta-analysis indicates that NSAIDs do not affect healing rate after arthroscopic rotator cuff repair, but they do significantly improve postoperative pain and functional outcomes. No significant difference was seen in pain or functional outcomes with the use of COX-2 inhibitors. Level I, meta-analysis of randomized controlled trials.

A systematic review of the measurement properties of the Pennsylvania Shoulder Score

BackgroundPennsylvania Shoulder Score (PSS) is a patient-reported outcome measure (PROM) that is gaining use when examining shoulder-specific outcomes. To date, a systematic review of the PSS measurement properties has not been published. PurposeTo systematically locate, appraise, and synthesize the evidence concerning the measurement properties of the PSS. Study DesignSystematic literature review. MethodsA pair of raters conducted a literature search using pre-defined keywords from 5 databases (PubMed, CINAHL, SPORTdiscus, PsychINFO, Scopus) during the week of October 23, 2022. Critical appraisal of study design for psychometric articles was used to assess methodological quality and risk of bias. Measurement property data were synthesized with pooled estimates for the indices of test-retest reliability (ICC), standard error of measurement (SEM), minimal detectable change (MDC), Cronbach α (CA), effect size (ES), and standardized response means (SRM) calculated from applicable studies. ResultsA total of 13 articles met the inclusion criteria for this review. Methodological quality was agreed upon between the 2 raters with a weighted kappa of 0.77, and 9/13 of the articles were rated above 70%. Test-retest reliability of the PSS total score ranged between 0.90 and 0.94, and construct validity was high when compared to other shoulder-specific PROMs (0.75 < r > 0.96). Responsiveness of the PSS was large across all studies with few PSS subscales dropping to moderate. Pooled MDC90 of the total PSS was 12.13 points, and the pooled ES of the total PSS was 0.85. ConclusionsThe scope of this review demonstrates positive measurement properties of the PSS as a reliable, valid, and responsive measurement of shoulder-specific PROM. However, there are few studies examining the measurement properties of the PSS and more research is needed to assess cross-cultural appropriateness and factor analysis of the questions contained in the PSS.

The clinical impact of retears after repair of posterosuperior rotator cuff tears: a systematic review and meta-analysis.

Structural integrity after rotator cuff repair is frequently not achieved, but the clinical consequences of a retear remain disputed. The purpose of this meta-analysis was to analyze the relationships between postoperative cuff integrity and shoulder pain and function. We searched the literature for studies of surgical repair of full-thickness rotator cuff tears published after 1999 describing rates of retear and clinical outcomes and providing sufficient data to estimate effect sizes (standardized mean differences [SMDs]). Baseline and follow-up data of healed and failed repairs were extracted, including shoulder-specific scores, pain, muscle strength, and health-related quality of life. Pooled SMDs, mean differences, and overall change from baseline to follow-up according to structuralintegrity at follow-up were calculated. Subgroup analysis was performed to assess the influence of study quality on differences. This analysis included 43 study arms with 3350 participants. The average age of the participants was 62 years (range, 52-78 years). The median number of participants per study was 65 (interquartile range, 39-108). At a median of 18 months' follow-up (interquartile range, 12-36 months), 844 repairs (25%) were described as retorn on imaging. The pooled SMD between healed repairs and retears at follow-up was 0.49 (95% confidence interval [CI], 0.37 to 0.61) for the Constant-Murley score, 0.49 (95% CI, 0.22 to 0.75) for the American Shoulder and Elbow Surgeons score, 0.55 (95% CI, 0.31 to 0.78) for other shoulder-specific outcomes combined, 0.27 (95% CI, 0.07 to 0.48) for pain, 0.68 (95% CI, 0.26 to 1.11) for muscle strength, and -0.001 (95% CI, -0.26 to 0.26) for health-related quality of life. The pooled mean differences were 6.12 (95% CI, 4.65 to 7.59) for the Constant-Murley score, 7.13 (95% CI, 3.57 to 10.70) for the American Shoulder and Elbow Surgeons score, and 0.49 (95% CI, 0.12 to 0.87) for pain, all below the commonly suggested minimal clinically important differences. The differences were not significantly affected by study quality and were generally modest compared with overall improvements from baseline to follow-up for both healed and failed repairs. The negative impact of retears on pain and function was statistically significant but judged to be of minor clinical importance. The results indicate that most patients may expect satisfactory outcomes despite retears.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure. A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered. Correlation was excellent for the SANE and the ASES (n=1838, r=0.81, P<.0001), the WORC (n=1793, r=0.82, P<.0001), and the SST (n=1836, r=0.76, P<.0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE=2.1, ASES=2.2, WORC=2.4, and the SST=1.8. The ES of the SANE=2.4, ASES=2.7, WORC=3.0, and the SST=2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P<.0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions. In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty?

There is no consensus as to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes for either clinical or research purposes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. To date, the Single Assessment Numeric Evaluation (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis of this study was that the SANE would correlate with and be equal or superior in responsiveness to other outcome measures that have been used in a stand-alone fashion in patients undergoing total shoulder arthroplasty (American Shoulder and Elbow Surgeons [ASES], Western Ontario Osteoarthritis of the Shoulder [WOOS], and Simple Shoulder Test [SST] scores). In addition, it was hypothesized that the SANE would be more relevant to each patient than the ASES assessment, further supporting the use of the SANE as a stand-alone shoulder-specific outcome measure. A retrospective review of a database of patients undergoing total shoulder arthroplasty was performed, in which the SANE score was recorded simultaneously with the ASES, WOOS, and/or SST score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of all scores.The relevance of the SANE and ASES assessments was examined using the scores of 150 consecutive patients to determine the number of questions on each assessment that were not answered. Correlation was excellent for the SANE score and the ASES score (n=1447, r=0.82, P<.0001), WOOS score (n=1514, r=0.83, P<.0001), and SST score (n=1095, r=0.81, P<.0001). The correlation of preoperative scores was moderate and that of postoperative scores was strong-moderate when the SANE score was compared with all 3 other scores. All scores were highly responsive, with standardized response mean values of 2.2 for the SANE score, 2.3 for the ASES score, 1.4 for the WOOS score, and 1.6 for the SST score. The effect size of the SANE score was 2.9; ASES score, 2.9; WOOS score, 2.9; and SST score, 2.3. One hundred percent of the SANE questions were answered completely compared with 61% of the ASES questions (P<.0001). In patients undergoing total shoulder arthroplasty, the SANE score highly correlated with the WOOS, ASES, and SST scores, which have been used as stand-alone shoulder-specific outcome measures. The SANE score may provide the same information as the WOOS, ASES, and SST score regarding outcomes with a significant reduction in responder burden. It is logical that the SANE can be used as a stand-alone instrument for patients undergoing total shoulder arthroplasty.

Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life.

Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life. The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications. Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤15P.) and group B with poor outcome (∆CMS ≥16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance. 138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36-167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9±19.2 [20.0-100] vs. 70.4±19.5 [15.0-98.0]; p=0.008) and EQ index (0.91±0.14 [0.19-1.00] vs. 0.82±0.17 [0.18-1.00]; p<0.001). In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

Correlation and responsiveness of global health, upper extremity-specific, and shoulder-specific functional outcome measures following reverse total shoulder arthroplasty for proximal humerus fracture

PurposeReverse total shoulder arthroplasty (rTSA) is effective and increasingly utilized for the management of proximal humerus fracture (PHF). However, the optimal patient-reported outcome metrics (PROMs) for the evaluation of patient outcomes after this surgery are unclear. We investigated the correlation among global, upper extremity-specific, and shoulder-specific PROMs in patients undergoing rTSA for PHF as well as the responsiveness of these PROMs as assessed by floor and ceiling effects. We hypothesized that patients’ post-operative outcome would be best reflected by a combination of these metrics.MethodsThirty patients with a history of rTSA for ipsilateral PHF filled out the following outcomes questionnaires at a minimum of 3 years post-op: EQ-5D, EQ-5D VAS, PROMIS physical function, DASH, SSV, SPADI, and ASES. Correlation between metrics was assessed using the Spearman correlation coefficient. Responsiveness was assessed by comparing the proportion of patients reaching floor or ceiling values using McNemar’s test.ResultsGlobal health metrics (EQ-5D and PROMIS physical function) were strongly correlated with the upper extremity-specific metric (DASH). Shoulder-specific outcomes (SPADI, ASES, and ASES) were moderately correlated with both the global metrics and DASH. There was no significant difference between PROMs with regards to floor and ceiling effects.ConclusionsThe DASH score has been shown to be valid and responsive for shoulder interventions, and our data demonstrate that it correlates strongly with overall quality of life. Shoulder-specific metrics are valid and responsive for shoulder interventions but correlate less with global quality of life. An optimal PROM strategy in rTSA for PHF might involve both DASH and a shoulder-specific score. Based on our assessment of floor and ceiling effects, none of these metrics should be excluded for poor responsiveness.

Analyzing outcomes after proximal humerus fractures in patients

There has been an increasing amount of interest and research examining best practices for the treatment of proximal humerus fractures (PHF). Recent, high-level randomized control trials and many retrospective cohort studies have failed to demonstrate clear benefit of surgical management for these injuries especially in the elderly (generally defined as ≥65 years old). There is a paucity of research available on outcomes after surgical and nonsurgical treatment of proximal humerus fractures in adults younger than 65 years, and comparative data are almost nonexistent. The purpose of our study was to perform a systematic review and meta-analysis on the available data to determine if the literature supports surgical management over conservative treatment for PHFs in adults younger than 65 years. Adhering to PRISMA guidelines, a systematic review of proximal humerus fractures was performed using MEDLINE and Google Scholar databases. Studies were included if they reported useable data such as outcome measures for adult patients younger than 65 years. Quality of nonrandomized studies was assessed utilizing the MINORs criteria. Extracted data were analyzed using statistical software with P-value set at 0.05. Six studies were included in the study for data extraction and statistical analysis. When comparing Constant Scores (CS) and Oxford Shoulder Scores (OSS) of operatively and nonoperatively treated adult patients aged less than 65 years, no statistical differences were found. Furthermore, no statistical differences in CS or OSS were found comparing elderly patients (defined as ≥65 years) and adult patients (defined as 18 to <65 years). Analysis of DASH outcome data did show statistical differences of the three cohorts (nonoperative <65, operative <65, and operative ≥65). Thus, only the limb-specific (not joint specific) outcome score (DASH) was found to be significantly different upon data analysis. Differences in shoulder-specific outcome scores (OSS and CS) failed to meet significance. The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. These results challenge the widely accepted practice of choosing surgical treatment in adult patients younger than 65 years with PHFs.

Return to Play After Biceps Tenodesis and Transfer in a Young, Athletic Population.

The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44(1):e13-e18.].

Current Applications of Single Shoulder-Specific or Upper Extremity Region-Specific Patient-Reported Outcome Measures in Swimmers: A Critically Appraised Topic

Clinical Question: What single shoulder-specific or upper extremity region-specific patient-reported outcome (PRO) measures (I) are used to assess self-perceived disability (O) in competitive swimmers (P)? Clinical Bottom Line: There is limited research on the use of single shoulder-specific or upper extremity region-specific PRO measures for self-perceived disability in competitive swimmers. Current use of single shoulder-specific or upper extremity region-specific PRO measures are inconsistent and select applications vary across studies. Future research on competitive swimmers should include single shoulder-specific or upper extremity region-specific PRO measures that address sport-related self-perceived disability. This would allow for additional evidence to support the recommendation and use of appropriate single shoulder-specific or upper extremity region-specific PRO measures for competitive swimmers, increased clinical applicability, and comparison of research findings across studies to assist with evidence-based practices.

Nepali translation, cross-cultural adaptation and measurement properties of the Shoulder Pain and Disability Index (SPADI)

BackgroundThe Shoulder Pain and Disability Index (SPADI) is a 13-item shoulder-specific patient-reported outcome measure (PROM). The English version is easy to use and has demonstrated excellent measurement properties for both clinical and research settings. The availability of the SPADI in Nepali would facilitate shoulder research and enhance management of patients with shoulder pain in Nepal. Therefore, the purpose of this study was to translate and cross-culturally adapt the SPADI into Nepali (SPADI-NP) and evaluate its measurement properties.MethodsThe translation and adaptation process followed international guidelines. Participants completed SPADI-NP on two assessments (N = 150 at initial and 119 at follow-up assessment). A Nepali version of the Global Rating of Change score was completed at follow-up. Assessment of measurement properties included analysis of internal consistency (Cronbach’s α), minimal detectable change (MDC) with standard error of measurement (SEM), test-retest reliability (intraclass correlation coefficient; ICC), validity (factor structure, construct using Pearson’s correlation with the Disability of Arm and Hand [DASH]) and responsiveness (area under the curve; AUC) with minimal important change (MIC).ResultsMinor changes were integrated in the adaptation process to improve cultural relevance such as dress items. Items were largely loaded under two factors (pain and disability), internal consistencies were good for the pain construct (α = 0.82) and disability (α = 0.88) and test-retest reliability was excellent (pain = 0.89, disability = 0.96). MDC was 5.7 (out of 100) with SEM = 2.1. Strong associations with the DASH (r = 0.63 pain, r = 0.81 disability) demonstrated its construct validity. The AUC was 0.68 and MIC was 12.3 (out of 100).ConclusionThe Nepali version of the SPADI demonstrated excellent reliability and validity. It can be used for the assessment of shoulder pain and disability in patients with shoulder pain in Nepal in both clinical practice and research.

General health measures in shoulder surgery: are we powered for success?

Surgeons, policymakers, and payers increasingly use changes in general health to guide decision-making. It is unknown how such measures are incorporated into shoulder surgery research, how strongly they are associated with changes in shoulder-specific outcomes, and whether they are appropriately powered. PubMed was searched for articles reporting shoulder-specific and general health measures after rotator cuff repair and total shoulder arthroplasty. Study characteristics, results at the study group level, reporting of power calculations, and statistical significance were recorded. Meta-regression was employed to describe the association of changes between shoulder-specific and general health measures. Of 360 identified abstracts, 21 articles with 28 patient groups were included. Only 1 article was published before 2000. There was a strong association of changes between shoulder-specific and general health measures(r = 0.66; P < .001). Power calculations were mentioned in 33% of studies and based on shoulder-specific measures. Of 20 studies conducting hypothesis tests, 75% reported agreement regarding the statistical significance of shoulder-specific and general health tests. Of 5 discordant studies, 4 found the shoulder-specific measure statistically significant and not the general health measure. Shoulder surgery research increasingly reports changes in general health measures that are associated with changes in shoulder-specific measures, suggesting that improvements in shoulder symptoms increase quality of life. When disagreement exists, it usually results from the general health measure's not meeting statisticalsignificance, which may simply reflect type II error. Research reporting general health measures should carefully report power considerations to avoid misinterpretation of findings failing to reach statistical significance.

Shoulder-specific outcomes 1 year after nontraumatic full-thickness rotator cuff repair: a systematic literature review and meta-analysis.

Nontraumatic full-thickness rotator cuff tears are commonly initially treated conservatively. If conservative treatment fails, rotator cuff repair is a viable subsequent option. The objective of the present meta-analysis is to evaluate the shoulder-specific outcomes one year after arthroscopic or mini-open rotator cuff repair of nontraumatic rotator cuff tears. A literature search was conducted in PubMed and EMBASE within the period January 2000 to January 2017. All studies measuring the clinical outcome at 12 months after nontraumatic rotator cuff repair of full-thickness rotator cuff tears were listed. We included 16 randomized controlled trials that met our inclusion criteria with a total of 1.221 shoulders. At 12 months after rotator cuff repair, the mean Constant score had increased 29.5 points; the mean American Shoulder and Elbow Score score increased by 38.6 points; mean Simple Shoulder Test score was 5.6 points; mean University of California Los Angeles score improved by 13.0 points; and finally, mean Visual Analogue Scale score decreased by 4.1 points. Based on this meta-analysis, significant improvements in the shoulder-specific indices are observed 12 months after nontraumatic arthroscopic or mini-open rotator cuff repair.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff.

Treating shoulders with osteoarthritis, an intact rotator cuff, and substantial glenoid bone loss is challenging. One option is reaming the glenoid flat and inserting a reverse prosthesis. This study reports the subjective, objective, and radiographic results of reverse total shoulder arthroplasty (RTSA) in this population. We retrospectively reviewed 42 consecutive patients (23 women; mean age, 71 years [range, 53 to 89 years]) with primary glenohumeral osteoarthritis, intact rotator cuffs, and Walch type-A2 (n = 19), B2 (n = 5), or C glenoids (n = 18) who had undergone a total of 42 RTSAs with glenoid reaming without bone-grafting between 2008 and 2013 (mean follow-up, 36 months [range, 24 to 66 months]). All patients were evaluated before and after surgery subjectively (using a visual analog scale for pain and 5 shoulder-specific outcome instruments), objectively (with goniometric examination of shoulder range of motion), and radiographically (to assess baseplate loosening and degree of scapular notching). One baseplate (2%) failed, requiring revision surgery. There were no other signs of baseplate loosening in any patient at the last follow-up. Preoperatively to postoperatively, pain improved significantly (p < 0.001), as did all patient-reported outcome measures and the following range-of-motion parameters (p ≤ 0.001): active abduction, active flexion, and active external rotation with the arm elevated 90°. Eight (19%) of the patients had notching. RTSA without bone-grafting and with medialization of the baseplate in patients with osteoarthritis and severe glenoid bone loss resulted in significant improvement in pain and function with reliable short-term implant survivorship and may be a good alternative to anatomical TSA. Longer follow-up is needed to determine the relative advantages and disadvantages. This was an "off-label" indication for this device. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Conceptualization and assessment of disability in shoulder-specific measures with reference to the International Classification of Functioning, Disability and Health.

To expand on a previous systematic review of shoulder-specific outcome measures by investigating how concepts of functioning were conceptualized and measured, using International Classification of Functioning, Disability and Health (ICF) constructs as a reference. The material consisted of the linked content of 17 condition-specific measures. The distribution of the key concepts of functioning was assessed in relation to the 3 ICF levels: body level (body functions and structures), personal level (activities) and societal level (participation). Based on this cate-gorization, the concepts were further explored; body functions as to whether they were informed by any contextual information, and activities and participation as to whether they measured a person's capacity, capability or performance. Seven measures assessed all 3 levels of functioning, 8 measured 2 levels, and 2 measured a single level. The majority of the 15 measures including body functions assessed a mix of decontextualized and contextualized functions. Of the 13 measures of activities, 7 measured capabilities, 4 performance and 2 used both constructs. In comparison, among the 11 measures of participation, 5 measured capabilities, 2 performance and 4 a mixture of these. No measure used the capacity construct. Shoulder-specific outcome measures differ in their choice of measurement levels and measurement constructs. The inconsistent use of the capability and performance constructs to measure activities and participation, raise important questions about the suitability of the measures for their intended use.

Responsiveness of outcome measures in patients with superior labral anterior and posterior lesions.

Evaluation of patients with superior labral anterior and posterior (SLAP) lesions requires outcome measures validated for the purpose. The present study aimed to evaluate the responsiveness of the Rowe score, Oxford Instability Shoulder Score (OISS), Western Ontario Shoulder Instability Index (WOSI) and EuroQol (EQ-5D and EQ-VAS) in patients treated for SLAP lesions. Eighty-nine patients were included: 34 had arthroscopic labral repair, 28 had mini-open biceps tenodesis and 27 had physical treatment. The outcome measures were administrated before treatment and after 6 months. Responsiveness was evaluated using standardized response mean (SRM), area under receiver-operating characteristic curve (ROCAUC), reliable chance proportion (RCP) statistics and hypothesis testing. Minimal clinically important change (MCIC) estimates were reported. All outcome measures had high values of SRM (0.86-1.92). RCPs for the improved group were 68% to 79% for OISS, WOSI and Rowe score, and 15% to 49% for EuroQol. ROCAUC was >0.70 for all outcomes. MCIC estimates were 8 and 10 for OISS; 451 and 569 for WOSI; 17 and 18 for Rowe score; 0.39 and 0.53 for EQ-5D; and 35 and 41 for EQ-VAS. Responsiveness tested with hypotheses favours the shoulder-specific outcomes. OISS, WOSI and Rowe score are more responsive than EuroQol in evaluation of patients with SLAP lesions.

Posterior Sternoclavicular Joint Injuries in Skeletally Immature Patients

The management of sternoclavicular injuries in skeletally immature patients has not been well described. The purpose of this study was to describe the authors' experience treating this rare and potentially life-threatening injury. All skeletally immature patients who underwent treatment for a medial clavicular physeal fracture or sternoclavicular dislocation between 2003 and 2011 were identified using ICD-9 diagnostic codes. Sternoclavicular injuries with posterior displacement were isolated from this cohort for a thorough chart review. Patients were contacted to complete brief phone surveys and shoulder-specific outcome instruments. A total of 12 boys (mean age, 14.8±2.74 years), followed for an average of 10.3 months (range, 0-54 months), were identified. The incidence of significant associated symptoms was 8.3% (1 of 12). Eight patients were initially treated with closed reduction, 2 (25%) successfully and 6 (75%) requiring subsequent open reduction. Four of the 12 patients underwent an immediate open reduction. Braided composite sutures were used to treat all injuries that underwent open reduction (10 of 12). Complete data were obtained from 6 patients, all of whose injuries had been treated with open reduction. All 6 had returned to their full activity level, and all self-reported perfect Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Simple Shoulder Test scores (0 and 12, respectively). Among skeletally immature patients, medial clavicular physeal fractures and sternoclavicular dislocations can be effectively managed with closed or open reduction. When closed reduction is unsuccessful or is contraindicated, open reduction with braided composite sutures is associated with excellent results.

Reliability of a novel, web-based, shoulder-specific, patient-reported outcome instrument

Background: Paper versions of patient-reported outcomes instruments frequently are used in clinical settings, but the use of multiple or time intensive instruments may reduce response rate because of responder burden. Methods: Using questions from eight commonly used existing shoulder-specific patient-reported outcomes instruments, a single, condensed, web-based instrument was created. Existing instruments include 108 questions and the condensed questionnaire has 68 or fewer questions. Sixty consecutive patients within a single surgeon's academic shoulder and elbow practice completed a paper version of the Disabilities of the Arm, Shoulder, and Hand (DASH) and the entire web-based instrument before and after an office visit. Patients were randomized to which instrument was completed before their visit and completed the other instrument after the visit. Results: Fifty-five patients completed both surveys. The mean score for the paper version of the DASH was 41.7 (SEM ±3.5, 95% CI: 34.6-48.8) and the mean for the web-based extracted score was 41.3 (SEM ±3.4, 95% CI: 34.4-48.1). Comparing the paper version with the web-based version of the DASH, the mean difference in scores was found to be −0.42 (SEM 1.0, 95% CI: −2.4-1.6, range −25.0-16.7). Conclusions: The web-based shoulder specific outcomes instrument used in this study was able to generate a DASH score that was statistically similar to the traditional paper-based version of the DASH.

The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis

Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. Level III, systematic review of Level I, II, and III studies.