Outcomeanalyse nach offener Rekonstruktion von Rotatorenmanschettenrupturen Eine vergleichende Beurteilung neuer Bewertungsverfahren

Outcome evaluation is becoming increasingly important for reconstructive surgery in musculoskeletal diseases. In addition to established shoulder-scores, new outcome-scores are being developed to cover all effects caused by a disease or intervention. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients suffering from rotator cuff deficiency. These were correlated to the Constant-Murley Shoulder Score and to a visual analogue scale for satisfaction. 7 women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 +/- 10.5, r/l: 14/9, FU 57.8 +/- 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons Shoulder Index (ASES), the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). In addition, a visual analogue scale for satisfaction was employed. All four scores as well as the visual analogue scale revealed improvement at a statistically significant level (paired, two-tailed t-test, P < 0.01) after surgery. All questionnaires had a significant correlation with the Constant-Murley Shoulder Score (Pearson's correlation coefficient: ASES: r = 0.871, P < 0.01; DASH: r = -0.758, P = < 0.01; SST: r = 0.494, P < 0.05). All were easy to apply and provided a reliable, postoperative evaluation of shoulder function. The SST was easy to apply, however compound outcome analysis was only possible with the ASES Shoulder Index and the DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination which is advantageous but must be carried out in the clinic. For postoperative assessment, without the patient having to return to the clinic, the ASES Shoulder Index is preferred as it correlates well with the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).     

Delayed surgical treatment of displaced midshaft clavicle fracture using Herbert cannulated screw with intramedullary bone graft

There is an increasing trend towards operative treatment for displaced midshaft clavicle fractures. This retrospective study was performed to assess the outcome of delayed fixation of displaced midshaft clavicle fractures and test the null hypothesis that there is no difference in results between early and delayed surgical treatment for displaced midshaft clavicle fractures. Using the hospital database, two groups of patients who were surgically treated using Herbert cannulated screw for displaced midshaft clavicle fractures were identified. There were 114 cases in acute (median time to operation of 5?days) and 21 cases in delayed groups (median time to operation 10.5?weeks). Thirty-five cases were available for follow-up in the acute and 16 cases in the delayed series. The primary outcome was assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons score (ASES) and Constant-Murley score. Union occurred in 14 cases in the delayed group. The median DASH, mean ASES and Constant-Murley scores were 4.1, 97 and 88.7, respectively. Compared with the delayed group, the early group had a higher union rate (P?=?0.033), trend towards lower DASH score (P?=?0.051), and higher ASES score (P?=?0.047). The delayed group had significantly more problems with prominent, symptomatic screws that required removal (P?=?0.002). There were no significant differences in union time and complication rate. Delayed fixation of displaced midshaft fractures using the Herbert cannulated bone screw and bone graft is effective and provides a good functional outcome that only slightly reduced from that recorded for early fixation.     

Scoring systems for the functional assessment of the shoulder

A number of instruments have been developed to measure the quality of life in patients with various conditions of the shoulder. Older instruments appear to have been developed at a time when little information was available on the appropriate methodology for instrument development. Much progress has been made in this area, and currently an appropriate instrument exists for each of the main conditions of the shoulder. Investigators planning clinical trials should select modern instruments that have been developed with appropriate patient input for item generation and reduction, and established validity and reliability. Among the other factors discussed in this review, responsiveness of an instrument is an important consideration as it can serve to minimize the sample size for a proposed study. The shoulder instruments reviewed include the Rating Sheet for Bankart Repair (Rowe), ASES Shoulder Evaluation Form, UCLA Shoulder Score, The Constant Score, Disabilities of the Arm, Shoulder and Hand (DASH), the Shoulder Rating Questionnaire, the Simple Shoulder Test (SST), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS), the Western Ontario Rotator Cuff Index (WORC), the Western Ontario Shoulder Instability Index (WOSI), Rotator Cuff Quality of Life (RC-QOL), and the Oxford Shoulder Scores (OSS).     

The subjective shoulder rating system

We developed a subjective shoulder rating system (SSRS) and tested its reliability against a recognized system (Constant-Murley Score) and a four-point verbal rating scale in 200 patients (mean age 43 years, range 18–71 years; 83 women and 117 men; 48 anterior shoulder reconstructions, 123 subacromial decompressions, 29 manipulations under anesthesia). Within the study period of 1 year, patients completed the SSRS preoperatively and at 1 and 2 weeks, also at 3, 6, and 12 months. The examination according to the Constant-Murley Score was performed preoperatively and at 3 and 12 months. Linear regression showed a highly significant correlation between the SSRS and the Constant-Murley Score (r = 0.83, n = 592, P < 0.001). Ninety-seven percent of the SSRS forms were completed and returned. The average time to complete the SSRS form was 55 s (range 20–310 s) as compared with an experienced examiner requiring an average of 410 s (range 190–720 s) to complete the Constant-Murley Score. The time difference was highly significant (P < 0.001).     

Defining maximal outcome improvement thresholds for patient satisfaction after reverse total shoulder arthroplasty: a minimum two-year follow-up study

BackgroundPrevious research has investigated the percentage of maximal outcome improvement (MOI) for the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores after reverse total shoulder arthroplasty (rTSA); however, few other outcome scores have been validated. The purpose of this study was to establish thresholds of MOI percentage for the Single Assessment Numeric Evaluation (SANE) and subjective Constant-Murley (Constant) scores associated with patient satisfaction at 2 years following rTSA.MethodsA retrospective review of institutional registry data for all patients who underwent primary rTSA between 09/2016 and 02/2018 was performed. All patients completed the ASES, SANE, and Constant outcome measures preoperatively and at a minimum of 2 years postoperatively. Changes were assessed with Wilcoxon signed-rank tests. MOI percentage was defined as the score improvement from baseline divided by the highest possible improvement from baseline based on the maximum value of the outcome score used. Receiver operating characteristic (ROC) analyses were used to determine optimal MOI percentage thresholds associated with postoperative satisfaction. Stepwise multivariate logistic regression was performed to identify variables associated with achieving the MOI.ResultsA total of 105 patients were included in the final analysis, with a mean (±standard deviation) age of 70.0 ± 7.5 years and BMI of 28.9 ± 5.6 kg/m². The majority of patients were satisfied postoperatively (81.0%). Statistically significant increases were observed from baseline to 2 years postoperatively for the outcome measures assessed (P < .001 for all). ROC analysis demonstrated that the optimal MOI percentage threshold for achieving satisfaction was 66.9% for ASES ([Area under curve, AUC]: 0.87), 71.0% for SANE (AUC: 0.89), and 37.5% for Constant (AUC: 0.85). The linear regression model fit between the proportion of satisfied patients and the calculated MOI percentages was moderate for SANE (r² = 0.313, P < .001) and weak for Constant (r² = 0.228, P < .001). Multivariate logistic regression demonstrated that comorbid diabetes was associated with a decreased likelihood of MOI achievement for SANE ([Odds Ratio, OR]: 0.66, P = .020) and Constant (OR: 0.72, P = .027). Preoperative diagnosis of rotator cuff arthropathy (OR: 0.84, P = 0.049) was associated with a decreased likelihood of MOI achievement for Constant. No factors were significantly associated with MOI achievement for ASES.ConclusionAchieving 66.9%, 71.0%, and 37.5% of the MOI for the ASES, SANE, and Constant scores is associated with postoperative satisfaction following rTSA. Comorbid diabetes and diagnosis of rotator cuff arthropathy were significantly associated with a decreased likelihood of MOI achievement.Level of evidenceLevel III; Retrospective Case Series (Prognostic)     

Postoperative pain control following arthroscopic release of adhesive capsulitis: A short-term retrospective review study of the use of an intra-articular pain catheter

Purpose: The purpose of this study was to examine the effectiveness of an arthroscopically placed intra-articular pain catheter for controlling postoperative pain and also review the results following arthroscopic release of refractor adhesive capsulitis. Type of Study: Retrospective clinical trial. Methods: Twenty-three consecutive cases (20 patients) of arthroscopic adhesive capsulitis release in which an intra-articular pain catheter was used were reviewed. Follow-up ranged from 12 to 37 months (average, 22.4 months). An intra-articular catheter was placed under direct arthroscopic visualization from a superior approach into the glenohumeral joint. Postoperatively, patients were injected with 10 mL of 0.5% bupivacaine every 6 hours as needed. Preoperatively, all patients had filled out a questionnaire based on the American Shoulder and Elbow Surgeons (ASES) outcome guidelines and examined for range of motion. Postoperatively, patients were asked for their precatheter and postcatheter injection pain level based on the visual analog scale (1 to 10 points, 1 = no pain). Patients were then examined for range of motion and retested with the outcome questionnaire. An ASES Shoulder Score Index was calculated for each patient before and after the procedure. Results: The average forward elevation preoperatively was 102° and external rotation at the side was 4.5°. At most recent follow-up, average forward elevation was 169° with external rotation at the side 47°. The Shoulder Score Index increased from an average of 37.1 out of 100 to 90.9 (P <.001). Before being injected with anesthetic through the catheter, patients had an average visual analog scale score of 8.1. Postinjection average pain level was 1.2 (P <.001) and all patients indicated that the pain catheter significantly reduced postoperative pain. Nineteen of 20 patients were satisfied with the procedure. Conclusions: Placement of an intra-articular pain catheter for delivery of bupivacaine was highly effective in controlling postoperative pain. In all cases, postoperative pain was essentially eliminated and this substantially assisted with range of motion exercises. Near complete restoration of range of motion without pain was achieved in 95% of the patients.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 4 (April), 2002: pp 359–365     

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up

Aims:The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions.Results:At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs.Conclusions:Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.     

快速康复外科理念在关节镜下治疗肩袖损伤中的应用

目的探讨快速康复外科理念在关节镜下治疗肩袖损伤中的应用效果。 方法回顾性分析自2015年2月至2016年8月咸宁市中心医院关节外科收治的肩袖损伤患者37例,所有患者术前诊断为单纯肩袖损伤并在关节镜下行肩袖缝合修补术。随机将37例无合并严重内科疾患的单纯肩袖损伤患者分为快速康复组(FTS)和传统康复组(TRG),其中FTS组19例,男10例,女9例,平均年龄(43±9)岁(22～60岁);TRG组18例,男11例,女7例,平均年龄(42±8)岁(19～63岁)。术后1周、1、3个月随访时比较两组Constant-Murley评分、美国肩与肘协会评分系统(ASES)、加州大学肩关节评分系统(UCLA)、患者满意度及术后住院时间。FTS组与TRG组均数比较采用t检验,切口愈合不良发生率比较采用Fisher检验,性别及肩袖损伤分类应用χ²检验。 结果术后1周Constant-Murley评分、ASES评分、UCLA评分、患者满意度FTS组均明显高于TRG组(t＝2.217,t＝2.255,t＝2.457,t＝2.537,P<0. 05),术后1个月Constant-Murley评分、ASES评分、UCLA评分、患者满意度FTS组均明显高于TRG组(t＝2.395,t＝2.693,t＝2.204,t＝2.183,P<0. 05)。术后住院时间、住院总费用FTS组均低于TRG组(t＝2.695,t＝2.179,P<0. 05);切口愈合不良发生率FTS组与TRG组差异无统计学意义(F＝0.717,P>0. 05)。FTS术后3个月的Constant-Murley评分、ASES评分UCLA评分及患者满意度与TRG比较无明显差异(t＝1.873,t＝1.737,t＝1.984,t＝1.483,P>0. 05)。 结论快速康复外科理念在关节镜下治疗肩袖损伤中的应用可有效促进术后患者的早期康复,改善肩关节评分,缩短住院时间,提高患者满意度等优点。     

全关节镜下肩袖修补术对老年肩袖损伤患者术后72 h内疼痛程度和并发症的影响

目的:分析全关节镜下肩袖修补术与小切口肩袖修补术对老年肩袖损伤患者的临床效果。方法:选取2017年1月至2018年11月收治的60例老年肩袖损伤患者作为研究对象,男37例,女23例;年龄61~77(63.45±12.34)岁;病程6~12(5.32±1.02)个月;左侧29例,右侧31例。其中,行全关节镜下肩袖修补术者30例,为观察组;行小切口肩袖修补术者30例,为对照组。观察并记录两组患者术前术后美国加州大学肩关节评分系统(University of California,Los Angeles,UCLA)评分,美国肩肘外科协会(American Shoulder and Elbow Surgeons,ASES)评分,Constant-Murley评分,肩关节前屈活动度、外旋活动度、外展活动度,术后72 h内视觉模拟疼痛评分(visual analogue scale,VAS)及并发症发生情况,然后进行对比分析。结果:两组患者术后UCLA评分、ASES评分、Constant-Murley评分较术前均显著提高(P<0.05),两组术后UCLA、ASES、Constant-Murley评分相比差异无统计学意义(P>0.05)。两组患者术后肩关节前屈活动度、外旋活动度、外展活动度较术前均显著增加(P<0.05),术后两组间比较差异无统计学意义(P>0.05);观察组术后24、48、72 h VAS低于对照组(P<0.05);观察组并发症总发生率13.33%(4/30)低于对照组33.33%(10/30)(P<0.05)。结论:全关节镜下肩袖修补术和小切口肩袖修补术均可以改善老年肩袖损伤后的肩部功能,但全关节镜下肩袖修补术后72 h内疼痛程度和并发症均明显优于小切口肩袖修补术,可根据患者临床实际情况与需求进行选择。     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

BackgroundObjective clinical outcomes and patient satisfaction via patient reported outcome measures (PROMs) can vary following reverse total shoulder arthroplasty (rTSA). The purpose of this study was to analyze patient specific preoperative factors that may predict postoperative PROMs and satisfaction following rTSA.MethodProspective data was collected on 144 consecutive patients who underwent primary rTSA at our institution between 2012 and 2018, all with minimum 2 year follow-up. Age, gender, race, BMI, previous surgery on the index shoulder, and comorbidity burden were analyzed as potential predictors. Shoulder specific clinical measures were collected both pre- and postoperatively via range of motion testing with active abduction, internal, and external rotation. PROMs included global shoulder function, Simple Shoulder Test (SST) and the American Shoulder and Elbow Surgeons (ASES) scoring systems, and cumulative patient satisfaction. Statistical analysis included comparison of pre- and postoperative outcome measures across the cohort as a whole and between each of the potential predictors in question. The relationship between predictors and postoperative cumulative satisfaction was investigated, with specific attention to identify the strongest predictors and account for confounding variables. Statistical significance was determined at P < .05.ResultsAll range of motion scores and PROMs were significantly improved from preoperative to postoperative assessment. Patient satisfaction was excellent with 92% rating their shoulder as “much better” or “better.” Women and minority patients displayed significantly worse preoperative active abduction, SST, and ASES, but were found to have no significant difference in these measures postoperatively. Younger age was associated with a significantly worse postoperative ASES score. Female sex was associated with significantly higher postoperative satisfaction, while minority status was associated with significantly lower cumulative satisfaction. Postoperative global shoulder function, SST, and ASES were not significantly influenced by sex, race, previous surgery, BMI, or comorbidity burden. Postoperative ASES and global shoulder function demonstrated to be independent predictors of “much better” satisfaction rating.ConclusionPostoperative PROMs and cumulative satisfaction are not influenced by BMI, previous surgery, or comorbidity burden in our cohort. Relative to their respective counterparts, older patients, females, and white patients are more likely to demonstrate higher satisfaction with their outcome following rTSA as measured by PROMs or cumulative satisfaction. Improvements in the ASES and global shoulder function scores most consistently predict higher postoperative satisfaction.Level of evidenceLevel IV; Case Series; Treatment Study     

Lessons learned during the cross-cultural adaptation of the American Shoulder and Elbow Surgeons shoulder form into German

Cross-cultural adaptation and testing of reliability and validity were performed by use of a sample of 118 patients after shoulder arthroplasty. They completed a questionnaire booklet containing the American Shoulder and Elbow Surgeons (ASES) questionnaire, Shoulder Pain and Disability Index (SPADI), Short Form 36, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 1 week later, they completed the ASES questionnaire again. The cross-cultural adaptation procedure revealed no major problems. The intraclass correlation coefficients (ICCs) for the subscales for pain and function and for the total score were very high (>0.84); the ICC for the subscale instability was unacceptably low. Function of the contralateral side was consistently better for all items (P < .01). Reliability for both function scales was similar (ICC >0). The ASES scores showed moderate correlation of 0.57 to 0.67 with the various scales of the SF-36 and higher correlation with the DASH (0.84) and SPADI (0.92). The German ASES showed good reliability and validity and can be used for shoulder-specific patient self-assessment in comparison to the contralateral (unaffected) side and provides additional information to objective parameters. The instability domain does not provide any additional clinical information.     

肩袖撕裂合并冻结肩行手法松解后的关节镜下表现及影响因素分析

目的 观察肩袖撕裂合并冻结肩行手法松解后的关节镜下表现,并分析其影响因素。方法 回顾性分析2017年9月至2019年9月收治的68例肩袖撕裂合并冻结肩病人的病例资料,其中,男35例,女33例,年龄为（52.68±6.54）岁,均行一期麻醉后手法松解联合关节镜检查并肩袖修复术,观察手法松解后的关节镜下表现,比较松解损伤病人和未损伤病人之间的性别、患侧、肩袖撕裂程度差异,分析患肩关节疼痛时间、肩关节活动受限病程和实施手法松解时间与手法松解损伤的相关性。收集病人的数字分级法（numerical rating scale, NRS）疼痛评分、美国肩肘外科医师学会（American Shoulder and Elbow Surgeons, ASES）评分、Constant-Murley评分及丹麦健康与医疗管理局（Danish Health and Medicine Authority）满意度评分。结果 共16例（23.53%）发生手法松解损伤,其中单一损伤者12例,两种及以上损伤者4例,损伤类型为前关节囊撕裂（3例,18.75%）、下关节囊撕裂（6例,37.50%）、盂肱中韧带撕裂（7例,43.75%）、盂肱下韧带肱骨端撕裂（humeral avulsion of the glenohumeral ligament, HAGL）（3例,18.75%）、前盂唇撕裂（2例,12.50%）。松解损伤病人和未损伤病人之间的年龄（P=0.431）、性别（P=0.893）、患侧（P=0.673）、肩袖撕裂程度（P=0.723）、患肩关节疼痛时间（P=0.813）、肩关节活动受限病程（P=0.250）、实施手法松解时间（P=0.125）均未见显著差异。松解损伤组和松解无损伤组术后NRS评分均较术前明显降低,肩关节功能评分较术前明显改善（P均＜0.05）;手术前后的NRS评分、肩关节功能ASES评分、Constant-Murley评分、病人满意度评分比较,差异均无统计学意义（P均＞0.05）。结论 肩袖撕裂合并冻结肩行麻醉后肩关节手法松解联合关节镜下肩袖修复术可能导致单一或合并的镜下损伤表现,年龄、性别、患侧、肩袖撕裂程度、患肩关节疼痛时间、肩关节活动受限病程、实施手法松解时间等因素与发生手法松解损伤无明确相关性。     

Patients' preoperative expectations predict the outcome of rotator cuff repair

BACKGROUND: We are not aware of any previous studies of the relationship between patients' expectations regarding rotator cuff repair and the actual outcome. We hypothesized that preoperative expectations are predictive of the outcome of rotator cuff repair. METHODS: One hundred and twenty-five patients who underwent unilateral primary repair of a chronic rotator cuff tear were included in the study. All operations were performed by a single surgeon. Each patient prospectively completed the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; three visual analogue scales for shoulder pain, shoulder function, and quality of life; and the Short Form-36 (SF-36) preoperatively and at one year (mean and standard deviation, 54.1 +/- 7.6 weeks) postoperatively. Preoperative expectations were quantified with use of six questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. RESULTS: Greater preoperative expectations correlated with better postoperative performance on the SST, DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.0001 to 0.03) as well as with greater improvement from the baseline scores on the DASH and SF-36 (p values ranging from <0.0001 to 0.018). A rigorous multivariate analysis controlling for age, gender, smoking, Workers' Compensation status, symptom duration, number of previous operations, number of comorbidities, tear size, and repair technique confirmed that greater expectations were a significant independent predictor of both better performance at one year and greater improvement on the SST, the DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.001 to 0.042). CONCLUSIONS: Patients' preoperative expectations regarding rotator cuff repair are associated with their actual self-assessed outcome. Variations in patient expectations may help to explain divergent results in published series as well as among various patient populations.     

Reliability by surgical status of self-reported outcomes in patients who have shoulder pathologies

STUDY DESIGN: A test-retest design was used to evaluate the reliability of the self-report sections of 4 shoulder pain and disability scales. OBJECTIVE: The objective of the study was to compare interitem consistency and test-retest reliability by surgical status (postoperative versus nonoperative) and to evaluate the effect of surgical status in the prediction of retest scores. BACKGROUND: Patients and healthcare providers evaluate shoulder status based on self-evaluations of pain and disability. Shoulder outcome measures have been developed that include self-reports, but the properties of these measures have not been assessed by surgical status. METHODS AND MEASURES: A questionnaire containing self-report sections of 4 shoulder scales was administered to study participants twice with 1 week between administrations. The outcome measures examined were the: (1) University of California at Los Angeles (UCLA) Shoulder Score; (2) Constant-Murley Scale (CMS); (3) American Shoulder and Elbow Society (ASES) Shoulder Index; and (4) Shoulder Pain and Disability Index (SPADI). Intraclass correlation coefficients (ICC) were calculated to estimate the test-retest reliability of each of the scales and subscales. The interitem consistencies of the multi-item subscales were assessed using Cronbach's alpha. The effect of surgical status on shoulder outcome scale reliability was evaluated using a general linear models approach. RESULTS: The interitem consistency estimates for the multi-item scales were high with both operative and nonoperative participants (0.88 to 0.96). With the exception of the satisfaction subscale of the UCLA Shoulder Score for the nonsurgical group, the estimated intraclass coefficients ranged from 0.51 to 0.91. The prediction of UCLA-satisfaction and ASES-disability, pain, and total retest scores was improved with the addition of surgical status into a regression model. CONCLUSIONS: The examined scales exhibited good internal consistency across surgical status. The postsurgical sample's reproducibility estimates tended to be higher than those of the nonsurgical sample. Reliability of shoulder outcome scales can be affected by patient surgical status.     

Efficacy of Hylan G-F 20 versus 6-methylprednisolone acetate in painful shoulder osteoarthritis: a retrospective controlled trial

Shoulder osteoarthritis affect about 32% of patients over 60 years. Conservative treatment are recommended to restore shoulder function while shoulder arthroplasty remains the standard treatment for severe osteoarthritis. When conservative therapies fail and surgical approach is precluded, viscosupplementation with HA may be the treatment of choice. Currently, there is minimal information available comparing the results of Hylan G-F 20 and corticosteroid injections for the treatment of shoulder osteoarthritis. Therefore, the purpose of this study was to examine the results of these two treatments at specific time points with validated outcome measurements. Retrospective comparative cohort study. The study population included 84 patients, 51 of whom treated with Hylan G-F 20 and 33 with a corticosteroid. Gleno-humeral osteoarthritis was graded according to Samilson-Prieto classification and rotator cuff was assessed with MRI. Both groups received three injections 1 week apart and were evaluated using a Visual Analog Scale (VAS) for pain and satisfaction, the Shoulder Pain and Disability Index (SPADI) and the Constant-Murley scale. Outcomes were registered at 1, 3, and 6 months. The Hylan G-F 20 group showed a significant pain reduction (P < 0.05), improvement in the Constant-Murley, SPADI scores (P < 0.05), and satisfaction (P < 0.01) at all three follow-up times. Pain, clinical scores, and subjective satisfaction in the corticosteroid group improved in the first post treatment month only (P < 0.05) compared with the baseline. Overall, lower clinical advantages were found in patients with greater degree of osteoarthritis and rotator cuff tears. Intra-articular injections with Hylan G-F 20 are effective in reducing pain for up to 6 months in gleno-humeral osteoarthritis whereas corticosteroids injections resulte in improvement at 1 month only. In patients with severe osteoarthritis and/or full-thickness, RC tears results tended to be worse.     

Clinical and patient-reported outcomes of reverse shoulder arthroplasty in patients receiving Social Security Disability Insurance or workers’ compensation

BackgroundEvidence suggests that reverse shoulder arthroplasty (RSA) patients receiving workers’ compensation (WC) have worse patient-reported outcomes (PROs) than those not receiving WC. It is unknown whether Social Security Disability Insurance (SSDI) recipients also have worse outcomes of RSA. Our goals were to (1) compare PROs and range of motion (ROM) after RSA according to whether patients were receiving SSDI, WC, or neither form of assistance, and (2) identify factors associated with poor PROs.MethodsFrom a US institutional database of 454 patients who underwent RSA from January 2009 through December 2016, we identified 19 SSDI recipients and 25 WC recipients. From the same database, we created a control group of 81 patients not receiving SSDI or WC, matched by demographic variables. Between groups, we compared age, sex, operative arm dominance, preoperative diagnosis, number of previous shoulder surgeries, primary or revision arthroplasty, and Charlson Comorbidity Index value. Patients were evaluated preoperatively and at a minimum of 2 years postoperatively by physical examination, including range of motion, visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, L'Insalata score, Simple Shoulder Test (SST), and Western Ontario Osteoarthritis of the Shoulder (WOOS) score. Significance was set at P< .05. Clinical relevance of improvements in forward flexion and abduction, VAS for pain, ASES, and SST were evaluated using established minimal clinically important difference (MCID) values.ResultsBoth the SSDI and WC groups experienced statistically significant improvements from preoperatively to postoperatively; these improvements exceeded MCID thresholds for forward flexion and abduction, VAS for pain, ASES (except in WC group), and SST score (all, P< .05). These outcomes were not significantly different between the SSDI and WC groups. Compared with the control group, both the SSDI and WC groups had statistically significantly worse outcomes for these same measures. The only factor associated with poor clinical outcomes was having undergone ≥2 previous surgical procedures on the same shoulder for which RSA was performed in both SSDI (odds ratio = 2.4, 95% confidence interval: 1.0-5.4) and WC (odds ratio = 1.6, 95% confidence interval: 1.1-4.5) groups.ConclusionAmong RSA patients, SSDI recipients did not have worse clinical outcomes than WC recipients. Having undergone ≥2 previous procedures on the same shoulder was associated with poor outcomes in both groups. These findings should be considered when determining the appropriateness of RSA for SSDI and WC recipients.Level of evidenceLevel III; Retrospective Cohort Comparison; Treatment Study     

Functional outcomes after arthroscopic treatment of lateral epicondylitis

Background  The purpose of this study was to evaluate surgical outcomes of arthroscopic débridement for lateral epicondylitis using a validated, patient-assessed scoring system as well as conventional outcome measures. We also wanted to identify potential predictive factors that may be associated with the outcomes. Methods  A total of 20 elbows in 18 patients with chronic lateral epicondylitis who underwent arthroscopic surgery were included. There were nine men and nine women with a mean age of 54 years (range 42–71 years). Operative treatment consisted of débridement of the extensor carpi radialis brevis (ECRB) origin and resection of the radiocapitellar synovial plica interposed in the joint. Outcomes were assessed using a patient rating, visual analogue scale (VAS) pain score, the Japanese Orthopaedic Association (JOA) elbow score, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. The average length of follow-up was 28 months (range 24–40 months). Results  After surgery, according to the patients’ reports, 14 of 20 elbows were much better, and 6 elbows were better. A mean preoperative VAS pain score at rest of 3.9 points improved to 0.3 points (P < 0.0001), and that during activity improved from 7.8 points to 0.9 points (P < 0.0001). The mean preoperative JOA elbow score of 29 points was improved to 90 points (P < 0.0001). The mean postoperative DASH score was 10.6 (range 0–50). Absent of T2-weighted high signal focus of the ECRB origin on preoperative magnetic resonance imaging (MRI) (P = 0.02) and receiving public assistance (P = 0.01) were significantly associated with worse DASH scores. Conclusions  Arthroscopic release was a satisfactory procedure for chronic lateral epicondylitis. Preoperative MRI of the ECRB origin and socioeconomic factors were significantly associated with postoperative residual symptoms evaluated with the DASH score.     

Inlay hemiarthroplasty of the humeral head for nontraumatic osteonecrosis

BackgroundOsteonecrosis of the humeral head often occurs in younger individuals and presents a difficult clinical situation. The purpose of this study was to evaluate the patient reported outcomes in patients undergoing inlay hemiarthroplasty for nontraumatic osteonecrosis of the humeral head. We hypothesized that patients would achieve a meaningful clinical improvement.MethodsA retrospective review of prospectively collected data on 9 patients undergoing inlay hemiarthroplasty for humeral head osteonecrosis was conducted. The American Shoulder and Elbow Surgeons Shoulder score (ASES), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and range of motion measurements were collected preoperatively and at final follow-up. Radiographs were evaluated for any evidence of component loosening or glenoid wear. The primary outcome was achievement of substantial clinical benefit (SCB) for ASES.ResultsPostoperatively at a mean of 7.2 years the ASES improved from 35 to 73 (p = 0.011), the SST improved from 2 to 6 (p = 0.038), and the VAS for pain decreased from 7 to 3 (p = 0.009). Forward elevation increased from 96° to 138° (p = 0.012) and external rotation increased from 13° to 63° (p = 0.007). SCB for ASES was seen in 7 out of the 9 patients (78%). Asymptomatic mild or moderate glenoid wear was seen in 4/9 (44%) of patients. One patient (11%) developed symptomatic glenoid wear necessitating conversion to total shoulder arthroplasty.ConclusionInlay hemiarthroplasty offers a viable solution to osteonecrosis of the humeral head.Level of Evidence: Level IV; Treatment Study     

The Munich Shoulder Questionnaire (MSQ): development and validation of an effective patientreported tool for outcome measurement and patient safety in shoulder surgery

ABSTRACT: BACKGROUND: Outcome measurement in shoulder surgery is essential to evaluate the patient safety and treatment efficiency. Currently this is jeopardized by the fact that most patient-reported selfassessment instruments are not comparable. Hence, the aim was to develop a reliable selfassessment questionnaire which allows an easy follow-up of patients. The questionnaire also allows the calculation of 3 well established scoring systems, i.e. the Shoulder Pain and Disability Index (SPADI), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand (DASH) Score. The subjective and objective items of these three systems were condensed into a single 30-questions form and validated against the original questionnaires. METHODS: A representative collective of patients of our shoulder clinic was asked to fill in the newly designed self-assessment Munich Shoulder Questionnaire (MSQ). At the same time, the established questionnaires for self-assessment of CONSTANT, SPADI and DASH scores were handed out. The obtained results were compared by linear regression analysis. RESULTS: Fifty one patients completed all questionnaires. The correlation coefficients of the results were r = 0.91 for the SPADI, r = -0.93 for the DASH and r = 0.94 for the CMS scoring system, respectively. CONCLUSIONS: We developed an instrument which allows a quantitative self-assessment of shoulder function. It provides compatible data sets for the three most popular shoulder function scoring systems by one single, short 30-item. This instrument can be used by shoulder surgeons to effectively monitor the outcome, safety and quality of their treatment and also compare the results to published data in the literature.