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Background: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. Purpose: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. Results: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, –0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, –0.06 [95% CI, –0.34 to 0.22]). Conclusion: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. Trial Registration: NCT00128076.

BACKGROUND Improvements in surgical fixation to repair distal biceps tendon ruptures have not fully translated to earlier postoperative mobilization; it is unknown whether earlier mobilization affords earlier functional return to work. This parallel-arm randomized controlled trial compared the impact of early mobilization versus 6 weeks of postoperative immobilization following distal biceps tendon repair. METHODS One hundred and one male participants with a distal biceps tendon rupture that was amenable to a primary repair with use of a cortical button were randomized to early mobilization (self-weaning from sling and performance of active range of motion as tolerated during first 6 weeks) (n = 49) or 6 weeks of immobilization (splinting for 6 weeks with no active range of motion) (n = 52). Follow-up assessments were performed by a blinded assessor at 2 and 6 weeks and at 3, 6, and 12 months. At 12 months, distal biceps tendon integrity was verified with ultrasound. The primary outcome was return to work. Secondary outcomes were pain, range of motion, strength, shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and tendon integrity. Intention-to-treat analysis was performed. A linear mixed model for repeated measures was used to compare pain, range of motion, strength, and QuickDASH between the groups over time; return to work was assessed with use of independent t tests. RESULTS The groups were similar preoperatively (p ≥ 0.16). The average age (and standard deviation) was 44.7 ± 8.6 years. Eighty-three participants (82%) were followed to 12 months. There were no differences between the groups in terms of return to work (p ≥ 0.83). Participants in the early mobilization group had significantly more passive forearm supination (p = 0.04), with passive forearm pronation (p = 0.06) and active extension and supination (p = 0.09) trending toward significantly greater range of motion in the early mobilization group relative to the immobilization group. Participants in the early mobilization group had significantly better QuickDASH scores over time than those in the immobilization group (p = 0.02). There were no differences between the groups in terms of pain (p ≥ 0.45), active range of motion (p ≥ 0.09), or strength (p ≥ 0.70). Two participants (2.0%, 1 in each group) had full-thickness tears on ultrasound at 12 months (p = 0.61). Compliance was not significantly different between the groups (p = 0.16). CONCLUSIONS Early motion after distal biceps tendon repair with cortical button fixation is well tolerated and does not appear to be associated with adverse outcomes. No clinically important group differences were seen. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Loss of reduction (LoR) can occur after locking plate fixation of proximal humerus fractures (PHFs). This study determined biomechanical features of fracture fixation associated with preventing LoR postoperatively. One-year reoperation rates were also compared between those with/without LoR. Methods: Population-based administrative data for 359 adults treated using a locking plate for PHF between 2010 and 2016 were examined. Two trained assessors reviewed standardized shoulder radiographs. LoR (Yes/No) was defined as any fracture displacement >0.5 cm, and/or >10° change in neck-shaft angle (NSA) alignment relative to intraoperative imaging. Multiple logistic regression assessed how the following affected maintaining reduction: (1) sex, (2) age, (3) Neer classification, (4) shaft impaction (SI), (5) shaft medialization (SM), (6) calcar reduction (CR), (7) NSA alignment, and (8) screw use. Results: LoR was seen in 79 (22%) patients. LoR was significantly associated with increasing age (odds ratio [OR] = 1.06/yr, P < .001), fracture severity (4-part vs. 2-part fracture; OR = 4.63, P = .001), and varus NSA alignment (

Background Providing physical therapists with evidence-based and consensus-derived guidelines to manage postoperative shoulder patients is essential; these guidelines should be readily available and provide clinically applicable information. Knowledge translation (KT) initiatives that encourage interaction between clinicians and researchers, that have multifaceted components and use a variety of strategies, can significantly change practice. Objective The objective of this study was to determine the uptake and acceptability of standardized postoperative shoulder guidelines with an accompanying online KT resource through evaluation of website analytics and a quantitative survey. Design A multi-pronged approach was used to assess uptake and acceptability of the guidelines and online KT resource. Methods Website analytics of usage and geographical location of users was measured as were physical therapist survey responses. Results Website analytics revealed that 5406 individuals used the online resource between October 2012 and September 2013 with the average visit lasting 8 minutes; only 47% of users were within the guideline developers’ surgical referral region. Physical therapists who used the new shoulder guidelines were very satisfied or satisfied (96%) with the guidelines, reporting they promoted patient-specific clinical decision-making extremely or very well (68%). They viewed the online KT resource positively, with 79% rating it as “very useful” or “quite useful.” Physical therapists from regions beyond those expected to use the new shoulder guidelines were also aware of the website and also rated it as very useful. Limitations The survey sample was relatively small and did not directly assess patient outcomes. Conclusions An online KT web resource developed in conjunction with standardized postoperative shoulder guidelines was perceived as useful based on website analytics and survey responses. Active KT strategies such as this can improve uptake and dissemination of best practice in physical therapy.

To assess the effect of early active shoulder movement after rotator cuff repair, compared to delayed active shoulder movement, on clinical outcomes, rotator cuff integrity, and return to work.Intervention systematic review.We searched 14 databases in November 2017 and updated the search in December 2018 and February 2020.We included comparative studies that assessed the effect of early active shoulder movement versus delayed active shoulder movement following rotator cuff repair.Means and SDs were used to calculate weighted mean differences and 95% confidence intervals for outcomes of interest. The sensitivity analysis included only randomized controlled trials and was performed when heterogeneity among studies was statistically significant.Eight studies with a total of 756 participants (early active shoulder movement, n = 379; delayed active shoulder movement, n = 377) were included. There was high-certainty evidence favoring early active movement for forward flexion (6 weeks), abduction (6 weeks), and external rotation (6 weeks and 3 and 6 months) postsurgery. There was moderate-certainty evidence of worse Western Ontario Rotator Cuff Index score (6 weeks) for the early active movement group, and no difference in rotator cuff integrity between the early and delayed active movement groups. There were no group differences for all other outcomes.Patients who commenced active shoulder movement early after rotator cuff repair had greater shoulder range of motion and worse shoulder-specific quality of life after surgery than patients who delayed active shoulder movement. However, the group differences did not appear to be clinically important, and rotator cuff integrity was similar.

BACKGROUND AND OBJECTIVES Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Purpose: Shoulder pain causes significant disability, with rotator cuff disease as a common diagnosis. Differentially diagnosing partial tears of the rotator cuff tendons is difficult despite use of imaging and clinical examination. Our objective was to determine if a clinical assessment framework could discriminate between patients with partial and full thickness tears.Materials and Methods: Pre-operative baseline data from two randomized controlled trials of 452 adult patients awaiting rotator cuff repair were analyzed in this secondary analysis. Nineteen items from a pre-defined clinical assessment framework were investigated for association with the outcome of surgically confirmed partial or full thickness tear. Logistic regression tested independent associations and multivariable models were developed to create the most parsimonious model.Results: Thirty-two participants (7%) had partial thickness tears. Constant Power Score was the sole item associated with partial thickness tears (OR 1.07, 95% CI 1.02-1.12). Traumatic mechanism of injury trended toward significance (OR 2.17, 95% CI 1.06-4.48).Conclusions: Greater abduction strength (i.e., Constant Power Score) was associated with partial thickness tears. Other clinical assessment items did not differentiate between partial and full tears. Our results add to the growing body of research showing most clinical findings are not associated with a diagnosis in rotator cuff disease.Implications for RehabilitationGreater shoulder abduction strength (as measured with the Constant Power Score) was associated with partial thickness rotator cuff tears.Most findings within our clinical assessment framework did not distinguish between partial thickness and full thickness rotator cuff tears and thus, did not contribute to a differential pathoanatomical diagnosis.Since structural integrity of the rotator cuff and patient presentation show poor association, and rehabilitation intervention is often impairment-based, pathoanatomical diagnosis may not adequately direct non-surgical treatment. Including movement-based diagnoses or treatment classification systems in evaluation of rotator cuff disease may improve selection of appropriate conservative treatment.

Aim Patients’ experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) – a tool that collects patients’ experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH). Background The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH’s dimensions. Methods This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test–retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing). Findings Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1–29). Only out-of-pocket utilization possessed an ICCA priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient’s continuum of care.

To compare the effect of early mobilization (EM) with standard rehabilitation (SR) over the initial 24 months following arthroscopic rotator cuff (RC) repair.A total of 206 patients with full-thickness RC tears undergoing arthroscopic repair were randomized following preoperative assessment of shoulder range of motion (ROM), pain, strength, and health-related quality of life (HRQOL) to either EM (n = 103; self-weaned from sling and performed pain-free active ROM during the first 6 weeks) or SR (n = 103; wore a sling for 6 weeks with no active ROM). Shoulder ROM, pain, and HRQOL were reassessed at 6 weeks and 3, 6, 12, and 24 months postoperatively by a blinded assessor. At 6, 12, and 24 months, strength was reassessed. At 12 months, ultrasound verified RC integrity. Independent t tests assessed 6-week group differences and 2-way repeated measures analysis of variance assessed changes over time between groups.The groups were similar preoperatively (P.12). The mean age of participants was 55.9 (minimum, 26; maximum, 79) years, and 131 (64%) were men. A total of 171 (83%) patients were followed to 24 months. At 6 weeks postoperatively, EM participants had significantly better forward flexion and abduction (P.03) than the SR participants; no other group differences were noted. Over 24 months, there were no group differences in ROM after 6 weeks (P.08), and pain (P.06), strength (P = .35), or HRQOL (P.20) at any time. Fifty-two (25%) subjects (30% EM; 33% SR) had a full-thickness tear present at 12-month postoperative ultrasound testing (P.8).EM did not show significant clinical benefits, but there was no compromise of postoperative ROM, pain, strength, or HRQOL. Repair integrity was similar at 12 months postoperatively between groups. Consideration should be given to allow pain-free active ROM within the first 6 weeks following arthroscopic RC repair.Level I, high-quality randomized controlled trial.

Author(s): Braman, Jonathan P; Bernthal, Nicholas; Freedman, Brett; Gofton, Wade; Hsu, Joseph; Sheps, David; Strauss, Eric

This study compared the clinical outcomes following mini-open rotator cuff repair (MORCR) between early mobilisation and usual care, involving initial immobilisation. In total, 189 patients with radiologically-confirmed full-thickness rotator cuff tears underwent MORCR and were randomised to either early mobilisation (n = 97) or standard rehabilitation (n = 92) groups. Patients were assessed at six weeks and three, six, 12 and 24 months post-operatively. Six-week range of movement comparisons demonstrated significantly increased abduction (p = 0.002) and scapular plane elevation (p = 0.006) in the early mobilisation group, an effect which was not detectable at three months (p > 0.51) or afterwards. At 24 months post-operatively, patients who performed pain-free, early active mobilisation for activities of daily living showed no difference in clinical outcomes from patients immobilised for six weeks following MORCR. We suggest that the choice of rehabilitation regime following MORCR may be left to the discretion of the patient and the treating surgeon. Cite this article: Bone Joint J 2015;97-B:1257–63.

Background Minimal information exists regarding the sub-supraspinatus recess superior to the labrum and inferior to the supraspinatus. Furthermore, movement of the superior labrum during glenohumeral range of motion has not previously been defined. The objectives of this arthroscopic study were to describe the (i) sub-supraspinatus recess dimensions and (ii) superior labral motion. Methods Forty-four patients were enrolled and underwent standardized arthroscopic assessment. Analysis consisted of static measurement of the sub-supraspinatus recess depth, as well as the amount of labral motion during passive shoulder motion. Labral movement was categorized relative to the glenoid rim (lateral to the rim, to the rim, or medial to the rim). Results All patients had a well-defined sub-supraspinatus recess varying from a depth of 0 mm to 5 mm ( n = 10; 22.7%), 5 mm to 10 mm ( n = 23; 52.3%) or >10 mm ( n = 11; 25%). External rotation in abduction demonstrated the greatest labral movement ( p Conclusions The sub-supraspinatus recess is consistently present with an average depth of 5 mm to 10 mm. Superior labral motion is present in most patients and is most pronounced in external rotation in abduction. This finding likely has clinical implications for superior labral repair surgery, especially for overhead athletes and laborers who require external rotation in an abducted position for a successful outcome.

OBJECTIVE To determine whether a posterior shoulder stretch was effective in increasing internal rotation (IR) and horizontal adduction (HAd) range of motion (ROM) in overhead athletes identified as having reduced mobility. DESIGN Randomized controlled trial (parallel design). SETTING University-based sports medicine clinic. PARTICIPANTS Thirty-seven university-level athletes in volleyball, swimming, and tennis, with IR ROM deficits ≥15°, were randomized into intervention or control groups. No subjects withdrew or were lost to follow-up. INTERVENTION The intervention group performed the "sleeper stretch" daily for 8 weeks, whereas the control group performed usual activities. MAIN OUTCOME MEASURES Independent t tests determined whether IR and HAd ROM differences between groups were significant at 8 weeks and 2-way repeated-measures analysis of variance tests measured the rate of shoulder ROM change. Subject-reported shoulder pain and function were obtained at each evaluation. RESULTS Significant differences were found between the intervention and control groups' IR and HAd ROM at 8 weeks (P < 0.001 and P = 0.003, respectively) compared with baseline (zero weeks) (P = 0.19 and P = 0.82, respectively). Significant improvements in IR were detected in the intervention group at 4 weeks (P < 0.001), whereas HAd demonstrated significant changes only at 8 weeks (P = 0.003). Reported shoulder function (P = 0.002) was different between study groups at 8 weeks. CONCLUSION Overhead, university-level athletes with an IR deficit ≥15° significantly increased their IR and HAd ROM after performing a posterior shoulder stretch for 8 weeks. CLINICAL RELEVANCE Effective management of posterior shoulder tightness through stretching may reduce the incidence of shoulder pathology in overhead athletes.

In this study we evaluated whether the Instability Severity Index Score (ISIS) and the Western Ontario Shoulder Instability Index (WOSI) could detect those patients at risk of failure following arthroscopic Bankart repair. Between April 2008 and June 2010, the ISIS and WOSI were recorded pre-operatively in 110 patients (87 male, 79%) with a mean age of 25.1 years (16 to 61) who underwent this procedure for recurrent anterior glenohumeral instability. A telephone interview was performed two-years post-operatively to determine whether patients had experienced a recurrent dislocation and whether they had returned to pre-injury activity levels. In all, six (5%) patients had an ISIS > 6 points (0 to 9). Of 100 (91%) patients available two years post-operatively, six (6%) had a recurrent dislocation, and 28 (28%) did not return to pre-injury activity. No patient who dislocated had an ISIS > 6 (p = 1.0). There was no difference in the mean pre-operative WOSI in those who had a re-dislocation and those who did not (p = 0.99). The pre-operative WOSI was significantly lower (p = 0.02) in those who did not return to pre-injury activity, whereas the ISIS was not associated with return to pre-injury activity (p = 0.13). In conclusion, neither the pre-operative ISIS nor WOSI predicted recurrent dislocation within two years of arthroscopic Bankart repair. Patients with a lower pre-operative WOSI were less likely to return to pre-injury activity. Cite this article: Bone Joint J 2014; 96-B:1688–92.

Background The Instability Severity Index Score (ISIS) was developed to help determine the prognosis for recurrent shoulder instability and to assist surgical decision-making. The radiographic portion of the ISIS represents a substantial portion of the total score. The present study examined the intra- and inter-rater agreement, reliability and accuracy of the radiographic components of the ISIS. Methods Four assessors evaluated 49 blinded shoulder radiographs. Assessors documented their observation of the presence of a Hill–Sachs lesion and/or a loss of glenoid contour. Radiographs were reviewed twice in random order over two sessions. Intra- and inter-rater reliability and accuracy were calculated. Results Intra-rater agreement ranged from 71% to 94% for the presence of a Hill–Sachs lesion and 85% to 94% for a loss of glenoid contour. Intra-rater kappa values ranged from 0.41 to 0.86 and 0.56 to 0.74, respectively. Inter-rater agreement was found to be 63% to 78% and 78% to 90% for Hill–Sachs and glenoid lesions, respectively. Corresponding kappa values were 0.31 and 0.48. Accuracy ranged from 29% to 57% for Hill–Sachs and 65% to 73% for glenoid lesions. Conclusions In the present study, intra- and inter-rater reliability of the radiographic portion of the ISIS demonstrated limited kappa and accuracy. We suggest that the ISIS should be used with caution as a guide for surgical management.

Background The lack of North American population-based incidence studies of fractures of the proximal radius and ulna creates challenges in the assessment of outcomes and corresponding complication rates. Such data may help to establish consensus regarding optimal treatments. The present study’s goal was to determine the population-based incidence of proximal radial and ulnar fractures in a large metropolitan area. Methods Over a 3-year period (April, 2002--March, 2005), cases of proximal radial and ulnar fractures were documented and classified according to the AO/OTA system. Overall, ageadjusted, age-specific, gender-specific, and fracture-specific rates were calculated according to patient demographic and 2001 Canadian census data. Rates were reported as per 10,000 persons per year. Results 1030 proximal radial and ulnar fractures were identified. Fractures occurred at an overall rate of 5.09 (95%CI: 4.78 to 5.40), while the age-adjusted incidence was 5.14 (95% CI: 5.05--5.23). The most common fracture types observed were B2.1 (simple articular fracture of radius, n ¼ 374), B1.1 (unifocal articular fracture of ulna, n ¼ 280), and A2.2 (simple extraarticular fracture of neck of radius, n ¼ 145). Fracture incidence was similar among all age groups (approximately five), with the exception of patients ages 80 years and older (8.70; 95% CI: 6.24--11.16). Males and females had similar fracture incidences at all ages. Conclusions As our results indicate similar incidences across age and gender groups, our data is likely generalizable to the general population, which may provide further insight into the assessment of outcomes and complication rates of such injuries.

Background The lack of North American population-based incidence studies of distal humeral fractures creates challenges in assessing outcomes and associated complication rates. Therefore, the aim of the present study was to determine the population-based incidence of distal humeral fractures among tertiary health care centers in a major metropolitan region. Methods Over a 3-year period, cases of distal humeral fracture within a major metropolitan health region were documented. Agespecific, gender-specific, and age-adjusted rates were calculated according to patient demographics and 2001 Canadian census data. Rates were reported as per 100,000 persons per year. Results One hundred and fifty-six distal humeral fractures were identified. Fractures occurred at an overall rate of 7.71 (95% CI: 6.50-8.92), while the age-adjusted incidence was 8.86 (95% CI: 8.47-9.24). Fracture incidence increased with age, from a low of 3.87 (95% CI: 2.13-5.61) among persons aged 18-29, to a high of 54.35 (95% CI: 34.90-73.80) among those 80 years and older. Females had a greater incidence than their male counterparts. Conclusions Our results provide true population-based estimates of the incidence of distal humeral fractures in North America, which may give further insight into the assessment of outcomes and complication rates of such injuries.

BackgroundThere are no current North American population-based incidence studies of elbow dislocations. This creates further challenges in assessing associated outcomes and complication rates. The present study aimed to determine the population-based incidence of elbow dislocations in a large Canadian city.MethodsFrom April 2002 to March, 2005, consecutive cases of elbow dislocation were documented. Age-specific, gender-specific and age-adjusted rates for simple and complex dislocations were calculated according to patient demographic and 2001 Canadian census data. All rates were reported per 10,000 persons per year.ResultsOne hundred thirty-seven dislocations (53 simple and 84 complex) were identified. Simple dislocations occurred at a rate of 0.262 (95% confidence interval [CI] = 0.191 to 0.332). Fracture-dislocations occurred at a rate of 0.415 (95% CI = 0.326 to 0.504). The overall age-adjusted incidence was 0.671 (95% CI = 0.638 to 0.704). With the exception of the 18 years to 29 years (rate = 0.916, 95% CI = 0.648 to 1.183) and ≥80 years groups (rate = 0.906, 95% CI = 0.112 to 1.700), all age groups had an approximate rate of 0.600.DiscussionThe results obtained in the present study are similar to those obtained in a previous European study. True population-based estimates of elbow dislocation incidence are provided, which may facilitate the assessment of outcomes and complication rates of such injuries.

Background Glenohumeral instability is a common problem following traumatic anterior shoulder dislocation. Two major risk factors of recurrent instability are glenoid and Hill-Sachs bone loss. Higher failure rates of arthroscopic Bankart repairs are associated with larger degrees of bone loss; therefore it is important to accurately and reliably quantify glenohumeral bone loss pre-operatively. This may be done with radiography, CT, or MRI; however no gold standard modality or method has been determined. A scoping review of the literature was performed to identify imaging methods for quantifying glenohumeral bone loss. Methods The scoping review was systematic in approach using a comprehensive search strategy and standardized study selection and evaluation. MEDLINE, EMBASE, Scopus, and Web of Science were searched. Initial selection included articles from January 2000 until July 2013, and was based on the review of titles and abstracts. Articles were carried forward if either reviewer thought that the study was appropriate. Final study selection was based on full text review based on pre-specified criteria. Consensus was reached for final article inclusion through discussion amongst the investigators. One reviewer extracted data while a second reviewer independently assessed data extraction for discrepancies. Results Forty-one studies evaluating glenoid and/or Hill-Sachs bone loss were included: 32 studies evaluated glenoid bone loss while 11 studies evaluated humeral head bone loss. Radiography was useful as a screening tool but not to quantify glenoid bone loss. CT was most accurate but necessitates radiation exposure. The Pico Method and Glenoid Index method were the most accurate and reliable methods for quantifying glenoid bone loss, particularly when using three-dimensional CT (3DCT). Radiography and CT have been used to quantify Hill-Sachs bone loss, but have not been studied as extensively as glenoid bone loss. Conclusions Radiography can be used for screening patients for significant glenoid bone loss. CT imaging, using the Glenoid Index or Pico Method, has good evidence for accurate quantification of glenoid bone loss. There is limited evidence to guide imaging of Hill-Sachs bone loss. As a consensus has not been reached, further study will help to clarify the best imaging modality and method for quantifying glenohumeral bone loss. Electronic supplementary material The online version of this article (doi:10.1186/s12891-015-0607-1) contains supplementary material, which is available to authorized users.

Background The proximal tibiofibular joint can be used as a source of osteochondral autograft with little to no morbidity at the harvest site. Methods CT scans of fourteen left and seven right fibular heads, seven right and six left ulnas obtained from healthy subjects were volume-scaled and analyzed. Ipsilateral ulnar articular surfaces were compared between subjects and contralateral ulnas were compared within the same subject. The average deviations between the surfaces were measured. Manual registration and best-fit alignment were used to locate the area on the fibular heads that would best-fit the 50% coronoid process surface. Findings The average deviations in the articular surface between subjects were (mean (SD) 0.79 mm (0.17) and 0.76 mm (0.14) for the left and right ulnas respectively and 0.35 mm (0.07) in the same subject. The average coronoid process height of the scaled ulnas was 15.92 mm (1.15). When comparing the 50% coronoid process with the ispsilateral fibular head geometries, the maximum deviations for all subjects were smaller than 2.0 mm. Two locations were identified as the best-fit locations. Interpretation When volume-scaled, the articular congruency of the proximal ulna articular surfaces between subjects is within the allowable limit for a typical intra-articular fracture step. Results suggest it is possible to use the CT scan of a patient's contralateral elbow as a template to estimate the morphology of the affected side. The fibular head could be an alternative replacement for damaged coronoid process since it is covered by articular cartilage and has locations with a similar curvature as the coronoid process.

Hypothesis Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. Materials and methods We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. Results The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm ( P = .8) or even 3 mm ( P = .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. Conclusions This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome.

This prospective study evaluated suprascapular nerve injury risk during arthroscopic superior labral repair in patients of average height or shorter. From 2009 to 2011, 12 patients

Health-related quality-of-life (HRQL) measures must detect clinically important changes over time and between different patient subgroups. Forty-three patients (32 M, 13 F; mean age = 26.00 ± 8.19 years) undergoing arthroscopic Bankart repair completed three validated shoulder questionnaires (Western Ontario Shoulder Instability index (WOSI), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment form (ASES), Constant score) preoperatively, and at 6, 12, and 24 months postoperatively. Responsiveness and discriminant validity was assessed between those with a satisfactory outcome and those with (1) a major recurrence of instability, (2) a single episode of subluxation, (3) any postoperative episode of instability. Eight (20%) patients reported recurrent instability. Compared to baseline, the WOSI detected improvement at the 6- (P<0.001) and 12-month (P=0.011) evaluations. The ASES showed improvement at 6 months (P=0.003), while the Constant score did not report significant improvement until 12 months postoperatively (P=0.001). Only the WOSI detected differential shoulder function related to shoulder instability. Those experiencing even a single episode of subluxation reported a 10% drop in their WOSI score, attaining the previously established minimal clinically important difference (MCID). Those experiencing a frank dislocation or multiple episodes of subluxation reported a 20% decline. The WOSI allows better discrimination of the severity of postoperative instability symptoms following arthroscopic Bankart repair.

Background The burden imposed by workplace rotator cuff (RC) injuries has been reasonably defined. However, literature associated with the demographic characteristics and 'best practices' to manage such injuries among workers' compensation (WC) patients is scant. Aims To consolidate the existing literature on full-thickness RC tears among WC patients. Subject, shoulder and injury characteristics were examined to determine if and how WC recipients may differ from their non-compensable counterparts. Methods A systematic search (databases, clinical practice guideline web resources, conference proceedings and reference lists) revealed 450 abstracts. Two blinded reviewers independently assessed abstracts for inclusion. Sixty abstracts were subsequently included in a blinded full manuscript review. Seventeen of these manuscripts (3.8% of sample; 11 intervention and 6 determinant) were included in the present review. Results Previous studies demonstrate that operative interventions are appropriate for full-thickness RC tears as substantial gains in range of motion, strength and quality of life were witnessed within the first post-operative year. Non-operative interventions, including workplace-based work hardening, physical therapy and the use of an early referral system, were shown to improve outcomes. Conflicting results exist with respect to determinants such as age and sex. Importantly, WC patients had consistently poorer outcomes than non-WC patients. Conclusions Our results show that although WC patients experience substantial benefits from various treatments for full-thickness RC tears, disparities exist between them and their non-WC counterparts. The lack of WC-specific literature limited our results. Larger studies, particularly ones comparing WC patients with their non-compensable counterparts, are crucial to allow for future evidence-based recommendations.

Many approaches exist for managing rotator cuff tears.To compare the benefits and harms of nonoperative and operative interventions on clinically important outcomes in adults with rotator cuff tears.12 electronic databases (1990 to September 2009), gray literature, trial registries, and reference lists were searched.Controlled and uncontrolled studies that assessed nonoperative or operative treatments or postoperative rehabilitation for adults with confirmed rotator cuff tears were included. Operative studies in English-language publications and nonoperative and postoperative rehabilitation studies in English, French, or German were considered. Studies were assessed in duplicate.2 reviewers assessed risk for bias by using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale. One reviewer rated the evidence by using a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Data were extracted by one reviewer and verified by another.137 studies met eligibility criteria. All trials had high risk for bias. Cohort and uncontrolled studies were of moderate quality. Reported functional outcomes did not differ between open versus mini-open repair, mini-open versus arthroscopic repair, arthroscopic repair with versus without acromioplasty, or single-row versus double-row fixation. Earlier return to work was reported for mini-open repair versus open repair and for continuous passive motion with physical therapy versus physical therapy alone. Open repairs showed greater improvement in function than did arthroscopic debridement. Complication rates were low across all interventions.Limited evidence, which was often of low quality, precluded conclusions for most comparisons. Language restrictions may have excluded some relevant studies, and selective outcome reporting may have introduced bias.Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive.Agency for Healthcare Research and Quality.

BACKGROUND: Radial head fractures are common injuries, and there is little information on the reliability of classification systems for such injuries. The purpose of our study was to report the interobserver reliability of 2 commonly used classification systems: the Hotchkiss modification of the Mason classification and the AO classification systems. METHODS: We compiled the radiographs from a cohort series of 43 patients with radial head fractures, and 5 observers classified the radiographs according to both classification systems. Additionally, we collapsed the systems, with types II and III combined for the Hotchkiss classification and the final digit dropped for the AO classification. We calculated percent agreement, the kappa statistic and the associated 95% confidence intervals (CIs). RESULTS: The mean percent agreement was 72.3% (95% CI 65.8%-78.9%) for the Hotchkiss classification and 37.7% (95% CI 30.5%-44.9%) for the AO classification. The kappa statistic was 0.585 (0.541-0.661) for the Hotchkiss classification and 0.261 (0.240-0.350) for the AO classification. The mean percent agreement was 89.3% (86.6%-92.0%) for the consolidated Hotchkiss classification and 67.4% (54.6%-80.3%) for the consolidated AO classification. The kappa statistic was 0.760 (0.691-0.805) for the consolidated Hotchkiss classification and 0.455 (0.372-0.521) for the consolidated AO classification. CONCLUSION: The interobserver reliability for the Hotchkiss modification of the Mason classification was moderate, and that for the AO classification was fair according to the criteria of Landis and Koch. Collapsing the Hotchkiss classification improved the reliability to substantial, and collapsing the AO system improved reliability to the lower end of moderate.

Surgical reconstruction of the anterior cruciate ligamentdeficient knee has become very common, with the majority of reconstructions performed using the semitendinosusgracilis tendon autograft construct or the central third bonepatellar tendon-bone autograft construct. Although generally uncommon, complications after anterior cruciate ligament reconstruction occur, and may include fractures of the distal femur, proximal tibia, or distal patella. The case described below is the seventh femur fracture reported after ACL reconstruction, and the first associated with the use of an EndoButton (Smith + Nephew, Andover, MA) for femoral fixation. The fracture was felt to result from a lower than expected level of energy, on the basis of the patient’s age, health, and bone quality, and was likely due to a stress riser created from multiple perforations through the anterolateral cortex of the femur from the femoral guide pin, in addition to the EndoButton tunnel.

Purpose: The purpose of the study was to better define the tibial insertion of the posterior cruciate ligament (PCL) and to identify landmarks that could be used to aid in placement of independent tibial tunnels for a 2-bundle PCL reconstruction. Type of Study: Descriptive anatomic study. Methods: Ten knees from 8 cadavers were dissected and the PCL was identified. The ligament was peeled away from its insertion and the sides of the insertion site were measured and recorded. The 4 corners of the insertion site were identified and marked. Observations were made of the morphology of the insertion site and the presence of any reproducible anatomic landmarks. A note was made of landmarks that could be easily identified on all of the specimens by direct vision and by palpation with a probe. Results: The ligament consisted of 2 regions, 1 anterolateral, and 1 posteromedial, with a gradual change in the laxity of the ligament as the knee was passed through flexion and extension. The insertion site was situated in a depression between the plateaus of the tibia and extended below the articular surface. The average length ± standard deviation of the 4 sides was 128 ± 21.2 mm (medial side), 107 ± 26.5 mm (superior side), 160 ± 30.0 mm (lateral side), and 169 ± 34.5 mm (inferior side). The shape and sides of the insertion site were visually similar among the 10 specimens. The superolateral and superomedial corners were both represented by depressions and a reproducible ridge represented the inferior border. These structures could be visualized as well as palpated on all specimens. Conclusions: Based on the findings of this study, we describe the anatomic characteristics of the tibial footprint of the PCL. Anatomic reference points that represent the corners of the tibial insertion of the PCL were identified by direct vision or palpation consistently on all specimens included in the study. These reference points could potentially aid in the placement of an anterolateral and posteromedial tibial tunnel for a 2 tibial tunnel PCL reconstruction. Clinical Relevance: Reproducible anatomic reference points exist at the tibial insertion of the PCL that can be identified by direct vision and palpation. These reference points may potentially aid in the placement of separate tibial tunnels for a 2-bundle PCL reconstruction.

Simple dislocations of the elbow or dislocations occurring without an associated fracture are common injuries. Evaluation of these injuries must include an assessment of the entire involved upper extremity and a complete neurovascular examination. Principles of management include a prompt, controlled reduction, a determination of postreduction stability, and an immediate rehabilitation protocol that considers the stability of the joint following reduction. For those joints that are stable throughout the arc of motion, an unrestricted range of motion protocol can be started. When instability is present after reduction, the degree of instability determines the need for dynamic bracing, ligament repair or reconstruction, or the need for a hinged external fixator. The long-term results of these injuries are generally good, with nonoperative treatment producing equivalent or better results than operative treatment. Residual flexion contracture is the most common complication and can be diminished with the use of early range of motion. Other common complications include residual pain and heterotopic ossification, whereas recurrent instability occurs infrequently. Chronic dislocations of the elbow occur uncommonly in North America and Western Europe, but when they occur, reason-able results can be achieved with open reduction of the joint and the use of a hinged external fixator within I year following the dislocation.