Arthroscopic shoulder stabilization is known to have excellent functional results, but many patients do not return to their preinjury level of sport, with return to play rates reported between 48% and 100% despite good outcome scores.To understand specific subjective psychosocial factors influencing a patient's decision to return to sport after arthroscopic shoulder stabilization.Case series; Level of evidence, 4.Semistructured qualitative interviews were conducted with patients aged 18 to 40 years who had undergone primary arthroscopic shoulder stabilization and had a minimum 2-year follow-up. All patients participated in sport before surgery without any further revision operations or shoulder injuries. Qualitative data analysis was performed in accordance with the Strauss and Corbin theory to derive codes, categories, and themes. Preinjury and current sport participation was defined by type, level of competition, and the Brophy/Marx shoulder activity score. Patient-reported pain and shoulder function were also obtained.A total of 25 patients were interviewed, revealing that fear of reinjury, shifts in priority, mood, social support, and self-motivation were found to greatly influence the decision to return to sport both in patients who had and had not returned to their preinjury level of play. Patients also described fear of sporting incompetence, self-awareness issues, recommendations from physical therapists, and degree of confidence as less common considerations affecting their return to sport.In spite of excellent functional outcomes, extrinsic and intrinsic factors such as competing interests, kinesiophobia, age, and internal stressors and motivators can have a major effect on a patient's decision to return to sport after arthroscopic shoulder stabilization. The qualitative methods used in this study provide a unique patient-derived perspective into postoperative recovery and highlight the necessity to recognize and address subjective and psychosocial factors rather than objective functional outcome scores alone as contributing to a patient's decision to return to play.
To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.Level II, randomized controlled trial.
Objectives: Most clinical studies pertaining to shoulder dislocation use age cutoffs of 16 years, and at present, only small case series of patients aged 10-16 years guide our management. Using a general population cohort aged 10 to 16 years, we sought to: 1) determine the overall and demographic-specific incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR), and 2) determine the rate of and risk factors for repeat shoulder CR. Methods: Using administrative databases, we identified all patients who underwent CR of a primary anterior shoulder dislocation by a physician in Ontario between April 2002 and September 2010 (the index event). Exclusion criteria included age (16 years), posterior dislocation, and prior shoulder dislocation or surgery. The IDR was calculated for the entire cohort and compared by age and sex subgroups. The main outcome, repeat shoulder CR, was sought until September 2012. A time-to-event analysis (cumulative incidence function) was used to determine the incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years for the entire cohort and subgroups based on age (10-12, 13, 14, 15, and 16 years). A competing risk model identified risk factors for repeat shoulder CR, which were reported using hazard ratios (HR) with 95% confidence intervals (CI). Results: We identified 2,066 patients aged 10-16 years who underwent CR following a primary anterior shoulder dislocation, of which, 1,937 met the exclusion criteria. The median age was 15.0 years and 79.7% were male. The IDR was 20.1 per 100,000 person-years, and was highest among 16 year-old males (164.4 per 100,000 person-years). In contrast, primary anterior shoulder dislocation was rare among patients aged 10-12 years [5.9% (N=115) of all primary dislocations]. Repeat shoulder CR was observed in 740 patients (38.2%) after a median of 0.8 years. The overall cumulative incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years was 13.0%, 21.3%, 29.2%, and 36.2%, respectively; however, the cumulative incidence by age (Figure 1) revealed the rate of repeat shoulder CR to be highest among 14-16 year-olds (37.2-42.3%), and considerably less among patients aged 10-13 years (0-25.0%). Male sex (HR 1.2, p=0.04; interpreted as a 20% increased risk for males as compared to females) and patient age (HR 1.2, p<0.001; interpreted as a 20% increased risk for each year over age 10) significantly influenced the risk of a repeat shoulder CR. Overall, 31.2% (N=604) of patients underwent shoulder stabilization, of which, half underwent surgery following the index shoulder CR (49.9%, N=369). Conclusion: Primary anterior shoulder dislocations are common among 14-16 year olds, and the rate of recurrence in this age group following non-operative management mirrors that of 17-20 year olds in previously published data. In contrast, both the incidence of primary anterior dislocation and rate of recurrence are considerably lower for patients aged 10-13 years. Going forward, clinicians should treat and counsel patients aged 14-16 years, particularly males, as they do older adolescents (17-20 years); however, patients 13 years of age or younger should be counselled regarding their low risk for recurrence.
Anatomic techniques of ankle ligament repair have the advantage of restoring the anatomy and kinematics of the joint. This study presents a technique for anatomic reconstruction of the lateral ligament complex by way of lateral ligament advancement using suture anchors associated with immediate protected full weightbearing; 2- to 5-year clinical outcomes are reported.This technique of providing an anatomic reconstruction with a secure fixation will enable early rehabilitation with immediate, protected weightbearing, with favorable outcomes.Case series; Level of evidence, 4.Fifty-five patients with chronic lateral ankle instability who failed nonoperative management underwent modified Broström repair (lateral ligament fibular advancement) between 2005 and 2008. The anterior talofibular ligament and calcaneofibular ligament were released from the fibula and advanced using 2 double-loaded metallic suture anchors (3.5 mm). Full weightbearing in a walking boot was allowed from the first postoperative day. Patients were assessed preoperatively and at a minimum 2-year follow-up using the Foot and Ankle Outcome Score. Complication, failure (recurrent instability), and return-to-sport rates were also recorded.Six patients (11%) were lost to follow-up, leaving a study group of 49 patients (23 men, 26 women). The mean age at the time of surgery was 25 years (range, 18-37 years), with a mean duration of symptoms of 1.8 years (range, 6 months to 5 years). The mean follow-up time was 42 months (range, 24-60 months). Significant improvement was seen in the Foot and Ankle Outcome Score from preoperatively to postoperatively (from 36 to 75.4, P < .001): the pain subscale improved from 35 to 75 (P < .001), the symptom subscale from 29 to 77 (P = .01), the function subscale from 45 to 77 (P < .001), the function in sports and recreation subscale from 38 to 70 (P < .001), and the foot and ankle-related quality of life subscale from 35 to 78 (P < .001). No significant difference in range of motion with the contralateral side was seen (P = .34). The failure rate was 6%, with 3 patients reporting residual instability after a traumatic retear. Two cases of superficial wound infection were seen. One case of temporary neurapraxia of the superficial peroneal nerve was observed. The return-to-sport rate was 94%.This study demonstrates that anterior talofibular ligament and calcaneofibular ligament advancement using suture anchor fixation is an effective procedure for the treatment of chronic lateral ankle instability and allows immediate weightbearing.
Background: Arthroscopic hip labral repair is a technically challenging and demanding surgical technique with a steep learning curve. Arthroscopic simulation allows trainees to develop these skills in a safe environment. Purpose: The purpose of this study was to evaluate the use of a combination of assessment ratings for the performance of arthroscopic hip labral repair on a dry model. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 47 participants including orthopaedic surgery residents (n = 37), sports medicine fellows (n = 5), and staff surgeons (n = 5) performed arthroscopic hip labral repair on a dry model. Prior arthroscopic experience was noted. Participants were evaluated by 2 orthopaedic surgeons using a task-specific checklist, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), task completion time, and a final global rating scale. All procedures were video-recorded and scored by an orthopaedic fellow blinded to the level of training of each participant. Results: The internal consistency/reliability (Cronbach alpha) using the total ASSET score for the procedure was high (intraclass correlation coefficient > 0.9). One-way analysis of variance for the total ASSET score demonstrated a difference between participants based on the level of training ( F 3,43 = 27.8, P < .001). A good correlation was seen between the ASSET score and previous exposure to arthroscopic procedures ( r = 0.52-0.73, P < .001). The interrater reliability for the ASSET score was excellent (>0.9). Conclusion: The results of this study demonstrate that the use of dry models to assess the performance of arthroscopic hip labral repair by trainees is both valid and reliable. Further research will be required to demonstrate a correlation with performance on cadaveric specimens or in the operating room.
The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability.Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated.The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o'clock), it was 50% at the 4:30 position (average position 3:42 o'clock) and 80% at the 5:30 position (average position 5:03 o'clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate).The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.
