Publications by authors named "John E Kuhn"

114 Publications

Consensus Statement on the Treatment of Massive Irreparable Rotator Cuff Tears - A Delphi Approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

J Shoulder Elbow Surg 2021 Jun 8. Epub 2021 Jun 8.

Department of Orthopedic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.

Background: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial due to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons (ASES) to determine areas of consensus regarding treatment options for a variety of MIRCTs.

Methods: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including: arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfers. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the six included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either: Preferred treatment, Acceptable treatment, Not acceptable/contraindicated, or Unsure/no opinion. Patient scenarios were declared to achieve consensus for the Preferred and Not acceptable/contraindicated categories where at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the Acceptable treatment category, defined by an Acceptable or Preferred treatment response.

Results: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an Acceptable treatment with RSA selected for eighteen scenarios and arthroscopic débridement and/or partial repair selected for two scenarios. RSA was selected as the singular Preferred treatment option in eight scenarios. Not acceptable/contraindicated treatment options reached consensus in eight scenarios, of which, four related to SCR, three to RSA, and one to partial repair with graft augmentation.

Conclusion: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

Level Of Evidence: Survey Study; Experts.
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http://dx.doi.org/10.1016/j.jse.2021.05.012DOI Listing
June 2021

Beach Chair Versus Lateral Decubitus Position: Differences in Suture Anchor Position and Number During Arthroscopic Anterior Shoulder Stabilization.

Am J Sports Med 2021 Jul 21;49(8):2020-2026. Epub 2021 May 21.

University of Iowa, UI Sports Medicine, Iowa City, Iowa, USA.

Background: Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o'clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions.

Hypothesis: Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o'clock position.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: This study was a cross-sectional analysis of a prospective multicenter cohort of patients undergoing primary arthroscopic anterior capsulolabral repair. Patient positioning in the BC versus LD position was determined by the operating surgeon and was not randomized. At the time of operative intervention, surgeon-reported labral tear length, total anchor number, anchor number in the inferior glenoid, and anchor placement at the 6-o'clock position were evaluated between BC and LD cohorts. Descriptive statistics and between-group differences (continuous: test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed.

Results: In total, 714 patients underwent arthroscopic anterior capsulolabral repair (BC vs LD, 406 [56.9%] vs 308 [43.1%]). The surgeon-reported labral tear length was greater for patients having surgery in the LD position (BC vs LD [mean ± SD], 123.5°± 49° vs 132.3°± 44°; = .012). The LD position was associated with more anchors placed in the inferior glenoid and more frequent placement of anchors at the 6-o'clock (BC vs LD, 22.4% vs 51.6%; < .001). The LD position was more frequently associated with utilization of ≥4 total anchors (BC vs LD, 33.5% vs 46.1%; < .001).

Conclusion: Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o'clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o'clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study.

Registration: NCT02075775 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/03635465211013709DOI Listing
July 2021

Acromioclavicular Joint Disk Tearing in Young Non-Arthritic Individuals: A Case Series.

J Orthop Case Rep 2020 May-Jun;10(3):90-94

Department of Orthopaedic Surgery, University of Michigan Medical School, MedSport Domino's Farms, 24 Frank Lloyd Wright Drive, Lobby A, Suite 1000, Ann Arbor, MI 48106 USA.

Introduction: Degeneration of the fibrocartilaginous acromioclavicular (AC) joint disk can become significant in later life and lead to primary osteoarthritis and shoulder pain. Younger, non-arthritic individuals may develop residual shoulder symptoms due to tearing of the disk itself.

Case Report: Six patients (seven shoulders) were included in this case series. They were athletic and between the ages of 17 and 22. They typically presented with lingering symptoms of pain, popping, and instability in and around the AC joint after prior trauma or injury involving their shoulder. For most, symptoms lasted longer than 2 months before they sought additional treatment. Plain films were negative, and magnetic resonance imaging occasionally demonstrated pathology at the AC joint. Conservative treatment provided limited relief. All patients included in this series underwent arthroscopic distal clavicle resection. Intraoperatively, the disk could be seen as acutely torn or degenerative in all cases. In some, it was hypermobile and could be manually subluxed in and out of the joint.

Conclusions: A torn AC joint disk may cause lingering symptoms in young patients without radiographic evidence of arthritis. Further study is needed to determine if these findings are truly causative or merely incidental.
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http://dx.doi.org/10.13107/jocr.2020.v10.i03.1764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051580PMC
May 2021

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Arthroscopy 2021 Jun 15;37(6):1740-1744. Epub 2021 Jan 15.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Purpose: To identify factors predictive of a large labral tear at the time of shoulder instability surgery.

Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects.

Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007).

Conclusions: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf.

Level Of Evidence: I, prognostic study.
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http://dx.doi.org/10.1016/j.arthro.2021.01.007DOI Listing
June 2021

Factors Associated With Symptomatic Rotator Cuff Tears: The Rotator Cuff Outcomes Workgroup Cohort Study.

Am J Phys Med Rehabil 2021 04;100(4):331-336

From the Vanderbilt University School of Medicine, Nashville, Tennessee (AZG); Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee (AS, NBJ); Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee (PK); Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee (GDA, JEK, NBJ); Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (GDA); King Edward Memorial Hospital, Hamilton, Bermuda (LDH); Orthopedic Institute of Sioux Falls, Sioux Falls, South Dakota (KMB); Department of Orthopaedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (EM); and Departments of Physical Medicine and Rehabilitation, Orthopaedics, and Population and Data Sciences, University of Texas Southwestern, Dallas, Texas (NBJ).

Objective: Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain.

Design: From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression.

Results: In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02-1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16-3.52), and a higher body mass index (per 1 kg/m2: odds ratio = 1.06, 95% confidence interval = 1.03-1.12) were independently associated with rotator cuff tears. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear.

Conclusions: In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research.

To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

Cme Objectives: Upon completion of this article, the reader should be able to: (1) Identify factors associated with an increased risk of developing rotator cuff tears in adults; (2) Describe the current epidemiological trends of rotator cuff tears in the United States; and (3) Discuss the pathophysiological role of aging in the development of nontraumatic rotator cuff tears.

Level: Advanced.

Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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http://dx.doi.org/10.1097/PHM.0000000000001684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969413PMC
April 2021

What Are the Effects of Remplissage on 6-Month Strength and Range of Motion After Arthroscopic Bankart Repair? A Multicenter Cohort Study.

Orthop J Sports Med 2020 Feb 27;8(2):2325967120903283. Epub 2020 Feb 27.

Investigation performed at The Ohio State University Wexner Medical Center, Department of Orthopaedics, Columbus, Ohio, USA.

Background: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM).

Hypothesis: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone.

Study Design: Cohort study; Level of evidence, 2.

Methods: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect.

Results: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction ( = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane ( = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors ( = .003), increased patient age ( = .02), and preoperative side-to-side deficits in ER ( = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness ( = .04), with no association with remplissage ( = .26).

Conclusion: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.
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http://dx.doi.org/10.1177/2325967120903283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686606PMC
February 2020

Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol.

J Shoulder Elbow Surg 2021 Jun 1;30(6):1431-1444. Epub 2020 Dec 1.

Department of Orthopaedics, Vanderbilt University, Nashville, TN, USA. Electronic address:

Purpose: A massive, irreparable rotator cuff tear may cause significant pain and dysfunction. However, the efficacy of nonoperative treatment modalities in this subset of patients is not currently well known. Also, there is currently no gold standard nonoperative protocol to guide treatment. The goal of the present systematic review is to determine if there is any evidence to support the use of various nonoperative treatment modalities and synthesize a standardized nonoperative treatment protocol for the patient with a massive irreparable rotator cuff tear.

Methods: A comprehensive review of the literature utilizing PRISMA guidelines was performed. Studies involving clinical outcomes of nonoperative treatment of massive, irreparable rotator cuff tears were included. Articles were reviewed by 2 reviewers to determine inclusion or exclusion based on established criteria. Selected articles were reviewed for results of clinical and functional outcomes. The studies were also reviewed to determine their level of evidence and potential sources of bias. A standardized nonoperative treatment protocol was developed by taking described elements of the protocols used in studies that demonstrated clinical improvement beyond the MCID for the outcome scores used by the authors.

Results: A total of 10 studies met inclusion criteria for our studies. Of the included studies, 1 was Level III evidence and the remaining 9 were Level IV evidence. Multiple studies showed significant improvement exceeding the MCID for functional outcome scores following treatment. Also, several studies demonstrated significant improvements in strength and range of motion. The overall success of nonoperative treatment ranged from 32%-96%. The synthesized nonoperative treatment protocol is characterized by requiring some supervised physical therapy, often requiring 12 weeks or more, focusing on supine exercises with gradual progression to upright. Corticosteroid injections and nonsteroidal anti-inflammatory drugs may also be of benefit.

Conclusion: Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. Using these results, a synthesized rehabilitation program was developed to guide clinicians when treating patients with massive irreparable rotator cuff tears.
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http://dx.doi.org/10.1016/j.jse.2020.11.002DOI Listing
June 2021

Upper Extremity Pain and Overuse Injuries in Fly-Fishing: A North American Cross-Sectional Survey and Implications for Injury Prevention.

Orthop J Sports Med 2020 Oct 21;8(10):2325967120959303. Epub 2020 Oct 21.

Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: Fly-fishing requires rhythmic, coordinated movements to successfully cast a fly line. Previous studies have shown that the biomechanical demands of fly-casting may cause some individuals to develop upper extremity pain or injuries.

Purpose: To report the rates, trends, and contributing factors of upper extremity pain and overuse injuries in a sample of North American recreational fly-fishers.

Study Design: Descriptive epidemiology study.

Methods: Participants were reached via 3 popular online fly-fishing forums in April 2019. Each consenting North American participant over 18 years of age was given a link to a unique survey that recorded his or her demographic and orthopaedic histories, fly-fishing experience, equipment, casting techniques, upper extremity pain after fly-fishing, and chronic outcomes.

Results: The 162 fly-fishers included were 63.3 (± 11.5) years of age, and 95.1% were men. In total, 59 (36.4%) reported experiencing upper extremity pain immediately after fly-fishing. Pain was rated a 4.0 (interquartile range, 3.0-6.0) on a 10-point Likert scale, commonly lasting less than 1 day (45.0%) or between 1 day and 1 week (45.0%). The majority (62.7%) reported not needing to see a medical provider for their pain/soreness. Those who did most commonly received diagnoses of elbow or rotator cuff tendinitis. Pain/soreness was associated with casting in an elliptical/sidearm fashion, compared with overhead or 2-handed casting ( = .006) using a weighted line or added weight (split-shot, weighted heads, etc) ( = .034) and with grip styles where the hand was pronated compared with being in a more neutral position ( = .046). The mean shortened version of the Disabilities of the Arm, Shoulder and Hand score was 10.8 (± 11.5). Higher scores were associated with a history of self-reported upper extremity orthopaedic injuries (B = 6.059 [95% CI, 2.476-9.642]; SE, 1.814; = .001) and having had surgery for these injuries (B = 8.484 [95% CI, 4.454-12.513]; SE, 0.314; < .001).

Conclusion: In this sample of recreational fly-fishers, no aspects of fly-fishing were associated with long-term upper extremity disability, and only a little more than a third reported having transient pain immediately after fishing. Casting style, using weighted lines or added weight, and grip style were all associated with pain. These are modifiable risk factors that can be adjusted to reduce the risk of upper extremity pain immediately after fly-fishing.
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http://dx.doi.org/10.1177/2325967120959303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588766PMC
October 2020

Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

J Shoulder Elbow Surg 2020 Dec 26;29(12):2429-2445. Epub 2020 Aug 26.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Background: The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD.

Methods: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations.

Results: Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes.

Conclusion: Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss.
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http://dx.doi.org/10.1016/j.jse.2020.08.011DOI Listing
December 2020

Comparative Time to Improvement in Nonoperative and Operative Treatment of Rotator Cuff Tears.

J Bone Joint Surg Am 2020 Jul;102(13):1142-1150

Departments of Physical Medicine and Rehabilitation (A.S. and N.B.J.), Orthopaedics and Rehabilitation (N.B.J. and J.E.K.), and Biostatistics (J.D. and G.D.A.), Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Comparative time to recovery after operative and nonoperative treatment for rotator cuff tears is an important consideration for patients. Hence, we compared the time to achieve clinically meaningful reduction in shoulder pain and function after treatment.

Methods: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative or nonoperative treatment was recruited. After propensity score weighting, the Kaplan-Meier method was used to estimate the time to achieve a minimal clinically important difference (MCID), >30% reduction, and >50% reduction in the Shoulder Pain and Disability Index (SPADI) and the American Shoulder and Elbow Surgeons (ASES) scores. (In our analysis, both ASES and SPADI were coded such that a lower number corresponded to a better outcome; thus, the word "reduction" was used to indicate improvement in both ASES and SPADI scores.) A 2-stage test was conducted to detect a difference between the 2 groups.

Results: In this cohort, 96 patients underwent nonoperative treatment and 73 patients underwent a surgical procedure. The surgical treatment group and the nonoperative treatment group were significantly different with respect to SPADI and ASES scores (p < 0.05). The maximum difference between groups in achievement of the MCID for the SPADI scores was at 3.25 months, favoring the nonoperative treatment group. The probability to achieve the MCID was 0.06 (95% confidence interval [CI], 0.00 to 0.12) for the surgical treatment group compared with 0.40 (95% CI, 0.29 to 0.50) for the nonoperative treatment group. The surgical treatment group had a greater probability of achieving >50% reduction in SPADI scores at 15.49 months (0.20 [95% CI, 0.12 to 0.29] for the surgical treatment group compared with 0.04 [95% CI, 0.00 to 0.09] for the nonoperative treatment group). The surgical treatment group had a greater probability of achieving >50% reduction in ASES scores at 24.74 months (0.96 [95% CI, 0.84 to 0.99] for the surgical treatment group compared with 0.66 [95% CI, 0.53 to 0.75] for the nonoperative treatment group). The differences for >30% reduction in SPADI and ASES scores and the MCID for ASES scores were not significant.

Conclusions: Patients undergoing nonoperative treatment had significantly better outcomes in the initial follow-up period compared with patients undergoing a surgical procedure, but this trend reversed in the longer term. These data can be used to inform expectations for nonoperative and operative treatments for rotator cuff tears.

Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.01112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508291PMC
July 2020

Predicting the need for surgical intervention prior to first encounter for individuals with shoulder complaints: a unique approach.

JSES Int 2020 Mar 12;4(1):207-214. Epub 2019 Dec 12.

Cleveland Clinic Sports Health Center, Cleveland, OH, USA.

Background: Increasing demand for musculoskeletal care necessitates efficient scheduling and matching of patients with the appropriate provider. However, up to 47% to 60% of orthopedic visits are made without formal triage. The purpose of this study was to develop a method to identify, prior to the initial office visit, the probability that a patient with shoulder symptoms will need surgery so that he or she can be appropriately matched with an operative or nonoperative provider. We hypothesized that patients who had an injury, previously saw an orthopedic provider, or previously underwent magnetic resonance imaging on the affected shoulder would be more likely to undergo surgery.

Methods: Drawing from expert opinion on potential risk factors (which could be identified prior to the initial office visit) for requiring operative intervention for a chief complaint of shoulder symptoms, we developed a branching-logic questionnaire that required a maximum of 7 responses from the patient during the scheduling process. We administered the questionnaire to patients calling with a chief complaint of shoulder symptoms at the time of initial appointment scheduling in a sports health network. A chart review was later completed to determine the ultimate treatment (operative vs. nonoperative) of each patient's complaint. A multivariate predictive model was then developed to determine the characteristics of patients with a higher surgical risk.

Results: We successfully developed a model capable of determining surgical risk from 7% to 90% based on patient sex, previous magnetic resonance imaging status, and injury status.

Conclusions: Our predictive model can aid in patient clinical scheduling and ensure optimal matching of a patient with the best provider for the patient's care. Decreased wait times and appropriate matching may lead to increased patient satisfaction, superior outcomes, and more efficient use of health care resources.
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http://dx.doi.org/10.1016/j.jses.2019.10.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075748PMC
March 2020

Surgical outcomes in the Frequency, Etiology, Direction, and Severity (FEDS) classification system for shoulder instability.

J Shoulder Elbow Surg 2020 Apr;29(4):784-793

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The Frequency, Etiology, Direction, and Severity (FEDS) system was developed as a simple but reliable method for classifying shoulder instability based on 4 factors attainable by history and physical examination: frequency (solitary, occasional, or frequent); etiology (traumatic or atraumatic); direction (anterior, posterior, or inferior); and severity (subluxation or dislocation). This study investigated the epidemiology and 2-year surgical outcomes for the FEDS categories in the prospective Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort.

Methods: At the time of surgery, 1204 patients were assigned to the FEDS categories. Follow-up data were available for 636 of 734 patients (86.6%) who had undergone surgery at least 2 years prior to analysis. The most common categories were further analyzed by patient-reported outcomes (PROs) (American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability index, Single Assessment Numeric Evaluation scores) and rates of recurrent subluxation, recurrent dislocation, and revision surgery.

Results: Of the 36 FEDS categories, 16 represented at least 1% of patients. Occasional traumatic anterior dislocation (OTAD) was the most common category, with 16.4% of patients. Five other anterior categories (solitary traumatic anterior subluxation, occasional traumatic anterior subluxation [OTAS], frequent traumatic anterior subluxation [FTAS], solitary traumatic anterior dislocation, and frequent traumatic anterior dislocation) and one posterior category (solitary traumatic posterior subluxation [STPS]) represented at least 5% of patients. PROs improved significantly for each category. The highest rates of recurrent subluxation occurred in FTAS, OTAS, and OTAD cases; dislocation, OTAS and FTAS cases; and further surgery, OTAD cases. The lowest rates of failure occurred in STPS cases. Downward trends in PROs and higher failure rates were noted with an increasing number of preoperative dislocations.

Conclusion: Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. Overall, outcomes decreased with a higher number of preoperative dislocations.
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http://dx.doi.org/10.1016/j.jse.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197435PMC
April 2020

Risk Factors for Intra-articular Bone and Cartilage Lesions in Patients Undergoing Surgical Treatment for Posterior Instability.

Am J Sports Med 2020 04 9;48(5):1207-1212. Epub 2020 Mar 9.

Investigation performed at University of California, San Francisco, San Francisco, California, USA.

Background: Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear.

Hypothesis: We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort were analyzed. Patients aged 12 to 99 years undergoing primary surgical treatment for shoulder instability were included. The glenohumeral joint was evaluated by the treating surgeon at the time of surgery, and patients were classified as having a BCL if they had any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of the number of instability events on the presence of BCLs was investigated by use of Fisher exact tests. Logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as < .05.

Results: We identified 271 patients (223 male) for analysis. Bone and cartilage lesions were identified in 54 patients (19.9%) at the time of surgical treatment. A glenoid cartilage injury was most common and was identified in 28 patients (10.3%). A significant difference was noted between the number of instability events and the presence of BCLs ( = .025), with the highest rate observed in patients with 2 to 5 instability events (32.3%). Multivariate logistic regression modeling indicated that increasing age ( = .019) and 2 to 5 reported instability events ( = .001) were significant independent predictors of the presence of BCLs. For bone lesions alone, the number of instability events was the only significant independent predictor; increased risk of bone lesion was present for patients with 1 instability event (OR, 6.1; = .012), patients with 2 to 5 instability events (OR, 4.2; = .033), and patients with more than 5 instability events (OR, 6.0; = .011).

Conclusion: Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.
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http://dx.doi.org/10.1177/0363546520907916DOI Listing
April 2020

The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Orthop J Sports Med 2020 Feb 4;8(2):2325967119894738. Epub 2020 Feb 4.

Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA.

Background: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty.

Purpose/hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain.

Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; < .001) and were more likely to be female (25.3% vs 17.4%; = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) ( < .001), more frequent depression (22.2% vs 8.3%; < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) ( < .01), and worse preoperative expectations ( < .01).

Conclusion: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes.
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http://dx.doi.org/10.1177/2325967119894738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000858PMC
February 2020

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study.

Am J Sports Med 2020 03 11;48(4):923-930. Epub 2020 Feb 11.

Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA.

Background: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss.

Purpose: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months.

Study Design: Case-control study; Level of evidence, 3.

Methods: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports.

Results: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; = .02).

Conclusion: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.
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http://dx.doi.org/10.1177/0363546520901538DOI Listing
March 2020

US Geographical Variation in Rates of Shoulder and Knee Arthroscopy and Association With Orthopedist Density.

JAMA Netw Open 2019 12 2;2(12):e1917315. Epub 2019 Dec 2.

Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee.

Importance: Although rates of arthroscopy have substantially increased, recent data question its comparative effectiveness.

Objectives: To assess time trends and geographical variations among several US states in arthroscopy rates and to assess the association of orthopedist density with arthroscopy rates.

Design, Setting, And Participants: In this cross-sectional study, procedure rates were calculated for knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair using data from the State Ambulatory Surgery and Services Databases for 2006 to 2016 (as available) for the states of California, Colorado, Florida, Iowa, Kentucky, Maryland, Maine, Michigan, Minnesota, North Carolina, Nebraska, New Jersey, Nevada, New York, Oregon, Utah, Vermont, and Wisconsin. Data were analyzed from June 2017 to October 2019.

Main Outcomes And Measures: Rates of knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair.

Results: The combined data sets included 4 856 385 records with 2 530 840 female patients (47%); mean (SD) patient age was 49.13 (16.34) years. Rates per 100 000 persons showed large geographical variations for knee arthroscopy (from 63.31 [95% CI, 5.92-198.95] to 721.72 [95% CI, 633.41-806.20]), shoulder arthroscopy (from 53.02 [95% CI, 2.80-164.36] to 438.25 [95% CI, 399.00-476.78]), and arthroscopic rotator cuff repair (from 11.94 [95% CI, 1.30-56.98] to 185.35 [95% CI, 143.84-226.20]) across US states and years. There were significant downward time trends in knee arthroscopy rates in California, Florida, Iowa, Maryland, Michigan, Nebraska, and New Jersey and upward trends for arthroscopic rotator cuff repair in Colorado, Florida, Kentucky, Maine, and North Carolina. Orthopedist density was not associated with knee arthroscopy rates (slope = 3.07; 95% CI, -9.88 to 16.03; P = .54), shoulder arthroscopy rates (slope = 2.74; 95% CI, -6.53 to 12.01; P = .47), or rates of arthroscopic rotator cuff repair (slope = 1.15; 95% CI, -2.77 to 5.05; P = .49).

Conclusions And Relevance: There is large geographical variation in arthroscopy rates despite the questionable comparative effectiveness of these procedures. The reasons for increasing rates of rotator cuff surgery should be further examined.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.17315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991208PMC
December 2019

Comparative Effectiveness of Operative Versus Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort.

Am J Sports Med 2019 11 13;47(13):3065-3072. Epub 2019 Sep 13.

King Edward VII Memorial Hospital, Hamilton, Bermuda.

Background: The evidence to support operative versus nonoperative treatment for rotator cuff tears is sparse and inconclusive.

Purpose: To assess pain and functional outcomes in patients undergoing operative and nonoperative treatments for rotator cuff tears.

Study Design: Cohort study; Level of evidence, 3.

Methods: From March 2011 to February 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative and nonoperative treatments was recruited. Patients completed a detailed history questionnaire, the Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) standardized form and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Propensity score weighting was used to balance differences in characteristics of the operative and nonoperative groups.

Results: Adjusted for propensity scores, the operative (n = 50) and nonoperative (n = 77) groups had similar characteristics, as evidenced by the small standardized mean differences between the groups. Adjusted mean differences in the SPADI and ASES scores between the operative and nonoperative groups were -22.0 points (95% CI, -32.1 to -11.8) and -22.2 points (95% CI, -32.8 to -11.6) at 18 months, respectively. The operative group had a significantly higher proportion of patients who showed ≥30% ( = .002) and ≥50% ( < .0001) improvement in SPADI and ASES scores as compared with the nonoperative group.

Conclusion: In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. Differences between the 2 groups in SPADI and ASES scores at the 6- to 18-month time points met the minimal clinically important difference (depending on the threshold used). A large randomized controlled trial is needed to answer this question more definitively.
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http://dx.doi.org/10.1177/0363546519873840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325686PMC
November 2019

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies.

Orthop J Sports Med 2019 Aug 9;7(8):2325967119862501. Epub 2019 Aug 9.

Investigation performed at the Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI).

Purpose: To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated.

Results: The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38).

Conclusion: Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.
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http://dx.doi.org/10.1177/2325967119862501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689926PMC
August 2019

Operative vs Nonoperative Treatment for Atraumatic Rotator Cuff Tears: A Trial Protocol for the Arthroscopic Rotator Cuff Pragmatic Randomized Clinical Trial.

JAMA Netw Open 2019 08 2;2(8):e199050. Epub 2019 Aug 2.

Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Rotator cuff disorders remain the most common cause of shoulder pain and are among the most common reasons for patients to seek care in primary and specialty settings. Although operative and nonoperative treatments are offered to patients with atraumatic rotator cuff tears, there is a lack of evidence to support operative vs nonoperative treatment. This paucity of evidence has been highlighted by several professional agencies and experts.

Objective: To perform a pragmatic randomized clinical trial, the Arthroscopic Rotator Cuff trial, comparing pain and functional outcomes in patients undergoing operative vs nonoperative treatment for atraumatic rotator cuff tears, and assessing heterogeneity of treatment effects by age and tear size.

Design, Setting, And Participants: Trial protocol of the Arthroscopic Rotator Cuff trial. This pragmatic randomized clinical trial of an estimated 700 patients is adequately powered to accomplish its aims with 488 patients. Primary analysis will be conducted on an intent-to-treat population in the context of a mixed model. The multicenter trial started recruitment in 2018 with a 1-year follow-up duration. Patients aged 50 years or older to younger than 85 years with magnetic resonance imaging-confirmed atraumatic rotator cuff tears that are suitable for either operative or nonoperative treatment will be enrolled. Block randomization will be performed and stratified by site, age, and tear size.

Intervention: Nonoperative treatment consists of an approximately 3-month standardized physical therapy program, whereas operative treatment consists of rotator cuff surgery followed by approximately 4 months of postoperative rehabilitation.

Main Outcomes And Measures: The primary outcome is patient-reported Shoulder Pain and Disability Index score, and the secondary outcome is American Shoulder and Elbow Surgeons Standardized Shoulder Form score measured at 1 year of follow-up.

Discussion: The Arthroscopic Rotator Cuff trial is ongoing, and 12 sites with more than 40 physicians are currently recruiting patients. Although there is variation by site, as of May 2, 2019, 13% of all patients screened (787 of 6293) were eligible for the trial, and 9% of eligible patients (74 of 787) were recruited. Results of this study may help patients, clinicians, and policy makers assess the comparative effectiveness of operative vs nonoperative treatment for atraumatic rotator cuff tears.

Trial Registration: ClinicalTrials.gov identifier: NCT03295994.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.9050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6692688PMC
August 2019

Epidemiology of Glenohumeral Instability Related to Sporting Activities Using the FEDS (Frequency, Etiology, Direction, and Severity) Classification System: A Multicenter Analysis.

Orthop J Sports Med 2019 Jul 31;7(7):2325967119861038. Epub 2019 Jul 31.

University of Iowa, Iowa City, Iowa, USA.

Background: Glenohumeral instability is common in athletes. There are an estimated 0.12 episodes of instability per 1000 sporting exposures. Instability can lead to time away from sport and an increased risk of shoulder arthritis.

Purpose: To determine the prevalence, demographic data, anatomic features, and likelihood of surgery for the different types of instability as defined by the FEDS (frequency, etiology, direction, and severity) classification system for different sports.

Study Design: Cohort study; Level of evidence, 3.

Methods: Databases at 3 institutions (University of Iowa, Vanderbilt University, and University of Pennsylvania) were searched for International Classification of Diseases--Ninth Revision codes related to shoulder instability in 2010. Demographic data, symptoms, causes, imaging findings, and operative reports were obtained. Data were entered into a custom-designed REDCap online survey. Patients with subjective instability related to sporting activities were included for analysis.

Results: A total of 184 athletes had glenohumeral instability; 20.1% were female. The mean age at the time of the first instability episode was 19.0 years for both male and female patients. The most common sports were football (29.3%), basketball (19.0%), and wrestling (9.8%). The most common type of instability based on the FEDS system was occasional, traumatic, anterior dislocation. Surgery was performed on 69.6% of athletes, and 14.1% had a recurrence of instability after surgery overall. Football had the highest rate of recurrence postoperatively at 23.8%. There was no difference in surgery rates between athletes with subluxations versus dislocations ( = .8458). Surgery was significantly more likely in those with frequent dislocations ( < .0001) and posterior instability ( = .027). There was a 10.7% recurrence rate overall with conservative treatment.

Conclusion: Glenohumeral instability most commonly occurs in contact sports, affects male more than female patients, and is most frequently in the anterior direction. Recurrent instability is most common in football players. Attention should be turned to the specific characteristics of each type of instability to determine the best treatment for each athlete.
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http://dx.doi.org/10.1177/2325967119861038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669843PMC
July 2019

Which Is the Best Outcome Measure for Rotator Cuff Tears?

Clin Orthop Relat Res 2019 Aug;477(8):1869-1878

D. I. Dabija, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN, USA J. S. Pennings, K. R. Archer, J. E. Kuhn, N. B. Jain, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA K. R. Archer, N. B. Jain, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA G. D. Ayers, Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA L. D. Higgins, E. Matzkin, Department of Orthopaedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA K. M. Baumgarten, Orthopedic Institute, Sioux Falls, SD, USA.

Background: The American Shoulder and Elbow Surgeons Standardized Shoulder Form (ASES), the Shoulder Pain and Disability Index (SPADI), and the shortened Disability of the Arm, Shoulder, and Hand (quickDASH) are patient-reported upper extremity-specific outcome scales currently used to evaluate patients with rotator cuff tears. This heterogeneity does not allow for a uniform metric for research and patient care.

Questions/purposes: Our objective was to determine psychometric properties (reliability, convergent and discriminant validity, and responsiveness) of five commonly used outcome instruments (the ASES, the SPADI, the quickDASH, the SF-12, and the EuroQol-5D) in a longitudinal study of patients undergoing treatment for rotator cuff tears.

Methods: From February 2011 through June 2015, 120 patients completed a standardized history, the five outcome scales under study, a physical examination, and an MRI. Of these, 47 (39%) were lost to followup before 18 months, and another 24 (20%) were accounted for at 18 months but had missing data at one or more of the earlier prespecified followup intervals (3, 6, or 12 months). Reliability (the reproducibility of an outcome instrument between subjects; tested by Cronbach's alpha), convergent and discriminant validity (determining which outcome measures correlate most strongly with others; tested by Spearman's correlation coefficients), and responsiveness (the change in outcome scales over time based on percent improvement in shoulder functionality using the minimal clinically important difference [MCID] and the subjective shoulder value) were calculated.

Results: All outcomes measures had a Cronbach's alpha above 0.70 (range, 0.74-0.94) and therefore were considered reliable. Convergent validity was demonstrated as the upper extremity-specific measures (SPADI, ASES, and quickDASH) were more strongly correlated with each other (rho = 0.74-0.81; p < 0.001) than with any of the other measures. Discriminant validity was demonstrated because the Spearman's correlation coefficients were stronger for the relationships between upper extremity measures compared with the correlations between upper extremity measures and general health measures for 53 of the 54 correlations that were compared. Both internal and external responsiveness of the measures was supported. Patients who achieved the MCID and at least a 30% change on the subjective shoulder value had more positive change in scores over time compared with those who did not. Mixed model linear regressions revealed that all three upper extremity-specific measures had a group by time interaction for the MCID, indicating that patients who achieved the MCID had greater change over time compared with those who did not achieve the MCID. Results showed that the measure with the best discrimination between groups, or best internal responsiveness, was the ASES (beta = -8.26, 95% confidence interval [CI], -11.39 to -5.14; p < 0.001; η = 0.089) followed by the SPADI (beta = 6.88, 95% CI, 3.78-9.97; p < 0.001; η = 0.088) then the quickDASH (beta = 3.43, 95% CI, 0.86-6.01; p = 0.009, η = 0.027). Measures with the best external responsiveness followed the same pattern of results.

Conclusions: All the upper extremity-specific scales had acceptable psychometric properties. Correlations were high and thus only one upper extremity-specific instrument is needed for outcome assessment. Given the overall psychometric assessment, we recommend SPADI be the shoulder-specific instrument used to assess outcomes in patients with rotator cuff tears.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000000800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000030PMC
August 2019

Clinical Outcomes After Anterior Shoulder Stabilization in Overhead Athletes: An Analysis of the MOON Shoulder Instability Consortium.

Am J Sports Med 2019 05;47(6):1404-1410

Investigation performed at the University of Michigan, Ann Arbor, Michigan, USA.

Background: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment.

Purpose: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively.

Study Design: Case series; Level of evidence, 4.

Methods: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up.

Results: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not.

Conclusion: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.
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http://dx.doi.org/10.1177/0363546519837666DOI Listing
May 2019

Physical therapy versus natural history in outcomes of rotator cuff tears: the Rotator Cuff Outcomes Workgroup (ROW) cohort study.

J Shoulder Elbow Surg 2019 May 13;28(5):833-838. Epub 2018 Dec 13.

Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Background: We compared the outcomes of patients who performed physical therapy versus those who did not in a longitudinal cohort of patients undergoing nonoperative treatment of rotator cuff tears. We also assessed whether there was a dose effect in which the pain and functional outcomes in patients performing physical therapy plateaued.

Methods: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment completed a detailed health and demographic questionnaire and the Shoulder Pain and Disability Index (SPADI) at baseline and 3, 6, 12, and 18 months. Longitudinal mixed models were used to assess whether physical therapy in the first 3 months predicted SPADI scores and dose effect.

Results: Among the 55 patients in our cohort, the performance of physical therapy within the first 3 months predicted better SPADI scores versus nonperformance of physical therapy at 3 months (P = .02). Scores were similar between groups at 6, 12, and 18 months. A threshold of 16 physical therapy sessions was observed for pain and functional improvement during follow-up, after which significant improvement was not seen.

Conclusions: Patients who performed physical therapy within the first 3 months had statistically significant improvements in pain and function as measured by the SPADI score at 3 months compared with patients who did not report performing physical therapy. Depending on the minimal clinically important difference used for the SPADI score, our results could be interpreted as meeting the minimal clinically important difference threshold or not. Improvement in outcomes was observed up to 16 sessions of physical therapy, after which outcomes plateaued.
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http://dx.doi.org/10.1016/j.jse.2018.10.001DOI Listing
May 2019

Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability.

J Shoulder Elbow Surg 2019 Jan 19;28(1):95-101. Epub 2018 Oct 19.

Vanderbilt Sports Medicine, Nashville, TN, USA.

Hypothesis: The purpose of this multicenter epidemiologic study was to determine the distribution of patients within the Frequency, Etiology, Direction, and Severity (FEDS) classification system to determine which categories are of clinical importance.

Methods: Shoulder instability patients were identified using International Classification of Diseases, Ninth Revision coding data from 3 separate institutions from 2005-2010. Data were collected retrospectively. Details of instability were recorded in accordance with the FEDS classification system. Each patient was assigned a classification within the FEDS system. After all patients were assigned to a group, each group was individually analyzed and compared with the other groups.

Results: There are a total of 36 possible combinations within the FEDS system. Only 16 categories were represented by at least 1% of our patient population. Six categories captured at least 5% of all patients with shoulder instability. Only 2 categories represented greater than 10% of the population: solitary, traumatic, anterior dislocation, with 95 patients (24.8%), and occasional, traumatic, anterior dislocation, with 63 patients (16.4%).

Conclusions: There are 16 categories within the FEDS classification that are clinically significant. Solitary, traumatic, anterior dislocation and occasional, traumatic, anterior dislocation were the most frequently observed in our cohort.
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http://dx.doi.org/10.1016/j.jse.2018.08.014DOI Listing
January 2019

Shoulder Instability: Interobserver and Intraobserver Agreement in the Assessment of Labral Tears.

Orthop J Sports Med 2018 Sep 6;6(9):2325967118793372. Epub 2018 Sep 6.

Investigation performed at the University of Iowa, Iowa City, Iowa, USA.

Background: The glenohumeral joint combines large range of motion and insufficient bony stabilization, making it susceptible to instability and dislocations. Arthroscopic surgery is routinely used as a diagnostic tool and has been considered the gold standard for the diagnosis of shoulder lesions. However, several studies have demonstrated variability in intraobserver and interobserver agreement.

Purpose: To evaluate interobserver and intraobserver agreement in the assessment of intra-articular lesions associated with shoulder instability among fellowship-trained shoulder surgeons.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: A total of 24 arthroscopic videos from patients treated for recurrent shoulder instability were shown to a group of 10 fellowship-trained shoulder surgeons who are members of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. They were presented to the surgeons on 2 different occasions at least 2 months apart. They were asked to classify labral tears by their position, type, extension, other intra-articular abnormality, and preferred treatment. No patient history or physical examination data were provided. The primary outcome was the median overall percentage of agreement for the surgeons performing a video review, measured for each variable evaluated. Intraclass correlation coefficients were used to evaluate continuous variables, and kappa values were used for categorical items.

Results: Interobserver agreement was good for anterior labral lesions; good for Hill-Sachs lesions; and moderate for lesions of the superior labrum, posterior labrum, anterior sublabral foramen, and position and extension of the tear. Intraobserver agreement was either good or very good for all variables evaluated, except for being poor for inferior labral lesions and moderate for lesions of the meniscoid superior labrum.

Conclusion: Interobserver and intraobserver reliability for the arthroscopic assessment of labral tears in patients with recurrent shoulder instability were good to moderate for the majority of anatomic structures assessed. There was relatively good agreement between shoulder instability surgeons on assessing and documenting shoulder instability-associated abnormalities. These findings are important when interpreting collaborative clinical cohort studies with numerous surgeons involved in the research.
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http://dx.doi.org/10.1177/2325967118793372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128077PMC
September 2018

Predictors of Pain and Functional Outcomes After the Nonoperative Treatment of Rotator Cuff Tears.

Orthop J Sports Med 2018 Aug 3;6(8):2325967118788531. Epub 2018 Aug 3.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Optimal patient selection is key to the success of nonoperative treatment for rotator cuff tears.

Purpose: To assess the predictors of pain and functional outcomes in a longitudinal cohort of patients undergoing nonoperative treatment.

Study Design: Cohort study; Level of evidence, 2.

Methods: A multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment was recruited from March 2011 to February 2015. Patients completed a detailed health questionnaire, completed standardized shoulder questionnaires including the Shoulder Pain and Disability Index (SPADI), and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Longitudinal mixed models were used to test predictors of the SPADI score, and interactions with time were assessed.

Results: In our cohort of 70 patients, being married as compared with being single/divorced/widowed ( = .02), a shorter duration of symptoms ( = .02), daily shoulder use at work that included light or no manual labor versus moderate or heavy manual labor ( = .04), alcohol use of 1 to 2 times per week or more as compared with 2 to 3 times per month or less ( = .007), and absence of fatty infiltration ( = .0009) were significantly associated with decreased SPADI scores (improved shoulder pain and disability) over time. When interactions with time were assessed, having a college level of education or higher compared with less than a college education showed a differential effect over time, with those with a college level of education or more having lower SPADI scores ( = .004). Partial-thickness tear versus full-thickness tear also had an interaction with follow-up duration, such that those with a partial-thickness tear had lower SPADI scores ( = .0002).

Conclusion: Longitudinal predictors of better outcomes of the nonoperative treatment of rotator cuff tears included being married, having at least a college education, shorter duration of symptoms, light or manual labor in daily work, alcohol use of 1 to 2 times per week or more, partial-thickness tear, and absence of fatty infiltration of the rotator cuff. Our results suggest that nonoperative treatment should be performed early for optimal outcomes. These data can be used to select optimal candidates for the nonoperative treatment of rotator cuff tears and to assist with patient education and expectations before treatment.
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http://dx.doi.org/10.1177/2325967118788531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080194PMC
August 2018

Does My Patient With Shoulder Pain Have a Rotator Cuff Tear?: A Predictive Model From the ROW Cohort.

Orthop J Sports Med 2018 Jul 16;6(7):2325967118784897. Epub 2018 Jul 16.

Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: Rotator cuff tears are the leading cause of shoulder pain and disability. However, the diagnosis of a rotator cuff tear based on patient characteristics, symptoms, and physical examination findings remains a challenge because of a lack of data. Moreover, data on the predictive ability of a combination of these characteristics and tests are not available from a large cohort of patients. Consequently, clinicians rely on expensive imaging, such as magnetic resonance imaging (MRI), to make a diagnosis.

Purpose: To model patient characteristics, symptoms, and physical examination findings that predict a rotator cuff tear. We present a nomogram based on our predictive model that can be used in patients with shoulder pain to determine the probability of the diagnosis of a rotator cuff tear without the need for imaging.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: We recruited patients from outpatient clinics who were ≥45 years of age and who had shoulder pain of at least 4 weeks' duration. A rotator cuff tear was diagnosed based on expert clinical impression and the presence/absence of a tear on a blinded review of MRI. Ultimately, 301 patients were included in the analysis.

Results: A total of 123 patients (41%) had rotator cuff tears, and 178 patients (59%) did not. The predictors of the diagnosis of a rotator cuff tear included external rotation strength ratio of the affected versus unaffected shoulder (odds ratio [OR], 1.20 [95% CI, 1.08-1.34]), male sex (OR, 1.98 [95% CI, 1.10-3.56]), positive lift-off test result (OR, 4.33 [95% CI, 1.46-12.86]), and positive Jobe test result (OR, 9.19 [95% CI, 4.69-17.99]). A nomogram based on these predictor variables was plotted.

Conclusion: Presented is a model that can accurately predict the diagnosis of a rotator cuff tear with satisfactory discrimination and calibration based on 4 variables: sex, lift-off test, Jobe test, and external rotation strength ratio. Data from this study can be used to aid in the diagnosis of a rotator cuff tear in day-to-day clinical practice in outpatient settings without the need for expensive imaging such as MRI.
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http://dx.doi.org/10.1177/2325967118784897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048628PMC
July 2018

Predictors of pain and functional outcomes after operative treatment for rotator cuff tears.

J Shoulder Elbow Surg 2018 Aug;27(8):1393-1400

Department of Orthopaedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

Background: Optimal patient selection is key to success of operative treatment for cuff tears. We assessed predictors of pain and functional outcomes in a longitudinal cohort of patients undergoing operative treatment.

Methods: From March 2011 to January 2015, a cohort of patients with rotator cuff tears undergoing rotator cuff surgery was recruited. Patients completed a detailed health and demographic questionnaire, standardized shoulder questionnaires, including the Shoulder Pain and Disability Index (SPADI), and underwent a magnetic resonance imaging scan. Patients received follow-up questionnaires at 3, 6, 12, and 18 months. We assessed longitudinal predictors of SPADI using longitudinal mixed models. Interactions with follow-up duration after surgery were also assessed.

Results: In our analysis (n = 50), a lower Fear-Avoidance Beliefs Questionnaire physical activity score (P = .001) predicted a lower SPADI score (better shoulder pain and function). Those consuming alcohol 1 to 2 times per week or more had lower SPADI scores than those consuming alcohol 2 to 3 times per month or less (P = .017). Both of these variables had a significant interaction with duration of follow-up. Variables that were not significant predictors of SPADI included sociodemographic characteristics, magnetic resonance imaging characteristics, such as tear size and muscle quality, shoulder strength, and variations in surgical techniques/performance of adjuvant surgical procedures.

Conclusions: Those with higher fear avoidance behavior and alcohol use of 1 to 2 times per week had worse shoulder pain and function at 18 months of follow-up. These data can be used to select optimal candidates for operative treatment of rotator cuff tears and assist with patient education and expectations before treatment.
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http://dx.doi.org/10.1016/j.jse.2018.04.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6085102PMC
August 2018

Early return to baseline range of motion and strength after anterior shoulder instability surgery: a Multicenter Orthopaedic Outcomes Network (MOON) shoulder group cohort study.

J Shoulder Elbow Surg 2018 Jul 23;27(7):1235-1242. Epub 2018 Mar 23.

Department of Orthopaedics and Rehabilitation, University of Kentucky, Lexington, KY, USA.

Background: Patients often return to higher-level activities and sports at 4 to 8 months after anterior shoulder stabilization procedures. It is unknown what percentage of patients have regained normal function at this time frame and what factors predict residual deficits, range of motion (ROM), and strength after anterior shoulder instability surgery.

Methods: Ten participating sites throughout the United States enrolled patients in a prospective cohort study including primary, revision, arthroscopic, and open anterior stabilization procedures. Baseline demographic data and patient outcomes questionnaires were collected with initial physical examination, treatment, surgical findings, and surgical repair details. At the 6-month follow-up visit, ROM and strength measurements were collected and compared with preoperative measurements.

Results: There were 348 patients identified who underwent surgical treatment for anterior shoulder instability. Of these, 259 patients (74.0%) returned to baseline, and 89 (26.0%) did not return to baseline shoulder ROM (≥20° loss of ROM) or strength. A higher Beighton score (P = .01) and number of dislocations (P < .01) were associated with failure to regain baseline ROM and strength at early follow-up. No surgical variables were found to influence return to baseline function, including open vs. arthroscopic surgery, primary vs. revision surgery, and number of suture anchors.

Conclusions: By 4 to 8 months postoperatively, 76% of patients return to baseline ROM, 98% return to baseline strength, and 74% return to both baseline ROM and strength. An increased number of dislocations and generalized joint laxity were associated with failure to return to baseline ROM and strength at early follow-up after anterior shoulder instability surgery.
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http://dx.doi.org/10.1016/j.jse.2018.02.035DOI Listing
July 2018

Descriptive Epidemiology of the MOON Shoulder Instability Cohort.

Am J Sports Med 2018 04 5;46(5):1064-1069. Epub 2018 Mar 5.

Investigation performed at CU Sports Medicine and Performance Center, Department of Orthopedics, University of Colorado School of Medicine, Boulder, Colorado, USA.

Background: Shoulder instability is a common diagnosis among patients undergoing shoulder surgery.

Purpose: To perform a descriptive analysis of patients undergoing surgery for shoulder instability through a large multicenter consortium.

Study Design: Case series; Level of evidence, 4.

Methods: All patients undergoing surgery for shoulder instability who were enrolled in the MOON Shoulder Instability Study were included. Baseline demographics included age, sex, body mass index, and race. Baseline patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Score, Western Ontario Shoulder Instability Index (WOSI), 36-Item Health Survey (RAND-36), and Single Assessment Numeric Evaluation (SANE). The preoperative physician examination included active range of motion (ROM) and strength testing. Preoperative imaging assessments with plain radiography, magnetic resonance imaging (MRI), and computed tomography were also included and analyzed.

Results: Twenty-six surgeons had enrolled 863 patients (709 male, 154 female) across 10 clinical sites. The mean age for the cohort was 24 years (range, 12-63 years). Male patients represented 82% of the cohort. The primary direction of instability was anterior for both male (74%) and female (73%) patients. Football (24%) and basketball (13%) were the most common sports in which the primary shoulder injury occurred. No clinically significant differences were found in preoperative ROM between the affected and unaffected sides for any measurement taken. Preoperative MRI scans were obtained in 798 patients (92%). An anterior labral tear was the most common injury found on preoperative MRI, seen in 66% of patients, followed by a Hill-Sachs lesion in 41%. Poor PRO scores were recorded preoperatively (mean: ASES, 72.4; WOSI, 43.3; SANE, 46.6).

Conclusion: The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. The results of this study provide important epidemiological information for patients undergoing shoulder stabilization surgery.
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http://dx.doi.org/10.1177/0363546518755752DOI Listing
April 2018
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