Publications by authors named "Ruth A Delaney"

10 Publications

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Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability.

Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors.

Conclusion: Overall, 84% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.022DOI Listing
July 2021

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Northwood Avenue, Santry Demesne, Dublin 9, D09 C523, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability.

Methods: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation.

Conclusion: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage.

Level Of Evidence: Level V: expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.023DOI Listing
July 2021

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability.

Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction.

Conclusion: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.019DOI Listing
July 2021

Rational use of shoulder MRI in the private setting: specialist-ordered MRIs influence clinical management significantly more often than primary care physicians.

Ir J Med Sci 2021 May 29;190(2):491-496. Epub 2020 Sep 29.

Dublin Shoulder Institute, Sports Surgery Clinic, Suite 4, Northwood Avenue, Santry, Dublin, Ireland.

Purpose: The aim of this study was to determine the difference in proportion of shoulder MRIs that influence the management plan of shoulder patients based on whether MRI was ordered by a shoulder specialist, orthopaedic surgeon or primary care provider prior to referral to a specialist.

Methods: This observational analytical study was conducted in a private practice setting. Data were obtained from 153 MRIs performed on 151 patients. Seventy-seven MRIs were ordered by a specialist shoulder surgeon and 76 by a primary care provider (general practitioner, non-operative sports medicine physician or physiotherapist).

Results: Specialist-ordered MRIs influenced patient management significantly more often than primary care-ordered MRIs (82% vs. 22%, p < 0.001). Fifty-four percent of referral letters from primary care providers to the specialist did not have documentation of a physical examination, yet an MRI had been ordered. The most common diagnoses for primary care-ordered MRIs which did not have influence on patient management were subacromial bursitis and adhesive capsulitis.

Conclusion: With less than 25% of primary care-ordered shoulder MRIs influencing clinical management, questions must be raised about the indications for MRI. Greater than 50% of referrals contained no documented physical examination, suggesting that MRI is being relied upon for assessment. If access to private MRI was to be rationalized, perhaps shoulder specialist-ordered CT and X-ray could be covered by insurance providers. Currently, they are not covered in our system, yet are more likely to influence clinical management than primary care-ordered MRIs, which are currently covered by insurance without restriction on indications.
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http://dx.doi.org/10.1007/s11845-020-02379-0DOI Listing
May 2021

Exploring expert variability in defining pseudoparalysis: an international survey.

J Shoulder Elbow Surg 2021 May 9;30(5):e237-e244. Epub 2020 Sep 9.

Dublin Shoulder Institute, Dublin, Ireland. Electronic address:

Background: There is currently disagreement among experts in the field of shoulder surgery when attempting to define the term "pseudoparalysis." Multiple surgical techniques to address this condition have been investigated; however, many studies have recruited heterogeneous patient populations and have used varying definitions of pseudoparalysis. This makes it difficult to compare outcomes among various techniques. To our knowledge, no previous study has surveyed international experts regarding the definition of pseudoparalysis using a questionnaire and video-based patient assessment. The purpose of this study was to evaluate the level of agreement among shoulder surgeons in defining and applying the term "pseudoparalysis." We hypothesized that inter-rater agreement for classifying patients as having pseudoparalysis would be poor.

Methods: Members of the American Shoulder and Elbow Surgeons, the European Society for Surgery of the Shoulder and the Elbow, and our national shoulder and elbow society were surveyed on 2 occasions using an electronic questionnaire. All surgeons were asked to identify their preferred definition of pseudoparalysis from 1 of 4 options. The surgeons then viewed video examinations of 10 patients and labeled them as having pseudoparalysis or not. Inter-rater reliability and intrarater reliability were calculated as κ coefficients. The Pearson χ test was used to detect associations between the preferred definition and demographic information.

Results: A total of 246 surgeons responded to at least 1 survey. Overall inter-rater agreement on classifying patients as having pseudoparalysis based on video consultation showed a κ value of 0.59 (95% confidence interval [CI], 0.58-0.60). The same verbal definition was selected by 56.1% of surgeons. The surgeons were not internally consistent in their choice of definition, with intrarater reliability showing a κ value of 0.64 (95% CI, 0.48-0.81). Intrarater reliability for classifying patients as having pseudoparalysis was better, with a κ value of 0.78 (95% CI, 0.72-0.83). An association was observed between how surgeons defined pseudoparalysis and their age (P = .03), as well as their shoulder caseload percentage (P = .04).

Conclusion: Shoulder surgeons do not agree on how best to define pseudoparalysis of the shoulder. Inter-rater agreement based on video consultation was weak overall and improved with the elimination of an outlier video. Intrarater agreement was less frequent when selecting a preferred definition compared with classifying patients as having pseudoparalysis based on video examinations. Surgeons may rely less on explicit criteria and more on a conceptual framework when assigning a "pseudoparalytic" label. Care should be taken with use of the term "pseudoparalysis" in clinical outcome studies when there is clearly a lack of consensus among experts in defining this term.
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http://dx.doi.org/10.1016/j.jse.2020.08.029DOI Listing
May 2021

Superior capsular reconstruction using a porcine dermal xenograft for irreparable rotator cuff tears: outcomes at minimum two-year follow-up.

J Shoulder Elbow Surg 2021 May 2;30(5):1053-1059. Epub 2020 Sep 2.

Dublin Shoulder Institute, Dublin, Ireland.

Purpose: To evaluate midterm outcomes of arthroscopic superior capsular reconstruction (SCR) using a decellularized porcine dermal xenograft in patients with massive, irreparable rotator cuff tears and to determine the influence of concomitant, repairable subscapularis tears.

Methods: This is a retrospective study of 56 patients with a minimum 2-year follow-up. Preoperative and postoperative range of motion, American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, and visual analog score for pain were measured. Postoperative data were collected at 3, 6, 12, 24, and 36 months.

Results: Of the 56 patients who underwent arthroscopic SCR, there were 39 men and 17 women. The mean age at operation was 65 ± 9 years, and the mean follow-up was 34 ± 8 months. The mean preoperative American Shoulder and Elbow Surgeons improved from 41 ± 19 to 78 ± 18 at 24 weeks, to 86± 16 at 12 months, and to 90±9 at 24 months, P < .0001. Similarly, the mean preoperative Subjective Shoulder Value improved from 39 ± 17 to 74 ± 18 at 24 weeks, to 80 ± 18 at 12 months, and to 80 ± 11 at 24 months, P < .0001. The mean preoperative visual analog score improved from 6.5 ± 2.1 to 1.4 ± 2.2 at 24 weeks, to 0.7± 1.1 at 12 months, and to 0.2 ± 0.4 at 24 months, P < .0001. There were no differences in outcome scores between patients with intact vs. repaired subscapularis. Similarly, no statistically significant differences were found in forward flexion or external rotation after SCR between patients with an intact vs. repaired subscapularis. Failure of the SCR graft was observed on magnetic resonance imaging in 14 patients, 4 of whom opted for revision to reverse shoulder arthroplasty. Eleven patients were truly pseudoparalytic before surgery; in 5 cases, pseudoparalysis was reversed after SCR.

Conclusions: SCR can alleviate pain and disability from irreparable rotator cuff tears and provide significant improvements in shoulder function; however, the xenograft technique resulted in inconsistent reversal of true pseudoparalysis. No difference was found between patients who required concomitant subscapularis repair vs. those who did not.
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http://dx.doi.org/10.1016/j.jse.2020.08.020DOI Listing
May 2021

Do trauma systems work? A comparison of major trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital.

Injury 2015 Jan 18;46(1):150-5. Epub 2014 Sep 18.

Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.

Trauma is an important matter of public health and a major cause of mortality. Since the late 1980s trauma care provision in the United Kingdom is lacking when compared to the USA. This has been attributed to a lack of organisation of trauma care leading to the formation of trauma networks and Major Trauma Centres in England and Wales. The need for similar centres in Scotland is argued currently. We assessed the activity of two quite different trauma systems by obtaining access to comparative data from two hospitals, one in the USA and the other in Scotland. Aggregate data on 5604 patients at Aberdeen Royal Infirmary (ARI) from 1993 to 2002 was obtained from the Scottish Trauma Audit Group. A comparable data set of 16,178 patients from Massachusetts General Hospital (MGH). Direct comparison of patient demographics; injury type, mechanism and Injury Severity Score (ISS); mode of arrival; length of stay and mortality were made. Statistical analysis was carried out using Chi-squared and Cochran-Mantel-Haenszel. There were significant differences in the data sets. There was a higher proportion of penetrating injuries at MGH, (8.6% vs 2.6%) and more severely injured patients at MGH, patients with an ISS>16 accounted for nearly 22.1% of MGH patients compared to 14.0% at ARI. ISS 8-15 made up 54.6% of ARI trauma with 29.6% at MGH. Falls accounted for 50.1% at ARI and 37.9% at MGH. Despite the higher proportion of severe injuries at MGH and crude mortality rates showing no difference (4.9% ARI vs 5.2% MGH), pooled odds ratio of mortality was 1.4 (95% confidence interval 1.2-1.6) showing worse mortality outcomes at ARI compared to MGH. In conclusion, there were some differences in case mix between both data sets making direct comparison of the outcomes difficult, but the effect of consolidating major trauma on the proportion and number of severely injured patients treated in the American Level 1 centre was clear with a significant improvement in mortality in all injury severity groups.
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http://dx.doi.org/10.1016/j.injury.2014.08.048DOI Listing
January 2015

2014 Neer Award Paper: neuromonitoring the Latarjet procedure.

J Shoulder Elbow Surg 2014 Oct 18;23(10):1473-80. Epub 2014 Jun 18.

Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

Background: We used intraoperative neuromonitoring to define the stages of the Latarjet procedure during which the nerves are at greatest risk.

Methods: Thirty-four patients with a mean age of 28.4 years were included. The Latarjet procedure was divided into 9 defined stages. Bilateral median and ulnar somatosensory evoked responses and transcranial motor evoked potentials from all arm myotomes were continuously monitored. A "nerve alert" was defined as averaged 50% amplitude attenuation or 10% latency prolongation of ipsilateral somatosensory evoked responses and transcranial motor evoked potentials. For each nerve alert, the surgeon altered retractor placement, and if there was no response to this, the position of the operative extremity was then changed.

Results: Of 34 patients, 26 (76.5%) had 45 separate nerve alert episodes. The most common stages of the procedure for a nerve alert to occur were glenoid exposure and graft insertion. The axillary nerve was involved in 35 alerts; the musculocutaneous nerve, in 22. Of the 34 patients, 7 (20.6%) had a clinically detectable nerve deficit postoperatively, all correlated with an intraoperative nerve alert. All cases involved the axillary nerve, and all resolved completely from 28 to 165 days postoperatively. Prior surgery and body mass index were not predictive of a neurologic deficit postoperatively. However, total operative time (P = .042) and duration of the stage of the procedure in which the concordant nerve alert occurred (P = .010) were statistically significant predictors of a postoperative nerve deficit.

Conclusions: The nerves, in particular the axillary and musculocutaneous nerves, are at risk during the Latarjet procedure, especially during glenoid exposure and graft insertion.
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http://dx.doi.org/10.1016/j.jse.2014.04.003DOI Listing
October 2014

Durability of partial humeral head resurfacing.

J Shoulder Elbow Surg 2014 Jan 5;23(1):e14-22. Epub 2013 Jul 5.

Harvard Shoulder Service, Brigham & Women's Hospital, Boston, MA, USA. Electronic address:

Background: Partial humeral head resurfacing arthroplasty uses a stemless device, which conserves bone and restores normal anatomy. We hypothesized that this does not offer a reasonable alternative to full resurfacing or total shoulder arthroplasty.

Methods: We performed a retrospective study of 39 shoulders with focal chondral defects of the humeral head treated with partial resurfacing arthroplasty. A minimum of 2 years' follow-up was reported, unless failure and operative intervention superseded this duration. The mean follow-up period was 51.3 months. The mean age was 45.6 years (range, 27-76 years). Preoperative and postoperative evaluation included history, physical examination, radiographs, and clinical scoring with the American Shoulder and Elbow Surgeons Shoulder Score Index and Subjective Shoulder Value.

Results: Of the 39 shoulders, 25 (64.1%) showed functional improvement and decreased pain. Significant mean improvements were observed in forward flexion (121° to 152°, P = .002), external rotation (37° to 58°, P = .0003), mean Subjective Shoulder Value (31% to 74%, P < .0001), and ASES score (29 to 70, P < .0001). However, at a mean of 26.6 months' follow-up, the failure group included 6 patients (15.3%) who underwent revision and another 4 (10.2%) who were recommended to undergo revision. Patients with no prior or concomitant procedures were rare (n = 5) but had the most reliable outcomes with partial resurfacing, with no failures in that group. Of the 24 patients with prior procedures, 5 had undergone revision, and the clinical outcome scores for the remaining patients were consistently lower than those seen in patients without prior procedures.

Conclusion: Concomitant pathology and prior or concomitant surgical procedures potentially impair the outcome of the resurfacing procedure and could be a contraindication. Long-term success remains guarded with this treatment modality, especially in patients whose chondral injury is not an isolated finding.
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http://dx.doi.org/10.1016/j.jse.2013.05.001DOI Listing
January 2014

Nonarthroplasty options for the management of massive and irreparable rotator cuff tears.

Clin Sports Med 2012 Oct;31(4):727-48

Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, WHT 535, Boston, MA 02114, USA.

Massive, irreparable rotator cuff tears remain a clinical challenge. In low-demand patients, debridement of the tear may relieve pain. Partial repair using the technique of margin convergence decreases the size of the tear gap and reduces strain. Biceps tenotomy or tenodesis has a role in providing pain relief in massive rotator cuff tears. Tendon transfers offer good results in patients with massive, irreparable rotator cuff tears. The treatment modality specifically chosen for the massive, irreparable rotator cuff tear must be tailored to the individual patient, their needs and expectations, and their ability to comply with intensive rehabilitation.
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http://dx.doi.org/10.1016/j.csm.2012.07.008DOI Listing
October 2012
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