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Journal: Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association


PURPOSE: Existing patient self-reported shoulder scoring systems fail to express physicians' points of view, and understanding the wording can sometimes lead to confusion in Easterners. We sought to develop a valid, reliable, and responsive shoulder scoring system that combines the points of view of physicians and patients and is easily understood for worldwide applicability. METHODS: Six steps were followed to develop the scale: (1) investigation, identification of a specific population, and patient and physician interviews; (2) item generation, according to existing shoulder scales, a literature review, and patient and physician interviews; (3) item reduction, by combining and adjusting items; (4) formatting of the questionnaire, designed using both subjective and objective scales, with a 100-point score range; (5) pretesting, to eliminate confusion and misunderstanding of items, and (6) preliminary evaluation. Pearson correlation coefficients were calculated to assess validity (compared with American Shoulder and Elbow Surgeons, Constant-Murley, and University of California, Los Angeles scores), intraclass correlation coefficients were calculated to assess reliability (with a 2-week test-retest interval), and the standardized response mean was calculated to assess responsiveness (comparing preoperative and postoperative scores in patients). RESULTS: The final scoring system was designed to have a 100-point score range, with higher scores indicating better function. It consisted of self-report assessment by patients (61 points in total) and objective assessment by physicians (39 points in total). Updated scales, including a night pain subscale, patient-physician satisfaction, and 2-dimensional visual analog scale tool, were incorporated in our system. Compared with the other 3 scoring systems (American Shoulder and Elbow Surgeons, Constant-Murley, and University of California, Los Angeles scores), the new scoring system has shown favorable validity, with a Pearson correlation coefficient greater than 0.7. In addition, the intraclass correlation coefficient was greater than 0.9 during a 2-week test-retest interval, indicating high reliability, and the standardized response mean of the new system was greater than that of the other 3 scoring systems, indicating sensitive responsiveness. CONCLUSIONS: A new shoulder scoring system has been developed based on patients' and physicians' points of view and worldwide applicability and was verified to be valid, reliable, and responsive. The new scoring system includes a 2-dimensional visual analog scale, night pain subscale, and patient-physician satisfaction scale, which are not included in the existing scoring systems. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria.

Concepts: Spearman's rank correlation coefficient, Physician, Assessment, Psychometrics, Correlation and dependence, Reliability, Pearson product-moment correlation coefficient, Covariance and correlation





PURPOSE: This study compared the status of suture knots immediately after repair and after shoulder motion to evaluate the possibility of movement-induced knot migration to a location nearer the glenoid. METHODS: We included 10 shoulders from 5 cadavers in the study. After posterior capsulotomy, a Bankart lesion was created. A capsulolabral repair was then performed with 3 knot-tying suture anchors. All knots were positioned on the capsular side, far from the articular surface. After the repair was complete, a photograph was taken with a metal rod placed to reference absolute distance. After passive pendulum motion was applied, another photograph was taken. The length of the suture strand from the knot base to the anchor insertion site was measured during both the initial repair and post-motion periods. RESULTS: Initial distances were 4.83 ± 1.09 mm for the inferior knot, 4.70 ± 0.97 mm for the middle knot, and 3.84 ± 1.25 mm for the superior knot. After motion, the distances were 3.52 ± 1.21 mm (P = .01), 3.07 ± 0.81 mm (P < .001), and 2.69 ± 1.18 mm (P = .016), respectively. Additional observations showed changes in direction and security of the knot. The change in knot direction from an initial orientation facing the capsular side to a new orientation facing the glenoid was observed in 5 of 10 inferior, 7 of 10 middle, and 6 of 10 superior knots. In addition, knot loosening was noted for the last half-hitches in 4 inferior knots and 1 middle knot. CONCLUSIONS: Intentional placement of suture knots away from the joint surface was not maintained after motion at the shoulder. CLINICAL RELEVANCE: Movement-induced knot migration may be detrimental to articular cartilage in the event that a knot becomes interposed between the glenoid and humeral head.

Concepts: Bone, Skeletal system, Humerus, Knee, Shoulder, Distance, Glenoid labrum, Scapula


PURPOSE: The purpose of this study was to compare elite athletes who underwent hip arthroscopy with and without microfracture with respect to their ability to return to sport at the professional level. METHODS: All elite male athletes who underwent hip arthroscopy between 1999 and 2010 were identified. Inclusion criteria were hip arthroscopy with treatment of labrum, femoroacetabular impingement, cartilage, ligamentum teres, capsule, and/or loose body removal. Exclusion criteria were diffuse degenerative joint disease, previous surgery, plans to retire, labral reconstruction, soft tissue release, and concomitant lower extremity injury. Thirty-nine athletes underwent hip arthroscopy with microfracture and were assigned to the microfracture treatment group. Eighty-one elite athletes (94 hips) underwent hip arthroscopy without microfracture and were assigned to the control group. Sports played included hockey, soccer, football, baseball, tennis, and golf. RESULTS: Seventy-seven percent (30 of 39) of athletes in the microfracture treatment group and 84% (79 of 94) in the control group returned to play. There was no statistical difference in rate of return to play between groups (odds ratio = 1.6; 95% confidence interval, 0.633 to 4.049). Those players who did return were followed for an average of 3 years (range, 2 to 12). Athletes in the microfracture treatment group who returned have averaged 3 seasons thus far, and 73% are still playing. We found no significant difference in the microfracture group in age, time from injury to surgery, number of seasons played preoperatively, or size of lesion for return versus no return. We also found no increased risk of not returning because of contact sport, multiple lesions, or lesion on weightbearing surface. CONCLUSIONS: There was no detectable statistically significant difference in return to play rate after hip arthroscopy with microfracture and hip arthroscopy without microfracture. Professional athletes who underwent hip arthroscopy with microfracture procedure were able to return to the same high level of competition after surgery at a high rate. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Concepts: Statistics, Mathematics, Statistical significance, Osteoarthritis, Microfracture surgery


PURPOSE: The aim of this study was to define a safety margin for coracoid process osteotomy that does not compromise the coracoclavicular ligaments and that can be used in the coracoid transfer procedures. METHODS: Thirty shoulders from 15 cadavers were dissected, exposing the coracoid process and attached anatomic structures. The distance of the insertion of these structures to the coracoid process apex was measured. RESULTS: The average length of the coracoid process was 4.26 ± 0.26 cm. The average width and height at the tip were 2.11 ± 0.2 and 1.49 ± 0.12 cm, respectively. The average distance from the tip to the anterior and posterior margin of the pectoralis minor was 0.1 ± 1.17 and 1.59 ± 0.27 cm, respectively. The average distance from the tip to the posterior margin of the coracoacromial ligament was 2.79 ± 0.33 cm. The average distance from the apex to the most anterior part of the trapezoid ligament was 3.33 ± 0.38 cm. We obtained a constant value of 0.85 cm for this measure, and the value increased with each 1.0-cm increase in the distance from the tip to the posterior margin of the pectoralis minor. The safety margin for osteotomy (i.e., available bone distance for the coracoid process transfer) was 2.64 cm. CONCLUSIONS: This study established a safety margin of 2.64 cm for the osteotomy of the coracoid process and its relation with the posterior margin of the pectoralis minor. The anatomic descriptions of bone and soft tissue, as well as a measure of correlation for the safety margin of the coracoid, provide tools for surgeons performing anatomic surgical procedures to correct glenohumeral instability with significant bone loss. CLINICAL RELEVANCE: Knowing the safety margin allows the surgeon to perform a safe osteotomy without direct visualization of the coracoclavicular ligaments attachments, thereby making procedures more anatomic.

Concepts: Bone, Surgery, Anatomy, Length, Distance, Coracoid process, Coracoacromial ligament, Coracoclavicular ligament


A systematic review was performed to assess the outcomes and complications of ultrasound-guided barbotage (repeated injection and aspiration) for calcific tendonitis of the shoulder.

Concepts: Tendinitis, Calcific tendinitis


PURPOSE: To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk. METHODS: Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged. RESULTS: Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity. CONCLUSIONS: Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction. CLINICAL RELEVANCE: Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

Concepts: Skeletal system, Anatomy, Ligament, Distance, Ankle, Sprained ankle, Peroneus longus, Anterior talofibular ligament


In part, people’s quality of life depends on the “health” of their cartilage because its damage or deterioration causes pain that limits mobility and reduces autonomy. Predisposing genetic factors and modern-life environmental factors, such as diet, excessive physical exercise, or the absence of any physical exercise, in addition to injuries that can occur, all contribute to the onset and development of chronic degenerative diseases such as osteoarthritis. Regenerative medicine focuses on the repair, replacement, or regeneration of cells, tissues, or organs to restore impaired function from any cause, including congenital defects, disease, and trauma.

Concepts: Medicine, Genetics, Developmental biology, Environment, Obesity, Degenerative disease, Weight loss, Degenerative disc disease