Osteoblastoma of the clavicle.

A 14-year-old female with a 1-year history of a painful clavicle mass underwent resection and reconstruction with an intercalated autograft and rigid plate fixation. The histopathology was diagnostic for osteoblastoma. Although a clavicle mass is a common entity following clavicle trauma, less common disorders such as bone tumors need to be considered in the differential diagnosis. Osteoblastoma is an uncommon, benign bone tumor representing 1% of all primary bone tumors. An extensive review of the literature reveals only one reported case of clavicular osteoblastoma.

Influence of the number of cortices on the stiffness of plate fixation of diaphyseal fractures.

OBJECTIVE: To determine the influence of the number of cortices of fixation on the stiffness of plate fixation of diaphyseal fractures. DESIGN: Canine experimental study. SETTING: Tertiary referral and teaching hospital in Toronto, Canada. PARTICIPANTS: Paired radii from fourteen skeletally mature, cross-bred dogs. MAIN OUTCOME MEASURE: One member of each pair of radii was tested intact as a control, and the other had a transverse osteotomy plated sequentially with five to ten cortices of fixation on either side of the simulated fracture. Dynamic compression plates and limited contact dynamic compression plates were used in two groups with seven paired radii each. Normalized torsional stiffness and four-point bending stiffness were determined in the elastic range for the control and each of the plated constructs in both groups, using a materials testing machine. RESULTS: The authors found no significant difference between the stiffness of the dynamic compression plates and limited contact dynamic compression plates. With either plate of a given length, significantly increased torsional stiffness is achieved with end bicortical screws. For bending stability with the plate at right angles to the bending plane, even short plated constructs have a stiffness exceeding that of intact bone. CONCLUSIONS: For a transverse osteotomy with no fracture interdigitation, the bending rigidity with the plate at right angles to the bending plane is greater than the original stiffness of the bone for all constructs tested, with the exception of the limited contact dynamic compression plate with five cortices of fixation. The torsional rigidity of fixation only approaches the original rigidity of the bone for ten cortices of fixation with the dynamic compression plate and the limited contact dynamic compression plate.

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach.

BACKGROUND: While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires). METHODS: We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing. RESULTS: The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy. CONCLUSIONS: The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons.

The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the elbow. This form was developed by the Research Committee of the American Shoulder and Elbow Surgeons and subsequently adopted by the membership. The patient self-evaluation section contains visual analog scales for pain and a series of questions relating to function of the extremity. The responses to the questions are scored on a 4-point ordinal scale. The physician assessment section has 4 parts: motion, stability, strength, and physical findings. It is hoped that adoption of this method of data collection will stimulate multicenter studies and improve communication between professionals who assess and treat patients with elbow disorders.

Pathophysiological effect of fat embolism in a canine model of pulmonary contusion.

BACKGROUND: The objective of this study was to determine the individual and combined effects of pulmonary contusion and fat embolism on the hemodynamics and pulmonary pathophysiology in a canine model of acute traumatic pulmonary injury. METHODS: After a thoracotomy, twenty-one skeletally mature dogs were randomly assigned to one of three groups. Unilateral pulmonary contusion alone was produced in Group 1 (seven dogs); pulmonary contusion and fat embolism, in Group 2 (seven dogs); and fat embolism alone, in Group 3 (seven dogs). Pulmonary contusion was produced by standardized compression of the left lung with a piezoelectric force transducer. Fat embolism was produced by femoral and tibial reaming followed by pressurization of the intramedullary canals. Cardiac output, systolic blood pressure, peak airway pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, partial pressure of arterial oxygen, and partial pressure of carbon dioxide were monitored for all groups. From these data, several outcome parameters were calculated: total thoracic compliance, alveolar-arterial oxygen gradient, and ratio of partial pressure of arterial oxygen to fractional inspired oxygen concentration. All of the dogs were killed after eight hours, and tissue samples were obtained from the brain, kidneys, and lungs for histological analysis. Lung samples were assigned scores for pulmonary edema (the presence of fluid in the alveoli) and inflammation (the presence of neutrophils or hyaline membranes, or both). The percentage of the total area occupied by fat was determined. RESULTS: Pulmonary contusion alone caused a significant increase in the alveolar-arterial oxygen gradient but only after seven hours (p = 0.034). Fat embolism alone caused a significant transient decrease in systolic blood pressure (p = 0.001) and a significant transient increase in pulmonary arterial pressure (p = 0.01) and pulmonary capillary wedge pressure (p = 0.015). Fat embolism alone also caused a significant sustained decrease in the ratio of partial pressure of arterial oxygen to fractional inspired oxygen concentration (p = 0.0001) and a significant increase in the alveolar-arterial oxygen gradient (p = 0.0001). The combination of pulmonary contusion and fat embolism caused a significant transient increase in pulmonary capillary wedge pressure (p = 0.0013) as well as a significant sustained decrease in partial pressure of arterial oxygen (p = 0.0001) and a significant decrease in systolic blood pressure (p = 0.001) that lasted for an hour. Pulmonary contusion followed by fat embolism caused a significant increase in peak airway pressure (p = 0.015), alveolar-arterial oxygen gradient (p = 0.0001), and pulmonary arterial pressure (p = 0.01), and these effects persisted for five hours. Total thoracic compliance was decreased 6.4 percent by pulmonary contusion alone, 4.6 percent by fat embolism alone, and 23.5 percent by pulmonary contusion followed by fat embolism. The ratio of partial pressure of arterial oxygen to fractional inspired oxygen concentration was decreased 23.7 percent by pulmonary contusion alone, 52.3 percent by fat embolism alone, and 65.8 percent by pulmonary contusion followed by fat embolism. The mean pulmonary edema score was significantly higher with the combined injury than with either injury alone (p = 0.0001). None of the samples from the lungs demonstrated inflammation. Fat embolism combined with pulmonary contusion resulted in a significantly greater mean percentage of the area occupied by fat in the noncontused right lung than in the contused left lung (p = 0.001); however, no significant difference between the right and left lungs could be detected with fat embolism alone. The mean percentage of the glomerular and cerebral areas occupied by fat was greater with fat embolism combined with pulmonary contusion than with fat embolism alone (p = 0.0001 and p = 0.01, respectively). (ABSTRACT TRUNCATED)

Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status.

OBJECTIVE: To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting. DESIGN: A retrospective review. SETTING: A single tertiary care centre. PATIENTS: Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally). INTERVENTION: Vascularized fibular grafting. OUTCOME MEASURES: Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage). RESULTS: Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores. CONCLUSIONS: Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.

Femoral bone blood flow after reaming and intramedullary canal preparation: a canine study using laser Doppler flowmetry.

This study was conducted to determine the effect of intramedullary reaming and canal preparation on bone blood flow in the proximal femur. Thirty-five adult dogs were randomly assigned to have their intramedullary canals prepared after reaming in the following manner: group 1, ream only; group 2, lavage; group 3, methylmethacrylate cement introduction; group 4, cement pressurization after placing a cement restrictor; group 5, lavage then cement introduction; and group 6, lavage then cement pressurization. Bone blood flow was measured at both metaphyseal and diaphyseal sites by using laser Doppler flowmetry before reaming, after reaming, after lavage, after cementing, and at 6 weeks after the procedure just before euthanasia. Reaming significantly decreased bone blood flow in the diaphysis (P = .046) but not in the metaphysis. Cement introduction and cement pressurization both significantly decreased bone blood flow in the metaphysis (P = .035, P = .004) and diaphysis (P = .007, P = .029). Pressurization of cement had a significantly greater relative effect than cement introduction alone in the diaphysis (P = .006) but not in the metaphysis. Lavage had no effect on bone perfusion. Bone blood flow was significantly increased at 6 weeks after the initial procedure in both the metaphysis (P = .049) and the diaphysis (P = .004). The results suggest that reaming decreases diaphyseal cortical but not metaphyseal bone blood flow significantly, whereas lavage has no effect. Cement introduction with or without pressurization has a significant detrimental effect on metaphyseal and diaphyseal blood flow. These findings have implications for intramedullary nailing and for canal preparation when performing arthroplasty.

Donor site morbidity following vascularized fibular grafting.

We examined donor site morbidity in thirty-nine patients with avascular necrosis of the femoral head treated by curettage and transplantation of a free ipsilateral fibular graft. Utilising our donor site morbidity questionnaire, scar, functional loss, wound healing, complications, and pain were analysed. Subjective complaints and objective findings were evaluated and compared. Subjective complaints were common and included a sense of instability in 42% and a sense of weakness in 37%. However, objective findings were limited. No clinical instability could be elicited and only great toe flexion (29%) and extension (43%) were found to be mildly weak. Only one patient required reoperation for a donor site problem (2%). Eighty-nine percent were pain free at time of follow-up, and 93% felt the scar was good. Range of motion of the knee and ankle of the donor site leg was not different from the nonoperated leg. Donor site morbidity for avascular necrosis of the femoral head is low.

Pulmonary and systemic fat embolization after medullary canal pressurization: a hemodynamic and histologic investigation in the dog.

BACKGROUND: The potential to produce fat embolism may be important in determining the ideal method and timing of fracture treatment in patients with preexisting lung injury. METHODS: Four dogs underwent femoral and tibial canal reaming and pressurization. Blood gas samples were analyzed, and pulmonary arterial pressure was monitored at 1 and 72 hours. Animals were killed 72 hours postoperatively, and the lungs, kidneys, and brain were examined histologically and compared with equivalent specimens from four control dogs that had not undergone femoral and tibial canal reaming and pressurization. RESULTS: Postmortem, intravascular fat persisted for 72 hours after induction of pulmonary fat embolism. Mean PaO2 was unchanged from baseline at 72 hours after canal pressurization. Canal pressurization caused a sustained increase in pulmonary arterial pressure (p=0.02) for 1 hour after canal pressurization. The mean pulmonary edema score at 72 hours was 29+/-3. Only a scant polymorph infiltrate (zero to two polymorphs per high-power field) was present at any time. No hyaline membranes were seen at any time. The percentage area occupied by intravascular fat in the lungs was 0.0214+/-0.0058 at 72 hours. No signs of ischemia or inflammation were seen in either the cerebral or the renal specimens. CONCLUSION: This study is the first to show that intravascular fat persists in the lungs, kidneys, and brain for 72 hours after canal pressurization and, by itself, does not cause pathologic evidence of acute inflammation.

A biomechanical assessment of ligaments preventing dorsoradial subluxation of the trapeziometacarpal joint.

Degenerative arthritis of the trapeziometacarpal joint is commonly associated with ligament laxity and joint subluxation. Specifically, key pinch in an affected joint often results in dorsoradial joint subluxation. This study examined the role the 4 ligaments of the trapeziometacarpal joint play in preventing dorsoradial subluxation. Six fresh-frozen cadaver hands were dissected of all soft tissue to expose the joint capsule and ligaments of the trapeziometacarpal joint. Serial random sectioning of the intermetacarpal ligament, anterior oblique ligament, palmar oblique ligament, and dorsoradial collateral ligament (RCL) was performed. Dorsoradial displacement of the metacarpal shaft in relation to the trapezium was measured using a linear variable dimension transformer. In all 6 specimens, sectioning of the RCL resulted in the greatest dorsoradial subluxation of the metacarpal. The mean displacement due to sectioning of the RCL was 1.4 mm, compared with 0.08 mm for the intermetacarpal ligament, 0.06 mm for the anterior oblique ligament, and 0.2 mm for the palmar oblique ligament. The importance of the RCL in preventing dorsoradial subluxation may have clinical significance. This study suggests that repairing or reconstructing the RCL during ligament reconstruction of the trapeziometacarpal joint should be considered.

Femoral and cruciate blood flow after retrograde femoral reaming: a canine study using laser Doppler flowmetry.

OBJECTIVE: To determine the effect of retrograde femoral reaming on the blood flow of the distal femur and the cruciate ligaments. DESIGN: Canine experimental study. SETTING: Tertiary referral and teaching hospital in Toronto, Canada. PARTICIPANTS: Thirteen skeletally mature, cross-bred dogs. MAIN OUTCOME MEASURE: Red cell flux (RCF) was measured by using a laser Doppler flowmetry probe at three bone sites in the distal femur (trochlear groove, medial condyle, and lateral condyle) and at the midportion of both the anterior and posterior cruciate ligaments before and after retrograde femoral reaming. RESULTS: There was a significant increase in the mean postreaming RCF at all the bone sites of the distal femur compared with prereaming values: trochlear groove (p = 0.0247), medial condyle (p = 0.0440), and lateral condyle (p = 0.0042). We also found a significant decrease in the mean postreaming RCF at both cruciate ligament sites compared with prereaming values (anterior cruciate, p = 0.0004; posterior cruciate, p = 0.0006). CONCLUSIONS: Retrograde femoral reaming and intramedullary nailing has become a popular option for the treatment of distal femoral and some femoral shaft fractures, but concerns regarding the effect of reaming through an intraarticular entry portal have been raised. Our experimental study found that after reaming perfusion of the anterior cruciate ligament decreased by 52 percent and perfusion of the posterior cruciate ligament decreased by 49 percent. Diminished perfusion after reaming may delay healing or exacerbate existing injury to the cruciate ligaments and adversely affect rehabilitation of the knee after femoral fracture.

Functional outcome after the L'Episcopo procedure.

A study was undertaken to assess functional outcome in 11 patients undergoing latissimus dorsi and teres major transfer (L'Episcopo procedure) for external rotation deficient shoulders. The mean age was 37 years (range 18 to 48 years). All of the patients had adult-onset brachial plexus injuries. The mean time for injury to operation was 32 months. Patients were evaluated by questionnaire, measurement of the range of motion, strength testing, and an overhead work simulation. Of the patients studied, 10 of the 11 patients were working (8 returned to their preinjury employment). The cumulative postoperative mean activities of daily living score was 20 (maximum possible 33) compared with 14 before surgery. No complications occurred. Ten patients reported confidence in the limb and believed the procedure was worthwhile. Mean active external rotation of the shoulder at 0 degrees and 90 degrees elevation was 28 degrees (range 15 degrees to 55 degrees and 36 degrees (range 0 degrees to 90 degrees), respectively. Postoperative external rotation strength was 0.32 that of the control side with the arm at the side. Seven of the nine patients tested were able to complete the Valpor overhead work simulation. The L'Episcopo muscle-tendon transfer reliably improves functional outcome in the late functional reconstruction of adult-onset brachial plexus lesions.

The effect of comorbidity and duration of nonunion on outcome after surgical treatment for nonunion of the humerus.

The purpose of our study was to assess the effect of comorbidity and duration of nonunion on the general health status and joint-specific outcome of a group of patients treated for nonunion of the humeral shaft. We identified 25 consecutive patients with nonunion of the humeral shaft, all treated with compression plating and bone grafting. Twenty-one patients returned for a comprehensive assessment including completion of the SF 36 Health Status Survey and determination of the Constant shoulder and Morrey elbow scores. Thirteen patients had > or = 1 comorbid conditions. Eleven patients had a nonunion of > 8 months' duration, and 10 had a nonunion of < 8 months' duration. Follow-up at a mean of 42 months (range 12 to 99 months) revealed that all nonunions united an average of 5 months after surgery. The mean Morrey elbow score was 94, Constant shoulder score 82, and "global" SF 36 score 59.4. The physical portion of the SF 36 score correlated well with the Constant and Morrey scores (p = 0.047 and p = 0.027, respectively). The presence of comorbid factors had a significant negative effect on the SF 36 scores (p = 0.001) but no effect on joint-specific Morrey or Constant scores. The duration of nonunion had no effect on SF 36 or joint-specific scores. Although the reliability of the SF 36 is illustrated by the close correlation between its "physical function" portion and standard (joint-specific) outcome measures, comorbidity has a significant negative effect on overall scores. This must be considered when such tools are used for assessment of orthopaedic intervention.

Validity of observer-based aggregate scoring systems as descriptors of elbow pain, function, and disability.

Current elbow-scoring systems are based on the observer-derived assessment of a variety of clinical and functional criteria, which are scored separately and then aggregated. The aggregate score then is assigned a categorical ranking that ranges from excellent to poor. The developers of different elbow-scoring systems have chosen different outcome criteria, assigned different weights to each criterion, and accorded different ranges of values to each categorical ranking. Five different elbow-scoring systems (the Mayo elbow-performance index and the systems of Broberg and Morrey, Ewald et al., The Hospital for Special Surgery, and Pritchard) were used to evaluate the same group of patients. The validity of the scoring systems was determined with use of visual-analog scales for the assessment of pain and function, patient and physician-derived ratings of the severity of impairment of the elbow, and two functional questionnaires completed by the patient (the Disabilities of the Arm, Shoulder and Hand questionnaire and the Modified American Shoulder and Elbow Surgeons patient self-evaluation form). The study sample consisted of sixty-nine patients who had sought treatment at one of two tertiary referral clinics because of problems related to the elbow. Pearson product-moment correlation coefficients were used to compare the raw aggregate scores, and kappa statistics were used to determine the level of agreement among the categorical rankings (excellent, good, fair, and poor). Examination of the five scoring systems revealed a remarkable lack of concordance with regard to the aspects of elbow function that were assessed. Good correlation was observed when the systems were compared on the basis of raw scores (Pearson product-moment correlation coefficients, 0.79 to 0.90), but only slight-to-moderate correlation was noted when the systems were compared on the basis of categorical rankings (quadratic weighted kappa coefficients, 0.18 to 0.49). Validity testing showed the system of Ewald et al. and the Mayo elbow-performance index to be the most discriminating, the system of Pritchard to be the least discriminating, and the system of The Hospital for Special Surgery and the system of Broberg and Morrey to be intermediate. The scores determined with the elbow-scoring systems demonstrated only moderate correlation with the score for function on the visual analog scale (Pearson product-moment correlation coefficients, 0.44 to 0.66), whereas those derived from the functional questionnaires completed by the patient demonstrated moderate-to-good correlation with the score for function (Pearson product-moment correlation coefficients, 0.72 and 0.80).

A biomechanical evaluation of different plates for fixation of canine radial osteotomies.

BACKGROUND AND METHODS: The biomechanical properties of plates depend on their geometries and elastic moduli. The low contact-dynamic compression plate (LC-DCP) with relieved undersurfaces is a modification of the dynamic compression plate (DCP). Little attention has been directed toward comparison of the biomechanical properties of the LC-DCP and the DCP. This study compared the stiffness and strength of bone-plate constructs using plates of various designs and materials for fixation of radial osteotomies. In 20 matched pairs of canine radii, midshaft transverse osteotomies were created and fixed with 3.5-mm eight-hole plates on the volar surface. In 10 pairs, stainless-steel LC-DCPs and stainless-steel DCPs were applied. In the other 10 pairs, stainless-steel LC-DCPs and titanium LC-DCPs were placed. Bending and torsional stiffness were determined. The plates were removed, and a 5-mm gap was created at the osteotomy site. The plates were reapplied to the bones with the interfragmental gap. Stiffness and yield point in the anteroposterior direction were determined. RESULTS: In the absence of a bone gap, no statistically significant differences in construct stiffness were seen between the paired groups. In the presence of a gap, the stainless-steel LC-DCP construct was stiffer than the titanium LC-DCP construct (p = 0.02), and the DCP construct was stiffer than the LC-DCP construct (p = 0.002). The yield point of the DCP-bone construct was 59% greater than that of the stainless-steel LC-DCP construct (p = 0.02). However, the yield points of the titanium and stainless-steel LC-DCP-constructs were similar (p = 0.35). CONCLUSION: The similar results between constructs in the absence of a gap indicate that plate design and material properties may be less significant for achieving adequate stability after plate fixation of simple fractures. The use of the stiffer dynamic compression plate may be advantageous when maximum stability is required, such as with comminution or bone loss.

The role of methylmethacrylate monomer in the formation and haemodynamic outcome of pulmonary fat emboli.

We examined the roles of methylmethacrylate (MMA) monomer and cementing technique in the formation, and haemodynamic outcome, of pulmonary fat emboli. The preparation of the femoral canal and the cementing technique were studied in four groups of adult dogs as follows: control (no preparation); lavage; cement pressurisation; and cement pressurisation after lavage. We measured the intramedullary pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure and bilateral femoral vein levels of triglyceride, cholesterol and MMA monomer at rest and after reaming, lavage, and cementing. Femoral vein triglyceride and cholesterol levels did not vary significantly from resting levels despite significant elevations in intramedullary pressure with reaming, lavage and cementing (p = 0.001). PAP was seen to rise significantly with reaming (p = 0.0038), lavage (p = 0.0031), cementing (p = 0.0024) and cementing after lavage (p = 0.0028) while the pulmonary capillary wedge pressure remained unchanged. MMA monomer was detected in femoral vein samples when cement pressurisation was used. Intramedullary lavage before cementing had no significant effect on the MMA level. Haemodynamic evidence of pulmonary embolism was noted with reaming and intramedullary canal preparation, irrespective of the presence of MMA monomer. We found no relationship between MMA monomer level and intramedullary pressure, PAP or pulmonary capillary wedge pressure. Our findings suggest that the presence of MMA monomer in femoral venous blood has no effect on the formation of fat emboli or their pulmonary haemodynamic outcome during cemented hip arthroplasty.

Assessing the reliability and responsiveness of 5 shoulder questionnaires.

The purpose of this study was to compare the test-retest reliability and responsiveness of 5 different shoulder questionnaires in a sample of patients with shoulder pain. Ninety-nine patients completed the following shoulder questionnaires on 2 occasions: Subjective Shoulder Rating Scale, Simple Shoulder Test, Modified-American Shoulder and Elbow Surgeons Form, Shoulder Severity Index, and the Shoulder Pain and Disability Index. The Short Form-36 was also included. Test-retest reliability was assessed with intraclass correlation coefficients. Standardized response means were calculated to assess responsiveness. This procedure was done on 33 subjects who underwent rotator cuff surgery or total shoulder arthroplasty and who believed that they had improved between testings. All questionnaires had acceptable reliability (coefficients > 0.75) except the Subjective Shoulder Rating Scale (coefficient = 0.71) and were more responsive (0.65 < Standardized response mean < 1.23) than the Short Form-36 (0.08 < Standardized response mean < 0.43) except for pain (0.91). In this longitudinal study a direct comparison of 5 shoulder questionnaires was carried out. We found the Subjective Shoulder Rating Scale to have lower reliability and responsiveness. The other 4 questionnaires including 1 developed to measure whole extremity function (Modified American Shoulder and Elbow Surgeons Form) rather than the shoulder only were comparable with good reliability and responsiveness. The results indicate that the shoulder questionnaires were more sensitive to change in patients with shoulder pain than the generic questionnaire (Short Form-36), and both types of questionnaires should be used in outcome evaluations.