Prospective cohort study of same-day discharge shoulder arthroplasty in patients of 85 years and younger.

Introduction: Shoulder arthroplasty is mostly performed as an inpatient procedure. Same-day discharge arthroplasty has shown positive results in hip and knee surgery. Primary objective of this study was to investigate whether a safe and satisfactory same-day discharge (SDD) can be predicted with a set of easy to use predefined criteria, without increasing complications and re-admissions. Methods: This study was a prospective cohort study. Patient selection criteria were: <85 years old, ASA 1, 2, and mild ASA 3. Primary outcome variables were successful SDD, complications, re-admissions and patient satisfaction. Secondary outcomes were patient-reported outcome scores. The results are compared with the inpatient cohort. Results: In total, 163 patients were treated for elective shoulder arthroplasty. Of which 51 patients were selected for same-day discharge arthroplasty. 94% of pre-planned same-day discharge arthroplasty patients were discharged on the day of surgery. In the same-day discharge group, there were no complications related to the early discharge and a 2% readmission rate as opposed to a 3% readmission rate in the inpatient group. Surgery related as well as medical complications did not differ between the same-day discharge and inpatient cohort. Discussion: Same-day discharge shoulder arthroplasty is a safe and satisfying treatment option in selected patient groups.

Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients.

BACKGROUND: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. METHODS: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. RESULTS: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €-1969, 95%CI= -3680 to -939) and third (mean difference €-2298, 95%CI= -4092 to -1288) compared to the first dislocation. CONCLUSIONS: Nonoperative treatment of shoulder instability has substantial societal costs. LEVEL OF EVIDENCE: III, economic analysis.

The Responsiveness and Minimal Important Change of the Western Ontario Shoulder Instability Index and Oxford Shoulder Instability Score.

Study Design Prospective cohort study. Background Patient-reported outcome measurements (PROMs) are widely used to evaluate functional limitations. Considering PROMs for shoulder instability, information is lacking with regard to what constitutes a relevant change from baseline scores. Objectives To evaluate the responsiveness of the Western Ontario Shoulder Instability Index (WOSI) and the Oxford Shoulder Instability Score (OSIS) and estimate their minimal important change (MIC). Methods One hundred five consecutive patients with shoulder instability completed 5 PROMs at baseline and at 6-month follow-up. The PROMs included the WOSI and OSIS, the Simple Shoulder Test, the Oxford Shoulder Score, and the Disabilities of the Arm, Shoulder and Hand assessment. Patients also rated their functional change on an anchor question at follow-up. Responsiveness was evaluated by testing 9 hypotheses regarding predefined correlations between the changes in PROM scores, by calculating the area under the receiver operating characteristic curve and by calculating the standardized response mean and effect size statistics. The MIC was determined by identifying the optimal cutoff on the receiver operating characteristic curve. Results Seven out of 9 hypotheses (78%) were confirmed; as expected, a high correlation (0.77) was found between change scores of the WOSI and OSIS, whereas the correlations of the change scores of the WOSI and OSIS with those of general shoulder PROMs were slightly lower (0.61-0.75). The area under the curve was 0.83 (95% confidence interval: 0.75, 0.91) for the OSIS and 0.82 (95% confidence interval: 0.74, 0.90) for the WOSI. The MIC was about 6 points for the OSIS and about 14 points for the WOSI. Conclusion Both the WOSI and OSIS are able to measure change in shoulder function in patients with shoulder instability. The estimated MIC is 6 points for the OSIS (on a scale from 0 to 48) and 14 points for the WOSI (on a scale from 0 to 100). J Orthop Sports Phys Ther 2017;47(6):402-410. doi:10.2519/jospt.2017.6548.

The Oxford Shoulder Instability Score; validation in Dutch and first-time assessment of its smallest detectable change.

BACKGROUND: The Oxford Shoulder Instability Score (OSIS) is a short, self-reported outcome measurement for patients with shoulder instability. In this study, the OSIS was validated in Dutch by testing the internal consistency, reliability, measurement error, validity and the floor and ceiling effects, and its smallest detectable change (SDC) was calculated. METHODS: A total of 138 patients were included. Internal consistency was calculated with Cronbach's α. Reliability (test-retest) was calculated with the intraclass correlation coefficient (ICC). The measurement error was calculated (SEM), and the SDC was estimated in a subgroup of 99 patients that completed the re-test after a mean of 13 days (5-30 days). Construct validity was evaluated by comparing the OSIS with the Western Ontario Shoulder Instability index (WOSI), the Simple Shoulder Test (SST), the Oxford Shoulder Score (OSS), the Disability of the Arm, Shoulder, and Hand assessment (DASH), and the Short Form-36 (SF-36). RESULTS: Internal consistency was good, with a Cronbach's α of 0.88. The reliability was excellent, with an ICC of 0.87. The SEM was 3.3 and the SDC was 9 points (on a scale of 0-48). Regarding the construct validity, 80% of the results were in accordance with the hypotheses, including a high correlation (0.82) with the WOSI. No floor or ceiling effects were found. CONCLUSIONS: The Dutch version of the OSIS showed good reliability and validity in a cohort of patients with shoulder instability.

The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear.

BACKGROUND: It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of rotator cuff tears. This study aimed to determine the diagnostic value of nine individual clinical tests for evaluating rotator cuff tear and to develop a prediction model for diagnosing rotator cuff tear. METHODS: This prospective cohort study included 169 patients with shoulder complaints. Patients who reported a previous shoulder dislocation were excluded from the analysis (N = 69). One experienced clinician conducted 25 clinical tests of which 9 are specifically designed to diagnose rotator cuff pathology (empty can, Neer, Hawkins-Kenney, drop arm, lift-off test, painful arc, external rotation lag sign, drop sign, infraspinatus muscle strength test). The final diagnosis, based on magnetic resonance arthrography (MRA), was determined by consensus between the clinician and a radiologist, who were blinded to patient information. A prediction model was developed by logistic regression analysis. RESULTS AND DISCUSSION: In this cohort, 38 patients were diagnosed with rotator cuff tears. The individual overall accuracy of the rotator cuff clinical tests was 61%-75%. After backward selection, the model determined that the most important predictors of rotator cuff tears were higher age and a positive Neer test. This internally validated prediction model had good discriminative ability (area under the receiver operating characteristic curve (AUC) = 0.73). CONCLUSION: Our results showed that individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. Our prediction model showed improved diagnostic value. However, the prediction value is still relatively low, supporting a low threshold for additional diagnostic tests for the diagnosis of rotator cuff tears. LEVEL OF EVIDENCE: Study of diagnostic test: level I.

Measurement properties of the Western Ontario Shoulder Instability index in Dutch patients with shoulder instability.

BACKGROUND: The Western Ontario Shoulder Instability index (WOSI) is a patient-reported outcome measure for patients with shoulder instability. The purpose of this study was to validate the WOSI in a Dutch population by evaluating its structural validity, internal consistency, measurement error, reliability, and construct validity. Floor and ceiling effects were also addressed. METHODS: Two cohorts were recruited, including a total of 138 patients with shoulder instability. Confirmatory factor analysis was used to assess the structural validity and Cronbach's α to assess internal consistency. The measurement error was calculated as the smallest detectable change (SDC). Reliability (test-retest) was estimated in a subgroup of 99 patients who completed the re-test after a mean of 13 days (5-30 days). Reliability was calculated with the intraclass correlation coefficient (ICC). Construct validity was evaluated by comparing the WOSI with the Oxford Shoulder Instability Score (OSIS), the Simple Shoulder Test, the Oxford Shoulder Score, the Disability of the Arm, Shoulder, and Hand assessment (DASH), and the Short Form-36 Health Survey. Measurement properties were evaluated for both the total WOSI score and its four domains. RESULTS: Factor analysis did not confirm the validity of the four domains. Best results were found for a one-factor model. Internal consistency was good, with Cronbach's α ranging from 0.93 to 0.96. Reliability was excellent (ICC 0.88-0.92 for all subscales). The measurement error (SDC) was 23.0% for the total WOSI and 23% to 28% for the subscales (on a scale of 0-100). Regarding the construct validity, 76% of the results were in accordance with the hypotheses, including a high correlation with the OSIS (0.82) and DASH (0.81) assessments. No floor or ceiling effects were found. CONCLUSION: The Dutch version of WOSI showed good reliability and validity in a cohort of patients with shoulder instability, although the factor structure remains unclear.

Determination and comparison of the smallest detectable change (SDC) and the minimal important change (MIC) of four-shoulder patient-reported outcome measures (PROMs).

BACKGROUND: There is a need for better interpretation of orthopedic treatment effects. Patient-reported outcome measures (PROMs) are already commonly used for patient evaluation. PROMs can be used to determine treatment effects in research as well as in clinical settings by calculating change scores, with pre- and post-treatment evaluation. The smallest detectable change (SDC) and minimal important change (MIC) are two important benchmarks for interpreting these change scores. The purpose was to determine the SDC and the MIC for four commonly used shoulder-related PROMs: Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand (DASH and QuickDASH), and the Oxford Shoulder Score (OSS). METHODS: A cohort of 164 consecutive patients with shoulder problems visiting an orthopedic outpatient clinic completed the SST, DASH, and the OSS at their first visit and 6 months after operative or non-operative treatment. The SDC was calculated with a test re-test protocol (0-2 weeks). For the MIC, change scores (0-6 months of evaluation) were calculated in seven subgroups of patients, according to an additional self-administered ranking of change over time (anchor-based mean change technique). The MIC is defined as the average score of the 'slightly improved' group according to the anchor. The QuickDASH was computed from the DASH. RESULTS: The SDC of the SST was 2.8, DASH 16.3, QuickDASH 17.1, and OSS 6.0. The MIC change score for the SST was 2.2, DASH 12.4, QuickDASH 13.4, and OSS 6.0. CONCLUSION: This study shows that on an individual patient-based level, when taking into account SDC and MIC, the change score should exceed 2.8 points for the SST, 16.3 points for the DASH, 17.1 points for the QuickDASH, and 6.0 points for the OSS to have a clinically relevant change on a PROM, which is not due to measurement error.

Diagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability.

BACKGROUND: It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of traumatic anterior shoulder instability. This study aimed to determine the diagnostic value of individual clinical tests and to develop a prediction model that combined patient characteristics, history, and clinical tests for diagnosis of traumatic anterior shoulder instability. MATERIALS AND METHODS: This prospective cohort study included 169 consecutive patients with shoulder complaints who were examined at an orthopaedic outpatient clinic. One experienced clinician conducted 25 clinical tests; of these, 6 were considered to be specific for testing of traumatic anterior shoulder instability (apprehension, relocation, release, anterior drawer, load and shift, and hyperabduction tests). Magnetic resonance arthrography was used to determine the final diagnosis. A prediction model was developed by logistic regression analysis. RESULTS: In this cohort, 60 patients (36%) were diagnosed with anterior shoulder instability on the basis of magnetic resonance arthrography. The overall accuracy of individual clinical tests was 80.5% to 86.4%. Age, previous shoulder dislocation, sudden onset of complaints, and the release test were important predictors for the diagnosis of traumatic anterior shoulder instability. The prediction model demonstrated high discriminative ability (AUC 0.95). CONCLUSION: Individual clinical shoulder tests provide good diagnostic accuracy. Young age, history of shoulder dislocation, sudden onset of complaints, and positive result of the release test were the most important predictors for traumatic anterior shoulder instability.

Validation of the Dutch version of the Simple Shoulder Test.

BACKGROUND: The Simple Shoulder Test (SST) is an internationally used patient-reported outcome for clinical practice and research purposes. It was developed for measuring functional limitations of the affected shoulder in patients with shoulder dysfunction and contains 12 questions (yes/no). The purpose of this study was to create a Dutch translation of the SST and to assess the reliability and validity. MATERIALS AND METHODS: The SST was translated into Dutch using forward and backward translations. A consecutive cohort of patients with shoulder problems visiting an orthopedic clinic completed the Dutch version of the SST twice within 28 days. In addition, the Dutch validated versions of the Disabilities of the Arm, Shoulder and Hand, Oxford Shoulder Score, and Constant-Murley shoulder assessment were completed for assessing construct validity. RESULTS: One hundred ten patients with a mean age of 39 years (SD, 14 years), 72% male, completed the questionnaires. The internal consistency was high (Cronbach α, 0.78). The test-retest reliability was very good (intraclass correlation coefficient, 0.92) (n = 55). The measurement error expressed in the standard error of measurement was 1.18, and the smallest detectable change was 3.3 on a scale from 0 to 12. The construct validity was supported by expected high correlations between the Dutch version of the SST and the Disabilities of the Arm, Shoulder and Hand (r = -0.74) and between the SST and the Oxford Shoulder Score (r = -0.74) and an expected moderate correlation between the SST and the Constant-Murley shoulder assessment (r = 0.59). CONCLUSION: The Dutch version of the SST seems to be a reliable and valid instrument for evaluating functional limitations in patients with shoulder complaints.

Long-term results after arthroscopic shoulder stabilization using suture anchors: an 8- to 10-year follow-up.

BACKGROUND: Arthroscopic stabilization using suture anchors is widely used to restore stability after anterior shoulder dislocations and is associated with low recurrence rates in short-term follow-up studies. PURPOSE: To evaluate the long-term follow-up after arthroscopic stabilization for traumatic recurrent anterior instability using suture anchors with emphasis on both redislocations and subjective shoulder function. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We included 67 consecutive patients with 70 affected shoulders. After 8 to 10 years, patients were asked to report the presence and course of their redislocations. Subjective shoulder function was addressed using the Oxford Instability Score (OIS), the Western Ontario Shoulder Instability Index (WOSI), and the Simple Shoulder Test (SST). Patients rated their health status using the Short Form-36 (SF-36). RESULTS: Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up; 35% reported a redislocation. Median shoulder function scores were 16 of 12 to 60, 22 of 0 to 210, and 12 of 0 to 12 for the OIS, WOSI, and SST, respectively. There was a significant difference in subjective function between patients with and without recurrent instability, respectively, 16 versus 24 for the OIS (P = .004), and 16 versus 47 for the WOSI (P = .05). We found a trend for an inverse relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (P = .06). Another trend was found with the presence of a Hill-Sachs defect slightly increasing the risk of a redislocation (P = .07). CONCLUSION: With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. The presence of a Hill-Sachs defect and the use of less than 3 suture anchors might increase the chance of a redislocation. Patients without a redislocation have a significantly better shoulder function compared with patients with a redislocation.

The "value added" of neurocognitive testing after sports-related concussion.

BACKGROUND: Neurocognitive testing has been endorsed as a "cornerstone" of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group. Neurocognitive testing is important given the potential unreliability of athlete self-report after injury. Relying only on athletes' reports of symptoms may result in premature return of athletes to contact sport, potentially exposing them to additional injury. HYPOTHESIS: Use of computer-based neurocognitive testing results in an increased capacity to detect postconcussive abnormalities after injury. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: High school and college athletes with a diagnosed concussion were tested 2 days after injury. Postinjury neurocognitive performance (Immediate Postconcussion Assessment and Cognitive Testing) and symptom (postconcussion symptom) scores were compared with preinjury (baseline) scores and with those of an age- and education-matched noninjured athlete control group. "Abnormal" test performance was determined statistically with Reliable Change Index scores. RESULTS: Sixty-four percent of concussed athletes reported a significant increase in symptoms, as judged by postconcussion symptom scores, compared with preinjury baseline at 2 days after injury. Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance. The addition of neurocognitive testing resulted in a net increase in sensitivity of 19%. Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms, relative to their own baseline; 30% of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms, as judged by postconcussion symptom scores. For the concussed group, use of symptom and neurocognitive test results resulted in an increased yield of 29% overreliance on symptoms alone. In contrast, 0% of the control group had both symptoms and abnormal neurocognitive testing. CONCLUSION: Reliance on patients' self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play. Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms.

Extracellular signal regulated kinase and SMAD signaling both mediate the angiotensin II driven progression towards overt heart failure in homozygous TGR(mRen2)27.

Angiotensin (Ang) II is a key player in left ventricular (LV) remodeling and cardiac fibrosis. Its effects are thought to be transferred at least in part by mitogen-activated protein kinases (MAPK), transforming growth factor (TGF) beta1, and the Smad pathway. In this study we sought to elucidate whether Ang II related effects on LV dysfunction and fibrosis in vivo are mediated via MAPK or rather via Smad stimulation. We treated homozygous REN2 rats (7-11 weeks) with placebo, Ang II type 1 (AT1) receptor blocker or tyrphostin A46 (TYR), an inhibitor of epidermal growth factor receptor tyrosine kinase that blocks extracellular signal-regulated kinase (ERK) activity. REN2 rats had LV hypertrophy (LVH) and LV dysfunction that progressed to heart failure between 10 and 13 weeks. Blood pressure normalized over time. Renin, N-terminal atrial natriuretic peptide (N-ANP), and ERK were activated while p38 MAPK was not. Treatment with AT1 receptor blockade prevented LVH and right ventricular hypertrophy, normalized systolic and diastolic d P/d t, N-ANP levels, and reduced collagen apposition. Similarly, TYR reduced LVH, N-ANP levels, and collagen apposition. Myocardial ERK activation did not depend on AT1 receptor signaling as it was not affected by AT1 receptor blockade. TYR abolished myocardial ERK activity. Smad2 activation was inhibited by AT1 receptor blockade but was unaltered by TYR. Ang II induced LV remodeling and fibrosis are dependent on both ERK and Smad2 activation. This process is prevented by both AT1 receptor blockade and TYR, and therefore inhibition of either pathway is equally efficacious in restoring LV function and architecture.