A self-administered questionnaire for assessment of symptoms and function of the shoulder.

A self-administered questionnaire was designed to assess the severity of symptoms related to and the functional status of the shoulder. It includes domains of global assessment, pain, daily activities, recreational and athletic activities, work, satisfaction, and areas for improvement. Each domain is graded separately and is weighted to arrive at the total score. The over-all scale and each domain were prospectively tested for validity, reliability, and responsiveness to clinical change. One hundred patients who were seen for evaluation of the shoulder were enrolled in the study. The validity of the scale was demonstrated by moderate-to-high correlation of the domains and individual questions of the Shoulder Rating Questionnaire with those of the Arthritis Impact Measurement Scales 2. Validity was supported further by significant correlation of the scores in each domain with the level of satisfaction in that domain and by significantly lower scores in domains that patients selected as areas important for improvement. The over-all scale and each domain were internally consistent (Cronbach alpha, 0.71 to 0.90). Reproducibility was evaluated by repeated administration of the questionnaire after a mean of three days to forty patients whose condition was clinically stable. Reproducibility of the over-all questionnaire and individual domains was excellent (Spearman-Brown index, 0.94 to 0.98). Individual questions were reproducible, with a weighted kappa value of more than 0.7 for each. Responsiveness was evaluated by comparison of the preoperative and postoperative scores of thirty patients who had a satisfactory result one year after an operation on the shoulder. The over-all Shoulder Rating Questionnaire and each domain were responsive to clinical change as demonstrated by favorable standardized response means (range, 1.1 to 1.9) and indices of responsiveness (range, 1.1 to 2.0). Similar analysis performed for individual diagnostic groups supported the validity, reliability, and responsiveness of the questionnaire in each group. The self-administered shoulder questionnaire was found to be valid, reliable, and responsive to clinical change. These qualities should make it a useful instrument for the prospective assessment of the outcome of treatment of disorders related to the shoulder.

Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts.

Thirty patients having had anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autograft and thirty patients having had ACL reconstruction with hamstring (HS) autograft were enrolled. All procedures were performed using an endoscopic technique with identical postoperative rehabilitation, such that the only variable was the type of graft and its fixation. Lateral and 45 degrees posteroanterior (PA) weightbearing radiographs were performed in each patient at 6-12 (mean 9) months postoperatively in the HS group and 9-22 (mean 13) months postoperatively in the PT group. The sclerotic margins of the tunnel were measured at the widest dimension of the tunnel by a single observer and were compared with the initially drilled tunnel size after correction for radiographic magnification. For the BPTB group, all bone plugs appeared to be incorporated radiographically. On the femoral side, the bone plug was incorporated at the roof of the intercondylar notch, such that no tunnel measurement could be made. Well-defined sclerotic margins were always present at the tibial and femoral tunnels for the HS group and at the tibial tunnel for the BPTB group. The mean percentage increase in tunnel size in the PA view was 9.7%+/-14.7% for the BPTB tibial tunnel, 20.9%+/-13.4% for the HS tibial tunnel, and 30.2%+/-17.2% for the HS femoral tunnel. The mean percentage increase in tunnel size in the lateral view was 14.4%+/-16.1% for the BPTB tibial tunnel, 25.5%+/-16.7% for the HS tibial tunnel, and 28.1%+/-14.7% for the HS femoral tunnel. The difference in HS and BPTB tibial tunnel expansion on both the PA and lateral views was statistically significant (P = 0.003 and P = 0.01, respectively). Inter-observer variability was excellent with an intra-class correlation coefficient of 0.92. Tunnel expansion was significantly greater following ACL reconstruction using HS autografts than in those using BPTB autografts. The points of fixation for the HS grafts are at a greater distance from the normal insertion site and biomechanical point of action of the ACL than the points of fixation for BPTB grafts. We believe that this greater distance creates a potentially larger force moment during graft cycling which may lead to greater expansion of bone tunnels.

Humeral head osteonecrosis: clinical course and radiographic predictors of outcome.

Forty-two patients (65 shoulders) with osteonecrosis of the humeral head were reviewed. Minimal follow-up was 2 years or until shoulder arthroplasty was performed for persistent severe pain and disability not responsive to conservative treatment. Thirteen shoulders had surgery shortly after presentation, whereas 22 others initially treated conservatively required surgery. Thirty shoulders in 20 patients have been treated without surgery and were evaluated at an average of 10 years after initial presentation. Fifteen shoulders are doing satisfactorily, whereas 15 others are doing poorly. Overall, 37 (71%) shoulders had clinical progression of disease requiring shoulder arthroplasty or resulting in severe pain and disability. All had radiographic stage III, IV, or V, and 41 (85%) had articular surface incongruity of 2 mm or greater. Humeral head drilling was not effective in preventing clinical or radiographic progression in stage III.disease. Radiographic stages of III or greater and documented radiographic disease progression were significantly associated with a poor outcome.