Relationship Between Patient-Reported Assessment of Shoulder Function and Objective Range-of-Motion Measurements

A new self-assessment tool following shoulder stabilization surgery, the auto-Walch and auto-Rowe questionnaires

PURPOSE

Patient-reported outcome measures (PROMS) are increasingly used for patient evaluation, as well as for scientific research. Few are used for practical purposes in the clinical setting, and few are reliable enough to allow proper feedback to physicians. Two of the most commonly used assessment tools in shoulder instability are the Walch-Duplay and the Rowe scores. The aim of this study was to evaluate the validity of self-administered versions of the Walch-Duplay and Rowe scores following shoulder stabilization procedure.

METHODS

Between the months of May and December 2021, all patients who were followed in one of six institutions for shoulder instability were included. Patients were required to anonymously fill a self-administered version of Walch-Duplay and Rowe score. The classic scores were measured by the surgeon. Correlations between self-assessment and physician-assessment were then recorded.

RESULTS

A total of 106 patients were evaluated during the study period. Using the Spearman coefficient for correlation, a strong correlation (r > 0.5) was found between the results of the self-administered questionnaire and the surgeon-measured score. The difference between surgeon- and patient-administered questionnaires was non-significant.

CONCLUSION

The self-administered version of the Walch-Duplay and Rowe questionnaires can reliably be used in the clinical setting for post-operative follow-up of patients undergoing shoulder stabilization procedures.

LEVEL OF EVIDENCE

Level II.

Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty?

BACKGROUND AND HYPOTHESIS

There is no consensus as to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes for either clinical or research purposes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. To date, the Single Assessment Numeric Evaluation (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis of this study was that the SANE would correlate with and be equal or superior in responsiveness to other outcome measures that have been used in a stand-alone fashion in patients undergoing total shoulder arthroplasty (American Shoulder and Elbow Surgeons [ASES], Western Ontario Osteoarthritis of the Shoulder [WOOS], and Simple Shoulder Test [SST] scores). In addition, it was hypothesized that the SANE would be more relevant to each patient than the ASES assessment, further supporting the use of the SANE as a stand-alone shoulder-specific outcome measure.

METHODS

A retrospective review of a database of patients undergoing total shoulder arthroplasty was performed, in which the SANE score was recorded simultaneously with the ASES, WOOS, and/or SST score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of all scores. The relevance of the SANE and ASES assessments was examined using the scores of 150 consecutive patients to determine the number of questions on each assessment that were not answered.

RESULTS

Correlation was excellent for the SANE score and the ASES score (n = 1447, r = 0.82, P < .0001), WOOS score (n = 1514, r = 0.83, P < .0001), and SST score (n = 1095, r = 0.81, P < .0001). The correlation of preoperative scores was moderate and that of postoperative scores was strong-moderate when the SANE score was compared with all 3 other scores. All scores were highly responsive, with standardized response mean values of 2.2 for the SANE score, 2.3 for the ASES score, 1.4 for the WOOS score, and 1.6 for the SST score. The effect size of the SANE score was 2.9; ASES score, 2.9; WOOS score, 2.9; and SST score, 2.3. One hundred percent of the SANE questions were answered completely compared with 61% of the ASES questions (P < .0001).

CONCLUSION

In patients undergoing total shoulder arthroplasty, the SANE score highly correlated with the WOOS, ASES, and SST scores, which have been used as stand-alone shoulder-specific outcome measures. The SANE score may provide the same information as the WOOS, ASES, and SST score regarding outcomes with a significant reduction in responder burden. It is logical that the SANE can be used as a stand-alone instrument for patients undergoing total shoulder arthroplasty.

Clinical outcome and return to sports activity after surgical treatment for recurrent shoulder instability with a modified Latarjet procedure

INTRODUCTION

The Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity.

HYPOTHESIS

The hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy.

MATERIAL AND METHODS

Thirty-two patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients' demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables.

RESULTS

All patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A.

DISCUSSION/CONCLUSION

The longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach.

LEVEL OF EVIDENCE

III; Retrospective cohort study.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

HYPOTHESIS

The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments.

RESULTS

After full-text review of 490 articles, 74 articles met all inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluation score was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data.

CONCLUSION

Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.

A 10-year experience with reverse shoulder arthroplasty: are we operating earlier?

INTRODUCTION

As surgeons' confidence in reverse shoulder arthroplasty (RSA) increases, they may tend to offer RSA earlier in the course of glenohumeral joint disease. This study evaluates the changes in the "tipping point" for primary RSA over a 10-year period to evaluate changes in practice.

METHODS

A total of 3975 primary RSAs performed over a 10-year period were retrospectively reviewed from a multi-institutional database. Of these, 3536 primary RSAs with preoperative diagnoses of osteoarthritis with rotator cuff deficiency (1626), irreparable rotator cuff tear (396), and rotator cuff tear arthropathy (1514) were included in the analysis. Preoperative range of motion (ROM) and patient-reported outcome measures (PROMs) were used to calculate tipping points for each subgroup on a yearly basis over a 10-year period, and assessed for changes over time.

RESULTS

PROMs (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test) and the Constant score remained similar over the 10-year study period, with all demonstrating slightly higher tipping points later in the study. ROM measures (forward elevation, abduction, and external rotation) all showed small increases over time, demonstrating better ROM before electing to undergo RSA in later years.

CONCLUSIONS

With the increasing use of RSA over the last decade, the ROM tipping point for patients electing to undergo surgery has increased, whereas the PROM tipping point has remained stable. This indicates that patients undergoing RSA in the present have greater ROM preoperatively compared with 10 years ago; however, their perceived disability remains similar. Surgeons and patients continue to pursue RSA at a similar preoperative morbidity over the last 10 years.

A concept analysis and overview of outcome measures used for evaluating patients with proximal humerus fractures

PURPOSE

It is unclear to which degree existing studies evaluate the primary goal of treatment for patients with proximal humerus fractures (restoration of daily activities). Our purpose was to systematically review and analyze the concepts reflected by outcome measures used in studies of patients with proximal humerus fractures.

METHODS

We reviewed three databases from 2000 to 2018. Two reviewers categorized outcomes in each study into concepts of the International Classification of Functioning, Disability and Health framework.

RESULTS

The most commonly represented concept across 35 studies was "Body Function/Structure Impairment", followed by aggregate measures that reflect multiple concepts to varying degrees. All patient-reported aggregate measures such as the Disabilities of the Arm, Shoulder, and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores better reflected "Activity Limitations", however, these measures were only reported in 34% of studies.

CONCLUSION

There may be misalignment between what studies measure, and the primary goal of treatment for patients with proximal humerus fractures. The Disabilities of the Arm, Shoulder and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores reflect concepts that more adequately address the restoration of daily activities following these injuries, and future studies should include at least one of these measures.Implications for rehabilitationWe have shown that there is a misalignment between what existing studies are measuring (primarily objective measures of impairment) and the primary goal of treatment and rehabilitation (restoring activities of daily living).This suggests that existing studies evaluating different treatment types for proximal humerus fracture patients are providing inadequate information to make evidence-based treatment and rehabilitation decisions following theses injuries.Our results tentatively suggest that the Disabilities of the Arm, Shoulder and Hand, the American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores may better reflect limitations in daily activities following these injuries and should be used in future studies and by clinicians.

Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, -2.4±5.0 vs -2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 2019; 42(5):276-284.].

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

BACKGROUND

It has been documented that the smooth and move procedure-smoothing the proximal humeral surface while maintaining the coracoacromial arch-can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation. This study sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure.

METHODS

We conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).

RESULTS

In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID). The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus. In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).

CONCLUSIONS

In addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.

The Shoulder Self-Administered Motion Evaluation Has Excellent Patient Reliability and Reproducibility on Both Physician and Repeat Follow-up Testing

Long-term clinical evaluation is becoming more important, yet difficulties exist because there are substantial patient costs for extended follow-up. The goal of this study was to validate whether a new shoulder motion evaluation is reproducible and reliable with physician examination. Consecutive patients were administered a shoulder motion assessment during their clinic visit. Patients completed the same evaluation 2 weeks after their visit to determine test-retest reliability. Exact and approximate (within 20° or 4 spinal levels) agreements between patient and physician measurements were calculated. A total of 112 patients (224 shoulders) with an average age of 56.7 years were evaluated. The most common diagnoses were osteoarthritis (33.0%) and rotator cuff tear (32.1%). All motion questions had greater than 50% exact patient-physician agreement and greater than 70% approximate agreement. When agreement was off, patients more often underestimated their motion. There was substantial clinician-patient agreement for all questions and almost perfect agreement for forward elevation (intraclass correlation coefficient, 0.78) and internal rotation (intraclass correlation coefficient, 0.77). On test-retest reliability testing, patient-patient agreement was substantial for external rotation at the side (intraclass correlation coefficient, 0.71). There was near perfect agreement for internal rotation (intraclass correlation coefficient, 0.83) and abduction (intraclass correlation coefficient, 0.81) testing. This shoulder assessment tool had both good agreement to physician examination and substantial agreement on correlation testing. There was substantial agreement between follow-up visits, suggesting excellent reproducibility. This motion assessment shows effectiveness with most shoulder pathologies. It is recommended as a good screening tool for both clinical and research purposes requiring long-term follow-up in which in-person clinical examinations may be costly and time consuming. [Orthopedics. 2018; 41(6):e820-e826.].

The "tipping point" for 931 elective shoulder arthroplasties

BACKGROUND

A patient with arthritis usually experiences the progression of symptoms over time. At some stage, the patient may decide that the symptoms have reached a level of severity that leads him or her to elect to proceed with joint replacement; we refer to this degree of symptom severity as the "tipping point." Our goal was to study the factors that influenced the tipping point for patients undergoing elective shoulder arthroplasty.

METHODS

We analyzed the characteristics of 931 patients undergoing shoulder arthroplasty to determine the factors affecting the tipping point as characterized by the patients' comfort and function at the time they determined their symptoms had progressed to the point when this elective surgery was merited.

RESULTS

The preoperative Simple Shoulder Test (SST) score for all patients averaged 3.6 ± 2.7. The average tipping points were different for the ream-and-run procedure (mean SST score, 5.0 ± 2.5), hemiarthroplasty (mean SST score, 3.1 ± 3.3), total shoulder arthroplasty (mean SST score, 3.0 ± 2.4), cuff tear arthropathy arthroplasty (mean SST score, 2.8 ± 2.5), and reverse total shoulder arthroplasty (mean SST score, 1.5 ± 1.8). A number of other factors were significantly associated with a higher tipping point: younger age, better health, male sex, commercial insurance, married, nonuse of narcotics, use of alcohol, and shoulder problem not related to work.

CONCLUSIONS

Analysis of the tipping point-the patients' self-assessed comfort and function at the point they decide to undergo shoulder joint replacement-provides a means by which surgeons can understand the factors influencing the indications for these procedures.

The Effect of Rotator Cuff Repair on Natural History: A Systematic Review of Intermediate to Long-Term Outcomes

Background:

Rotator cuff disease can have a progressive natural history of increasing tear size and worsening function. It remains unknown whether rotator cuff repair alters this natural history.

Methods:

A systematic review of the intermediate to long-term (minimum 5-year) results of operative rotator cuff repair and no repair of rotator cuff injuries was performed to compare (1) patient-based outcomes, (2) future surgical intervention, (3) future tear progression or recurrence, and (4) tear size. The no-repair group included both conservative treatment and surgical treatment without repair. After the application of selection criteria, 29 studies with 1,583 patients remained. Meta-regression was conducted to adjust for baseline age, sex, tear size, and duration of follow-up.

Results:

Comparison of the repair and no-repair groups revealed no significant differences in terms of age (p = 0.36), sex (p = 0.88), study level of evidence (p = 0.86), or Coleman methodology score (p = 0.8). The duration of follow-up was significantly longer for the no-repair group (p = 0.004), whereas baseline tear size was significantly larger in the repair group (p = 0.014). The percentage of patients requiring additional surgery was significantly higher in the no-repair group after adjustment for age, sex, duration of follow-up, and tear size (9.5% higher in estimated means between groups [95% confidence interval, 2.1% to 17%]; p = 0.012). The likelihood of a recurrent defect (repair group) or extension of the prior tear (no-repair group) was not different between groups after adjustment for age, sex, duration of follow-up, and tear size (p = 0.4). There were no differences between the repair and no-repair groups in terms of the Constant score after adjustment for age, sex, duration of follow-up, and tear size (p = 0.31). The final tear size was significantly larger in the no-repair group than the repair group (967 mm² higher in estimated means between groups [95% confidence interval, 771 to 1,164 mm²]; p < 0.001).

Conclusions:

At intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased need for future surgery after adjusting for age, sex, duration of follow-up, and tear size. The likelihood of a recurrent defect after rotator cuff repair did not differ from that of tear extension after nonoperative treatment. Thus, rotator cuff repair may not alter natural history.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity

BACKGROUND

The rationale for rotator cuff repair surgery is that better integrity of the cuff should be associated with better comfort and function. However, in patients with cuff disease, there is not good evidence that the degree of rotator cuff integrity is closely associated with the shoulder's comfort, function, or active motion. The goal of this study was to explore these relationships in shoulders with surgically documented cuff disease.

METHODS

In 55 shoulders having surgery for cuff-related symptoms, we correlated the preoperative Simple Shoulder Test score with the objectively measured preoperative active shoulder motion and with the integrity of the cuff observed at surgery.

RESULTS

The 16 shoulders with tendinosis or partial-thickness tears had an average Simple Shoulder Test score of 3.7 ± 3.3, active abduction of 111° ± 38°, and active flexion of 115° ± 36°. The corresponding values were 3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and 3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.

CONCLUSION

In this study, surgically observed cuff integrity was not strongly associated with the shoulder's comfort or function. Whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.