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Background The Popeye sign is a frequently reported finding following long head of the biceps (LHB) surgery and may be more often detected by doctors than by patients. This study investigates agreement between patients and doctors regarding the presence of a Popeye sign following LHB surgery. Method This interobserver study investigates agreement between patients and consulting physicians with regard to assessment of a Popeye sign in patients following LHB surgery. Furthermore, this was compared with assessments by non–consulting physicians (observers) using digital photographs of the operated arm, taken both preoperatively and postoperatively. Data about gender, age, and body mass index (BMI) were collected to investigate their role in doctor’s reporting of a Popeye sign. Patient’s dissatisfaction with a Popeye sign in the operated arm was evaluated as well. Results Ninety-seven patients (mean age 61 ± 6.0 years, 62% male) underwent LHB surgery. A Popeye sign was reported by 2 patients (2%) as opposed to 32 cases (40%) by consulting physicians, of which only 1 case was in agreement. Krippendorff’s alpha (Kalpha) for agreement between observers for preoperative photographs was 0.074 (95% CI −0.277, 0.382) and 0.495 (95% CI 0.317, 0.659) for postoperative cases. Kalpha between observers and consulting physicians for pre- and postoperative cases were 0.033 (95% CI −970, 0.642) and 0.499 (95% CI 0.265, 0.699), respectively. Phi coefficient analysis showed a moderate, statistically significant correlation between male sex and Popeye sign identification. Rank-biserial calculation revealed negligible correlation between BMI and age with regard to detecting a Popeye sign by both consulting physicians and observers. Dissatisfaction about swelling in the upper arm was reported in 1 case, though in a location that did not correspond to the location of a Popeye sign. Conclusion The Popeye sign is more often identified by doctors than by patients after undergoing LHB surgery. BMI and age are not related to the detection of a Popeye sign, but sex is moderately correlated. Together with the low percentage of dissatisfaction of patients with this swelling, this signifies that a Popeye sign seems to be a doctor’s rather than a patient’s problem.

Background The Western Ontario Rotator Cuff Index (WORC) is a widely used disease-specific outcome tool developed for patients with rotator cuff injuries. The determination of age- and sex-adjusted normative WORC values enables us to determine whether a procedure is more beneficial in specific patient groups because the results can be compared with a matched standard. The purpose of this study was to determine normative WORC values and assess whether the WORC needs an adjusted score for age and sex. Methods We included participants using an online data-capturing program. We collected the following variables: age, sex, presence of shoulder pathology, Subjective Shoulder Value, and WORC score. We defined the mean normative WORC score per age category and analyzed sex differences in WORC scores per age category and in all domains of the WORC score. Results A total of 470 participants filled out the questionnaire. We excluded 44 participants because of pre-existing shoulder complaints or incomplete questionnaires. The mean total WORC score was 94% (standard deviation, 9%), and the mean total WORC score in every age and sex category was >90%. Of all participants, 85% scored between 91% and 100%; 63 participants (15%) scored 100%. The mean overall Subjective Shoulder Value was 98% (standard deviation, 6%). We found no statistically significant differences between sexes in the overall score, in the domain scores, and within the age categories. Conclusion We defined normative values for the WORC questionnaire in a random prospective cohort and found no difference in scores between sexes. The mean normative scores all were within the variance of the maximum, and the WORC score did not deteriorate with age. It seems that the results of this subjective questionnaire change with the participant's perspective. An adjusted WORC score for age and sex is not necessary. This information can serve as a basis for comparison with patients with shoulder disease.

Rationale While theoretical frameworks for optimization of the outpatient processes are abundant, practical step-by-step analyses to give leads for improvement, to forecast capacity, and to support decision making are sparse. Aims and objectives This article demonstrates how to evaluate and optimize the triad of demand, (future) capacity, and access time of the outpatient clinic using a structured six-step method. Methods All individual logistical patient data of an orthopaedic outpatient clinic of one complete year were analysed using a 6-step method to evaluate demand, supply, and access time. Trends in the data were retrospectively analysed and evaluated for potential improvements. A model for decision making was tested. Both the analysis of the method and actual results were considered as main outcomes. Results More than 25 000 appointments were analysed. The 6-step method showed to be sufficient to result in valuable insights and leads for improvement. While the overall match between demand and capacity was considered adequate, the variability in capacity was much higher than in demand, thereby leading to delays in access time. Holidays and subsequent weeks showed to be of great influence for demand, capacity, and access time. Using the six-step method, several unfavourable characteristics of the outpatient clinic were revealed and a better match between demand, supply, and access time could have been reached with only minor adjustments. Last, a clinic specific prediction and decision model for demand and capacity was made using the 6-step method. Conclusions The 6-step analysis can successfully be applied to redesign and improve the outpatient health care process. The results of the analysis showed that national holidays and variability in demand and capacity have a big influence on the outpatient clinic. Using the 6-step method, practical improvements in outpatient logistics were easily found and leads for future decision making were contrived.

Purpose To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. Methods This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. Results The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, –∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. Conclusions Although statistically “inconclusive” regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. Level of Evidence Level I, randomized controlled trial and treatment study.

Hypothesis This study determined the response shift in patients undergoing rotator cuff repair using the Western Ontario Rotator Cuff index (WORC), a disease-specific quality of life questionnaire. We hypothesized there would be a response shift with a positive recalibration (overestimated their preoperative disability) on the WORC and increases over time. Methods The study prospectively included 36 patients undergoing arthroscopic rotator cuff repair. At baseline, 3 months (T1), and 1 year (T2) after surgery the WORC, EuroQol (EQ)-5D-3L, and the patient's level of satisfaction after surgery were scored. To evaluate the response shift, patients also completed the WORC at 3 months (Pre-T1) and 1 year (Pre-T2) as how they perceived themselves to have been before surgery. Results The result on Pre-T1 and Pre-T2 results revealed that patients retrospectively rated their overall WORC score comparable with the baseline WORC score (Pre-T0; T0 = 40.5 ± 18.4, Pre-T1 = 45.0 ± 22.7, Pre-T2 = 34.3 ± 21.3). No response shift was observed on all domains except a negative recalibrated response shift for emotional disability on T1 ( P = .04). Conclusions No significant group-level response shift was observed using the WORC, except for the subdomain emotional disability at 3 months after arthroscopic rotator cuff repair. With the absence of any shift in patient's perception on the self-administered quality of life–related WORC questionnaire, this study suggests one could retrospectively reliably conduct group-level preoperative baseline information on quality of life up to 1 year after surgery.

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [

Purpose To study the effects on pain as the main outcome parameter and on function and cuff integrity as the secondary outcome parameters after arthroscopic rotator cuff repair in the short term comparing the abduction brace with an antirotation sling for postoperative shoulder immobilization. Methods Eligible patients were between the ages of 18 and 75 years who were diagnosed with a traumatic or degenerative tear of the supraspinatus and/or infraspinatus tendon, confirmed by magnetic resonance imaging, for which an arthroscopic footprint repair was indicated and performed. Patients were randomly allocated to the antirotation sling or abduction brace group. Postoperative pain and use of analgesics were accurately registered up to 3 months after surgery using a patient diary. Follow-up examinations including the Constant-Murley score, Western Ontario Rotator Cuff index, and glenohumeral range of motion were scheduled 6 weeks, 3 and 6 months, and 1 year after surgery. Results The average level of pain measured directly postoperation up to 1 year after surgery was not significant different between groups. Postoperatively, function scores and glenohumeral range of motion improved significantly for both groups; however, no differences were observed between groups. No retears were observed on ultrasonograph 3 months after surgery. Conclusions In the short term, the level of pain, function, and quality of life were not significantly different between the use of an abduction brace and that of an antirotation sling after arthroscopic rotator cuff repair. Based on these findings, the abduction brace used in this study does not seem to be the solution for decreasing the pain experienced in the first postoperative weeks after arthroscopic rotator cuff repair, and both are recommendable. Level of Evidence Level I, randomized controlled trial.

Disease-specific instruments of quality of life (QOL) are more sensitive to disease-specific changes. The purpose of this study is to identify prognostic factors for disease-specific QOL after all-arthroscopic rotator cuff (RC) repair using the Western Ontario Rotator Cuff Index (WORC). A total of 140 patients were evaluated after an RC repair with a mean follow-up of 22 ± 6.7 months. Evaluations included the WORC, EQ-5D and anchor questions. Preoperative patient demographics and radiologic characteristics were assessed to identify predictors of disease-specific QOL. Most patients (81.4 %) were satisfied with their surgical result. Minor tear retraction (odds ratio [OR] 2.97, p = 0.030), male gender (OR 3.67, p = 0.003), no social benefits (OR 3.67, p = 0.042) and pre-surgical complaints for more than six months (OR 3.03, p = 0.021) were independent predictors for superior postoperative WORC score in multivariable analysis. None of these factors were predictive for a higher EQ-5D score. These findings highlight the important impact of retraction on QOL after RC repair and underline the utility of disease-specific instruments. Future studies should focus on how these significant predictors can be used to improve decision making and to develop new treatment approaches.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Background Studies concerning prognostic factors of recovery after arthroscopic rotator cuff repair mostly focus on tendon integrity or functional recovery as an outcome. Little is known about how they influence quality of life after surgery. We therefore tried to identify prognostic factors having an impact on quality of life after arthroscopic rotator cuff repair. Methods This study included 30 patients who underwent arthroscopic rotator cuff repair. We assessed Western Ontario Rotator Cuff Index as primary outcome and RAND-36, Constant-Murley score, and a shoulder hindrance score as secondary outcomes. Patients were repeatedly measured: once preoperatively and 4 times postoperatively. Preoperative range of motion, obesity, fatty infiltration, and cuff retraction were preselected as prognostic factors. Results Patients were significantly improved at 3 months and 6 months after arthroscopic rotator cuff repair. In multiple regression analysis, none of the preselected factors could be identified as a prognostic factor influencing quality of life after arthroscopic rotator cuff repair (measured with the Western Ontario Rotator Cuff Index). For the outcome variables RAND-36 (6 months, 1 year) and shoulder hindrance score (1 year), fatty infiltration Goutallier stages 1 and 2 and retraction grades II, III, and IV were significant predictors. Conclusion Although fatty infiltration and retraction grade predict the RAND-36 and shoulder hindrance score, this study could not support preoperative range of motion, obesity, fatty infiltration, or retraction of the cuff as a prognostic factor for quality of life after arthroscopic rotator cuff repair. This study shows that if selection of patients is done properly, these factors do not influence a successful outcome.

Background: The diagnostic value of an oblique radiograph, in addition to a lateral radiograph, for detecting osteophytes in the anterior ankle impingement syndrome was evaluated in a prospective study. The hypothesis was that the application of a lateral radiograph is insufficient to detect osteophytes that are located in the anteromedial aspect of the ankle joint. Oblique anteromedial impingement (AMI) radiographs were hypothesized to be a relevant adjunct, because of their utility to detect these anteromedially located osteophytes. Methods: Presence or absence of tibial and talar osteophytes on both radiographs was compared with the combined findings of CT, MRI scan, and arthroscopic surgery. Estimates of test characteristics were obtained for 60 consecutive patients with an anterior ankle impingement syndrome. Results: It was shown that the sensitivity of lateral radiographs for detecting anterior tibial and talar osteophytes was 40% and 32%, respectively (specificity, 70% and 82%). When the lateral radiograph was combined with an oblique AMI radiograph, these figures increased to 85% and 73%, respectively (specificity decreased to 45% and 68%). This increase was due to the high sensitivity of the oblique AMI radiographs for detecting anteromedial osteophytes (93% for tibial and 67% for talar osteophytes). Conclusion: A lateral radiograph is insufficient to detect all anteriorly located osteophytes. An oblique AMI radiograph is a useful adjunct to routine radiographs and is recommended to detect anteromedial tibial and talar osteophytes.

The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff, originally developed in English. The purpose of this study was to cross-culturally adapt the WORC for use in the Dutch population and to evaluate reliability, agreement and floor and ceiling effects of this Dutch version in a population of patients with rotator cuff disease. Reliability was tested by measuring the Cronbach’s alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Agreement was measured using the Standard Error of Measurement (SEMagreement); and the smallest detectable change (SDC) was calculated based on the SEM. Pearson Correlations Coefficients were used to comparing the WORC with the RAND-36, the Constant Score and 11-point shoulder hindrance scale. Fifty-seven patients entered into this study of whom 50 were available for test-retest validation. The internal consistency of the Dutch WORC tested by Cronbach’s alpha was 0.95 for the total questionnaire. The ICC for the WORC is 0.91 with a 95% confidence interval of 0.85-0.95. Standard Error of Measurement was 6.0 points with a Smallest Detectable Change of 16.7 points on a 0-100 scale. Pearson Correlations Coefficients showed a significant positive correlation between the Dutch WORC and Constant Score (r = 0.60) and a strong reversed correlation with the shoulder hindrance scale (r = -0.75). The Dutch WORC seems to be a reliable health-related quality of life questionnaire for patients with rotator cuff disorders. NCT01532492 .

Background Arthroscopic rotator cuff repair is described as being a successful procedure. These results are often derived from clinical general shoulder examinations, which are then classified as 'excellent', 'good', 'fair' or 'poor'. However, the cut-off points for these classifications vary and sometimes modified scores are used. Arthroscopic rotator cuff repair is performed to improve quality of life. Therefore, disease specific health-related quality of life patient-administered questionnaires are needed. The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff. The score is validated for rotator cuff disease, but not for rotator cuff repair specifically. The aim of this study is to investigate reliability, validity and responsiveness of WORC in patients undergoing arthroscopic rotator cuff repair. Methods/Design An approved translation of the WORC into Dutch is used. In this prospective study three groups of patients are used: 1. Arthroscopic rotator cuff repair; 2. Disorders of the rotator cuff without rupture; 3. Shoulder instability. The WORC, SF-36 and the Constant Score are obtained twice before therapy is started to measure reliability and validity. Responsiveness is tested by obtaining the same tests after therapy.

Total claviculectomy is a rare surgical procedure that has been performed for more than 90 years for a variety of indications, such as malignancy, trauma, and infection. What are the results for the pain score, and what is the influence of a total claviculectomy on the range of motion of the shoulder? We could not find the answers in the literature and analyzed 6 cases of total claviculectomy. The pain scores are good in a chronic osteitis case and in the two malignancy cases. In the 3 posttraumatic cases, the indication was pain, and all 3 had poor results because of persistent pain. All 6 patients had full range of motion. A resection of the entire clavicle did not disturb the motion of the shoulder. A tendency but no final conclusions can be drawn because of too few patients and heterogeneous indications.

Objective: The aim of this study was to develop a radiographic view to detect anteromedial talotibial osteophytes that remain undetected on standard radiographs. Design and patients: In 10 cadaver specimens the maximal size was measured of anteromedial tibial osteophytes that remain undetected on a standard lateral radiograph projection, due to the presence of the anteromedial fibial rim. The average projection of the most prominent anterolateral tibial rim over the anteromedial rim was found to be 7.3 mm. A 7 mm barium-clay osteophyte was attached to this anteromedial rim of the distal tibia. Anteromedial osteophytes become most prominent on an oblique view, in which the radiographic beam is tilted into a 45degrees craniocaudal direction with the leg in 30degrees external rotation. This oblique view was compared with the findings of arthroscopic surgery in 25 consecutive patients with anterior ankle impingement syndrome. Results: Medially located tibial and talar osteophytes remained undetected on a standard lateral projection and became visible on the oblique anteromedial impingement (AMI) radiograph. Anterolateral tibial and talar osteophytes were well detected on a standard lateral radiograph projection but were invisible on the AMI view. There was a high correlation between the location of the osteophyte and the location of symptoms and the findings at arthroscopy. Conclusion: A combination of lateral and oblique radiographs can be used to differentiate between anteromedial and anterolateral bony ankle impingement