Purpose

This prospective, expertise-based randomized clinical trial compares arthroscopic to open shoulder stabilization by measuring the disease-specific quality of life outcome in patients with traumatic unidirectional anterior shoulder instability, and determining the incidence of recurrent instability at 2-years post-operatively.

Purpose: A major issue in the Canadian health care system are the extensive wait times for consultation with an orthopaedic surgeon. We identified that a high percentage of patients referred to shoulder surgery sub-specialists for chronic full thickness rotator cuff tears had not undergone appropriate non-operative treatment prior to being referred, and ultimately did not require surgery. In an effort to improve the referral process and to optimize patient care, we sought to identify clinical predictors for outcome of non-operative treatment of chronic full-thickness rotator cuff tears. This would allow general practitioners to clearly identify patients who are most likely to fail non-operative treatment and actually require surgical consultation. The primary purpose of this study was to determine if the outcome of non-operative treatment in chronic, symptomatic, full-thickness rotator cuff tears could be predicted based upon presenting clinical characteristics, including: age, dominant extremity involvement, gender, duration of symptoms, onset (acute or chronic), forward elevation range of motion, external rotation strength, size of tear, smoking status, and the Rotator Cuff Quality of Life Questionnaire score (RCQOL).

Method: Fifty patients, between the ages of 40 and 85 years, with a documented full-thickness tear on ultrasound or magnetic resonance imaging (MRI), were recruited prospectively. They underwent a three month home-based program of non-operative treatment under the supervision of an experienced physiotherapist and sport medicine physician. At the conclusion of the three month program, patients were evaluated by an orthopaedic surgeon and were defined as having been successful or as having failed non-operative treatment. Successful patients declined surgical treatment after consulting with the surgeon, whereas failed patients elected to undergo surgery, or, if avoiding surgery for other health or “life” reasons, had not experienced adequate improvement with the non-operative program to have been considered successful. The patient’s baseline clinical characteristics were analyzed using logistic regression to determine which characteristics were predictive of outcome.

Results: Thirty-eight of 50 (76%) of patients were successful with the non-operative program. Univariate analysis showed that a patient’s Rotator Cuff Quality of Life questionnaire score was a significant predictor of outcome of non-operative treatment (p = 0.017). Patients who were successful with non-operative treatment had a mean baseline RCQOL score of 49/100, whereas patients who failed non-operative treatment had a mean baseline RCQOL score of 31/100. The two factors of patient age and dominant extremity involvement also trended toward significance.

Conclusion: Baseline RCQOL score can predict which patients will be successful with non-operative treatment and which patients will fail non-operative treatment for a chronic, full-thickness rotator cuff tear.

Purpose: The purpose of this randomised controlled trial was to compare outcomes of operative and non-operative management of Achilles tendon ruptures.

Method: Patients with acute complete Achilles tendon ruptures were randomised to receive open suture repair followed by graduated rehabilitation or graduated rehabilitation alone. The primary outcome measure was re-rupture rate. Assessments at three and six months, and one and two years included a modified Leppelhati score (no strength data), range of motion, calf circumference, and isokinetic strength at one and two years. We report the two year findings.

Results: Two centres randomized 145 patients (118 males and 27 females), mean age 40.9±8.8 years (22.5 – 67.2) to operative (n=73) and non-operative (n=72) treatment. Fourteen were lost to follow-up. Re-rupture occurred in three patients in both groups. The mean modified Lep-pelhati score (out of 85) was 78.2±7.7 in the operative group and 79.7±7.0 in the non-operative group, which was not significant (−1.5 95%CI −6.4 to 3.5, p=0.55). Mean side-to-side difference in plantar flexion and calf-circumference in the operative group was −2.0±3.2° and −1.4±1.2cm, and in the non-operative group −0.9±3.0°and −1.6±1.8cm respectively. Mean isokinetic plantar flexion strength was 62.4±24.2 for the operative and 56.7±19.3 for the non-operative group, which was not significant (5.7, 95%CI −3.1 to 14.5, p=0.20). There were a greater number of serious adverse events in the operative group, including pulmonary embolus in one patient, deep vein thrombosis in one and deep infections requiring irrigation and debridement in three.

Conclusion: This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events.

Purpose: Shoulder instability is a common problem affecting patients in their most active years resulting in an impact on their quality of life. The WOSI is a validated, disease-specific (shoulder instability) evaluative quality of life measure. It has not been tested for its ability to discriminate between those who require surgical care and those who do not. The purpose of this study is to determine if the WOSI can discriminate between surgical and non-surgical patients and between patients with different types of shoulder instability.

Method: Sixty patients with a confirmed diagnosis of shoulder instability were included as cases. Twenty had documented multidirectional instability requiring surgery: Group 1 Surgical MDI – 20 patients had documented recurrent traumatic anterior dislocations requiring surgery: Group 2 Surgical Anterior – 20 patients were first time anterior dislocators who were followed for a minimum one year who had no further recurrences and did not require surgery: Group 3 Non-Surgical First Time Anterior – The cases were compared to 60 age and gender matched control patients with no history of shoulder problems: Group 4 Control – WOSI scores were analyzed using a one-way ANOVA.

Results: The WOSI scores were as follows: Group 1 Surgical MDI- mean 30.5 (95% CI 23.1–37.8); Group 2 Surgical Anterior- mean 39.8 (95% CI 33.1–46.5); Group 3 Non-Surgical First time Anterior- mean 76.2 (95% CI 66.4–86.0) and Group 4 Control- mean 96.6 (95% CI 95.8–97.4). Based on the 95% Confidence Intervals, there were statistically significant differences between the two surgical groups (Group 1 Surgical MDI and Group 2 Surgical Anterior) compared to the non-surgical patients (Group 3 Non Surgical First Time Anterior) and the controls (P=0.000). There is a trend to discriminate between the two surgical groups (P=0.079).

Conclusion: The WOSI Index clearly discriminates between surgical and non-surgical patients with shoulder instability, and the control population with normal shoulders. There is a trend to discriminate between MDI and recurrent anterior traumatic dislocators.

Purpose: The optimal autograft choice for ACL reconstruction remains controversial. Twelve recently published reviews comparing Patellar Tendon (PT) to Hamstring Tendon (HT) autografts in ACL reconstruction vary in their methodology, quality and application of sensitivity analyses. The present review and meta-analysis follows the rigorous methodology of the Cochrane Collaboration of Systematic Reviews and includes more recent trials that utilize modern surgical techniques and concealed randomization.

Method: Randomized Clinical Trials (RCT) and Quasi-randomized Trials (QRCT) with a minimum 2-year follow-up comparing PT with HT autografts in patients undergoing primary ACL reconstruction were included. Non-English articles were professionally translated. Four electronic databases were searched from 1969-present. Bibliographies and proceedings of major orthopaedic meetings were handsearched. Two teams of investigators independently reviewed all citations, selected relevant studies, extracted the data and assigned quality scores. Consensus was achieved within and between each team for all stages of the review process.

Results: Three hundred and twenty-six citations were originally identified with the search criteria. Following rigorous review, 26 relevant studies were identified. Nine were excluded due to missing information, inadequate follow-up, ongoing trials or low quality scores, leaving 17 studies included in the final analysis. Outcomes related to stability (Lachman test, instrumented laxity, and pivot shift) showed trends towards improved stability with PT reconstruction. When QRCTs were excluded there was a significant difference favoring PT reconstructions only with respect to the pivot shift test. All other outcomes were similar between the PT and HT reconstructions including IKDC categories, anterior knee pain (trend in favor of HT), re-rupture rate, and activity levels. No information was available to distinguish between the outcome of acute and chronic reconstructions, long term information or validated patient based outcomes.

Conclusion: The current literature fails to demonstrate significant differences in multiple outcomes comparing PT to HT reconstruction of the ACL. The overall quality of trials is questionable and fails to use validated patient based outcomes or sufficiently long-term results to assess the development of osteoarthritis.