Why Are Some Patients Unhappy after “Successful” Repair of Shoulder Instability?
It has been estimated that 13% to 16% of patients who undergo arthroscopic stabilization procedures for recurrent shoulder instability are dissatisfied with their outcome, despite a technically “successful” operation. Similarly high rates of patient dissatisfaction in the face of an objectively “well-done” surgery are pervasive in most orthopaedic subspecialties and often leave both surgeon and patient frustrated and perplexed. Prior research has suggested that patient expectations, psychological characteristics, and socioeconomic factors play a major role in these cases of patient dissatisfaction. But identifying precise patient or injury factors that can alert surgeons as to which patients may be unsatisfied after their procedure has remained elusive for many common injuries.
In the June 19, 2019 issue of The Journal, Park et al. examine the bases for patient dissatisfaction after arthroscopic Bankart repair (with or without remplissage) for recurrent shoulder instability. Not surprisingly, patient age, size of the glenoid bone defect, and the number of patient postoperative instability events correlated with an objective failure of the operation (i.e., instability requiring a repeat operation). However, the study found that the number of instability events and the preoperative width of the Hill-Sachs lesion correlated with the subjective failure of the operation (i.e., the patient was dissatisfied based on response to a single question about “overall function” 2 years after surgery). For the 14 out of 180 patients who were dissatisfied despite not experiencing a revision, intermittent pain plus psychological characteristics such as apprehension and anxiety about recurrent instability were common reasons for dissatisfaction.
It is becoming clearer with each passing year that simply correcting anatomic pathologies does not always result in happy patients. Orthopaedic surgeons need to employ patient interviewing techniques to identify issues such as anxiety, depression, pain-perception concerns, and substance abuse—all of which can negatively influence the degree of patient satisfaction with the result and are somewhat modifiable preoperatively.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Shoulder and Elbow Surgery 2018
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Robert Tashjian, MD, co-author of the October 17, 2018 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.
Progression of Primary Osteoarthritis
–A study evaluating the relationship between glenoid erosion patterns and rotator cuff muscle fatty infiltration found that fatty infiltration was associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. The authors recommend close observation of patients with B-type glenoids, as the progression of glenoid erosion is more likely in B-type than A-type glenoids.
Perioperative Pain Management
–In a randomized controlled trial of perioperative pain management in patients undergoing primary shoulder arthroplasty, narcotic consumption during the first 24 postoperative hours was similar between a group that received interscalene brachial plexus blockade and a group that received intraoperative soft-tissue infiltration of liposomal bupivacaine. The interscalene group had lower VAS pain scores at 0 and 8 hours postoperatively; both groups had similar VAS pain scores at 16 hours; and the soft-tissue infiltration group had lower pain scores at 24 hours postoperatively.
Rotator Cuff
–In a reevaluation of patients with nonoperatively treated chronic, symptomatic full-thickness rotator cuff tears that had become asymptomatic at 3 months, researchers found that at a minimum of 5 years, 75% of the patients remained asymptomatic.1 The Constant scores in the group that remained asymptomatic were equivalent at 5 years to those who initially underwent surgical repair. While these findings suggest that nonoperative treatment can yield clinical success at 5 years, the authors caution that “individuals with substantial tear progression or the development of atrophy will likely have a worse clinical result.”
–A recent study of the progression of fatty muscle degeneration in asymptomatic shoulders with degenerative full-thickness rotator cuff tears found that larger tears at baseline had greater fatty degeneration, and that tears with fatty degeneration were more likely to enlarge over time. Median time from tear enlargement to fatty degeneration was 1 year. Because the rapid progression of muscle degeneration seems to occur with increasing tear size, such patients should be closely monitored if treated nonoperatively.
Shoulder Instability in Athletes
–An evaluation of outcomes among 73 athletes who had undergone Latarjet procedures found that, after a mean follow-up of 52 months, ASES scores averaged 93. However, only 49% of the athletes returned to their preoperative sport level; 14% decreased their activity level in the same sport; and 12% changed sports altogether. While the Latarjet can help stabilize shoulders in athletes, the likelihood is high that the athlete won’t return to the same level in the same sport after the procedure.
Reference
- Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-8.
JBJS 100: Bankart Repair, Carpal Tunnel Assessment
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Bankart Procedure: A Long-Term End-Result Study
C R Rowe, D Patel, W W Southmayd: JBJS, 1978 January; 60 (1): 1
This was the first large clinical series with long follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent or good, and this study contributed to the demise of nonanatomic shoulder repairs.
A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome
D W Levine, B P Simmons, M J Koris, L H Daltroy, G G Hohl, A H Fossel, J N Katz: JBJS, 1993 January; 75 (11): 1585
Distinguishing interventions that work from those that don’t requires rigorous outcomes research, which, in turn, relies on standardized, patient-centered measures that have proven reliability and validity. Meeting these criteria are the Symptom Severity and Functional Status Scales for carpal tunnel syndrome described in this oft-cited JBJS study from 25 years ago.
A Paean to Shoulder Pioneer Doug Harryman
The June 7, 2017 issue of JBJS contains one more in a series of personal essays where orthopaedic clinicians tell a story about a high-impact experience they had that altered their worldview, enhanced them personally, and positively affected the care they provide as orthopaedic physicians.
This “What’s Important” piece comes from Dr. Frederick A. Matsen, III of the University of Washington. In his moving tribute to former colleague Doug Harryman, Dr. Matsen explains how his friend and mentor’s devotion to improving patient outcomes was matched by an unwavering faith that permeated every aspect of his life. The article includes a link to a series of engaging videos that Dr. Harryman made to share his many discoveries about shoulder function with the world.
If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.
Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.
Sports Medicine Update
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
The May 17, 2017 JBJS Specialty Update on Sports Medicine reflects evidence in the field of sports medicine published from September 2015 to August 2016. Although this review is not exhaustive of all research that might be pertinent to sports medicine, it highlights many key articles that contribute to the existing evidence base in the field.
Topics covered include:
- Prevention of Musculoskeletal Injuries
- Autograft vs Allograft ACL Reconstruction
- Anterior Shoulder Stabilization
- Hip Arthroscopy
Long-Term, Latarjet Beats Bankart for Anterior Shoulder Instability
In a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.
Specific 10-year outcome comparisons included:
- Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
- Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
- Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
- Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group
Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”
What’s New in Shoulder and Elbow Surgery: Level I and II Studies
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the October 21, 2015 Specialty Update on shoulder and elbow surgery:
Shoulder
–A prospective evaluation of 224 subjects with asymptomatic rotator cuff tears followed annually for an average of five years found that the risk of tear enlargement and muscle degeneration was greater in full-thickness tears, and that pain and supraspinatus muscle degeneration were associated with tear enlargement.
–The authors of a randomized trial comparing physical therapy and primary surgical repair for initial management of degenerative rotator cuff tears concluded that the effects of surgery were not profound enough to justify surgical management for patients who present initially with painful degenerative cuff tears.
–A randomized trial comparing clinical outcomes in 58 patients with a rotator cuff tear and symptomatic acromioclavicular joint arthritis found no differences in function or pain scores between those who underwent cuff repair + distal clavicle resection and those who underwent cuff repair alone.1
–After two years of follow-up, no differences in functional outcomes or rate or quality of postoperative tendon healing were found in a randomized trial comparing patients who received platelet-rich plasma following surgical cuff repair and those who did not.2
–In a three-way randomized trial comparing physical therapy, acromioplasty + physical therapy, and cuff repair + acromioplasty + physical therapy for treating symptomatic, nontraumatic supraspinatus tendon tears in patients older than 55, there were no between-group differences in the mean Constant score one year after treatment.3
–A randomized trial comparing treatments for calcific tendinitis found that ultrasound-guided needling plus a subacromial corticosteroid injection resulted in better functional scores and larger decreases in calcium-deposit size than extracorporeal shock wave therapy.4
–A randomized trial of 196 patients with recurrent traumatic anterior shoulder instability found no significant differences in WOSI and ASES scores or range of motion between groups that underwent open or arthroscopic stabilization procedures.
–A randomized study comparing the effectiveness of immobilization in abduction (15°) and external rotation (10°) versus adduction and internal rotation after primary anterior shoulder dislocation found that after two years, only 3.9% of patients in the abduction/external-rotation group had repeat instability, compared to 33.3% in the adduction/internal-rotation group.5 A separate randomized trial found no significant difference in instability recurrence after one year between a group immobilized in internal rotation (sling) and a group immobilized in adduction and external rotation (brace).6
–A randomized trial of 250 patients (mean age of 65 years) with displaced surgical neck fractures of the proximal humerus compared surgical treatment (internal fixation or hemiarthroplasty) with conservative treatment. Finding no statistically or clinically significant difference in outcomes, the authors concluded that these results do not support the recent trend toward surgical management for proximal humeral fractures.7
–A randomized trial comparing reverse shoulder arthroplasty with hemiarthroplasty for acute proximal humeral fractures found that after two years of follow-up, reverse arthroplasty yielded better functional scores, better active elevation, and fewer complications than hemiarthroplasty.8
–A randomized trial comparing the use of concentric and eccentric glenospheres in reverse shoulder arthroplasty revealed no differences in scapular notching rates or clinical outcomes at a minimum follow-up of two years.
–A systematic review comparing radiographic and clinical survivorship of all-polyethylene versus metal-backed glenoid components used in total shoulder arthroplasty found that all-poly glenoids had a higher rate of radiolucencies and radiographic loosening but a much lower rate of revision after a mean follow-up of 5.8 years.
–A retrospective review found that arthroscopic biopsy was much more accurate than fluoroscopically guided fluid aspiration in diagnosing periprosthetic shoulder infections caused by Propionibacterium acnes.
–In a randomized trial of 76 workers’-comp patients with a displaced midshaft clavicular fracture, those receiving surgical management had faster time to union and return to work and better Constant scores than those managed conservatively.9
–Two studies compared plate fixation with intramedullary fixation for stabilizing clavicular fractures. One that randomized 59 patients found no differences in functional outcomes or time to healing. The other, which randomized 120 patients, found no between-group differences in DASH or Constant-Murley scores, but shoulder function improved more quickly in the plate-fixation group.
–A study that compared standard arthroscopic capsular release with capsular release extending to the posterior capsule for treating frozen shoulder found no difference in postoperative clinical or range-of-motion outcomes between the two groups.10
Elbow
–A randomized trial comparing regional analgesia to local anesthetic injections in patients undergoing elbow arthroscopy found no differences in pain, oral analgesic use, or patient satisfaction within 48 hours after surgery.11
–A randomized trial comparing eccentric and concentric resistance exercises for the treatment of chronic lateral epicondylitis found that the eccentric-exercise group had faster pain regression, lower pain scores at 12 months, and greater strength increases.12
References
- Park YB, Koh KH, Shon MS, Park YE, Yoo JC. Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial. Am J Sports Med. 2015 Apr;43(4):985-90.Epub 2015 Jan 12.
- Malavolta EA, Gracitelli ME, Ferreira Neto AA, Assunção JH, Bordalo-RodriguesM, de Camargo OP. Platelet-rich plasma in rotator cuff repair: a prospective randomized study. Am J Sports Med. 2014 Oct;42(10):2446-54. Epub 2014 Aug 1.
- Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V.Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81.
- Kim YS, Lee HJ, Kim YV, Kong CG. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg. 2014 Nov;23(11):1640-6. Epub 2014 Sep 12.
- Heidari K, Asadollahi S, Vafaee R, Barfehei A, Kamalifar H, Chaboksavar ZA,Sabbaghi M. Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. J Shoulder Elbow Surg. 2014 Jun;23(6):759-66. Epub 2014 Apr 13.
- Whelan DB, Litchfield R, Wambolt E, Dainty KN; Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS).External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. 2014 Aug;472(8):2380-6.
- Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L,Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
- Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014Oct;23(10):1419-26. Epub 2014 Jul 30
- Melean PA, Zuniga A, Marsalli M, Fritis NA, Cook ER, Zilleruelo M, Alvarez C.Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg.2015 Apr;24(4):587-92. Epub 2015 Jan 22.
- Kim YS, Lee HJ, Park IJ. Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study. Am J Sports Med. 2014 May;42(5):1143-9. Epub 2014 Feb 28.
- Wada T, Yamauchi M, Oki G, Sonoda T, Yamakage M, Yamashita T. Efficacy of axillary nerve block in elbow arthroscopic surgery: a randomized trial. J Shoulder Elbow Surg. 2014 Mar;23(3):291-6. Epub 2014 Jan 15.
- Peterson M, Butler S, Eriksson M, Svärdsudd K.A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Sep;28(9):862-72. Epub 2014 Mar 14.
Long-Term Success with Open Bankart Repairs
Reporting in the September 2, 2015 issue of The Journal of Bone and Joint Surgery, European researchers Moroder et al. found that 7 of 45 patients (17.5%) without substantial glenoid bone loss who underwent open Bankart repairs had a recurrence of instability during an average 22 years of follow-up.
This high failure rate is in line with findings from previous studies, but the authors include data indicating that, compared to patients who did not experience recurrent instability, “the recurrence of instability did not appear to significantly affect the subjective and objective outcome scores or the degree of work and sports impairment.”
The study found an unsurprising association between higher shoulder-specific activity levels and an increased risk for recurrence of instability. In fact, three of the seven late failures occurred during a high-energy sports accident. Etiologically, the authors hypothesize that “a lifestyle with high demands on the shoulders leads to weakening of the Bankart repair over time because of repetitive stress of the anterior capsulolabral complex.”
What’s New in Sports Medicine: Level I and II Studies
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the April 15, 2015 Specialty Update on sports medicine:
Shoulder
–A systematic review of Level-I and II studies suggests that the structural integrity of rotator cuff repairs (or lack thereof) does not correlate with validated patient subjective outcome measures.
–Authors of a randomized clinical trial comparing open and arthroscopic stabilization for recurrent anterior shoulder instability concluded that young male patients with visible Hill-Sachs lesions on radiographs may fare better with open repairs.
–A quantitative literature synthesis of 31 studies (2,813 shoulders) supported primary surgery for highly active young adults who sustain an anterior shoulder dislocation.
–Following rotator cuff surgery, patients randomized to receive a combined axillary and suprascapular nerve block experienced less pain and a lower frequency of rebound pain in the first 36 hours than those receiving only a suprascapular nerve block.
–A Level-II meta-analysis of early passive motion versus strict sling immobilization after arthroscopic rotator cuff repair found that early passive motion resulted in improved forward flexion at 6 and 12 months, with no apparent increased retear rate.
Knee
–A randomized trial comparing single- and double-bundle ACL reconstruction with the use of hamstring autograft found no differences in pivot shift or clinical scores at two years.
–Twenty patients with subacute ACL injuries were randomized to “prehabilitation” or control groups. At 12 weeks after surgery, the prehab group showed sustained improvements in single-leg hop and Cincinnati scores, but peak torque and muscle-mass gains had regressed to levels similar to those in the control group.
–A randomized study comparing contralateral versus ipsilateral hamstring tendon harvest for ACL repair identified neither drawbacks nor advantages with the contralateral approach.
–Sixty patients who’d received an isolated meniscal repair were randomized to get either a traditional rehab protocol (brace and toe-touch weigh bearing) or “free rehabilitation.” Based on MRI, partial healing or lack of healing occurred in 28% of the free rehabilitation group and in 36% of the traditional group.
–Authors of a systematic review concluded that nonirradiated allogenic tissue may be superior to radiated allografts for primary ACL reconstruction.
Cartilage Regeneration
–A randomized controlled trail comparing microfracture alone to microfracture plus application of a novel chitosan-based device demonstrated greater lesion filling and superior repair tissue with the novel device, although there were no differences in clinical benefit and safety at 12 months.
–A randomized controlled trial comparing accelerated with conventional rehabilitation following cartilage repair found that the accelerated group reached full weight-bearing two weeks earlier than the conventional group and reported higher quality-of-life scores.
Hip
–In a Level-II study of a population with acute hamstring injuries, those who received a single autologous platelet-rich plasma injection plus rehab had significantly reduced return-to-play time than a group that received rehab without the injection.
Elbow
–A randomized study of 230 patients with chronic lateral epicondylitis found that those receiving leukocyte-enriched platelet-rich plasma had “clinically meaningful improvement” in pain at 24 weeks, compared to those in an “active control” group.
Foot & Ankle
–A randomized study of 84 patients with nonsurgically treated Achilles tendon tears showed no significant differences in rerupture rates or return-to-work times between a group given a weight-bearing cast and a group given a non-weight-bearing cast.
–A randomized trial of 200 patients with Achilles ruptures compared stable surgical repair and accelerated rehabilitation to nonoperative management. Surgical repair was not found to be superior to nonoperative treatment in terms of functional results, physical activity, or quality of life.
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