Advertisement

Authors' Reply

      We thank Drs. van der Linde, van Kampen, and Willems for their interest and kind words regarding our article and appreciate their comments. They recognize a challenging postoperative evaluation of shoulder stability and recommend consideration of subluxations as failures based on sound argument. Both pre- and postoperatively, the assessment of shoulder stability exhibits a wide spectrum from positional apprehension to frank dislocation requiring manual reduction. In between, there is significant variation in the patient's reporting of “instability.” Since the primary purpose of surgery for instability is to gain stability, the subjective feeling of one's “shoulder popping out” after surgery is largely a “failure.” In fact, even without dislocation, this may lead a patient to undergo revision stabilization. We agree with Dr. van der Linde et al.
      Given the subjective nature of “apprehension” and “subluxation,” the ability to clearly define a patient's outcome regarding where they fit on the stability spectrum is seldom reported unless it is a frank dislocation or stable status, because these are quantifiable entities. In a systematic review, the quality of the review is only as good as the quality of the articles it analyzes. In our review, there was significant heterogeneity in the reporting of recurrence of instability. Therefore, we used strict criteria that could be assimilated to measure instability, with the recognition and admission that it is an underestimate of the true proportion of patients with unstable shoulders after surgery. Additionally, Van der Linde et al. also emphasize the use of patient-reported outcomes in shoulder instability and recognize that they are increasingly used to guide treatment recommendations. There are unfortunately no questionnaires that make this distinction clear.
      The Western Ontario Shoulder Instability (WOSI) score is a 21-item valid, reliable, and responsive questionnaire developed for patients with shoulder instability. Although it contains only one item that queries the patient regarding a “feeling of instability or looseness in the shoulder,” the remaining 20 items characterize the effect that instability may have on pain, motion, strength, endurance, function, and sports. Nonetheless, it does not ask the question, “Does your shoulder fully dislocate and require manual reduction, does your shoulder partially dislocate or subluxate and pop back in spontaneously, or does your shoulder feel like it's going to dislocate completely or partially”? Similarly, the Walch-Duplay score, which correlates with the WOSI,
      • Khiami F.
      • Sariali E.
      • Rosenheim M.
      • Hardy P.
      Anterior shoulder instability arthroscopic treatment outcomes measures: The WOSI correlates with the Walch-Duplay score.
      does ask one specific question regarding stability. However, it is a clinician-measured and reported instrument, not a patient-reported outcome and does not distinguish dislocation from subluxation or apprehension. The American Shoulder and Elbow Surgeons self-reported score does not inquire about instability or apprehension. The Melbourne Instability Shoulder Score (MISS) does, like the WOSI, specifically ask questions regarding shoulder instability. However, the MISS also asks 5 specific questions that discuss a feeling of apprehension versus the shoulder actually coming out of the joint. Still, the MISS does not distinguish manual reduction by a clinician versus patient-performed or spontaneous reduction. Further, it does not distinguish the patient's description of subluxation and dislocation.
      Thus, we agree with Drs. van der Linde, van Kampen, and Willems and acknowledge the important similarities and differences between apprehension, subluxation, and dislocation and their influence on the success or failure of surgery. We did recognize this limitation in the Discussion section of our manuscript and direct readers to it for further detail. Nevertheless, we re-emphasize that future research in surgery for shoulder instability should clearly state the patient's subjective feeling of stability, apprehension, partial dislocation, or complete dislocation requiring reduction.

      Reference

        • Khiami F.
        • Sariali E.
        • Rosenheim M.
        • Hardy P.
        Anterior shoulder instability arthroscopic treatment outcomes measures: The WOSI correlates with the Walch-Duplay score.
        Orthop Traumatol Surg Res. 2012; 98: 48-53

      Linked Article

      • How Should We Define Failure After Surgical Shoulder Stabilization?
        ArthroscopyVol. 29Issue 10
        • Preview
          With great interest, we read the systematic review by Harris et al.1 entitled “Long-Term Outcomes After Bankart Shoulder Stabilization,” and we compliment the authors on their extensive and well-designed overview. They describe the long-term outcome, including recurrent instability, return to sport, postoperative osteoarthritis, and Rowe and Constant scores, after the most frequently used Bankart repair techniques, both open and arthroscopic.
        • Full-Text
        • PDF