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• W2014371453 abstract "“I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.”1William Thomson, 1st Baron Kelvin. Available at: http://en.wikipedia.org/wiki/William_Thomson,_1st_Baron_Kelvin. Accessed 9 February 2013.Google Scholar Lord Kelvin, 1891Or as they say in business today, “You can't manage what you can't measure.”Our assertion of the same should come as no surprise to readers because, as we've said before,2Lubowitz J.H. Poehling G.G. Shoulder arthroscopy: Evolution of the revolution.Arthroscopy. 2009; 25: 823-824Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar “a key component of proper research methods is the proper selection of outcome measures,3Irrgang Lubowitz J.H. Measuring arthroscopic outcome.Arthroscopy. 2008; 24: 718-722Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar ‘which should be specifically validated for the disease, condition, body part, or procedure tested.’”4Lubowitz J.H. Poehling G.G. A new year.Arthroscopy. 2008; 24: 2-3Abstract Full Text Full Text PDF Scopus (20) Google Scholar And, as we have previously admired Plancher and Lipnick's, “Analysis of Evidence-Based Medicine for Shoulder Instability,”5Lipnick S. Plancher K. Analysis of evidence-based medicine for shoulder instability.Arthroscopy. 2009; 25: 718-722Google Scholar which is worthy of review, in this issue we recommend to readers, “Outcome Instruments for the Shoulder” by Roller, Mounts, DeLong, and Hanypsiak.6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Shoulder surgeons and related researchers may prefer to consider this article before they peruse the other excellent clinical shoulder articles in this issue, which we consider below.However, before we further consider shoulder outcome measures, we note that the authors of “Outcome Instruments for the Shoulder”6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar include orthopaedic industry employees. A general rule for our journal is that orthopaedic industry employees are permitted to coauthor original scientific articles, but may not author review articles. Rules are made to be broken, and as this review mentions no commercial products or techniques, and considers a topic of significant interest, this submission has been accepted for publication. Relations with industry introduce potential conflicts, but can also be necessary and beneficial7Poehling G.G. Lubowitz J.H. Brand R. Buckwalter J.A. Wright T.M. Canale S.T. et al.Patient care, professionalism, and relations with industry.Arthroscopy. 2008; 24: 4-6Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 8Lubowitz J.H. Provencher M.T. Poehling G.G. Conflict of interest.Arthroscopy. 2011; 27: 1168-1170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar; this article represents an example of the latter.Regarding the content of “Outcome Instruments for the Shoulder,” the authors argue that there is a need for consistency when reporting outcomes and that knowledge of outcome scores allows surgeons to best practice evidence-based medicine. In addition, it allows surgeons to “successfully navigate the increasingly complex reimbursement system,” because “with increasing cost pressures and outcome-based payments looming on the horizon, orthopaedic surgeons will need to show conclusively that their procedures improved patient outcomes and were cost-effective.” We strongly agree.9Crall T.S. Bishop J.A. Guttman D. Kocher M. Bozic K. Lubowitz J.H. Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.Arthroscopy. 2012; 28: 1755-1765Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 10Lubowitz J.H. McIntyre L.F. Provencher M.T. Poehling G.G. AAOS rotator cuff clinical practice guideline misses the mark.Arthroscopy. 2012; 28: 589-592Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 11Lubowitz J.H. Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee arthroscopy and knee anterior cruciate ligament reconstruction.Arthroscopy. 2011; 27: 1317-1322Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 12Lubowitz J.H. Poehling G.G. Access to arthroscopy: Ethical imperatives and economic challenges.Arthroscopy. 2009; 25: 1363-1364Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 13Lubowitz J.H. Poehling G.G. Comparative effectiveness research: We must lead (so as not to be misled).Arthroscopy. 2009; 25: 455-456Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar The authors further assert that our community of orthopaedic surgeons could benefit by achieving consensus on “what constitutes a good outcome.”6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar A limitation of the review is the absence of suggestions recommending optimal or best measures for various shoulder-related conditions. However, by defining important terms such as comparative-effectiveness research, validity, reliability, responsiveness, and quality-adjusted life years, as well as reviewing general-health outcome instruments like the EuroQual and SF Health Surveys, and shoulder-specific outcome instruments such as the American Shoulder and Elbow Surgery (ASES), Constant Shoulder Score, Disabilities of the Arm, Shoulder, and Hand (DASH), Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder Score, Oxford Shoulder Instability Score (OSIS), Oxford Shoulder Score (OSS), Rotator Cuff–Quality of Life (RC-QOL), Rowe Shoulder Score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA) Rating Scale, University of Pennsylvania Shoulder Score (PSS), Western Ontario Osteoarthritis of the 381 Shoulder (WOOS), Western Ontario Rotator Cuff Index (WORC), and the Western Ontario Shoulder Instability Index (WOSI), the authors lay the groundwork for future scholars to investigate what outcome measures are appropriate for diverse shoulder conditions. In addition, the sheer number of outcome measures considered feels somewhat overwhelming, and thus indicates a problem worthy of additional research.The excellent clinical shoulder articles in the current issue show well the challenge we face in refining or, more appropriately, “defining” shoulder outcome measures:•Ko, Kang, and Hwang of Ulsan, Korea evaluate suprascapular nerve block for arthroscopic acromioplasty in patients with rotator cuff impingement syndrome, and measure outcome using pain visual analogue scale (VAS), narcotic and antiemetic drug consumption, and UCLA and ASES pain domains.14Ko S.H. Kang B.S. Hwang C.H. Ultrasonography- or electrophysiological-guided suprascapular nerve block in arthroscopic acromioplasty: A prospective, double-blind, parallel-group, randomized controlled study of efficacy.Arthroscopy. 2013; 29: 794-801Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar•Arthroscopy journal Associate Editor Giuseppe Milano and colleagues Saccomanno, Careri, Taccardo, De Vitis, and Fabbriciani from Rome evaluate rotator cuff repair outcome using DASH, Constant, and MRI assessment of tendon healing.15Milano G. Saccomanno M.F. Careri S. Taccardo G. De Vitis R. Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: A prospective randomized study.Arthroscopy. 2013; 29: 802-810Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar•Stuart, Karzel, Ganjianpour, and Snyder of Van Nuys, California, evaluate rotator cuff repair using UCLA and SF-36.16Stuart K.D. Karzel R.P. Ganjianpour M. Snyder S.J. Long-term outcome for arthroscopic repair of partial articular-sided supraspinatus tendon avulsion.Arthroscopy. 2013; 29: 818-823Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar•Maier, Jaeger, Izadpanah, Bornebusch, Suedkamp, and Ogon of Freiburg, Germany evaluate treatment of rotator cuff calcific tendonitis using Constant and radiography.17Maier D. Jaeger M. Izadpanah K. Bornebusch L. Suedkamp N.P. Ogon P. Rotator cuff preservation in arthroscopic treatment of calcific tendinitis.Arthroscopy. 2013; 29: 824-831Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar•Lin, Mall, Dhawan, Sherman, McGill, Deputy Editor Matthew Provencher, Nicholson, Cole, Solomon, Associate Editor Nikhil Verma, and Romeo, corresponding from Chicago, evaluate rotator cuff repair outcome using SANE, ASES, Constant, pain VAS, SST, range-of-motion, strength, and binary satisfaction scale.18Lin E.C. Mall N.A. Dhawan A. Sherman S.L. McGill K.C. Provencher M.T. et al.Arthroscopic primary rotator cuff repairs in patients aged younger than 45 years.Arthroscopy. 2013; 29: 811-817Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarIn sum, when considering just 5 studies all focused on the shoulder rotator cuff, in a single issue of the journal, the challenge of defining more universal outcome measures is well-illustrated. To be clear, the problem is bias, specifically reporting bias, which occurs when different published studies report different outcome measures. Why is reporting bias a problem? Because when different studies report outcomes using different measures, it is clearly difficult, or frankly impossible, to compare the results with other reported studies.19Arthroscopy Journal Review Course. Available at: www.arthroscopyjournal.org/webfiles/images/journals/yjars/Coursebooklet.ppt. Accessed 9 February 2013.Google ScholarFinally, regarding the clinical shoulder articles in the current issue, Harris, Gupta, Mall, Abrams, McCormick, Cole, Bach, Romeo, and Associate Editor Nikhil Verma, corresponding from Chicago, systematically review shoulder instability.20Harris J.D. Gupta A.K. Mall N.A. Abrams G.D. McCormick F.M. Cole B.J. et al.Long-term outcomes after Bankart shoulder stabilization.Arthroscopy. 2013; 29: 920-933Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar Twenty-six articles matched their study inclusion criteria and were systematically reviewed. We find it difficult to imagine how many different measures of outcome were used in these 26 different shoulder instability studies. Suffice it to say, the authors' statement that, “The subjective and objective measure used in this review to assess surgical outcome and ‘success’ are…heterogeneous” is an understatement. Heterogeneous indeed! This well-performed review, in addition to reporting interesting conclusions, devotes the major portion of the Discussion to the issue of measuring shoulder instability outcome. We find this Discussion to be of immense educational value and, in the context of this editorial, posit that readers may choose to concentrate on this section with heightened interest. The authors cite a systematic review of patient-administered shoulder instability outcome scores that identified a whopping 25 different scoring systems.21Rouleau D.M. Faber K. MacDermid J.C. Systematic review of patient-administered shoulder functional scores on instability.J Shoulder Elbow Surg. 2010; 19: 1121-1128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar This review by Rouleau et al. was very specific, and included only patient-reported outcome measures of shoulder instability, not physician-reported measures, not measures of other shoulder conditions, not measures of general health.The examples described in the 2 preceding paragraphs further illustrate the challenge of achieving an orthopaedic consensus on how to best measure outcome. Having delineated the problem and acknowledged the challenge, it is with extreme humility that we encourage future scholarly research with a goal of more narrowly defining optimal disease, condition, body part, and procedure specific outcome measures. “I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.”1William Thomson, 1st Baron Kelvin. Available at: http://en.wikipedia.org/wiki/William_Thomson,_1st_Baron_Kelvin. Accessed 9 February 2013.Google Scholar Lord Kelvin, 1891 Or as they say in business today, “You can't manage what you can't measure.” Our assertion of the same should come as no surprise to readers because, as we've said before,2Lubowitz J.H. Poehling G.G. Shoulder arthroscopy: Evolution of the revolution.Arthroscopy. 2009; 25: 823-824Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar “a key component of proper research methods is the proper selection of outcome measures,3Irrgang Lubowitz J.H. Measuring arthroscopic outcome.Arthroscopy. 2008; 24: 718-722Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar ‘which should be specifically validated for the disease, condition, body part, or procedure tested.’”4Lubowitz J.H. Poehling G.G. A new year.Arthroscopy. 2008; 24: 2-3Abstract Full Text Full Text PDF Scopus (20) Google Scholar And, as we have previously admired Plancher and Lipnick's, “Analysis of Evidence-Based Medicine for Shoulder Instability,”5Lipnick S. Plancher K. Analysis of evidence-based medicine for shoulder instability.Arthroscopy. 2009; 25: 718-722Google Scholar which is worthy of review, in this issue we recommend to readers, “Outcome Instruments for the Shoulder” by Roller, Mounts, DeLong, and Hanypsiak.6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Shoulder surgeons and related researchers may prefer to consider this article before they peruse the other excellent clinical shoulder articles in this issue, which we consider below. However, before we further consider shoulder outcome measures, we note that the authors of “Outcome Instruments for the Shoulder”6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar include orthopaedic industry employees. A general rule for our journal is that orthopaedic industry employees are permitted to coauthor original scientific articles, but may not author review articles. Rules are made to be broken, and as this review mentions no commercial products or techniques, and considers a topic of significant interest, this submission has been accepted for publication. Relations with industry introduce potential conflicts, but can also be necessary and beneficial7Poehling G.G. Lubowitz J.H. Brand R. Buckwalter J.A. Wright T.M. Canale S.T. et al.Patient care, professionalism, and relations with industry.Arthroscopy. 2008; 24: 4-6Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 8Lubowitz J.H. Provencher M.T. Poehling G.G. Conflict of interest.Arthroscopy. 2011; 27: 1168-1170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar; this article represents an example of the latter. Regarding the content of “Outcome Instruments for the Shoulder,” the authors argue that there is a need for consistency when reporting outcomes and that knowledge of outcome scores allows surgeons to best practice evidence-based medicine. In addition, it allows surgeons to “successfully navigate the increasingly complex reimbursement system,” because “with increasing cost pressures and outcome-based payments looming on the horizon, orthopaedic surgeons will need to show conclusively that their procedures improved patient outcomes and were cost-effective.” We strongly agree.9Crall T.S. Bishop J.A. Guttman D. Kocher M. Bozic K. Lubowitz J.H. Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.Arthroscopy. 2012; 28: 1755-1765Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 10Lubowitz J.H. McIntyre L.F. Provencher M.T. Poehling G.G. AAOS rotator cuff clinical practice guideline misses the mark.Arthroscopy. 2012; 28: 589-592Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 11Lubowitz J.H. Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee arthroscopy and knee anterior cruciate ligament reconstruction.Arthroscopy. 2011; 27: 1317-1322Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 12Lubowitz J.H. Poehling G.G. Access to arthroscopy: Ethical imperatives and economic challenges.Arthroscopy. 2009; 25: 1363-1364Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 13Lubowitz J.H. Poehling G.G. Comparative effectiveness research: We must lead (so as not to be misled).Arthroscopy. 2009; 25: 455-456Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar The authors further assert that our community of orthopaedic surgeons could benefit by achieving consensus on “what constitutes a good outcome.”6Roller A.S. Mounts R.A. DeLong J.M. Hanypsiak B.T. Outcome instruments for the shoulder.Arthroscopy. 2013; 29: 955-964Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar A limitation of the review is the absence of suggestions recommending optimal or best measures for various shoulder-related conditions. However, by defining important terms such as comparative-effectiveness research, validity, reliability, responsiveness, and quality-adjusted life years, as well as reviewing general-health outcome instruments like the EuroQual and SF Health Surveys, and shoulder-specific outcome instruments such as the American Shoulder and Elbow Surgery (ASES), Constant Shoulder Score, Disabilities of the Arm, Shoulder, and Hand (DASH), Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder Score, Oxford Shoulder Instability Score (OSIS), Oxford Shoulder Score (OSS), Rotator Cuff–Quality of Life (RC-QOL), Rowe Shoulder Score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA) Rating Scale, University of Pennsylvania Shoulder Score (PSS), Western Ontario Osteoarthritis of the 381 Shoulder (WOOS), Western Ontario Rotator Cuff Index (WORC), and the Western Ontario Shoulder Instability Index (WOSI), the authors lay the groundwork for future scholars to investigate what outcome measures are appropriate for diverse shoulder conditions. In addition, the sheer number of outcome measures considered feels somewhat overwhelming, and thus indicates a problem worthy of additional research. The excellent clinical shoulder articles in the current issue show well the challenge we face in refining or, more appropriately, “defining” shoulder outcome measures:•Ko, Kang, and Hwang of Ulsan, Korea evaluate suprascapular nerve block for arthroscopic acromioplasty in patients with rotator cuff impingement syndrome, and measure outcome using pain visual analogue scale (VAS), narcotic and antiemetic drug consumption, and UCLA and ASES pain domains.14Ko S.H. Kang B.S. Hwang C.H. Ultrasonography- or electrophysiological-guided suprascapular nerve block in arthroscopic acromioplasty: A prospective, double-blind, parallel-group, randomized controlled study of efficacy.Arthroscopy. 2013; 29: 794-801Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar•Arthroscopy journal Associate Editor Giuseppe Milano and colleagues Saccomanno, Careri, Taccardo, De Vitis, and Fabbriciani from Rome evaluate rotator cuff repair outcome using DASH, Constant, and MRI assessment of tendon healing.15Milano G. Saccomanno M.F. Careri S. Taccardo G. De Vitis R. Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: A prospective randomized study.Arthroscopy. 2013; 29: 802-810Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar•Stuart, Karzel, Ganjianpour, and Snyder of Van Nuys, California, evaluate rotator cuff repair using UCLA and SF-36.16Stuart K.D. Karzel R.P. Ganjianpour M. Snyder S.J. Long-term outcome for arthroscopic repair of partial articular-sided supraspinatus tendon avulsion.Arthroscopy. 2013; 29: 818-823Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar•Maier, Jaeger, Izadpanah, Bornebusch, Suedkamp, and Ogon of Freiburg, Germany evaluate treatment of rotator cuff calcific tendonitis using Constant and radiography.17Maier D. Jaeger M. Izadpanah K. Bornebusch L. Suedkamp N.P. Ogon P. Rotator cuff preservation in arthroscopic treatment of calcific tendinitis.Arthroscopy. 2013; 29: 824-831Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar•Lin, Mall, Dhawan, Sherman, McGill, Deputy Editor Matthew Provencher, Nicholson, Cole, Solomon, Associate Editor Nikhil Verma, and Romeo, corresponding from Chicago, evaluate rotator cuff repair outcome using SANE, ASES, Constant, pain VAS, SST, range-of-motion, strength, and binary satisfaction scale.18Lin E.C. Mall N.A. Dhawan A. Sherman S.L. McGill K.C. Provencher M.T. et al.Arthroscopic primary rotator cuff repairs in patients aged younger than 45 years.Arthroscopy. 2013; 29: 811-817Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar In sum, when considering just 5 studies all focused on the shoulder rotator cuff, in a single issue of the journal, the challenge of defining more universal outcome measures is well-illustrated. To be clear, the problem is bias, specifically reporting bias, which occurs when different published studies report different outcome measures. Why is reporting bias a problem? Because when different studies report outcomes using different measures, it is clearly difficult, or frankly impossible, to compare the results with other reported studies.19Arthroscopy Journal Review Course. Available at: www.arthroscopyjournal.org/webfiles/images/journals/yjars/Coursebooklet.ppt. Accessed 9 February 2013.Google Scholar Finally, regarding the clinical shoulder articles in the current issue, Harris, Gupta, Mall, Abrams, McCormick, Cole, Bach, Romeo, and Associate Editor Nikhil Verma, corresponding from Chicago, systematically review shoulder instability.20Harris J.D. Gupta A.K. Mall N.A. Abrams G.D. McCormick F.M. Cole B.J. et al.Long-term outcomes after Bankart shoulder stabilization.Arthroscopy. 2013; 29: 920-933Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar Twenty-six articles matched their study inclusion criteria and were systematically reviewed. We find it difficult to imagine how many different measures of outcome were used in these 26 different shoulder instability studies. Suffice it to say, the authors' statement that, “The subjective and objective measure used in this review to assess surgical outcome and ‘success’ are…heterogeneous” is an understatement. Heterogeneous indeed! This well-performed review, in addition to reporting interesting conclusions, devotes the major portion of the Discussion to the issue of measuring shoulder instability outcome. We find this Discussion to be of immense educational value and, in the context of this editorial, posit that readers may choose to concentrate on this section with heightened interest. The authors cite a systematic review of patient-administered shoulder instability outcome scores that identified a whopping 25 different scoring systems.21Rouleau D.M. Faber K. MacDermid J.C. Systematic review of patient-administered shoulder functional scores on instability.J Shoulder Elbow Surg. 2010; 19: 1121-1128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar This review by Rouleau et al. was very specific, and included only patient-reported outcome measures of shoulder instability, not physician-reported measures, not measures of other shoulder conditions, not measures of general health. The examples described in the 2 preceding paragraphs further illustrate the challenge of achieving an orthopaedic consensus on how to best measure outcome. Having delineated the problem and acknowledged the challenge, it is with extreme humility that we encourage future scholarly research with a goal of more narrowly defining optimal disease, condition, body part, and procedure specific outcome measures." @default.
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