Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization

PURPOSE

This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery.

METHODS

A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used.

RESULTS

A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study.

CONCLUSION

The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Clinical Significance Thresholds in Primary and Revision Latarjet Procedures With Comparable Outcome Achievements

BACKGROUND

Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results.

PURPOSE

To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated.

RESULTS

The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis.

METHODS

A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES.

CONCLUSIONS

In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review

PURPOSE

To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR.

METHODS

We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

RESULTS

We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency.

CONCLUSIONS

There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Effect of Patient Characteristics on the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds After Arthroscopic Bankart Repair

BACKGROUND

There is scarce literature on clinically significant values after arthroscopic Bankart repair (ABR).

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) thresholds at 1 year for the Rowe and Athletic Shoulder Outcome Scoring System (ASOSS) scores after ABR and to determine the effect of patient characteristics on these metrics after ABR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of patients undergoing ABR from a single institution between January 2017 and January 2020 was performed. Patients with at least 1 episode of instability and a minimum follow-up of 12 months were included. The exclusion criteria were as follows: bony defects of >20% on the anteroinferior portion of the glenoid based on a preoperative computed tomography scan; engaging Hill-Sachs lesions at 90° of abduction and 90° of external rotation based on an arthroscopic examination; previous surgery on the same shoulder; multidirectional instability or concomitant repair of full-thickness rotator cuff tears; superior labral anterior to posterior lesions; posterior labral tears; or humeral avulsion of the glenohumeral ligament lesions. Patient-reported outcome measures were collected both preoperatively and 1-year postoperatively. Delta was defined as the change between preoperative and 1-year postoperative scores. Distribution-based (one-half the standard deviation of the difference between pre- and postoperative outcome scores) and anchored-based approaches (response to a satisfaction question at 1 year) were used to estimate the MCID and the PASS, respectively. The optimal cutoff point, where sensitivity and specificity were maximized, and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, 190 patients were included. The distribution-based MCID for the Rowe and ASOSS scores were calculated to be 8.2 and 8.7, respectively. The rate of patients who achieved MCID thresholds was 96% for the Rowe and 96% for ASOSS scores. The PASS threshold for the Rowe and ASOSS scores were ≥80 and ≥90, respectively. The rate of patients who achieved PASS scores after ABR were 86% and 83%, respectively. The MCID and PASS values showed great variability based on sex (men: 8.5 and ≥85 for Rowe / 8.9 and ≥90 for ASOSS, respectively, vs women: 6.7 and ≥73 for Rowe / 8.1 and ≥75 for ASOSS), age (≥21: 8.4 and ≥80 / 9.2 and ≥90 vs <21: 7.8 and ≥75 / 7.7 and ≥85), sports participation (sports: 8.8 and ≥85 / 9.5 and ≥90 vs no sports: 8.1 and ≥75 / 8.6 and ≥80), and type of athlete (competitive: 8.4 and ≥85 / 8.9 and ≥87 vs recreational: 7.5 and ≥73 / 8.1 and ≥68).

CONCLUSION

This study identified the MCID and PASS thresholds for the Rowe and ASOSS scores at 1 year after ABR. However, these values showed great variability when accounting for different patient characteristics such as sex, age, sports participation, and type of athlete, highlighting the importance of considering individual patient-specific characteristics for optimal treatment decision-making and ensuring treatment success tailored to each patient's unique needs and expectations.

Functional outcomes after arthroscopic double button fixation of distal clavicular fractures in athletes

Distal third clavicle fractures are a frequent pathology in young, active patients, accounting for 30% of all clavicle fractures. There are several treatments available, which range from orthopedic management to surgical treatment with various options including: locking plates, tension bands and button fixation. The aim of this study was to evaluate the clinical and radiologic results of a group of patients treated with the arthroscopic double button fixation technique and, secondly, to analyze the complications and the rate of return to sports.

METHODS

Nineteen patients (15 male and 4 Female) with a mean age of 38.2 years (21-64) were included. In all cases, an arthroscopic surgery with double button fixation of the distal third of the clavicle was performed. Functional Outcomes were evaluated with the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons scale (ASES) for functional outcomes. Range of Motion (ROM) was also assessed.

RESULTS

The mean follow up was 27.3 months (12 to 54 months). The mean VAS was 0.63 and the mean ASES score was 94.1. The ROM was fully recovered in 17 patients (89,4%). All patients returned to regular sports practice at 3.5 months. Finally, a total of 2 complications were registered (11,6%).

CONCLUSION

The arthroscopic double button fixation of distal clavicular fractures is a safety and reliable procedure, and it is associated with favorable functional and radiological outcomes in most patients.

Unicortical versus bicortical plate fixation for midshaft clavicular fractures

BACKGROUND

The aim of this study was to compare the functional and radiological outcomes of unicortical vs bicortical fixation in patients with midshaft clavicular fractures who were treated using pre-contoured locking plates.

METHODS

We performed a prospective multicenter study of 45 individuals who underwent open reduction and internal fixation of midshaft clavicular fractures with precontoured locking plates between March 2017 and December 2019. Twenty-five patients were treated with bicortical screws and 20 patients with unicortical screws. Functional outcomes were assessed at 6 months and 12 months after surgery using the Constant score, the 11-item version of the Disabilities of Arm, Shoulder and Hand (Quick- DASH) score and the Single Assessment Numeric Evaluation (SANE) score. Pain was evaluated using a visual analog scale (VAS). The rate of return to work and sports was also recorded. Radiologic evaluation was obtained in the immediate postoperative day, monthly until fracture consolidation, at 6 months and 12 months. All intraoperative and postoperative complications were documented.

RESULTS

At both 6 and 12 months, the follow-up rates were 100%, and the mean age was 28.5 years (range, 20 to 45 years). The mean postoperative Constant score, Quick DASH, and SANE score at 12 months were 93.5 (±6), 2.3 (±3), and 92% (±7), respectively. There were no significant differences in the functional scores between the groups neither at 6 months nor at 12 months. Of the 30 active workers, 97% were able to return to their previous working routine and from the 25 patients who practiced sports before the injury,92% returned to sports all at the same level. All the fractures healed in both groups. There were 6 complications (13%).

CONCLUSION

In young, active patients with displaced midshaft clavicular fractures, both unicortical and bicortical locked plates achieved 100% bone consolidation, with excellent functional outcomes and a low rate of complications without significant differences between the groups. Therefore, locked plates with unicortical fixation could be a very good alternative for the management of young patients with midshaft clavicular fractures, potentially avoiding severe neurovascular complications.

LEVEL OF EVIDENCE

Prospective comparative (Level II).

A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years

BACKGROUND

There is a great discrepancy between the rates of recurrent instability reported after arthroscopic Bankart repair in relation to the follow-up time.

PURPOSE

To analyze the rate of recurrences after arthroscopic Bankart repair in the long term, emphasizing whether a minimum follow-up of 2 years is adequate to assess this outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2008 and April 2013, a total of 356 athletes underwent arthroscopic Bankart repair for anterior glenohumeral instability at our institution. Return to sports, the Rowe score, the Subjective Shoulder Value (SSV), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. We analyzed the proportion of recurrences before and after 4 years of follow-up. Additionally, we performed a Kaplan-Meier analysis to evaluate recurrence-free time in patients with a recurrence.

RESULTS

The mean follow-up was 10.5 ± 1.6 years, and the mean age was 20.8 ± 3.9 years. In total, 90% of patients were able to return to sports; of these, 91% returned to their preinjury level of play. The Rowe, SSV, and ASOSS scores showed a statistical improvement after surgery (P < .01). The proportion of patients with a recurrence during the follow-up period was 25% (95% CI, 20%-31%; n = 70), and the mean time until a recurrence was 3.8 ± 2.6 years. Only 39% of the recurrences (95% CI, 30%-48%) occurred in the first 2 years after surgery, while 61% (95% CI, 50%-73%) occurred in the first 4 years after surgery.

CONCLUSION

In our study, the effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time. Indeed, less than half of the recurrences occurred after 2 years of follow-up. Therefore, we propose that the recommended minimum follow-up should be 4 years; otherwise, it is very likely that the actual rate of recurrences will be significantly underestimated.

Similar Clinical, Return to Sports, Recurrence, and Revision Outcomes Between Female and Male Athletes Following Arthroscopic Bankart Repair

PURPOSE

To compare return to sports, functional outcomes, and recurrences rates between female and male athletes following arthroscopic Bankart repair (ABR).

METHODS

A retrospective comparative study was performed between male and female athletes who underwent an ABR between January 2008 and December 2019. Sports practiced primarily by men in our practice (including rugby, soccer, boxing, and martial arts) were excluded. Functional outcomes included the Rowe score, visual analog scale (VAS) for pain, and shoulder-dependent sports ability measured with the Athletic Shoulder Outcome Scoring System (ASOSS). Return to sport, recurrence, and revisions were evaluated. Additionally, we assessed the period (months) between surgery and recurrence events.

RESULTS

A total of 58 female and 106 male patients were available for analysis at a median follow-up of 60 (interquartile range [IQR], 36-84) months. Ninety-one percent of the patients (n = 150) returned to sports and 84% (n = 126) returned to their preinjury level at a median of 6 months (IQR, 5-8) postoperatively. There were no differences in the rate of return to sports between females and males (91 vs 92% respectively, P = .997). There were no differences between the groups regarding postoperative functional outcomes, with most patients achieving the minimal clinically significant difference (Rowe: 98% female and 99% male, P = .584; ASOSS: 100% female and 99% male, P = .646). The overall recurrence rate was 9.7% (n = 16), with a rate of 10.3% (n = 6) in female and 9.4% (n = 10) in male athletes (P = .851). Time to event analysis showed that the median time to recurrence was 48 months in both groups (P = .848). The overall revision rate was 3% (n = 4), without significant differences between groups (P = .556).

CONCLUSIONS

When compared within similar sports, there does not appear to be sex-related differences in functional outcomes, recurrence, or return to play following ABR.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Classic Versus Congruent-Arc Latarjet Procedures

Glenohumeral instability remains a frequent pathology, specifically in athletes and active patients. As such, several treatment options have been described. In the setting of significant glenoid bone loss (i.e., >20%), off-track Hill-Sachs lesions, and failed previous soft-tissue-based repairs, glenoid bone-augmentation techniques must be considered. These techniques restore stability by a triple blocking effect of the bony graft, the capsulolabral complex repair, and the dynamic sling effect of the conjoined tendon. The classic Latarjet procedure consists in performing a coracoid osteotomy along with the conjoined tendon attachment followed by transfer and fixation to the anterior glenoid, positioning the lateral surface of the coracoid to be flush with the articular side. Then, a modification of this technique defined as "congruent-arc Latarjet" (CAL) was described. This approach involves rotating the coracoid process 90° along its longitudinal axis using the inferior surface to recreate the native glenoid arc. Biomechanical studies have discussed advantages and disadvantages of these techniques. The CAL allows a greater glenoid surface area, which may be relevant in patients with increased glenoid bone loss. However, the bone contact area is reduced, which increases the technical difficulty of screw positioning with an increased risk of graft fragmentation. The classic Latarjet technique has a greater initial fixation strength between the graft and the glenoid and a greater potential for bone consolidation due to the broader contact bone area. Excellent clinical and sports outcomes with low recurrence rates have been observed in both techniques. Imaging findings have exhibited high bone block healing and no difference in graft placement, but CAL demonstrated a greater incidence of fibrous or nonunion rates and errors in screw fixation. Finally, while similar early complications have been reported, long-term outcomes are still needed in CAL for comparing osteoarthritis progression. These results emphasize that either technique can be considered to manage glenohumeral instability when appropriately indicated.

The Short, 5-Item Shoulder Instability-Return to Sport After Injury (SIRSI) Score Performs as Well as the Longer Version in Predicting Psychological Readiness to Return to Sport

PURPOSE

To reduce the length of the Shoulder Instability-Return to Sport After Injury (SIRSI) scale and determine the predictive validity of the short version compared with the original form.

METHODS

This study included patients who underwent an arthroscopic Bankart repair or open Latarjet procedure between 2017 and 2019. One group was used for the SIRSI scale-reduction process, and a second group was used to test the predictive validity of the proposed short SIRSI scale. The Cronbach α value was used to evaluate internal consistency. Validity was determined by calculating the Pearson correlation coefficient with the Western Ontario Shoulder Instability Index scale. Predictive validity was assessed using receiver operating characteristic (ROC) curve statistics.

RESULTS

A total of 158 patients participated in the scale-reduction process, and 137 patients participated in the predictive-validation process. The SIRSI scale was successfully reduced to a 5-item scale constructed by 1 underlying factor accounting for 60% of the variance. The short version showed good internal consistency (Cronbach α = 0.82) and was highly correlated with the Western Ontario Shoulder Instability Index scale and the long version. The short SIRSI scores were significantly different between patients who returned to sports and those who did not. The SIRSI scale had excellent predictive ability for return-to-sport outcomes (area under ROC curve of 0.84 for short version [95% confidence interval, 0.7-0.9] and 0.83 for long version [95% confidence interval, 0.7-0.9]).

CONCLUSIONS

A valid 5-item, short version of the SIRSI scale was successfully developed in our patient population. The short version was found to be as robust as the long scale for discriminating and predicting return-to-sport outcomes.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Relationship of the SIRSI Score to Return to Sports After Surgical Stabilization of Glenohumeral Instability

BACKGROUND

Literature is scarce regarding the influence of psychological readiness on return to sports after shoulder instability surgery.

PURPOSE

To evaluate the predictive ability of the Shoulder Instability-Return to Sport after Injury (SIRSI) score in measuring the effect of psychological readiness on return to sports and to compare it between athletes who returned to sports and athletes who did not return to sports.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective analysis was performed of patients who underwent an arthroscopic Bankart repair or a Latarjet procedure between January 2019 and September 2020. Psychological readiness to return to play was evaluated using the SIRSI instrument. Preoperative and postoperative functional outcomes were measured by the Rowe, Athletic Shoulder Outcome Scoring System, and Western Ontario Shoulder Instability Index scores. The predictive validity of the SIRSI was assessed by the use of receiver operating characteristic (ROC) curve statistics. The Youden index was calculated and used to determine a SIRSI score cutoff point that best discriminated psychological readiness to return to sports. A logistic regression analysis was performed to evaluate the effect of psychological readiness on return to sports and return to preinjury sports level.

RESULTS

A total of 104 patients were included in this study. Overall, 79% returned to sports. The SIRSI had excellent predictive ability for return-to-sport outcomes (return to sports: area under ROC curve, 0.87 [95% CI, 0.80-0.93]; return to preinjury sports level: area under ROC curve, 0.96; [95% CI, 0.8-0.9]). A cutoff level of ≥55 was used to determine whether an athlete was psychologically ready to return to sports and to return to preinjury sports level (Youden index, 0.7 and 0.9, respectively). Of those who returned to sports, 76.8% were psychologically ready to return to play, with a median SIRSI score of 65 (interquartile range, 57-80). In comparison, in the group that did not return to sports, only 4.5% achieved psychological readiness with a median SIRSI score of 38.5 (interquartile range, 35-41) (P < .001). Regression analysis for the effect of SIRSI score on return to sports was performed. For every 10-point increase in the SIRSI score, the odds of returning to sports increased by 2.9 times. Moreover, those who did not achieve their preinjury sports level showed poorer psychological readiness to return to play and SIRSI score results.

CONCLUSION

The SIRSI was a useful tool for predicting whether patients were psychologically ready to return to sports after glenohumeral stabilization surgery. Patients who returned to sports and those who returned to their preinjury sports level were significantly more psychologically ready than those who did not return. Therefore, we believe that the SIRSI score should be considered along with other criteria that are used to decide whether the patient is ready to return to sports.

The playing position significantly influences return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players

BACKGROUND

The purpose of our study was to investigate the influence of the different rugby playing positions on return to sports, functional outcomes, and recurrences after an arthroscopic Bankart repair.

METHODS

A total of 88 rugby players were treated for anterior shoulder instability in our institution between 2010 and 2018. Functional outcomes, return to sports, recurrences, complications, and revisions rates were evaluated according to the playing position.

RESULTS

Overall, 73.8% of the patients returned to rugby and 60% returned at the same level as before the injury. The tight forwards and outside backs experienced a significant decrease in their competitive level after surgery, and showed the lowest functional outcomes. The tight forwards and outside backs showed a statistically significant increase in recurrence and revision rates, and an OR for recurrence of 12.8 and 9.6, respectively.

DISCUSSION

The playing position significantly influenced return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players. Specifically, the tight forwards and outside backs have returned to a lower level than they had before surgery, showed the lowest functional outcomes, and a significant increase in recurrences and revisions rates than the other groups.

Factors That Influence the Return to Sport After Arthroscopic Bankart Repair for Glenohumeral Instability

Numerous studies have reported high rates of return to sports following arthroscopic Bankart repair (ABR) However, there is enormous controversy regarding the optimal management of these patients in the postoperative period. Controversy issues include rehabilitation, criteria for returning to sports, and the specific management of each athlete according to the sport they practice. Even though there are several rehabilitation protocols published in the literature, wide variability exists concerning the key elements of rehabilitation after an ABR. Regarding criteria for return to sports, there is a wide variation across the different published studies. The type of sports has been shown to affect an athlete’s decision to return to sports. Nevertheless, most research is evaluated by classifications that cluster different sports into categories that may have other influences in return to sports when analyzed separately. Finally, in addition to physical readiness, the athlete’s psychological state is crucial for returning to sports. However, the contribution of psychological readiness to an athlete’s return to sports after shoulder instability surgery remains uncertain and unexplored.

Midterm functional outcomes and tendon integrity after in situ repair of partial bursal supraspinatus tears without acromioplasty

BACKGROUND AND PURPOSE

The purpose of this study was to analyze midterm functional outcomes and tendon integrity in patients treated with in situ arthroscopic repair of Partial Bursal Rotator Cuff Tears (PBRCTs) without acromioplasty.

MATERIALS AND METHODS

Sixty two patients were included. Clinical assessment consisted of glenohumeral range of motion measurement and the American Shoulder and Elbow Surgeons (ASES) score. Pain was rated by using a visual analog scale (VAS). A postoperative ultrasound image control was performed at a minimum 5 years follow up to assess tendon integrity.

RESULTS

Mean age was 57.2 years (range, 44-77 years) and mean follow up was 7 years (range of 5-9 years). Significant improvements in range of motion, functional outcomes and pain were observed postoperatively (P<.0001). The ASES score improved from 46.5 to 90.2; and the VAS improved from 6.5 to 1.73 (P<.0001). Fifty six patients (90%) performed ultrasound evaluation at the end of follow up. Fifty-one patients (91%) presented tendon integrity on ultrasound. Five patients presented re-tears (9%). Three patients (5%) had a complete tendon re-tear and two patients (4%) had a partial re-tear. No difference in range of motion or functional outcomes were found between patients with intact tendon and those who had re-tears.

CONCLUSIONS

In the midterm follow up, arthroscopic in situ repair PBRCTs without acromioplasty showed excellent functional outcomes and high healing rates in most patients with low complication rates.

Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up

Background:

There is a lack of information regarding the reasons why patients do not return to sports after an arthroscopic Bankart repair and whether there is a relationship between return to sports and functional outcomes.

Purpose:

To evaluate the reasons why competitive athletes who underwent arthroscopic Bankart repair did not return to sports and whether there was a relationship between returning to sports and postoperative outcome scores and complications.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Of 217 competitive athletes who underwent arthroscopic Bankart repair for isolated anterior glenohumeral instability between June 2014 and December 2017, a total of 208 athletes (96%) were evaluated at minimum 2-year follow-up. Return to sports, the level of sports achieved, and the time between surgery and return to competition were assessed, and patients who did not return to sports were asked to provide the reasons for cessation. The Rowe score and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences, reoperations, and complications were also evaluated.

Results:

The mean patient age was 24 years (range, 18-30 years), and the mean follow-up was 44 months (range, 24-90 months). Of the 208 athletes, 73% were able to return to sports (65% returned to their preinjury level), and 27% did not return to sports. Of those who did not return, the most frequent reasons were fear of reinjury (44%), lack of confidence in their shoulder (12%), and concern about a new rehabilitation process in case of recurrence (10%). The Rowe and ASOSS scores showed significant postoperative improvement in all patients (P < .001), with no significant differences between the 2 study groups at the final follow-up. There were 21 recurrences (10%) and 5 complications (2.4%), and 11 patients (5.3%) underwent revision surgery, with no significant differences in these rates between the groups.

Conclusion:

Of patients who did not return to sports, 74% left for a reason independent of shoulder function, with the most frequent causes being fear of reinjury and a concern about new rehabilitation process. Neither outcome scores nor complications varied significantly between patients who returned and those who did not return to sports.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss.

METHODS

A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus.

RESULTS

After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out.

CONCLUSIONS

The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed.

LEVEL OF EVIDENCE

Level V, consensus statement.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Surgical fixation of displaced midshaft clavicular fractures with precontoured plates in adolescents

BACKGROUND

The use of plate fixation to treat displaced midshaft clavicular fractures in adults reduces complications and residual shoulder disability. New features of the precontoured locking plates have been shown to reduce the need for hardware removal in adults. There is a lack of studies evaluating surgical fixation of displaced clavicular fractures with precontoured plates in adolescents. We evaluate outcomes and complications of adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates.

MATERIALS AND METHODS

40 adolescents with displaced midshaft clavicular fractures were surgically treated from January 2010 to May 2017. Outcomes were evaluated using the Constant score, the 11- item version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaires, and radiographs, and a visual analog scale. Return-to-sport rate, level achieved, and complications were recorded.

RESULTS

Mean follow-up was 50 months (18 - 108 months). Constant, Quick-DASH, and visual analog scale scores were 95.6, 2.8 and 0.5 points, respectively. 100% of adolescents returned to sports at the same level they had before injury. Mean time to return was 69 days and 95% of patients were able to return before 12 weeks. Complication rate was 12.5%, 3 patients (7.5%) required hardware removal.

CONCLUSIONS

Adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates exhibited satisfactory outcomes and low complication rate. Compared to other reports, this study had lower rates, anatomic plates might reduce hardware-related complications.

High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20

Purpose

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%.

Methods

All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

Results

A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases.

Conclusions

In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences

Level of Evidence

Therapeutic case series; Level of evidence, IV

High Variability in Functional Outcomes and Recurrences Between Contact Sports After Arthroscopic Bankart Repair: A Comparative Study of 351 Patients With a Minimum 3-Year Follow-Up

Purpose

To compare return to sports, functional outcomes, and complications of a consecutive series of contact athletes with anterior glenohumeral instability treated with isolated arthroscopic Bankart repair for isolated anterior instability.

Methods

Between January 2008 and December 2016, 351 competitive athletes who participated in contact or collision sports underwent isolated arthroscopic Bankart repair at our institution (rugby n = 105, soccer n = 90, martial arts n = 36 boxing n = 28, field hockey n = 30, handball n = 31, and basketball n = 31). Return to sports, the Rowe score, and the Athletic Shoulder Outcome Scoring System (ASOSS) score were used to assess functional outcomes. Complications also were evaluated.

Results

The mean follow-up period was 66.7 months (range, 36-148 months) and the mean age of the 351 patients was 21.3 years (range, 17-30 years).Overall, 309 patients (88%) were able to return to sports, and 284 (81%) returned at the same level as before the injury. The mean time to return to sports was 5.3 months. The rate of return to sports, the level achieved by the patients, and time to return to sports varied significantly between sports. The Rowe and ASOSS scores showed statistical improvement after operation (P < .001). The ASOSS score varied significantly between sports (P < .001). There were 40 recurrences (11.3%), 7 complications (2%) and 21 patients (6%) underwent revision surgery. There was a significant difference in the rate of recurrences and revisions between the different contact sports.

Conclusions

In athletes with glenohumeral instability who undergo isolated arthroscopic Bankart repair for isolated anterior instability, there is great variability in the rate of return to sport at the same level, in shoulder performance after returning to competition, and in the postoperative recurrence rates. Due to the high variability found in our study, results after arthroscopic Bankart repair in contact athletes should not be reported globally by including the different sports under the "collision or contact sports" label.

Level of Evidence

Retrospective Case Series; Level of evidence, 4.

Similar Results in Return to Sports, Recurrences, and Healing Rates Between the Classic and Congruent-Arc Latarjet for Athletes With Recurrent Glenohumeral Instability and a Failed Stabilization

PURPOSE

To compare the return-to-sport rate, functional outcomes, and complications of the "classic Latarjet" surgery with those of the "congruent arc Latarjet" surgery in athletes with recurrent glenohumeral instability and failed previous stabilization procedures.

METHODS

All the included patients were operated between May 2009 and April 2017. The inclusion criteria were athletes with recurrent anterior glenohumeral instability, a glenoid bone defect greater than 20%, at least 1 previous failed stabilization surgery operated with the classic or the congruent-arc Latarjet procedures, and a minimum 2 years of follow-up. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale for pain, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications were also evaluated.

RESULTS

A total of 135 athletes were included in the study (55 patients were operated with the classic technique and 80 with the congruent arc technique). The mean follow-up was 40.3 months (range, 24-88 months) and the mean age was 26.5 years (range, 18-45 years). Overall, 87% were able to return to sports and 92% returned at the same level. No significant difference regarding return to sports was found between the groups. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between patients operated with the classic and congruent arc procedures. There were 6 recurrences (4%). There was no significant difference in the recurrence rate between groups. The bone block healed in 92% of the cases.

CONCLUSIONS

In athletes with recurrent anterior glenohumeral instability and a failed previous operative repair, the Latarjet procedure produced excellent functional outcomes and most athletes returned to sport at their preinjury level with a very low rate of recurrences, regardless of whether the Latarjet was performed with the classic or with the congruent arc technique.

LEVEL OF EVIDENCE

Retrospective comparative study; Level of evidence, 3.

Results of partial resurfacing of humeral head in patients with avascular necrosis

OBJECTIVE

The aim of this study was to report the short-term results and complications of partial humeral head resurfacing (HemiCup^®) in patients treated by avascular necrosis.

MATERIAL AND METHODS

Between 2010 and 2014, 9 patients who underwent partial resurfacing of humeral head were evaluated. All the patients were treated by avascular necrosis. The mean follow-up was 44 months (minimum 24 months). The average age was 47 years (range 32-57 years). The patients were evaluated clinically and radiologically. Complications were reported.

RESULTS

The patients had a significant improvement in functional scores and mobility between the pre-operative and last follow-up control. The Constant score improved from 35 to 79 points (P<.001), ASES score improved from 31 to 76 points (P<.001), forward flexion and external rotation improved from 101 to 150° (P<.001), and from 24 to 45° (P<.001), respectively. One patient presented symptomatic glenoid wear during follow-up, requiring revision surgery.

CONCLUSION

In our patients treated by avascular necrosis, the partial resurfacing of humeral head (HemiCup^®) demonstrated a significant improvement in functional scores and mobility with an average follow-up of 44 months.

Midterm Outcomes After Arthroscopic Anteroinferior Capsular Release for the Treatment of Idiophatic Adhesive Capsulitis

PURPOSE

The purpose of this study is to report the early and midterm functional outcomes and complications of a consecutive series of patients with primary adhesive capsulitis who were treated with isolated anteroinferior arthroscopic capsular release after they did not respond to conservative treatment.

METHODS

Thirty-two consecutive patients with idiopathic adhesive capsulitis who did not respond to conservative physiotherapy were included in the study. Arthroscopic anteroinferior capsular release was performed in all cases. The primary outcome was improvement in range of motion in the short- and midterm follow-up. We also evaluated pain relief with the visual analog scale, functional outcomes with the Constant-Murley score, and we registered postoperative complications.

RESULTS

The mean age was 49.6 years (range, 33-68 years) and the mean follow-up was 63 months (range, 18-84). Overall, there was significant improvement in the Constant-Murley score from 42.4 to 86 points (P < .001). The visual analog scale decreased by approximately 6.3 points compared with the preoperative value (P < .001). All parameters improved significantly the first 6 months and then remained stable until the end of follow-up (P < .001). There was an additional minor improvement in both parameters between the sixth month and the final follow-up; however, this improvement was less than in the first 6 months and it was not statistically significant.

CONCLUSIONS

In patients who don't respond to conservative treatment for primary adhesive capsulitis, isolated anteroinferior capsular release provides a reliable improvement in pain and range of motion that is maintained in the mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic, case series study.

Arthroscopic Transtendon Repair of Partial-Thickness Articular-Side Rotator Cuff Tears

PURPOSE

To evaluate the clinical outcomes and complications in a series of patients with painful partial articular cuff tears treated with the arthroscopic transtendinous repair with a minimum 2-year follow-up.

METHODS

Eighty patients with a mean age of 51 ± 5.4 years who had undergone an arthroscopic transtendon repair for a painful articular-sided rotator cuff tear with a minimum of 2-year follow-up were contacted. Clinical outcomes using a patient-based questionnaire, the University of California at Los Angeles score, the American Shoulder and Elbow Surgeons score, and the visual analog scale were evaluated. Postoperative complications were also assessed.

RESULTS

After arthroscopic repair, the University of California at Los Angeles scores improved from 13.6 to 31.5; the American Shoulder and Elbow Surgeons scores improved from 44.4 to 76.1; and the visual analog scale scores improved from 6.3 to 1.3 (P < .0001). A total of 92.5% of patients were satisfied with their results. Only 5 patients developed a postoperative adhesive capsulitis that responded favorably to physical therapy. Eleven patients had concurrent procedures performed at the time of surgery. We found no difference between these patients and those who had an isolated tendon repair.

CONCLUSIONS

Arthroscopic transtendon repair of partial-thickness articular-side rotator cuff tears is a reliable procedure that can be expected to produce satisfactory functional improvements and pain relief in most patients with a low rate of complications in the midterm follow-up. Concurrent procedures performed at the time of supraspinatus repair do not change functional outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic Removal and Rotator Cuff Repair Without Acromioplasty for the Treatment of Symptomatic Calcifying Tendinitis of the Supraspinatus Tendon

Background:

Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. Although most patients respond well to conservative treatment, some eventually require surgical treatment.

Purpose:

To evaluate the clinical outcome with arthroscopic removal of calcific deposit and rotator cuff repair without acromioplasty for the treatment of calcific tendinitis of the supraspinatus tendon.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study retrospectively evaluated 30 consecutive patients with a mean age of 49.2 years. The mean follow-up was 35 months (range, 24-88 months). Pre- and postoperative functional assessment was performed using the Constant score, University of California Los Angeles (UCLA) score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH). Pain was assessed by visual analog scale (VAS). Radiographs and magnetic resonance imaging (MRI) were performed to evaluate the recurrence of calcifications and the indemnity of the supraspinatus tendon repair.

Results:

Significant improvement was obtained for pain (mean VAS, 8.7 before surgery to 0.8 after; P < .001). The mean Constant score increased from 23.9 preoperatively to 85.3 postoperatively (P < .001), the mean Quick DASH score decreased from 47.3 preoperatively to 8.97 postoperatively (P < .001), and the UCLA score increased from 15.8 preoperatively to 32.2 postoperatively (P < .001). MRI examination at last follow-up (70% of patients) showed no tendon tears, and 96.2% of patients were satisfied with their results.

Conclusion:

Arthroscopic removal and rotator cuff repair without acromioplasty can lead to good results in patients with symptomatic calcifying tendonitis of the supraspinatus tendon.

The stigma of burns

The objective of this ethnographic study was to investigate the cultural meanings reported by 25 relatives of burned patients about their loved one's impending hospital discharge. Data were collected by means of participant observation and semi-structured interviews conducted during hospital visiting hours, and support group meetings with relatives. The following inter-related phases were considered in the analysis process: reading of the material and data reduction (selection of data using the objective of the study as a guide), data display, conclusion outlining, and verification. Following this process, the data were coded and similar codes were grouped into categories. It was found that the relatives of burned patients felt afraid when faced with the prospect of hospital discharge. Their descriptions reveal the family's feelings and attitudes in face of other people's reactions, and in face of the patient's own reactions in the context of possible changes in their social roles.

Body image of patients with burns sequellae: evaluation through the critical incident technique

The present investigation is a descriptive study, with a retrospective, ex-post facto, design. The objectives of this study were to characterize the body image changes in patients with burn sequellae, through the critical incident technique and to identify and categorize critical incidents, comparing them to the characteristics defined by the Taxonomy of the North American Nursing Diagnoses Association (NANDA) for the body image disturbance nursing diagnosis. Thirty-five patients were interviewed. Two types of critical incidents were identified: 'facing the mirror'--the moment the patient looks at himself/herself and notices the changes in his/her body, and 'facing other people'--the moment the patient becomes aware that he/she calls the attention of others. Associated with the perceptions of changes in their bodies, the patients reported feelings of fear (19), rebellion (18) and shame (12). They also presented coping mechanisms of denial (12), rationalization (7), minimization (7) and repression (2). NANDA's body image disturbance diagnosis was identified in all patients.

[Evaluation of nursing notes based on the nursing process]

This is a retrospective study that analyzed the nursing notations in a Specialized Unit which develops the care to the patient based on Nursing Process. The data were collected through two promptuaries utilizing instrument constructed for this purpose. Aspects which valuate appearance and content were considered in the analysis. The nursing assistant was distinguished in the results considering the bigger number of extensive and not very specific notations, and in the registrations achieved by the nurse, it was observed a bigger number of legible and objective notations. By expressing the Nursing work, greater investments must be made to become more objective and full the nursing notations.

[The process of caring for burned patients: cultural significance attributed by relatives]

This study aimed at investigating the cultural meanings attributed by relatives to their participation in the process of delivering care to burned people; identifying the care strategies focused on by relatives during their participation in the care process. Data were collected by means of semi-structured interviews with 25 relatives of burned patients admitted in a Unit for Burned and by participant observation. The results of this study show that the perspective of giving care to a burned person has two dimensions: a physical dimension and a moral one; and generates mainly fear.

[The nursing process at a burns unit: an ethnographic study]

This ethnographic study aimed at understanding the cultural meaning that nursing professionals working at a Burns Unit attribute to the nursing process as well as at identifying the factors affecting the implementation of this methodology. Data were collected through participant observation and semi-structured interviews. The findings indicate that, to the nurses from the investigated unit, the nursing process seems to be identified as bureaucratic management. Some factors determining this perception are: the way in which the nursing process has been taught and interpreted, routine as a guideline for nursing activity, and knowledge and power in the life-world of the Burns Unit.

[Implementation strategies of nursing processes for an HIV-positive patient]

Aiming at valuing the use of strategies such as teaching and learning methods, the relaxation technique and coping are described in a case study concerning a hospitalized HIV-positive person presenting the Acquired Immuno-Defficiency Syndrome (AIDS). The Conceptual Model proposed by Dorothéia Orem (OREM, 1985), Risner's proposal for the conduction of diagnostic thinking and the Nursing Diagnostic Unifying System proposed by NANDA (NANDA, 1996) were use as theoretical framework. Among the identified diagnoses, three were selected in order to exemplify the planning, implementation and process evaluation phases.

[Nursing diagnoses from NANDA's taxonomy in women with hospitalized premature child and King's conceptual system]

This study aimed at identifying nursing diagnoses presented by mothers with a hospitalized preterm child in an NICU by the use of King's Conceptual System and Taxonomy I of NANDA's nursing diagnoses. The case-study methodology was applied to 35 puerperal women. Eight diagnoses were identified, the frequency of which was over 50%, as follows: Risk of Infection, Risk of Injury, Impaired Tissue Integrity, Altered Health Maintenance, Risk of Inefficient Breast-feeding; Risk of Altered Parent/Infant Attachment; Fear; Parental Role Conflict and Impaired Social Interaction.

[Incidence hepatitis C virus seroconversion after the implementation of a prevention and control program at a hemodialysis unit]

This study aimed at reporting the incidence of the hepatitis C virus as well as the prevention and control measures adopted in an hemodialysis unit. It is a prospective study developed with patients attended from September 1996 to December 1998 in an hemodialysis unit. The consultations from September 1996 to December 1996 were considered the control group and the ones from January 1997 to December 1998 the intervention group. Regarding the period of the control group, the routine of the unit was organized based on the regulation 2042 that systematizes the services of renal therapy. In the subsequent period, complementary measures were implemented. From 1997 to 1998, authors observed the reduction in the number of cases of hepatitis C.

[The pain of burns: terrible for him who feels it, stressful for those who care for him]

The goals of the study were to understand the cultural meaning that the nursing team and burn patients attribute to burn pain. Participant observations were carried out during one year at a Burn Unit. Semi-structured interviews with four nurses, five nursing auxiliaries and 12 patients were recorded. The burn pain is understood by nurses as physical and emotional pain. For professionals and patients, bath and dressing changes are stressful. For patients, burn pain is terrible and they can not explain it. However, they feel they should hold it up.

[Nursing diagnosis of the patient in the immediate postoperative period]

The aim of this study was to identify the nursing diagnoses that are more frequent in patients in immediate post-operative period. Data were collected and recorded on specially cards, through evaluation of 28 patients in the first two hours after the admission of the patient. The nursing diagnoses were set by one of the authors, based on Taxonomy I, proposed by North American Nursing Diagnosis Association--NANDA. The diagnoses that occurred mostly were: Risk for injury (100.0%), Risk for infection (92.8%), Sensory perceptual alterations (89.2%), Risk for aspiration (82.1%), Impaired physical mobility (71.4%), Impaired tissue integrity (82.1%) and Hypothermia (67.8%).

Analysis of cost of dressings in the care of burn patients

This study aimed at analyzing the costs of material used in the occlusive dressings of burn patients. The subjects of the study were patients over the age of 18 years who were admitted to the Burns Unit of the Ribeirão Preto Medical School Clinical Hospital, University of São Paulo-Brazil, from 15 January to 11 September 1998. Data were collected concerning the costs and duration of bathing and dressing of these patients. We concluded that there was a positive relation between the real costs of the materials used and the percentage of the body surface burned. In addition, there was a positive correlation between the number of staff involved in care and the size of the burns. There was no significant difference between the cost of materials used in dressings for burns of different depths.

[Ethical and legal aspects of the nursing records of organ donors for transplant]

The objective of this study was to verify the ethical and legal aspects concerning the documentation of nursing practice in the organ donor's records. The records of the 12 organ donors admitted in a Brazilian University Hospital, from January/1992 to august/1996 were analysed. The donor consent was reported by nurses in 16.7% of the records. Defects that preclude legal value for the charting such as missing date or signature, erasure were found in 91.7% of the records.

[Burns: characteristics of cases treated in a teaching hospital in Ribeirão Preto (São Paulo), Brazil]

Burns are a significant health problem in Brazil, but there have been few data collected that could shape treatment and prevention programs. To help overcome that knowledge gap, this study looked at the types of accidents and the characteristics of 138 burn patients admitted into the burn unit of the University of São Paulo Hospital in Ribeirão Preto, state of São Paulo, Brazil, between November, 1991, and December, 1993. Patient charts were reviewed to collect data on age, sex, region of the body affected, burn depth and surface affected, agent causing the burn, and circumstances in which the burn happened. Of the 138 cases, 71% occurred in the home. In 50% of all accidents the victims were children. Boiling water was the agent responsible for 59% of the accidents among children younger than 3 years of age; fuel alcohol used in the home for cooking and other purposes caused 57% of the accidents among children between 7 and 11 years, the most affected pediatric group. Among adults, the group between 20 and 39 years of age was the most affected (23%); 84% of the victims in this age group were male. Seventeen percent of all cases involved adult males at work. Women suffered burns in accidents at home (67%) and in suicide-related events (33%). Seventy-five percent of the suicide cases were women. The strategies to reduce the incidence of burn injuries should aim at eliminating environmental risk factors and implementing educational programs disseminated through radio and television.

Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto, Brazil

The objectives of this study were to verify which circumstances are present in burn accidents of patients under 12 years of age and to gather information to ground strategies to prevent those accidents. Parents or guardians of 26 patients aged under 12 years, admitted to the burns unit of the Clinical Hospital of Ribeirão Preto Medical School, Brazil, were interviewed, from March 1996 to March 1997. Fifty percent of the injured children were under 3 years of age and had suffered a scald. The kitchen and the backyard were identified as the places where the majority of accidents (84.6%) happened. At least one parent was present in 80.7% of cases. The results speak for the necessity of implementation of programs to prevent burn accidents, focusing on the domestic setting, chiefly activities in the kitchen.

[Fluid volume deficit: profile of defining characteristics in patients with burns]

The present study aimed at describing the profile of defining characteristics in patients with the nursing diagnosis "Fluid volume deficit" related to active loss of fluid secondary to burns. Data were collected by means of a tool, containing 29 possible defining characteristics of this diagnosis. Seven nurses, that worked at the Burnt Unit for at least five years ago, provided opinions about the degree to which each defining characteristic is indicative of this diagnosis. Nurses rated each defining characteristic of diagnosis being tested on a scale of zero to one. The results confirmed all, except one (increased body temperature) defining characteristics presented by NANDA for this diagnosis and indicated 10 new defining characteristics.

Influence of a changed care environment on bacterial colonization of burn wounds

This study investigated the influence of a conditioned care environment per se on bacterial colonization of burn wounds. Two cohorts of burn patients were treated in the successive years 1992 and 1993, the first group in a (permanent) purpose-designed unit and the second in wards of traditional 'open' design, during renovation of the unit. Patients who were admitted to the permanent and temporary units numbered 224 and 231 respectively, the groups being similar in features that generally influence the course and outcome of burn injuries. The principles and practice of treatment by the burn care team remained the same in both years. No significant difference in wound colonization rates was found between the two groups. We conclude that while the other known advantages of managing burn patients in purpose-designed units remain valid, a conditioned care environment per se does not influence bacterial colonization rates of burn wounds.

[The nursing process in a burn unit: analysis and reformulation of teaching]

The present study aims at elaborating and applying an education plan for nurses in an Unit for Burnt Patients, with the proposal of analysing and reformulating the practice of the nursing process in this service. The framework proposed by Charles MAGUEREZ, was employed as a guideline, which led to the selection and application of the teaching and learning strategies implemented in this plan. We concluded that the framework proposed by MANGUEREZ made possible a substantial improvement in the nursing process in this service, and that this new reality claims for further studies.