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Outcomes & Research

Elbow outcomes research: PROMs, UCLR trends in MLB, and value-based care metrics for shoulder arthroplasty & elbow reconstruction.

99 citationsUpdated Aug 2026

Overview

Future objective, outcome-based, and comparative studies are required to evaluate optimal treatment modalities for multi-ligament injured knees before evidence-based recommendations can be established [1]. Similarly, comparative studies must utilize appropriate outcome measures with adequate sample sizes to provide meaningful results in shoulder arthroplasty outcomes [28]. Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches for the arthroscopic treatment of off-track Hill-Sachs lesions using fresh osteochondral allograft plugs [30].

Evidence-based clinical practice guidelines, appropriate use criteria, outcome measures, and patient-reported outcome measures are critical tools to ensure the best clinical care and will be increasingly integrated into care pathways [2]. Developing a core outcome set would allow for more effective comparison across studies in systematic reviews of shoulder arthroplasty [4]. Factors leading to impactful conclusions and clinical change include the role of outcome selection, study design, presentation of results, and stakeholder involvement [12].

Case series on the use of elbow arthroscopy for management of the pediatric elbow have demonstrated significant improvements in functional outcomes and low rates of major complications [13]. Evidence surrounds several potential indications for elbow arthroscopy in the pediatric population beyond osteochondritis dissecans [13]. Heterogeneity in implant type, patient characteristics, and outcome measures, along with inadequate reporting of study details, restricts definitive conclusions in functional outcomes post-radial head arthroplasty [7]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [11].

Orthopaedic registry studies differ from randomized controlled trials in many ways and offer certain advantages, requiring an understanding of the strengths and limitations of both registry cohort studies and RCTs to properly evaluate the literature [31]. Artificial intelligence analysis of biomedical, large, clinical registry data using machine learning requires tens of thousands of subjects and a focus on substantial clinical benefit, as the minimal clinically important difference is too low a bar [5]. Registries should include validated patient-reported outcome scores and measures of clinical relevance and expectations [5].

Anatomy & Pathophysiology

Kinematics and Stability

The most common mechanism of acute elbow dislocation involves a valgus moment to an extended elbow, suggesting some dislocations result from acute valgus instability and are distinct from posterolateral rotatory instability [86]. Repetitive pitching (100 balls) induces a significant reduction in the dynamic stabilizing ability of the medial elbow against valgus laxity in high school baseball players [90].

Normative Values and Pain Effects

Elbow range of motion is influenced by age, sex, and BMI [83]. Normative values for isometric elbow strength exhibit large standard deviations and lack consensus on measurement devices and positions, requiring cautious interpretation [91]. Pain originating from the long head of the biceps tendon induces an approximately 30% decrease in shoulder abduction and elbow flexion strength despite the absence of structural or biomechanical abnormalities [95].

Pathologic Classification

A pathologic classification for elbow stiffness provides a new perspective on the understanding and standardization of elbow arthrolysis [22].

Classification

Evidence-based clinical practice guidelines, appropriate use criteria, outcome measures, and patient-reported outcome measures are critical tools to ensure the best clinical care for patients and will be increasingly integrated into care pathways [2]. Developing a core outcome set allows for more effective comparison across studies in systematic reviews [4] and helps standardize outcome reporting to ensure future research is relevant, interpretable, and amenable to systematic review and/or meta-analysis [6].

Elbow Stiffness: A proposed pathologic classification for elbow stiffness provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes [22].

Greater Trochanteric Pain Syndrome (GTPS): An intraoperative classification system and treatment algorithm for surgical treatment of various GTPS types yields favorable patient-reported outcomes [43].

Knee Replacement: Several countries' Diagnosis-Related Groups (DRG) systems for knee replacement might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities [47].

Shoulder Arthroplasty: Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff [59].

Meniscal Extrusion: Integrating dynamic factors and clinical outcomes in MRI-based classifications informs treatment approaches for meniscal extrusion [8].

FEDS Categories: Different Frequency, Etiology, Direction, and Severity (FEDS) categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education [67].

Other Considerations: Heterogeneity in the type of implant, patient characteristics, and outcome measures used, along with inadequate reporting of study details, restricts definitive conclusions in functional outcomes post-radial head arthroplasty [7]. The first requirement to make progress in the field of upper-extremity musculoskeletal disorders is to agree on unambiguous terminology and classification [74]. Comprehensive registries collecting information on orthopaedic injuries, treatment, complications, and outcomes are required to characterize trauma, evaluate treatment options, and improve care and outcomes [76]. Registries should include validated patient-reported outcome scores and measures of clinical relevance and expectations [5]. Epidemiology and non-epidemiology-trained reviewers can apply the levels-of-evidence guide to published studies with acceptable interobserver agreement, though the validity of this system remains a question for future research [66]. The Musculoskeletal Outcomes Data Evaluation and Management System achieved its goal regarding the development of validated questionnaires, but the data collection component did not [73].

Clinical Presentation

Assessment Frameworks: Evidence-based clinical practice guidelines, appropriate use criteria, outcome measures, and patient-reported outcome measures are critical tools for ensuring best clinical care and are increasingly integrated into care pathways [2].

Outcome Standardization: Development of a core outcome set helps standardize outcome reporting in Dupuytren’s disease research, ensuring future research is relevant, interpretable, and amenable to systematic review or meta-analysis [6]. A combination of generic patient reported outcomes, a disease-specific questionnaire, and physical measures using standardised protocols should be used for future outcomes studies in Dupuytren’s disease [15]. Standardizing outcomes reporting facilitates comparisons across the literature and improves understanding of the prognosis for superior labrum anterior and posterior tears [16]. There has been a demonstrated increase in core outcome sets developed for both research and routine practice, with consistently high inclusion of patient participants [44].

Patient-Reported Outcome Measures (PROMs): Patient-reported outcomes are highly useful when they inform other relevant outcomes, such as predicting return to sport, and psychological factors are potentially modifiable, allowing for early identification and intervention to improve final outcomes [33]. Only 57% of primary medical providers use patient reported outcome measures within their practice, with the information largely used for research rather than clinical decision-making [36]. Before developing or translating a new patient-reported outcome, researchers should review existing measures to determine if one already suits clinical or research needs, as new PROs should only be developed for constructs with no existing measures or for specific needs like faster completion [38]. The Persian version of the international knee documentation committee subjective knee form (IKDC-SF) demonstrates strong psychometric performance across subgroups and clinically meaningful change thresholds, supporting its use in both clinical and research settings [39]. Failure to attempt a return to sport after hip arthroscopy does not equate to a poor clinical outcome, as patients can still experience statistically significant and clinically meaningful improvements in patient-reported outcome measures [40].

Registry and Data Requirements: Artificial intelligence analysis of biomedical large clinical registry data requires tens of thousands of subjects and a focus on substantial clinical benefit, as the minimal clinically important difference is considered too low a bar [5]. Registries should include validated patient-reported outcome scores and measures of clinical relevance and expectations [5].

Diagnostic and Classification Integration: Integrating dynamic factors and clinical outcomes in MRI-based classifications supports informing treatment approaches for meniscal extrusion [8]. Prognostic subgrouping reveals more diverse patterns in pain and function recovery over 1 year than traditional diagnostic groups, potentially better reflecting the diversity in recovery of common musculoskeletal disorders [42].

Clinical Discrepancies and Follow-up: Discrepancies in patient-reported outcomes exist, with patients declining enrolment in trials investigating weight loss versus knee arthroplasty reporting more severe symptoms than those accepting participation [32]. Patients with giant cell tumour should be followed indefinitely and referred promptly if new symptoms, particularly pain, emerge [45].

Research Gaps and Methodology: Future objective outcome-based and comparative studies are needed to evaluate optimal treatment modalities for multi-ligament injured knees before evidence-based recommendations can be made [1]. Larger and long-term controlled trials are needed to support the clinical effectiveness of autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease [3]. There is a need for consistent and transparent reporting of outcomes when treating complex cases, such as two-stage revisions for periprosthetic joint infections [41]. Factors leading to impactful conclusions and clinical change include the role of outcome selection, study design, presentation of results, and stakeholder involvement [12].

Investigations

MRI: Integrating dynamic factors and clinical outcomes into MRI-based classifications can inform treatment approaches for meniscal extrusion [8]. The MRI-based BOGIE score correlates with early clinical function after autologous osteochondral grafting for osteochondritis dissecans of the capitellum and may be useful as an adjunct tool in decision making on activity progression for this condition [61]. A reliable 6-stage MRI-based classification addressing ulnar collateral ligament (UCL) tear grade and location may confer decision making between operative and nonoperative management of UCL tears [81]. Postoperative MRI findings reflect clinical outcomes in arthroscopic debridement for refractory lateral epicondylitis, with improvement of tendinopathy area being 60% in recovered versus 16% in unrecovered groups [68]. Improvements in MRI scores followed and continued longer than improvements assessed by clinical scores after platelet-rich plasma injection in patients with lateral epicondylitis [35].

Plain Radiography: Radiographic angles of total knee arthroplasty using true unrestricted kinematic alignment are sparsely and inconsistently reported [20]. Radiographic osteoarthritis was correlated with higher failure rates, increased conversion to total hip arthroplasty, and worse outcomes after surgical management of femoroacetabular impingement [84]. Radiographic predictors for failure in surgical hip dislocation for femoroacetabular impingement were related to over- and undertreatment of acetabular rim trimming [85]. Correlation of retrieval findings with radiographic and clinical data may help establish predictors of prostheses at risk for failure in revision reverse total shoulder arthroplasty [89].

CT: Ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended for effective monitoring of patients experiencing pain or limited range of motion after primary anatomic and reverse total shoulder arthroplasty [65].

Other Considerations: Future objective outcome-based studies and comparative studies are needed to evaluate optimal treatment modalities for operative management of the medial collateral ligament in multi-ligament injured knees [1]. A longer follow-up period is required to determine the influence of radiological findings on final outcomes in total knee arthroplasty comparing cemented versus uncemented femoral components [17]. Different alignment strategies are often grouped under the umbrella term of kinematic alignment, contributing to conflicting reports and unresolved questions regarding the efficacy of true unrestricted kinematic alignment [20]. Comparing clinical outcomes between different modalities should consider not only statistically significant differences but also the minimal clinically important difference (MCID) [71].

Treatment

Non-Operative

Non-operative management is effective for a majority of adolescent patients with femoroacetabular impingement syndrome (FAI), with significant improvements in patient-reported outcomes (PROs) persisting at a mean 5-year follow-up [77]. Arthroscopic treatment and corticosteroid injection both demonstrate clinical effects in the management of FAI [23]. For partial anterior cruciate ligament rupture, non-operative treatment is justified as it yields good results in the majority of patients, although a substantial number will aggravate their injury over time [82]. In lumbar spinal stenosis, surgery reduces pain and disability better than nonoperative treatment, with effectiveness sustained over 2 years [48]; however, objective measures of walking ability improved in both operative and nonoperative groups, with no statistical difference between the two [48]. The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients [25]. Non-operative management of hip and knee osteoarthritis using PROs requires further research to clarify effects on patient outcomes [52].

Operative

Indications: Obesity is not a contraindication to unicompartmental knee arthroplasty (UKA) provided other patient selection criteria are adhered to [34]. Low and high body mass index, along with lower numbers of screws in the articular segment, are risk factors for non-union of distal humeral fractures in the elderly [69]. Non-union is associated with poor clinical outcomes in this population [69]. Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy [70]. Custom hemiarthroplasty appears to be a reasonable method to salvage proximal humeral dysplasia epiphysealis hemimelica when nonsurgical management has failed to provide relief [92]. Total elbow arthroplasty in juvenile idiopathic arthritis patients provides long-term benefit with satisfactory clinical outcomes and implant durability [10].

Surgical Approach / Technique: Operative treatment of full-thickness rotator cuff tears resulted in greater improvement in Constant scores and significantly decreased pain scores compared to nonoperative management [72].

Implant Selection: Heterogeneity of implant type, patient characteristics, and outcome measures, along with inadequate reporting of study details, restricts definitive conclusions regarding functional outcomes post-radial head arthroplasty [7].

Adjuncts: Limited evidence supports bone marrow aspirate concentrate as an additive to bone marrow stimulation for osteochondral lesions of the talus [37]. Until sufficiently powered, patient- and researcher-blinded, prospective randomised controlled trials are conducted, authors advise not to implement bone marrow aspirate concentrate therapy for osteochondral lesions of the talus without clinical evidence justifying the additional costs [37]. Larger and long-term controlled trials are needed to support the clinical effectiveness of autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease [3].

Other Considerations: Future objective outcome-based and comparative studies are needed to evaluate the optimal treatment modality for the medial collateral ligament in multi-ligament injured knees [1]. Evidence-based clinical practice guidelines, appropriate use criteria, outcome measures, and patient-reported outcome measures are critical tools to ensure the best clinical care for patients [2]. Developing a core outcome set would allow for more effective comparison across studies in systematic reviews of shoulder arthroplasty research [4]. Development of a core outcome set will help standardize outcome reporting and ensure future research in Dupuytren’s disease is relevant, interpretable, and amenable to systematic review and/or meta-analysis [6]. A combination of generic patient reported outcomes, a disease-specific questionnaire, and physical measures using standardised protocols should be used for future outcomes studies on Dupuytren’s disease [15]. Patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [11]. Outcome evaluation is a systematic and objective procedure to determine the impact and success of a therapeutic program, focusing on the patient's well-being in daily life [46]. Understanding what constitutes a real-world benefit from treatment is key to designing and critically appraising clinical research [50]. Non-responders to patient-reported outcomes in hip and knee arthroplasty had significantly increased mortality and significantly worse baseline scores despite similar demographics and revision risk [63]. Findings point to a lack in robustness for conclusions drawn from randomized controlled trials relating to nonoperative treatment for lateral epicondylitis, where a reversal of only 3 patient outcomes could considerably influence reported statistically significant findings [54]. No evidence exists on outcomes following non-operative management of femoroacetabular impingement with concomitant Tönnis Grade 2 or more hip osteoarthritis [78]. Expanded indications or changing surgical preferences are possible reasons for trends in the surgical treatment of cubital tunnel syndrome [29]. The overall decrease in anterior cruciate ligament tears, anterior cruciate ligament reconstruction, and nonoperative management found in the United States from 2010 to 2020 is a reversal from trends reported in the literature from previous decades [88].

Complications

Nerve palsy: Distal peripheral neuropathy develops as a new onset complication in 14.6% of previously asymptomatic patients undergoing arthroscopic rotator cuff repair, with 91.7% of those cases resolving by 3 months [27].

Shoulder Arthroplasty Complications: Anatomic total shoulder arthroplasty in patients younger than 50 years of age is associated with moderately inferior functional outcomes and long-term survivorship compared to older patients [18]. A history of prior implant complication is the most important patient feature for predicting complications and unplanned readmission following primary anatomic total shoulder replacements [98]. Patients undergoing shoulder surgery with a history of cervical spine conditions have increased rates of surgical complications compared to patients without dual shoulder-cervical spine pathology [93]. Surgeon experience significantly modifies patient selection, results, and complications for reverse shoulder arthroplasty [106]. The stemless reverse total shoulder arthroplasty design implant is associated with a low complication rate and good early clinical outcomes [96].

Elbow Arthroplasty Complications: Complication rates remain high for linked total elbow replacement systems despite design advances [99].

Hand Surgery Complications: Postoperative complication rates for distal biceps tendon repair are similar to prior studies, although the true rate of rerupture may be higher than previously thought [103]. Major complications occur at roughly half the rate in the staged group compared to the single-stage group for fasciectomy in severe PIPJ contractures in Dupuytren disease, although the study was underpowered for complication analysis [104].

Other Considerations: Autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease requires larger and long-term controlled trials to support its clinical effectiveness [3].

Recovery

Light activity (weeks): Specific timelines for light activity are not defined in the current evidence base. However, early functional status changes are observed between 1- and 2-year follow-up assessments following hip arthroscopy, where 21.5% of patients improved and 18.6% declined in self-reported functional status [51].

Full activity (months): Long-term functional outcomes vary by procedure and patient age. Patients under 50 years of age undergoing anatomic total shoulder arthroplasty may expect moderately inferior functional outcomes and long-term survivorship compared to older patients [18]. Conversely, minimally invasive Oxford unicompartmental knee arthroplasty ensures excellent functional outcome and high survivorship in the long term [49]. Total elbow arthroplasty with the Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction at a 4-year mean follow-up [9].

Complete recovery / outcome plateau (months): Final outcomes for certain interventions require extended observation. A longer follow-up period is required to determine the influence of radiological findings on final outcome for cemented versus uncemented femoral components in total knee arthroplasty [17]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity after Autologous Matrix-Induced Chondrogenesis for treatment of focal cartilage defects in the knee [53]. For distal biceps short head tears, good outcomes are achieved with acute and delayed reconstruction, though the natural history is poor akin to complete tears [26].

Rehabilitation protocol: Functional ability and health-related quality of life improved after rehabilitation in a structured national rehabilitation program for patients with musculoskeletal disorders [62]. For revision rotator cuff repair, short-term clinical outcomes were similar to primary rotator cuff repair [60].

Functional milestones: Outcomes reporting requires standardization. Standardization of outcomes reporting for superior labrum anterior and posterior tears is needed to facilitate comparisons across the literature and improve understanding of prognosis [16]. In the context of chondrosarcoma of the pelvis and upper end of the femur, a ten or fifteen-year survival rate is more meaningful than a five-year rate for assessing cure [114]. Lesser improvements in survival have been seen in patients with metastatic or recurrent Ewing sarcoma family of tumors compared to those with localized disease [115].

Other Considerations: Several procedural and demographic factors influence recovery trajectories. Autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease requires larger and long-term controlled trials to support its clinical effectiveness [3]. Prospective, long-term observational studies are needed to understand the natural history of early post-traumatic osteoarthritis before formulating and studying interventions [24]. Longitudinal studies require continued contact and evaluation of patients for many years after the administration of treatment, and every reasonable effort should be made to obtain information on all patients in a study to ensure meaningful data [111].

Total elbow arthroplasty provides long-term benefit with satisfactory clinical outcomes and implant durability in patients with juvenile idiopathic arthritis [10]. Total elbow arthroplasty offers satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term [19]. Early reimplantation (abbreviated two-stage) provides similar outcomes to traditional two-stage exchange, though optimal timing and selection criteria remain undefined [112]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up [113]. Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [116].

Non-surgical management of lumbar disc herniation shows an overall incidence of regression of 63% among symptomatic patients [25]. Following arthroscopic rotator cuff repair, 14.6% of previously asymptomatic patients develop new onset distal peripheral neuropathy, but 91.7% of those experience resolution by 3 months [27].

Key Evidence

  • [L4] Future objective outcome-based studies as well as comparative studies are needed to further evaluate the optimal treatment modality before evidence-based recommendations can be made. [1] (10.1007/s00167-009-0810-4)
  • [L4] Larger and long-term controlled trials are needed to support its clinical effectiveness. [3] (10.1186/s12891-018-2067-x)
  • [L2] Developing a core outcome set would allow for more effective comparison across studies in systematic reviews. [4] (10.1371/journal.pone.0187865)
  • [L5] Registries should include validated patient-reported outcome scores and measures of clinical relevance and expectations. [5] (10.1016/j.arthro.2023.10.035)
  • [L1] Development of a core outcome set will help standardize outcome reporting, and ensure future research in this field is relevant, interpretable, and amenable to systematic review and/or meta-analysis. [6] (10.1177/1753193420903624)
  • [L4] The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made. [7] (10.1177/1758573214524934)
  • [L4] Results also support integrating dynamic factors and clinical outcomes in MRI-based classifications to inform treatment approaches. [8] (10.1002/ksa.12183)
  • [L4] The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction. [9] (10.1016/j.jse.2014.08.013)
  • [L4] However, most benefit from the intervention for a long term with satisfactory clinical outcomes and implant durability. [10] (10.1016/j.jse.2014.03.012)
  • [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. [11] (10.1007/s11999-008-0585-9)
  • [Paper] The purpose of this review is to discuss which factors lead to impactful conclusions and clinical change, including the role of outcome selection, study design, presentation of results, and stakeholder involvement. [12] (10.1016/j.injury.2019.10.082)
  • [L1] Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications, with evidence surrounding several potential indications beyond osteochondritis dissecans. [13] (10.1016/j.arthro.2021.01.047)
  • [L1] A combination of generic patient reported outcomes, a disease-specific questionnaire, and physical measures using standardised protocols should be used for future outcomes studies. [15] (10.1186/1471-2474-14-131)
  • [L4] Efforts to standardize outcomes reporting would facilitate comparisons across the literature and improve our understanding of the prognosis of this injury. [16] (10.1016/j.jse.2016.04.020)
  • [L1] A longer follow-up period is required to determine the influence of radiological findings on final outcome. [17] (10.1007/s00167-010-1347-2)
  • [L4] Compared to older patients, those under 50 may expect moderately inferior functional outcomes and long-term survivorship. [18] (10.1016/j.jse.2025.09.005)
  • [L4] Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term. [19] (10.1016/j.jse.2020.11.014)
  • [L1] Different alignment strategies are often grouped under the umbrella term of kinematic alignment, which contributes to conflicting reports, confusion and unresolved questions regarding the efficacy of true unrestricted kinematic alignment. [20] (10.1002/ksa.12494)
  • [L4] Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period. [21] (10.1016/j.jse.2021.03.142)
  • [L4] This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes. [22] (10.1016/j.jse.2019.08.001)
  • [L1] AT and CT both can have clinical effects when facing FAI. [23] (10.1186/s13018-022-03187-1)
  • [L5] The conference identified critical gaps between laboratory and clinical investigations, emphasizing the need for prospective, long-term observational studies to understand the natural history of early post-traumatic osteoarthritis before formulating and studying interventions. [24] (10.1177/0363546511411654)
  • [L1] The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients. [25] (10.1186/s12891-020-03548-z)
  • [L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. [26] (10.1016/j.jse.2020.04.038)
  • [L2] Additionally, 14.6% of previously asymptomatic patients develop new onset DPN, but 91.7% of those also experience resolution by 3 months. [27] (10.1016/j.jse.2016.12.039)
  • [L1] Comparative studies need to use appropriate outcome measures with adequate sample sizes to provide meaningful results. [28] (10.1016/j.jse.2024.11.029)
  • [L3] Possible reasons include expanded indications or changing surgical preferences. [29] (10.1016/j.jhsa.2013.04.044)
  • [L4] Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches. [30] (10.1016/j.jse.2024.06.008)
  • [L3] Orthopaedic registry studies differ from randomized controlled trials in many ways and offer certain advantages; the strengths and limitations of registry cohort studies and RCTs must be understood to properly evaluate the literature. [31] (10.2106/jbjs.n.01332)
  • [L4] We observed discrepancies in patient-reported outcomes, with those who declined enrolment reporting more severe symptoms. [32] (10.1002/ksa.12546)
  • [L5] Patient-reported outcomes are highly useful when they inform other relevant outcomes, such as predicting return to sport, and psychological factors are potentially modifiable, allowing for early identification and intervention to improve final outcomes. [33] (10.1016/j.arthro.2022.11.028)
  • [L4] Improvements in the MRI scores followed and continued longer than improvements assessed by the clinical scores. [35] (10.1016/j.jse.2022.01.147)
  • [L4] Only 57% of primary medical providers are using patient reported outcome measures within their practice, with the information largely used for research rather than clinical decision-making. [36] (10.1177/2325967119s00107)
  • [L1] Until sufficiently powered, patient- and researcher-blinded, prospective randomised controlled trials are conducted, the authors advise not to implement this therapy without clinical evidence that justifies the additional costs. [37] (10.1007/s00167-023-07651-1)
  • [L5] Before developing or translating a new patient-reported outcome (PRO), researchers should review existing measures to determine if one already suits the clinical or research needs, as new PROs should only be developed for constructs with no existing measures or for specific needs like faster completion. [38] (10.1016/j.jht.2015.01.010)
  • [L3] Its strong psychometric performance across subgroups and clinically meaningful change thresholds supports its use in both clinical and research settings. [39] (10.1016/j.jisako.2025.101053)
  • [L5] Failure to attempt a return to sport does not equate to a poor clinical outcome, as patients can still experience statistically significant and clinically meaningful improvements in patient-reported outcome measures. [40] (10.1016/j.arthro.2022.01.015)
  • [L4] There is a need for consistent and transparent reporting of outcomes when treating complex cases. [41] (10.1016/j.arth.2025.10.031)
  • [L3] Prognostic subgrouping revealed more diverse patterns in pain and function recovery over 1 year than observed in the same patients classified by traditional diagnostic groups and may better reflect the diversity in recovery of common MSK disorders. [42] (10.1186/s12891-021-04332-3)
  • [L3] This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. [43] (10.1016/j.arthro.2021.01.058)
  • [L2] There has been a demonstrated increase in core outcome sets developed for both research and routine practice, and consistently high inclusion of patient participants. [44] (10.1371/journal.pone.0244878)
  • [L4] Patients with GCT should be followed indefinitely, and referred promptly if new symptoms, particularly pain, emerge. [45] (10.1302/0301-620x.104b12.bjj-2022-0401.r1)
  • [L5] Outcome evaluation is a systematic and objective procedure to determine the impact and success of a therapeutic program, focusing on the patient's well-being in daily life. [46] (10.1016/j.otsr.2013.06.012)
  • [L3] Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. [47] (10.1007/s00167-013-2374-6)
  • [L1] The effectiveness for pain and disability was sustained over 2 years, but the objective measure of walking ability improved in both groups, with no statistical difference between operative and nonoperative groups. [48] (10.2106/jbjs.8908.ebo2)
  • [L3] Oxford UKA of the medial compartment ensures good long-term survivorship with an excellent functional outcome. [49] (10.1007/s00167-018-5299-2)
  • [L5] Understanding what constitutes a real-world benefit from treatment is key to designing and critically appraising clinical research. [50] (10.1177/1753193419870100)
  • [L3] Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. [51] (10.1177/03635465221122769)
  • [L2] Further research is necessary to clarify the effects on patient outcomes of using PROs in clinical practice. [52] (10.1186/s12891-019-2620-2)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. [53] (10.1007/s00167-010-1042-3)
  • [L2] Findings point to a lack in robustness for conclusions drawn from RCTs relating to nonoperative treatment for lateral epicondylitis, where a reversal of only 3 patient outcomes could considerably influence reported statistically significant findings. [54] (10.1016/j.xrrt.2025.03.008)
  • [L3] Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses. [59] (10.1016/j.jse.2023.08.029)
  • [L3] The short term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [60] (10.1177/2325967114s00016)
  • [L3] The MRI-based BOGIE score appears to correlate with early clinical function and may be useful as an adjunct tool in decision making on activity progression. [61] (10.1177/0363546520902475)
  • [L3] Functional ability and health related quality of life improved after rehabilitation. [62] (10.1186/1471-2474-14-57)
  • [L3] Non-responders had significantly increased mortality and significantly worse baseline scores despite similar demographics and revision risk. [63] (10.1302/0301-620x.108b1.bjj-2025-0683.r1)
  • [L3] Compared with CTA patients, RA patients achieved similar clinical outcomes following RSA. [64] (10.1016/j.jse.2020.05.022)
  • [L4] For patients experiencing pain or limited range of motion, ongoing assessment using additional X-rays, computed tomography scans, or other diagnostic tests is recommended for effective monitoring. [65] (10.1016/j.jse.2024.11.010)
  • [L4] Epidemiology and non-epidemiology-trained reviewers can apply the levels-of-evidence guide to published studies with acceptable interobserver agreement, though the validity of this system remains a question for future research. [66] (10.2106/00004623-200408000-00016)
  • [L2] Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. [67] (10.1016/j.jse.2019.12.002)
  • [L4] In the recovered and unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. [68] (10.1016/j.arthro.2022.07.019)
  • [L3] Non-union is associated with poor clinical outcomes. [69] (10.1177/17585732221131923)
  • [L4] Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy. [70] (10.1177/1758573219872730)
  • [L4] To compare clinical outcomes between different modalities, we should consider not only statistically significant differences but also the MCID. [71] (10.1016/j.jse.2017.10.032)
  • [L1] Operative treatment resulted in greater improvement in Constant scores and significantly decreased pain scores compared to nonoperative management. [72] (10.1016/j.jse.2017.09.032)
  • [L4] The Musculoskeletal Outcomes Data Evaluation and Management System achieved its goal regarding the development of validated questionnaires, but the data collection component did not. [73] (10.1097/01.blo.0000137589.23853.61)
  • [L1] The first requirement to make progress in this field is to agree on unambiguous terminology and classification of UEDs. [74] (10.1186/1471-2474-7-7)
  • [L5] Comprehensive registries collecting information on orthopaedic injuries, treatment, complications, and outcomes are required to characterize trauma, evaluate treatment options, and improve care and outcomes. [76] (10.1016/j.injury.2005.02.027)
  • [L2] Nonoperative management of FAI syndrome is effective in a majority of adolescent patients, with significant improvements in PROs persisting at a mean 5-year follow-up. [77] (10.1177/03635465211030512)
  • [L4] No evidence exists on outcomes following non-operative management of FAI with concomitant Tönnis Grade 2 or more OA of the hip. [78] (10.1007/s00167-022-07274-y)
  • [L3] IM and EM guides provided comparable radiographic and clinical outcomes, allowing flexible selection based on patient anatomy and surgical conditions. [79] (10.1186/s12891-025-09390-5)
  • [L4] A reliable 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management. [81] (10.1016/j.jse.2018.11.063)
  • [L3] Non-operative treatment of partial ACL rupture is justified as it yields good results in the majority of patients, though a substantial number will aggravate their injury over time. [82] (10.1007/s001670050015)
  • [L4] Elbow ROM is influenced by age, sex and BMI. [83] (10.1177/1758573217728711)
  • [L1] Radiographic osteoarthritis was correlated with higher failure rates, increased conversion to total hip arthroplasty, and worse outcomes after surgical management of femoroacetabular impingement. [84] (10.5435/jaaos-d-17-00380)
  • [L4] Radiographic predictors for failure were related to over- and undertreatment of acetabular rim trimming. [85] (10.1007/s11999-014-4025-8)
  • [L4] The most common mechanism appears to involve a valgus moment to an extended elbow, suggesting some acute elbow dislocations may result from acute valgus instability and are distinct in nature and mechanism from posterolateral rotatory instability. [86] (10.1016/j.jhsa.2012.12.017)
  • [L3] The overall midterm risk of revision after RSA for CTA was low (5%). [87] (10.1016/j.jse.2018.02.060)
  • [L4] The overall decrease in ACL tears, ACLR, and nonoperative management found in this study is a reversal from trends reported in the literature from previous decades. [88] (10.1016/j.arthro.2024.08.018)
  • [L4] Correlation of retrieval findings with radiographic and clinical data may help establish predictors of prostheses at risk for failure. [89] (10.1016/j.jse.2015.06.004)
  • [L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. [90] (10.1016/j.jse.2023.11.001)
  • [L4] Large standard deviations of normative values in combination with different measurement devices used, as well as the different measurement positions of the subjects, demonstrated that there is no consensus about measuring the isometric elbow strength and therefore the normative values have to be interpreted with caution. [91] (10.1177/1758573217748643)
  • [Case_report] This appears to be a reasonable method to salvage this difficult and challenging problem when nonsurgical management has failed to provide relief. [92] (10.1016/j.jse.2011.08.043)
  • [L2] Patients undergoing shoulder surgery with a history of a cervical spine condition have increased rates of surgical complications and mixed but consistently nonsuperior patient-reported outcomes compared to patients without dual shoulder-cervical spine pathology. [93] (10.1016/j.arthro.2025.01.010)
  • [L4] Pain originating from LHBT induced an approximately 30% decrease of shoulder abduction and elbow flexion strength despite there being no structural or biomechanical abnormalities in this model. [95] (10.1016/j.jse.2018.05.009)
  • [L4] The study observed a low complication rate and good early clinical outcomes, indicating that this approach can be considered for broader use in the future. [96] (10.5397/cise.2024.00836)
  • [L3] History of prior implant complication was the most important patient feature for XGBoost performance, a novel patient feature that surgeons should consider when counseling patients. [98] (10.1177/24715492221075444)
  • [L3] Despite design advances, complication rates remain high. [99] (10.1302/0301-620x.96b10.33815)
  • [L4] Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought. [103] (10.1016/j.jse.2015.11.012)
  • [L3] Major complications occurred at roughly half the rate in the staged group, suggesting a potential safety advantage, although the study was underpowered for complication analysis. [104] (10.1016/j.jhsa.2025.10.019)
  • [L3] Experience did not lead us to operate on younger patients, but significantly modified patient selection, results, and complications. [106] (10.1016/j.jse.2011.11.010)
  • [L5] Longitudinal studies require continued contact and evaluation of patients for many years after the administration of treatment, and every reasonable effort should be made to obtain information on all patients in a study to ensure meaningful data. [111] (10.2106/00004623-199803000-00018)
  • [L1] Early reimplation (abbreviated two-stage) provides similar outcomes to traditional two-stage exchange, though optimal timing and selection criteria remain undefined. [112] (10.1016/j.arth.2025.10.075)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. [113] (10.1016/j.jisako.2022.03.003)
  • [L5] Despite marked improvements in survival during the past 40 years for patients with localized disease, lesser improvements have been seen in patients with metastatic or recurrent disease. [115] (10.5435/00124635-201002000-00004)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. [116] (10.2106/jbjs.j.00157)

See Also

References

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[2] Chapter 2 Evidence-Based Quality and Outcomes Assessment in Pediatric Orthopaedics. 2020.

[3] Use of autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease: a preliminary report. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2067-x

[4] Inconsistent selection of outcomes and measurement devices found in shoulder arthroplasty research: An analysis of studies on ClinicalTrials.gov. PLOS ONE. 2017. DOI: 10.1371/journal.pone.0187865

[5] Editorial Commentary: Artificial Intelligence Analysis of Biomedical, Large, Clinical Registry Data Using Machine Learning Requires Tens of Thousands of Subjects and a Focus on Substantial Clinical Benefit: Minimal Clinically Important Difference Is too Low a Bar. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.10.035

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[21] Long-term outcomes of radial head arthroplasty for radial head fractures—a systematic review at minimum 8-year follow-up. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.142

[22] A new pathologic classification for elbow stiffness based on our experience in 216 patients. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.08.001

[23] Conservative therapy versus arthroscopic surgery of femoroacetabular impingement syndrome (FAI): a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03187-1

[24] Closing the Gap Between Bench and Bedside Research for Early Arthritis Therapies (EARTH). The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511411654

[25] The incidence of regression after the non-surgical treatment of symptomatic lumbar disc herniation: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03548-z

[26] Distal biceps short head tears: repair, reconstruction, and systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.038

[27] Distal peripheral neuropathy in arthroscopic rotator cuff repair: a prospective investigation. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.12.039

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[29] Trends in the Surgical Treatment of Cubital Tunnel Syndrome: An Analysis of the National Survey of Ambulatory Surgery Database. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.044

[30] Outcomes following arthroscopic treatment of off-track Hill-Sachs lesions using fresh osteochondral allograft plugs: a case series. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.06.008

[31] Understanding Orthopaedic Registry Studies. The Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.n.01332

[32] Characteristics of eligible patients with knee osteoarthritis accepting versus declining participation in a randomised trial investigating the effect of weight loss versus knee arthroplasty to explore generalisability: A cross‐sectional study. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12546

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[35] Repeated magnetic resonance imaging at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.147

[36] THE USE OF PATIENT REPORTED OUTCOME MEASURES BY PRIMARY MEDICAL PROVIDERS IN THE PEDIATRIC SPORTS POPULATION. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00107

[37] Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07651-1

[38] Why do we need new patient-reported outcomes?. Journal of Hand Therapy. 2015. DOI: 10.1016/j.jht.2015.01.010

[39] Psychometric validation and cultural adaptation of the Persian version of international knee documentation committee subjective knee form (IKDC-SF) across diverse knee pathologies. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2025.101053

[40] Editorial Commentary: Failure to Return to Sport, or Rather a Failure to Attempt a Return After Hip Arthroscopy Is Not Correlated With Poor Clinical Outcome: The Devil Is in the Details. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.01.015

[41] Lower Reported Success Rates of Two-Stage Revisions for Periprosthetic Joint Infections Using Musculoskeletal Infection Society Outcome Reporting Tool at a Specialty Referral Center. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.031

[42] Recovery trajectories in common musculoskeletal complaints by diagnosis contra prognostic phenotypes. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04332-3

[43] Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.01.058

[44] Choosing important health outcomes for comparative effectiveness research: 6th annual update to a systematic review of core outcome sets for research. PLOS ONE. 2021. DOI: 10.1371/journal.pone.0244878

[45] A systematic review of multicentric giant cell tumour with the presentation of three cases at long-term follow-up. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b12.bjj-2022-0401.r1

[46] Outcome evaluation in pediatric orthopedics. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.06.012

[47] Knee replacement and Diagnosis‐Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2374-6

[48] Surgery Reduced Pain and Disability in Lumbar Spinal Stenosis Better Than Nonoperative Treatment. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.8908.ebo2

[49] Minimally invasive Oxford unicompartmental knee arthroplasty ensures excellent functional outcome and high survivorship in the long term. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5299-2

[50] Different terminologies that help the interpretation of outcomes. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419870100

[51] Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221122769

[52] Implementing patient-reported outcomes in clinical decision-making within knee and hip osteoarthritis: an explorative review. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2620-2

[53] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[54] Randomized controlled trial outcomes for nonoperative management of lateral epicondylitis of the elbow are statistically fragile: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.03.008

[59] Prognostic value of the Walch classification for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.029

[60] Primary Versus Revision Arthroscopic Rotator Cuff Repair - An Analysis In 350 Consecutive Patients. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00016

[61] Early Radiographic Healing and Functional Results After Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum: Introduction of a New Magnetic Resonance Imaging–Based Scoring System. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520902475

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[64] Comparison of outcomes after reverse shoulder arthroplasty in patients with rheumatoid arthritis and cuff tear arthropathy. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.05.022

[65] Utility of radiographs for asymptomatic patients following primary anatomic and reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.010

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[67] Surgical outcomes in the Frequency, Etiology, Direction, and Severity (FEDS) classification system for shoulder instability. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.002

[68] Arthroscopic Debridement for Refractory Lateral Epicondylitis Results for Substantial Improvement in Tendinosis Scores and Good Clinical Outcomes: Qualitative and Quantitative Magnetic Resonance Imaging Analysis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.07.019

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[71] Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.10.032

[72] Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.09.032

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[77] Nonoperative Management of Femoroacetabular Impingement in Adolescents: Clinical Outcomes at a Mean of 5 Years: A Prospective Study. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211030512

[78] No evidence exists on outcomes of non‐operative management in patients with femoroacetabular impingement and concomitant Tönnis Grade 2 or more hip osteoarthritis: a scoping review. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07274-y

[79] Intramedullary and extramedullary tibial alignment guides applied to each knee of the same patient resulted in no significant differences in radiological or clinical outcomes. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09390-5

[81] Prognostic utility of an magnetic resonance imaging-based classification for operative versus nonoperative management of ulnar collateral ligament tears: one-year follow-up. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.063

[82] Can we predict the outcome of a partial rupture of the anterior cruciate ligament?. Knee Surgery, Sports Traumatology, Arthroscopy. 1997. DOI: 10.1007/s001670050015

[83] Normative values and affecting factors for the elbow range of motion. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217728711

[84] Outcome of Surgical Treatment of Hip Femoroacetabular Impingement Patients with Radiographic Osteoarthritis: A Meta-analysis of Prospective Studies. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00380

[85] Eighty Percent of Patients With Surgical Hip Dislocation for Femoroacetabular Impingement Have a Good Clinical Result Without Osteoarthritis Progression at 10 Years. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-4025-8

[86] An Online Video Investigation Into the Mechanism of Elbow Dislocation. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.12.017

[87] Risk and risk factors for revision after primary reverse shoulder arthroplasty for cuff tear arthropathy and osteoarthritis: a Nordic Arthroplasty Register Association study. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.060

[88] Decreasing Incidence of Anterior Cruciate Ligament Tears and Increasing Utilization of Anterior Cruciate Ligament Reconstruction in the United States From 2010 to 2020. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.08.018

[89] Elucidating trends in revision reverse total shoulder arthroplasty procedures: a retrieval study evaluating clinical, radiographic, and functional outcomes data. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.06.004

[90] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[91] Normative values of isometric elbow strength in healthy adults: a systematic review. Shoulder & Elbow. 2018. DOI: 10.1177/1758573217748643

[92] Treatment of proximal humeral dysplasia epiphysealis hemimelica with custom hemiarthroplasty: a case report. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.08.043

[93] Concurrent Cervical Spine Pathology Is Associated With No Clear Difference in Clinical Outcomes, but Increased Complication Rates Following Shoulder Surgery: A Systematic Review. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.01.010

[95] Differences in subacromial distance during shoulder axial rotation between standing and supine positions. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.009

[96] Reconsidering the clinical outcomes of the stemless reverse total shoulder arthroplasty design implant. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2024.00836

[98] Development of a Machine Learning Algorithm for Prediction of Complications and Unplanned Readmission Following Primary Anatomic Total Shoulder Replacements. Journal of Shoulder and Elbow Arthroplasty. 2022. DOI: 10.1177/24715492221075444

[99] Medium-term clinical results of a linked total elbow replacement system. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b10.33815

[103] Trends associated with distal biceps tendon repair in the United States, 2007 to 2011. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.012

[104] Single-Stage Versus Staged Fasciectomy for Severe PIPJ Contractures in Dupuytren Disease: A Retrospective Comparative Study. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.10.019

[106] Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon’s experience?. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.010

[111] Current Concepts Review - Methods for Locating Missing Patients for the Purpose of Long-Term Clinical Studies. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199803000-00018

[112] 2025 ICM: Abbreviated Two- and 1.5-Stage. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.075

[113] Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.03.003

[114] Chondrosarcoma of the Pelvis and Upper End of the Femur: AN ANALYSIS OF FACTORS INFLUENCING SURVIVAL TIME IN ONE HUNDRED AND THIRTEEN CASES.. The Journal of Bone and Joint Surgery. American Volume. 1972.

[115] Ewing Sarcoma Family of Tumors. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201002000-00004

[116] Mobile and Fixed-Bearing (All-Polyethylene Tibial Component) Total Knee Arthroplasty Designs. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.j.00157

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.