A comparison of the Constant and Oxford shoulder scores in patients with conservatively treated proximal humeral fractures

doi:10.1016/j.jse.2007.04.019

Journal of Shoulder and Elbow Surgery

Volume 17, Issue 1, January–February 2008, Pages 37-41

https://doi.org/10.1016/j.jse.2007.04.019 Get rights and content

The Oxford shoulder scores (OSS) and Constant scores were collected prospectively for 103 patients treated conservatively for proximal humeral fractures. The paired scores were analyzed by assessing the degree of correlation, the agreement between the scores, and their sensitivity to change. Linear regression analysis was also performed. The scores correlated well with a coefficient of .84 (P < .001), demonstrating a clear relationship between the scoring systems. There was good agreement between the scores and both were sensitive to change over time (P < .001). We have also produced a regression equation (R2 = .70, P < .001) to predict the Constant score from the OSS. This study documents and compares the behavior of two scoring systems commonly used in the assessment of patients with proximal humeral fractures. The OSS may be considered as an alternative for assessing longer term follow-up, as, being solely subjective, it is easier to administer and correlates well with the Constant score.

Section snippets

Methods and materials

Between April 2000 and July 2003, OSS and Constant scores were collected prospectively for 103 consecutive adult patients treated conservatively for fractures of the proximal humerus. The decision to treat these fractures conservatively was made by the treating consultants, all of whom are experienced orthopaedic surgeons. There were 80 women and 23 men. The proximal humeral fracture was the only injury in all the patients.

The scores were collected by an experienced physiotherapist with a

Results

One-hundred and seventy-seven sets of scores were collected in 94 patients over the study period. Eighty-three patients attended at both 3 and 12 months, and 11 patients attended only once. The male/female ratio was 1:4. Mean age was 61.4 years (range, 15-85). A breakdown of patient demographics by fracture type is given in Table I.

The mean Constant score was 53.6 (standard deviation, 25.4) over a range of scores between 5 and 100. The mean OSS was 27.3 (standard deviation, 12.7) over a range

Relationship between scoring systems

Figure 1 shows the scatter plot with a trend line for the OSS against the Constant score and Figure 2 that for the OSS against the Constant score without the strength component. The correlation was in a negative direction with a Pearson's correlation coefficient (r) of 0.84 (P < .001, n = 177) in both cases. The scores also correlated well at 3 months r = 0.77 (P < .001, n = 94) and 12 months r = 0.87 (P < .001, n = 83). This demonstrates a clear relationship between the OSS and the Contant

Discussion

The assessment of outcome following interventions in patients with shoulder pathology is generally derived from a variety of scoring systems available to the orthopaedic surgeon. These scoring systems usually involve an assessment of a number of domains¹⁰ (ie, pain, activities of daily living (ADL's), range of movement (ROM), strength, instability, patients satisfaction) in combination to arrive at an overall measurement of function. Two of the more commonly used measures are the Constant score

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The 12 most used anatomic total shoulder arthroplasty implants on the New Zealand Joint Registry were included in the study. Implants were categorized by stem length—conventional, short, and stemless. The primary outcome was revision up to 7 years postsurgery. Secondary outcomes included revision cause, implant survival, and early functional outcomes as evaluated by the Oxford Shoulder Score. Analysis was stratified by age and surgeon volume to control for potential confounding.
A total of 3952 patients (conventional, 3114; short, 360; stemless, 478) were included in the study. No significant difference in revision rate per 100 component-years was found between stemless, short-stem, and conventional stemmed implants (revision rate per 100 component-years: conventional, 1.01 [95% confidence interval (CI) 0.89-1.14]; short, 0.54 [95% CI 0.25-1.03]; stemless, 0.99 [95% CI 0.51-1.74]). This finding was irrespective of patient age or surgeon volume. There were no cases of humeral loosening up to 7 years' follow-up and no cases of intraoperative humeral fracture in the stemless group. Functional outcomes at 6 months postsurgery suggested better outcomes in the stemless group compared with the conventional stem group (mean Oxford Shoulder Score: conventional, 39.4; stemless, 40.7; P value = .023).
The medium-term survival of stemless implants for anatomic total shoulder arthroplasty appears comparable to short-stem and conventional stemmed implants. Further follow-up is required to understand the long-term survivorship and functional outcomes between these groups.
Conflicts of interest among patients: do they exist and can they bias patient-reported outcome measures? A survey of shoulder and elbow patients
2022, Journal of Shoulder and Elbow Surgery
Potential conflicts of interest (COIs) are common among physicians and may bias physician-reported outcome assessment in orthopedic research. It is unclear whether patients have COIs and whether these COIs could affect patient-reported outcome measures (PROMs). The purposes of this study were to investigate (1) the existence of COIs among patients and (2) the potential of these COIs to bias PROMs with a pseudonymized survey among consecutive shoulder and elbow patients.
Between February and May 2021, 144 shoulder and elbow patients who underwent consultation at our outpatient clinic were included in the survey study. Of these patients, 79.2% (n = 114) completed the 11-item questionnaire. Variables including sex, existence of chronic diseases, level of education, and economic status were also assessed to investigate any association between these variables and patients' perceptions of COIs.
Whereas 33.3% of respondents (n = 38) believe that COIs exist among patients and 28.1% (n = 32) believe that COIs could bias PROMs in general, fewer patients admit to personal COIs (24.6%, n = 28) and COIs biasing their self-assessment (23.7%, n = 27). Patients more frequently suggest COIs in their personal environment, such as among family members or friends (27.2%, n = 31), than in their own medical treatment. Financial factors such as sick pay (34.2%, n = 39) are thought to be the most likely reason for having COIs, followed by interpersonal reasons such as maintaining medical affection or bonds (29.8%, n = 34). Of respondents, 42.1% (n = 48) believe that sole usage of PROMs poses risks in treatment evaluation and only 21% (n = 24) consider PROMs reliable. In addition, 43% of respondents (n = 49) believe that patients should disclose COIs routinely in medical treatment. Multinomial logistic regression analysis revealed that wealthier patients are more likely to believe COIs could bias PROMs (odds ratio for poor vs. middle class, 0.23 [95% confidence interval, 0.053-0.963]; odds ratio for lower-middle class vs. middle class, 0.19 [95% confidence interval, 0.052-0.677]).
Although the majority of shoulder and elbow patients deny having self-experienced COIs and deny biased PROMs due to COIs in their own medical treatment, a considerable number of patients admit to having experienced both. Further studies might be justified to investigate the actual clinical relevance of patients' COIs and their impact on value-based health care.
Preoperative partial-thickness rotator cuff tears do not compromise anatomic total shoulder replacement outcomes: medium-term follow-up
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Reverse total shoulder replacement (TSR) in elderly patients with primary osteoarthritis (OA) and rotator cuff pathology is increasingly being performed. The purpose of our study was to determine the medium-term results of anatomic TSR for OA in patients with established preoperative partial-thickness rotator cuff tears on magnetic resonance imaging (MRI) scans.
We reviewed a cohort of patients who had undergone anatomic TSR for OA with a preoperative MRI diagnosis of partial-thickness rotator cuff tear. Patients were assessed with preoperative and post operative Oxford Shoulder Scores, evaluation of their range-of-movement and clinical rotator cuff assessment. Anteroposterior and axillary radiographs were used to assess for any proximal humeral migration (using the Torchia classification) and any evidence of loosening. The Lazarus score was used to grade glenoid radiolucencies.
The study comprised 36 patients (14 men and 22 women) who underwent TSR and had partial-thickness rotator cuff tears on MRI; preoperatively, all showed mild to moderate fatty infiltration. The mean age of the patients was 79.2 years (range, 75-88 years); the mean follow-up period was 5.8 years (range, 5-9 years). Significant improvements in pain and range of movement were reported in all cases. At the final follow-up, the mean Oxford Shoulder Score was 42 points (range, 32-46 points), with a minimum improvement of 14 points (P = .001). External rotation (20° vs. 40°, P = .001), forward flexion (80° vs. 140°, P = .015), abduction (45° vs. 90°, P = .015), and internal rotation also improved. Lucencies were observed in 8 glenoids, with 6 showing grade 1 Lazarus changes, 2 showing grade 2, and none showing grade 3. There were no cases of implant loosening. Clinically, 4 patients had rotator cuff weakness but only 2 showed evidence of proximal migration. One patient remained satisfied, whereas the other patient, with moderate-grade proximal migration according to the Torchia classification, underwent revision for rotator cuff failure; one further patient underwent washout and DAIR (débridement, antibiotics, and implant retention) for infection.
There is a paucity of literature on whether a preoperative partial-thickness rotator cuff tear has an adverse effect on the outcome of TSR. Our results show that the presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic TSR in the medium term. With anatomic TSR having less morbidity for patients and allowing greater potential options for revision, we believe that the use of reverse shoulder arthroplasty in this cohort of patients, with partial rotator cuff tears, may not be necessary and we advocate consideration of anatomic TSR in this patient group.
Outcome measures reported for the management of proximal humeral fractures: a systematic review
2020, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The CMS is used for many different shoulder pathologies, and is considered an appropriate test for assessing outcomes for proximal humerus fractures. However, this appears to be based only on face validity and imitation, and has not been validated for proximal humerus fractures.2,45 Van de Water et al44 reported on the minimal clinically important difference (MCID) for the CMS in a population of proximal humerus fracture patients, but noted a concern regarding the test-retest reliability in this population as well.
The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.
A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.
Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.
Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.
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2019, Journal of Shoulder and Elbow Surgery
Multiple validated outcome scores are used to assess patients undergoing shoulder arthroplasty. The purpose of this study was to determine whether a correlation exists between 3 commonly used patient-reported outcome (PRO) measures in this population: Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Assessment Form, and Simple Shoulder Test (SST).
We performed a retrospective review of a shoulder arthroplasty database that routinely collects SPADI, ASES, and SST scores at each visit prospectively. Patients undergoing primary shoulder arthroplasty were identified. Assessments of correlation coefficients (Pearson correlation coefficient for ASES and SPADI scores and Spearman correlation coefficient for SST score) between each combination of PROs were performed overall and at each time point (preoperatively and 3, 6, 12, and 24 months postoperatively) to determine the level of association between PROs.
In total, 848 shoulder arthroplasty procedures were performed in 754 patients with 2796 unique clinical encounters. Preoperative correlations among PROs were moderate to strong (range, 0.66-0.77) but had the lowest correlation among all comparisons. Postoperative correlations were strong for all PRO comparisons (range, 0.73-0.94). Postoperative PRO correlations continued to strengthen over longer follow-up, with all values exceeding 0.78 at 2 years postoperatively. Conversion equations between PROs were calculated based on these highly correlated data.
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Video examination via the smartphone: A reliable tool for shoulder function assessment using the constant score
2019, Journal of Orthopaedic Science
Citation Excerpt :
CS relies heavily on shoulder strength and motion, while OSS accounts solely for pain and activities of daily living [14]. The CS has been validated for total shoulder arthroplasty, rotator cuff surgery, adhesive capsulitis, clavicle fractures and treatment of proximal humerus fractures [1,15–18]. The aim of this cross-sectional study was to validate a VE-based CS for clinical and research purposes.
The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination.
Fifty-one subjects (age 19–80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance.
Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was −0.53 points (95%CI: −2.6:1.6), with limits of agreement of −7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively.
VE can obtain a reliable estimate of shoulder function. The mean video CS was only −0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the “gold standard” estimate.

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Original articleA comparison of the Constant and Oxford shoulder scores in patients with conservatively treated proximal humeral fractures

Section snippets

Methods and materials

Results

Relationship between scoring systems

Discussion

J Elbow Shoulder Surg

J Elbow Shoulder Surg

A clinical method of functional assessment of the shoulder

Clin Orth Rel Res

Questionnaire on the perceptions of patients about shoulder surgery

J Bone Joint Surg [Br]

Treatment of displaced proximal humeral fractures in elderly patients

J Bone Joint Surg [Br]

Epidemiology of fracture of the upper end of the humerus

Clin Orthop

Original article
A comparison of the Constant and Oxford shoulder scores in patients with conservatively treated proximal humeral fractures