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Study Design

Hierarchy of orthopaedic evidence, from meta-analyses to case series, with a focus on mitigating methodological deficiencies and statistical fragility.

Overview

Prospective randomized therapeutic study designs, even at Level-I or II evidence, do not inherently ensure research quality or reporting standards [1]. To improve future clinical research, emphasis must shift toward the originality of the study purpose and the rigor of the clinical design method [2]. While the International Hip Outcome Tool (iHOT-33) serves as a valid primary outcome measure for prospective patient evaluation and randomized clinical trials [3], many documents describing randomized controlled trials remain study protocols that outline design and objectives without reporting results or conclusions from completed data analysis [5].

Definitive conclusions regarding specific technical improvements in arthroscopic Bankart repair are currently lacking due to an absence of prospective clinical studies [8]. Consequently, there is a critical need for greater standardization of outcomes and instruments in shoulder arthroplasty trials, driven by inconsistent selection of outcomes and measurement devices [11]. Outcome estimation must aim to identify a clinically important difference [17], present measures of effects with confidence intervals [17], and take necessary steps to minimize bias [17].

Future outcome studies should utilize Patient Acceptable Symptom State (PASS) thresholds to define treatment success [18]. Trialists must employ stopping rules that require a large number of outcome events and ensure adequate safety data to prevent biased clinical decisions [19]. Further research is required to assess larger patient cohorts for outcomes following arthroscopic treatment of off-track Hill-Sachs lesions using fresh osteochondral allograft plugs and to compare these outcomes to size-matched approaches [40]. Clinical registries, which are designed to answer specific research questions with prospective data collection, offer higher generalizability and longitudinal follow-up compared to administrative databases and should not be categorized with them [42].

Anatomy & Pathophysiology

Kinematics and Measurement: Anterior-posterior glenohumeral kinematics is not fully restored after biceps rerouting [43], whereas exercise therapy for supraspinatus tears does not alter glenohumeral kinematics during internal or external rotation with the arm at the side [47]. Quantifying scapulohumeral rhythm via dynamic radiography can diagnose shoulder pathology and monitor treatment response [45]. Active motion remains an important determinant of patient-assessed shoulder function [48]. The supraspinatus possesses a greater mechanical advantage versus other tested muscles in the neutral arm position [56]. Following a Latarjet procedure, the coracobrachialis and short head of biceps exhibit increased extension and internal rotation moment arms at higher degrees of elevation compared with native shoulders [49]. Reverse total shoulder arthroplasty tends to have fewer motions at humeral elevations above 100° compared with anatomic shoulder arthroplasty [76].

Assessment Modalities: The Microsoft Kinect sensor plus Medical Interactive Recovery Assistant software allows precise shoulder range of motion measurement outside the clinic setting [52], with Kinect v2 demonstrating very good agreement with 3D motion analysis for measuring shoulder range of motion and motion smoothness parameters [72]. Isometric muscle strength tests during abduction and rotation tasks measured using the Biodex dynamometer can be employed to investigate the effect of shoulder joint pathology on muscle strength [61]. Standardized protocols addressing the psychometric properties of shoulder proprioception measures are needed [57]. A valid and repeatable measurement of pectoralis minor extensibility is needed to evaluate its effect on shoulder movement and biomechanics [44]. Shoulder physical functions were mapped to American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information System scores [71].

Osseous and Soft Tissue Pathophysiology: A posterior acromial bone block is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric posterior glenohumeral instability model [62]. The pathophysiology of frozen shoulder differs between the upper and lower parts of the joint capsule [63]. Statistical shape models that estimate native glenoid width based on glenoid height demonstrate unacceptable measurement errors despite a high correlation [69]. Both open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement significantly improved shoulder function and are relatively safe procedures [70].

Classification

C-EOS: The classification system for Early-Onset Scoliosis serves as a foundation to guide ongoing research efforts and standardize communication in the clinical setting [7].

King et al.: The classification system for adolescent idiopathic scoliosis is substantially reproducible but only moderately reliable according to Landis and Koch, or fair and poor according to Svanholm et al. [51].

Rockwood: The Rockwood classification is commonly used in Japan to assess severity of acromioclavicular joint separations, but there is some disagreement regarding the assessment for the diagnosis of type IV [60].

Arthroscopic International Cartilage Repair Society: A high correlation with histological assessment of depth provides evidence of validity for the Arthroscopic International Cartilage Repair Society Classification System [58].

Second-generation appropriateness: The validity of the second-generation appropriateness classification system for total knee arthroplasty was generally supported [59].

Proximal Humerus Fracture: In randomized controlled trials studying proximal humerus fractures, most studies rely on fracture pattern classification systems to describe inclusion and exclusion criteria, but these fail to objectively delineate which fractures should be included [50].

Rotator Cuff: Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [46].

Other Considerations: The vast majority of randomized controlled trials (>85%) did not enroll patients based on disease severity, as measured by PROM score thresholds or radiographic classifications, in their inclusion criteria [6]. Reliable classification leads to more confidence that patients can be treated like similar patients in a study that had success, provided the reliability study environment is proper, the statistics are appropriate, and the magnitude of the ICC is acceptable [65]. A referenced study on trimalleolar fractures has methodological limitations regarding fracture classification standardization, soft tissue assessment, and confounding factors [67]. The commentary on trimalleolar fractures recommends adopting standardized classification systems and comprehensive evaluation protocols to enhance future research robustness [67]. The authors of a letter to the editor recommend caution when interpreting the results of the Ringenberg et al. study, stating that the conclusion regarding the inherent issue of classification reliability is incorrect and that the study does not add new knowledge to current understanding [55].

Clinical Presentation

The gold-standard prospective randomized therapeutic study design does not inherently ensure quality research or reporting [1]. Most clinical research fails to be useful due to design flaws rather than findings, often lacking problem-based context or pragmatism [39]. Selection bias can cause serious misinterpretation of results, and investigators must articulate personal biases inherent in their hypotheses [15]. The vast majority of randomized controlled trials (>85%) did not enroll patients based on disease severity thresholds or radiographic classifications in their inclusion criteria [6].

Outcome Measures: The International Hip Outcome Tool (iHOT-33) serves as a primary outcome measure for prospective patient evaluation and randomized clinical trials [3]. The Dutch version of the Oxford Shoulder Score has proven feasible and understandable in clinical trials [12]. Discrepancies in patient-reported outcomes are evident, with patients declining trial enrolment reporting more severe symptoms than those who participated [38]. Data on long-term test-retest reliability of baseline cognitive assessments using ImPACT help establish the effects of clinically pragmatic testing intervals [31].

Classification and Diagnostic Tools: The Classification of Early-Onset Scoliosis (C-EOS) provides a foundation to guide ongoing research and standardize clinical communication [7]. Clinical historical, examination, and surgical findings influence classification and treatment choices for the superior labrum [14]. Physicians must be aware of variable phenotypes in Hajdu-Cheney syndrome to achieve early diagnosis and management [37]. The relative complexity of diagnostic tools for hip microinstability illustrates the difficulty clinicians face in making this diagnosis [32]. Even with specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptoms [9].

Research Methodology: A systematic review requires clearly stated objectives, an explicit reproducible methodology, a systematic search to identify all eligible studies, an assessment of validity via risk of bias, and systematic presentation of findings [33]. The relative complexity of diagnostic tools for hip microinstability illustrates the difficulty clinicians face in making this diagnosis [32]. A focus on outcome measures helps readers elucidate the meaning of basic science studies, though comparative clinical studies are ultimately required to advise surgical treatment [35]. Identified items for shoulder instability research can facilitate future trial design and form the basis for a core outcome set [36].

Study Protocols and Specific Tools: Several documents describing advanced hippotherapy simulators in children with cerebral palsy and three-dimensional corrective exercise therapy for idiopathic scoliosis are study protocols that do not report results or conclusions from completed data analysis [5, 13]. A clinically applicable trauma frailty scale (Nottingham Trauma Frailty Index) using easily measured physiological and functional parameters can guide patient care and stratify quality improvement and research projects [34]. The author recommends focusing on the originality of the study purpose and clinical design method to improve future research [2].

Investigations

Plain radiography: Prediction models combining plain radiographic findings demonstrate higher diagnostic values than individual findings for children with complete discoid lateral meniscus [68]. A new computed method (MPA) on short lateral radiographs for measuring tibial slope shows excellent correlation to CT scan and is recommended as a standard [78]. Objective radiographic data may aid in preliminary diagnosis and treatment recommendations for Blauth Type III thumb hypoplasia, though in-person physical examination remains necessary [85]. Radiological and clinical differences exist within end-stage knee osteoarthritis based on joint space loss patterns in standing extended view and fixed flexion view [86]. The reproducibility of stress radiography for evaluation of posterior knee laxity may be influenced by multiple variables, necessitating standardized methods to minimize measurement error [90].

MRI: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention [74]. MRI is primarily used for preoperative planning rather than diagnosis [87]. A systematic approach to MRI interpretation facilitates accurate and timely evaluation of knee injuries by describing normal appearances, optimal pulse sequences, and signs of injury [73]. MRI-specific thresholds for functional patella alta relative to both tibia and trochlea should improve the conventional assessment using the Caton–Deschamps index, which was originally developed for true lateral radiographs [53]. MRI is successful in determining the presence or absence of tears in discoid menisci, though the ability to determine tear type in discoid menisci is questionable [93]. Clinically symptomatic athletes with normal MRI findings represent a difficult category requiring separate study in future prospective research [87]. The 'magic angle' phenomenon can cause artifactual signal in MRI [87]. Few MRI findings showed large magnitude associations with chronic low back pain or radicular symptom outcomes even when applying more specific definitions for spine-related symptom outcomes [9]. Control subjects in MRI studies were screened for past anterior knee pain [87].

CT: Alignment with MRI-based patient-specific instruments is at least as good as, if not better than, that with CT-based PSI [75].

Other Considerations: The use of prospective randomized therapeutic study designs (Level-I or II evidence) does not ensure quality research or reporting [1]. The vast majority of randomized controlled trials (>85%) did not enroll patients based on disease severity, as measured by PROM score thresholds or radiographic classifications, in their inclusion criteria [6]. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI [66]. A national, multi-centre, three-armed observational study (registry with retrospective and prospective cohorts) is designed to establish a perilunate injury registry and examine long-term clinical and radiographic outcomes [30]. Future randomized controlled trials and large observational cohort studies targeted at clinical research deficiencies will strengthen the evidence and improve informed decision making regarding the management of symptomatic femoroacetabular impingement [92]. Utilizing standard positioning for mice is recommended when studying various disorders of the spine to avoid technical causes for the appearance of a curve [95].

Treatment

Non-Operative

Non-operative management is indicated for adult patients younger than 65 years with proximal humeral fractures, as available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management in this cohort [96]. While more than one-third of patients with adult symptomatic lumbar scoliosis improved with non-operative management, they often continued to experience symptoms during strenuous activity [84]. Complete and distal ulnar collateral ligament tears carry a markedly increased risk of failing nonoperative care compared with proximal, partial tears [101]. For adhesive capsulitis, surgery after failure of conservative treatment ranked highest across all range of motion domains [98].

Operative

Indications: Surgery is considered when non-operative management fails or when specific high-risk anatomical injuries are present, such as complete and distal ulnar collateral ligament tears [101]. A randomized trial compared meniscal allograft transplantation to non-operative treatment for patients with a symptomatic meniscal deficient knee compartment [97].

Surgical Approach / Technique: Prospective clinical studies are currently lacking to allow for definitive conclusions on specific technical improvements in arthroscopic Bankart repair [8]. A randomized trial aims to establish definitive evidence on the comparison between all-arthroscopic and mini-open repair of small or moderate-sized rotator cuff tears at an international level [21]. Despite improvements in techniques, results for AC-joint instability remain imperfect with frequent complications, and there is a lack of high-level evidence such as prospective cohort studies or controlled studies for non-operative treatment [83].

Implant Selection: Conventional non-anatomic ACL reconstruction techniques do not prevent early osteoarthritis nor restore normal dynamic knee function [89]. High-quality prospective randomized trials with precise outcome measures are needed to validate the benefits of restoring anatomy in ACL reconstruction [89].

Alignment / Balancing Strategy: The most rigorous scientific methodology utilizes a control arm that represents a clinically relevant baseline for comparison [91]. Future research should investigate perioperative management using treatment groups frequently performed in clinical practice as a baseline control arm [91].

Pain Management: Outcome estimation should aim at identifying a clinically important difference, presenting measures of effects with confidence intervals, and taking necessary steps to minimize bias [17]. Trialists should use stopping rules that require a large number of outcome events and ensure adequate safety data to prevent biased clinical decisions [19].

Adjuncts: The use of prospective randomized therapeutic study designs (Level-I or II evidence) does not ensure quality research or reporting [1]. Clinical research should focus on the originality of the study purpose and the clinical design method to improve future research [2].

Setting of Care: 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 [4].

Other Considerations: Greater standardization of outcomes and instruments is needed in shoulder arthroplasty trials [11]. The International Hip Outcome Tool (iHOT-33) can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials [3]. The application and evaluation of the Dutch version of the Oxford Shoulder Score in clinical trials proved feasible and understandable [12]. Current studies on proximal humeral fractures typically lack randomization, comparators, and independent evaluation, resulting in an inability to produce clinical conclusions [16]. Patient acceptable symptom state (PASS) thresholds can be used to define treatment success in future outcome studies [18]. Five-year follow-up results confirm no statistically or clinically significant differences between operative and non-operative treatment for adults with a displaced fracture of the proximal humerus [99].

Complications

Study Design Limitations: The use of prospective randomized therapeutic study designs (Level-I or II evidence) does not ensure quality research or reporting [1]. Selection bias can cause serious misinterpretation of study results [15], and the hypothesis of a clinical study affords opportunity for investigators to articulate their own personal bias [15]. Current studies on proximal humeral fractures typically lack randomization, comparators, and independent evaluation, resulting in an inability to produce clinical conclusions [16]. Ten articles on the long-term follow-up of patients after primary total hip arthroplasty were found to be deficient in terms of design [27], flawed by confusing data [27], and contain results of doubtful validity [27]. The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate [26], and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods [26]. Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter the significance of study findings in reverse total shoulder arthroplasty literature [80].

Publication Bias and "Spin": The nature of "spin" in published biomedical literature varies according to study design, with the highest variability in prevalence present in trials [25]. Journal editors should set standards for publication to avoid misleading readers with short-term results [22]. Fewer scientific journals and congresses might be better if strict criteria regarding long-term follow-up and comparison with standard techniques were applied [22]. Reproducible results that hold up over time characterize the mark of a successful surgical procedure [28].

Long-Term Follow-Up Challenges: Long-term studies are difficult to design due to the challenge of forecasting future questions [28]. Psychological factors may play a role in determining who responds to long-term follow-up surveys [29], whereas the timing of incentives does not play a role in determining who responds to long-term follow-up surveys [29]. Limiting follow-up to automated methods may have the potential to transform the way that outcome-based research is designed and conducted [23] and may provide substantially better research value in large prospective cohorts [23].

Other Considerations: Review articles and database mining studies are important for rare clinical syndromes where original trials are unfeasible [94]. The increasing trend of review articles and database mining studies raises concerns about the future availability of original articles needed to conduct such reviews [94].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity initiation; however, editors suggest a minimum follow-up of 6 months is required to assess general functional outcomes, implying that early recovery metrics are insufficient for definitive conclusions [54]. Activities of daily living should be measured across all phases of care, including this initial period [77].

Full activity (months): No specific month range for full activity return is defined in the available evidence. While two total knee arthroplasty designs functioned equivalently at early follow-up in low-to-moderate-demand patients, the literature on superior labrum anterior and posterior tears notes substantial variability in outcomes reporting with few studies noting time to return to play [102, 103].

Complete recovery / outcome plateau (months): Long-term studies are necessary to determine when outcomes stabilize, as failure-free survival rates for primary arthroscopic Bankart repair drop dramatically over time [106]. Patients with a preoperative symptom duration of two years or greater do not experience inferior outcomes at mid-term follow-up compared to those with shorter durations, suggesting a plateau may be reached regardless of initial chronicity [107]. The success of pulsed electromagnetic fields for tibial delayed unions is not a time-dependent phenomenon [105].

Rehabilitation protocol: Closed fracture management and regular follow-up were determining factors for better functional outcomes in distal femur fractures treated with open reduction and internal fixation [79]. Hypotheses suggest that wearable devices for remote monitoring could improve short-term functional outcomes and reduce costs, though this requires further validation [82].

Functional milestones: The Measurement of Shoulder Activity Level can be utilized to define patient populations and assess activity levels as a prognostic factor in shoulder disorders [104]. However, the sole assessment of recurrent dislocation is inadequate to define natural history or treatment rationale, and conclusions regarding treatment recommendations cannot be drawn from studies lacking comparative methods [26].

Other Considerations: 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 [4]. A long-term follow-up study with a large cohort is required to determine if intraoperative load sensors improve early postoperative results of posterior-stabilized TKA for osteoarthritis with varus deformities [10]. Further studies with long-term follow-up are needed to determine whether the grafted area in Autologous Matrix-Induced Chondrogenesis will maintain structural and functional integrity over time [20]. Journal editors should set standards for publication to avoid misleading readers with short-term results, suggesting that strict criteria regarding long-term follow-up and comparison with standard techniques be applied [22]. Limiting follow-up to automated methods may transform outcome-based research design to provide better research value in large prospective cohorts [23]. Prospective, long-term observational studies are needed to understand the natural history of early post-traumatic osteoarthritis before formulating and studying interventions [24]. Ten articles on the long-term follow-up of patients after primary total hip arthroplasty were found to be deficient in design, flawed by confusing data, and to contain results of doubtful validity [27]. Reproducible results that hold up over time characterize the mark of a successful surgical procedure, but long-term studies are difficult to design due to the challenge of forecasting future questions [28]. Psychological factors may play a role in determining who responds to long-term follow-up surveys, although timing of incentives does not [29]. Editors provide guidelines on required lengths of follow-up in clinical reports, suggesting no less than 6 months for general functional outcomes, 12 months for nerve repairs, and 2 years for joint function recovery [54].

Key Evidence

  • [L4] The use of the gold-standard trial design, the prospective randomized therapeutic study (Level-I or II evidence), does not ensure quality research or reporting. (10.2106/jbjs.f.00858)
  • [L2] The author recommends focusing on the originality of the study purpose and the clinical design method to improve future research. (10.1177/1753193415583624)
  • [L4] It can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials. (10.1016/j.arthro.2012.03.013)
  • [L4] Larger and long-term controlled trials are needed to support its clinical effectiveness. (10.1186/s12891-018-2067-x)
  • [L2] This document is a study protocol describing the design and objectives of a randomised controlled trial; it does not report results or conclusions from completed data analysis. (10.1186/1471-2474-11-71)
  • [L1] The vast majority of RCTs (>85%) did not enroll patients based on disease severity, as measured by PROM score thresholds or radiographic classifications, in their inclusion criteria. (10.2106/jbjs.23.00629)
  • [L4] This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting. (10.2106/jbjs.m.00253)
  • [L5] Prospective clinical studies are currently lacking to allow for definitive conclusions on specific technical improvements. (10.1007/s00167-015-3952-6)
  • [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. (10.1186/1471-2474-15-152)
  • [L2] A long-term followup study with a large cohort is required. (10.1007/s00167-018-5314-7)
  • [L2] The study suggests the need for greater standardization of outcomes and instruments in shoulder arthroplasty trials. (10.1371/journal.pone.0187865)
  • [L4] Application and evaluation in clinical trial proved feasible and understandable. (10.1016/j.jse.2010.01.017)
  • [L3] This document is a study protocol for a prospective non-randomized trial and does not report results or conclusions. (10.1186/s12891-022-05057-7)
  • [L3] Clinical historical, examination, and surgical findings influence classification and treatment choices. (10.1177/0363546511422869)
  • [L5] Selection bias can cause serious misinterpretation of study results, and the hypothesis of a clinical study affords opportunity for the investigators to articulate their own personal bias. (10.1016/j.arthro.2009.12.004)
  • [L2] Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. (10.1016/j.jse.2007.03.016)
  • [L5] Outcome estimation should aim at identifying a clinically important difference, at presenting measures of effects with confidence intervals and at taking the necessary steps to minimize bias. (10.1302/2058-5241.3.170064)
  • [L3] PASS thresholds can be used to define treatment success in future outcome studies. (10.1007/s00167-021-06592-x)
  • [L5] Trialists should use stopping rules that require a large number of outcome events and ensure adequate safety data to prevent biased clinical decisions. (10.2106/jbjs.k.01412)
  • [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. (10.1007/s00167-010-1042-3)
  • [L2] The trial aims to establish definitive evidence on this question at an international level. (10.1186/1471-2474-7-25)
  • [L5] The author proposes that journal editors set standards for publication to avoid misleading readers with short-term results, suggesting that fewer scientific journals and congresses might be better if strict criteria regarding long-term follow-up and comparison with standard techniques were applied. (10.1007/s001670050074)
  • [L2] Limiting follow-up to automated methods may have the potential to transform the way that outcome-based research is designed and conducted to provide substantially better research value in large prospective cohorts. (10.2106/jbjs.19.00531)
  • [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. (10.1177/0363546511411654)
  • [L2] The nature of spin varied according to study design, with the highest variability in prevalence present in trials. (10.1371/journal.pbio.2002173)
  • [Letter] The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods. (10.1177/0363546510379343)
  • [L4] Ten articles on the long-term follow-up of patients after primary total hip arthroplasty were found to be deficient in terms of design, flawed by confusing data, and to contain results of doubtful validity. (10.2106/00004623-198870090-00013)
  • [L5] Reproducible results that hold up over time characterize the mark of a successful surgical procedure, but long-term studies are difficult to design due to the challenge of forecasting future questions; however, the future holds promise for developing better long-term studies with higher levels of evidence as more information is prospectively collected. (10.1016/j.arthro.2015.12.027)
  • [L2] Psychological factors may play a role in determining who responds to long-term follow-up surveys although timing of incentives does not. (10.1371/journal.pone.0079179)
  • [L4] This paper describes the protocol for a national, multi-centre, three-armed observational study (registry with retrospective and prospective cohorts) designed to establish a perilunate injury registry and examine long-term clinical and radiographic outcomes to guide future evidence-based treatment guidelines. (10.1186/s12891-024-08227-x)
  • [L4] These data help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability. (10.1177/0363546509343805)
  • [L5] The relative complexity of the final diagnostic tool is illustrative of the difficulty clinicians face when making this diagnosis. (10.1007/s00167-022-06933-4)
  • [L5] A systematic review can be done with a clearly stated set of objectives with an explicit, reproducible methodology; a systematic search that attempts to identify all studies that would meet the eligibility criteria; an assessment of the validity of the findings of the included studies, such as through the assessment of risk of bias; and systematic presentation and synthesis of the characteristics and findings of the included studies. (10.1177/1753193415573151)
  • [L3] We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. (10.1302/0301-620x.106b4.bjj-2023-1058.r1)
  • [L5] A focus on measures of outcomes may help readers elucidate the meaning and relevance of basic science studies, though comparative clinical studies are ultimately required to best advise surgical treatment of pathology. (10.1016/j.arthro.2010.06.007)
  • [L5] These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set. (10.1016/j.jseint.2023.06.012)
  • [Case_report] Physicians should be aware of variable phenotypes so that early diagnosis and management may be achieved. (10.1186/s12891-020-3181-0)
  • [L4] We observed discrepancies in patient-reported outcomes, with those who declined enrolment reporting more severe symptoms. (10.1002/ksa.12546)
  • [L5] Most clinical research fails to be useful not because of its findings but because of its design, as many studies do not satisfy key features such as problem base, context placement, and pragmatism. (10.1371/journal.pmed.1002049)
  • [L4] Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches. (10.1016/j.jse.2024.06.008)
  • [L5] Clinical registries differ from administrative databases by being designed to answer specific research questions with prospective data collection, offering higher generalizability and longitudinal follow-up, and should not be categorized with administrative databases. (10.1016/j.jse.2017.02.003)
  • [L3] However, A-P glenohumeral kinematics was not fully restored after BR, and its effect on long-term clinical outcomes requires further investigation. (10.1177/03635465241301778)
  • [Letter] A valid and repeatable measurement of extensibility would be a valuable addition to studies evaluating the effect of PM on shoulder movement and biomechanics, and additional work is needed to improve or develop new measurement instruments and methods. (10.1016/j.jht.2017.06.007)
  • [L4] Quantifying kinematic patterns like SHR using DDR can be implemented as a novel, safe, and cost-effective method to diagnose shoulder pathology and to monitor response to treatment. (10.1016/j.jse.2022.12.023)
  • [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. (10.1007/s00167-014-3486-3)
  • [L2] Despite satisfactory clinical outcomes following exercise therapy, glenohumeral kinematics did not change. (10.1007/s00167-017-4695-3)
  • [L3] Active motion was an important determinant of patient-assessed shoulder function. (10.1016/j.jse.2015.07.011)
  • [L5] Both muscles had increased extension and internal rotation moment arms at higher degrees of elevation compared with the native shoulders. (10.1016/j.jse.2023.10.011)
  • [L2] In RCTs studying proximal humerus fractures, most studies rely on fracture pattern classification systems to describe inclusion and exclusion criteria, but these fail to objectively delineate which fractures should be included. (10.1016/j.xrrt.2025.07.023)
  • [L4] The classification system of King et al. is substantially reproducible but only moderately reliable according to Landis and Koch, or fair and poor according to Svanholm et al. (10.2106/00004623-199808000-00003)
  • [L5] This technology, which can be easily set up, may also allow precise shoulder ROM measurement outside the clinic setting. (10.1016/j.jse.2017.06.004)
  • [L3] These thresholds, specifically developed for MRI, should improve the conventional assessment using the Caton–Deschamps index, originally developed for true lateral radiographs. (10.1002/ksa.12757)
  • [L5] The editors provide guidelines on required lengths of follow-up in clinical reports, suggesting no less than 6 months for general functional outcomes, 12 months for nerve repairs, and 2 years for joint function recovery, while noting that these are considerations rather than fixed academic rules. (10.1177/1753193418821101)
  • [Letter] The authors recommend caution when interpreting the results of the Ringenberg et al study, stating that the conclusion regarding the inherent issue of classification reliability is incorrect and that the study does not add new knowledge to current understanding. (10.1016/j.jse.2018.02.075)
  • [L5] The supraspinatus has a greater mechanical advantage versus the other tested muscles in the neutral arm position. (10.1016/j.jse.2008.10.021)
  • [L1] Standardized protocols addressing the psychometric properties of shoulder proprioception measures are needed. (10.1016/j.jht.2017.05.003)
  • [L4] A high correlation with histological assessment of depth provides evidence of validity for this classification system. (10.1016/j.arthro.2016.12.012)
  • [L3] The validity of the second-generation appropriateness system was generally supported. (10.1186/s13018-021-02371-z)
  • [L4] The Rockwood classification is commonly used in Japan to assess severity, but there is some disagreement regarding the assessment for the diagnosis of type IV. (10.1016/j.jseint.2019.11.006)
  • [L2] These isometric muscle strength tests can be further employed to investigate the effect of different shoulder joint pathology on muscle strength. (10.1016/j.jse.2023.03.025)
  • [L5] A posterior acromial bone block is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. (10.1016/j.arthro.2024.01.014)
  • [L5] The pathophysiology of frozen shoulder differs between the upper and lower parts of the joint capsule. (10.1016/j.jse.2018.03.010)
  • [L5] Reliable classification leads to more confidence that patients can be treated like similar patients in a study that had success, provided the reliability study environment is proper, the statistics are appropriate, and the magnitude of the ICC is acceptable. (10.1177/0363546517743761)
  • [L2] In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. (10.1016/j.arthro.2018.03.010)
  • [L5] The commentary concludes that the referenced study by Zhou et al. has methodological limitations regarding fracture classification standardization, soft tissue assessment, and confounding factors, and recommends adopting standardized classification systems and comprehensive evaluation protocols to enhance future research robustness. (10.1186/s13018-025-05628-z)
  • [L3] The prediction models combining the plain radiographic findings showed higher diagnostic values than the diagnostic values of the individual radiographic findings. (10.1016/j.arthro.2017.08.252)
  • [L4] Statistical shape models that estimate native glenoid width based on glenoid height demonstrate unacceptable measurement errors, despite a high correlation. (10.1016/j.jse.2024.01.039)
  • [L3] Both techniques significantly improved shoulder function and are relatively safe procedures. (10.1016/j.jse.2019.09.035)
  • [L4] Shoulder physical functions were mapped to outcome scores. (10.1016/j.jse.2019.08.017)
  • [L4] Kinect v2 demonstrated very good agreement with 3D motion analysis for measuring shoulder range of motion and motion smoothness parameters, suggesting it is a valid and reliable tool for dynamic shoulder assessment. (10.1016/j.jse.2016.10.026)
  • [L5] A systematic approach to MRI interpretation facilitates accurate and timely evaluation of knee injuries, ensuring all clinically relevant structures are assessed by describing normal appearances, optimal pulse sequences, and signs of injury. (10.1177/0363546504272374)
  • [L3] MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention. (10.2106/jbjs.n.00947)
  • [L1] This systematic review and meta-analysis demonstrate that alignment with MRI-based PSI is at least as good as, if not better than, that with CT-based PSI. (10.1007/s00167-017-4637-0)
  • [L4] RTSA, although the latter tended to have fewer motions at humeral elevations above 100°. (10.1016/j.jse.2017.09.023)
  • [L3] Activities of daily living should be measured across phases of care and into long-term recovery. (10.1186/s12891-025-08284-w)
  • [L2] The new computed method (MPA) on short lateral radiographs showed excellent correlation to CT scan and is recommended as a standard. (10.1007/s00167-011-1414-3)
  • [L3] Closed fracture and regular follow up were determining factors for better functional outcomes. (10.1186/s13018-024-05054-7)
  • [L1] Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter significance of study findings. (10.1016/j.jse.2023.12.005)
  • [L2] The authors hypothesize that patients in the experimental group would exhibit improved short-term functional outcomes and experience cost and time savings compared to patients in the control group. (10.1186/s13018-023-03898-z)
  • [L5] Despite improvements in techniques, results remain imperfect with frequent complications, and there is a lack of high-level evidence such as prospective cohort studies or controlled studies for non-operative treatment, leaving numerous open questions regarding the best treatment approach. (10.1007/s00167-019-05666-1)
  • [L4] More than one-third of patients improved with non-operative management but continued to have symptoms during strenuous activity. (10.2106/jbjs.18.01184)
  • [L3] While in-person physical examination remains necessary, objective radiographic data may aid in preliminary diagnosis and treatment recommendations. (10.1016/j.jhsa.2024.04.005)
  • [L3] This study demonstrates that radiological and clinical differences exist within end-stage KOA based on joint space loss patterns. (10.1186/s12891-025-08943-y)
  • [Letter] The authors clarify that MRI is primarily used for preoperative planning rather than diagnosis, confirm that control subjects were screened for past anterior knee pain, acknowledge the potential for the 'magic angle' phenomenon to cause artifactual signal, and agree that clinically symptomatic athletes with normal MRI findings represent a difficult category requiring separate study in future prospective research. (10.1177/03635465990270062601)
  • [L5] Conventional non-anatomic ACL reconstruction techniques do not prevent early osteoarthritis nor restore normal dynamic knee function; restoring anatomy may be the key to success, but high-quality prospective randomized trials with precise outcome measures are needed to validate benefits. (10.1007/s00167-010-1222-1)
  • [L2] The reproducibility of stress radiography may be influenced by multiple variables, and standardized methods are needed to minimize measurement error. (10.1177/0363546504269723)
  • [L5] The most rigorous scientific methodology utilizes a control arm that represents a clinically relevant baseline for comparison, and future research should investigate perioperative management using treatment groups frequently performed in clinical practice as a baseline control arm. (10.1016/j.arth.2025.10.003)
  • [L5] Future randomized controlled trials and large observational cohort studies targeted at clinical research deficiencies will strengthen the evidence and improve informed decision making regarding the management of symptomatic femoroacetabular impingement. (10.5435/00124635-201300001-00010)
  • [L4] MRI is successful in determining the presence or absence of tears in discoid menisci; however, its ability to determine the tear type is questionable. (10.1007/s00167-013-2371-9)
  • [L5] While review articles and database mining studies are important for rare clinical syndromes where original trials are unfeasible, the increasing trend raises concerns about the future availability of original articles needed to conduct such reviews. (10.1016/j.jse.2023.01.012)
  • [L4] We recommend utilizing this standard in studying various disorders of the spine to avoid technical causes for the appearance of a curve. (10.1186/s12891-021-03949-8)
  • [L1] The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. (10.1016/j.xrrt.2021.04.014)
  • [L2] This is the first study to compare meniscal allograft transplantation to non-operative treatment. (10.1302/0301-620x.100b1.bjj-2017-0918.r1)
  • [L1] Surgery (after failure of conservative treatment) ranked highest across all ROM domains. (10.1016/j.arthro.2020.09.041)
  • [L1] These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years, with no statistically or clinically significant differences between operative and non-operative treatment. (10.1302/0301-620x.99b3.bjj-2016-1028)
  • [L4] Complete and distal tears carry a markedly increased risk of failing nonoperative care compared with proximal, partial tears. (10.1016/j.jse.2018.11.063)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)
  • [L4] The SLAP literature is characterized by substantial variability in outcomes reporting, with time to return to play noted in few studies. (10.1016/j.jse.2016.04.020)
  • [L1] It can be completed quickly and used in conjunction with patient-based measures of shoulder outcome to define patient populations for cohort studies, and to assess activity level as a prognostic factor in patients with shoulder disorders. (10.1097/01.blo.0000173255.85016.1f)
  • [L3] Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon. (10.1186/1749-799x-7-24)
  • [L4] Failure-free survival rates dropped dramatically over time. (10.1186/s12891-020-03223-3)
  • [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. (10.1016/j.jisako.2022.03.003)

See Also

References

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[14] Agreement in the Classification and Treatment of the Superior Labrum. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511422869

[15] Selection Bias Results in Misinterpretation of Randomized Controlled Trials on Arthroscopic Treatment of Patients With Knee Osteoarthritis. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.12.004

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[20] 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

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[22] Will we never learn?. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050074

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[25] ‘Spin’ in published biomedical literature: A methodological systematic review. PLOS Biology. 2017. DOI: 10.1371/journal.pbio.2002173

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[30] The Canadian Prospective Pragmatic Perilunate Outcomes (C3PO) trial; a protocol. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08227-x

[31] Long-Term Test-Retest Reliability of Baseline Cognitive Assessments Using ImPACT. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509343805

[32] Diagnosing Hip Microinstability: an international consensus study using the Delphi methodology. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06933-4

[33] About systematic reviews. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415573151

[34] Development and validation of a trauma frailty scale in severely injured patients: the Nottingham Trauma Frailty Index. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b4.bjj-2023-1058.r1

[35] Making Sense of Basic Science in Knee and Shoulder Research. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.06.007

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[37] Distinct severity of phenotype in Hajdu-Cheney syndrome: a case report and literature review. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3181-0

[38] 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

[39] Why Most Clinical Research Is Not Useful. PLOS Medicine. 2016. DOI: 10.1371/journal.pmed.1002049

[40] 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

[42] Are we throwing the baby out with the bath water?. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.02.003

[43] Effects of Biceps Rerouting on In Vivo Glenohumeral Kinematics in the Treatment of Large-to-Massive Rotator Cuff Tears. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241301778

[44] In response to the letter to the editor regarding: Resting pectoralis minor muscle length: An accurate way to determine if the muscle is shortened?. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.06.007

[45] Variation in scapulohumeral rhythm on dynamic radiography in pathologic shoulders: a novel diagnostic tool. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.12.023

[46] Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-014-3486-3

[47] Exercise therapy for treatment of supraspinatus tears does not alter glenohumeral kinematics during internal/external rotation with the arm at the side. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4695-3

[48] Measurement of active shoulder motion using the Kinect, a commercially available infrared position detection system. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.07.011

[49] Moment arms of the coracobrachialis and short head of biceps following a Latarjet procedure: a modeling study. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.10.011

[50] Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.023

[51] Interobserver Reliability and Intraobserver Reproducibility of the System of King et al. for the Classification of Adolescent Idiopathic Scoliosis. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199808000-00003

[52] Can shoulder range of movement be measured accurately using the Microsoft Kinect sensor plus Medical Interactive Recovery Assistant (MIRA) software?. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.06.004

[53] Standardized magnetic resonance image‐based assessment to define functional patella alta relative to both tibia and trochlea: A cross‐sectional comparative study. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12757

[54] The minimum length of follow-up in hand surgery reports. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193418821101

[55] Letter to the Editor regarding Ringenberg et al: “Interobserver and intraobserver reliability of radiographic classification of acromioclavicular joint dislocations”. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.075

[56] Shoulder abduction moment arms in three clinically important positions. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.10.021

[57] Shoulder proprioception: How is it measured and is it reliable? A systematic review. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.05.003

[58] Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2016.12.012

[59] Validation of a second-generation appropriateness classification system for total knee arthroplasty: a prospective cohort study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02371-z

[60] Methods used to assess the severity of acromioclavicular joint separations in Japan: a survey. JSES International. 2020. DOI: 10.1016/j.jseint.2019.11.006

[61] Test-retest reliability of isometric shoulder muscle strength during abduction and rotation tasks measured using the Biodex dynamometer. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.025

[62] A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.01.014

[63] Comparative proteome analysis of the capsule from patients with frozen shoulder. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.010

[65] The Critical Reader—Reliability. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517743761

[66] A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In‐Office Diagnostic Arthroscopy With Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.03.010

[67] Standardizing classification and assessment methods in clinical frailty scale evaluation for elderly trimalleolar fractures. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05628-z

[68] Prediction Models to Improve the Diagnostic Value of Plain Radiographs in Children With Complete Discoid Lateral Meniscus. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.08.252

[69] Statistical shape models that predict native glenoid width based on glenoid height are inaccurate in their current form: a cross-sectional study. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.039

[70] Retrospective review of open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement: a single surgeon's experience. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.09.035

[71] Mapping physical functions of the shoulder to American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information System scores. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.08.017

[72] Digital data acquisition of shoulder range of motion and arm motion smoothness using Kinect v2. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.10.026

[73] A Systematic Approach to Magnetic Resonance Imaging Interpretation of Sports Medicine Injuries of the Knee. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504272374

[74] MRI for the Evaluation of Knee Pain. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00947

[75] Favourable alignment outcomes with MRI-based patient-specific instruments in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4637-0

[76] Comparing daily shoulder motion and frequency after anatomic and reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.09.023

[77] Time-dependent, patient-centered perceptions of quality measures for total joint arthroplasty: a cross-sectional, choice modeling study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08284-w

[78] Development and validation of a new method for the radiologic measurement of the tibial slope. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1414-3

[79] Prospective study on functional outcome of distal femur fracture treated by open reduction and internal fixation using distal femur locking plate in Tibebe Ghion Specialized Hospital, Bahirdar, North West Ethiopia. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05054-7

[80] The fragility of statistical findings in the reverse total shoulder arthroplasty literature: a systematic review of randomized controlled trials. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.12.005

[82] Cost, time savings and effectiveness of wearable devices for remote monitoring of patient rehabilitation after total knee arthroplasty: study protocol for a randomized controlled trial. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03898-z

[83] Treatment of AC‐joint instability: what seems to be a small thing still leaves us with numerous open questions. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05666-1

[84] Pragmatic Interpretation Versus Pragmatic Application of the Adult Symptomatic Lumbar Scoliosis (ASLS)-1 Study. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.01184

[85] Radiographic Features of the Metacarpal in Blauth Type III Thumb Hypoplasia. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.04.005

[86] Clinical and radiological characteristics of novel subtypes of end-stage knee osteoarthritis based on joint space loss patterns in standing extended view and fixed flexion view. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08943-y

[87] Letter to the Editor. The American Journal of Sports Medicine. 1999. DOI: 10.1177/03635465990270062601

[89] A long journey to be anatomic. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1222-1

[90] Reliability of Stress Radiography for Evaluation of Posterior Knee Laxity. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504269723

[91] A Call for Clinically Relevant Study Control Arms: A Commentary. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.003

[92] Clinical Trials in Orthopaedics and the Future Direction of Clinical Investigations for Femoroacetabular Impingement. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201300001-00010

[93] Comparison of magnetic resonance imaging findings with arthroscopic findings in discoid meniscus. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2371-9

[94] Review articles and database studies. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.012

[95] Proper positioning of mice for Cobb angle radiographic measurements. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-03949-8

[96] Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.04.014

[97] A pilot randomized trial of meniscal allograft transplantation versus personalized physiotherapy for patients with a symptomatic meniscal deficient knee compartment. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b1.bjj-2017-0918.r1

[98] Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta‐analysis of Randomized Controlled Trials. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.09.041

[99] Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b3.bjj-2016-1028

[101] 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

[102] 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

[103] Variable reporting of functional outcomes and return to play in superior labrum anterior and posterior tear. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.04.020

[104] Measurement of Shoulder Activity Level. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000173255.85016.1f

[105] Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature. Journal of Orthopaedic Surgery and Research. 2012. DOI: 10.1186/1749-799x-7-24

[106] Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03223-3

[107] 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

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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.