Context:Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. “Posterior instability” may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.Evidence Acquisition:Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.Study Design:Clinical review.Level of Evidence:Level 4.Results:In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.Conclusion:Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings.

Return to full duty following ACLR in active duty soldiers is lower than may be expected. More than 50% of service members have activity limitations or are unable to return to duty following surgery. These findings allow for preoperative discussion of expected outcome and the possibility that an anterior cruciate ligament tear even when reconstructed can lead to permanent military activity limitations and MEB.

Patient reported outcome measures (PROMs) are key tools when performing clinical research and PROM data are increasingly used to inform clinical decision-making, patient-centered care, health policy and more recently, reimbursement decisions. PROMs must possess particular properties before they are used. Thus purpose of this paper is to give an overview of PROMs, their definition, how their evidence can be assessed, how they should be reported in clinical research, how to choose PROMs, the types of PROMs available in orthopaedics, where these measures can be found, PROMs in orthopaedic clinical practice and what are some key next steps in this field. If PROMs are used in accordance with the guidance in this article, I believe we will gain considerable insight into PROMs in orthopaedics and will advance this field in a way that can contribute to science, improve patient care and save considerable resources. Why Patient Reported Outcome Measures? The development, testing and implementation of tools to aid in the measurement of phenomena in medicine are central to clinical practice and clinical research. Measurements in clinical practice form the basis of diagnosis, prognosis, evaluation and follow-up. Measurements in clinical research allow for the collection of data that afford us the information needed to test specific hypotheses [1]. The field of measurement in medicine includes both psychometrics and clinimetrics [2-4]. But, it has been argued thatthere is little distinction between these two areas [3]. Throughout this paper the term psychometrics will be used and more generally the term measurement to refer to these fields.

Background Meniscal allograft transplantation (MAT) is considered a viable surgical treatment option in the symptomatic, postmeniscectomy knee and as a concomitant procedure with ACL revision and articular cartilage repair. Although promising outcomes have recently been reported in active and athletic populations, MAT has not been well-studied in the high-demand military population. Questions/purposes (1) What proportion of active-duty military patients who underwent MAT returned to full, unrestricted duty? (2) What demographic and surgical variables, if any, correlated with return to full, unrestricted duty? Methods Between 2005 and 2015, three fellowship-trained sports surgeons (TMD, SJS, BDO) performed 110 MAT procedures in active-duty military patients, of which 95% (104 patients) were available for follow-up at a minimum 2 years (mean 2.8 ± SD 1.1 year). During the study period, indications for MAT generally included unicompartmental pain and swelling in a postmeniscectomized knee and as a concomitant procedure when a meniscal-deficient compartment was associated with either an ACL revision reconstruction or cartilage repair. Demographic and surgical variables were collected and analyzed. The primary endpoints were the decision for permanent profile activity restrictions and military duty termination by a medical board. The term “medical board” implies termination of military service because of medical reasons. We elected to set statistical significance at p < 0.001 to reduce the potential for spurious statistical findings in the setting of a relatively small sample size. Results Forty-six percent (48 of 104) of eligible patients had permanent profile activity restrictions and 50% (52 of 104) eventually had their military duty terminated by a military board. Only 20% (21 of 104) had neither permanent profile activity restrictions nor medical-board termination and were subsequently able to return to full duty, and only 13% (13 of 104) continued unrestricted military service beyond 2 years after surgery. Age, gender, tobacco use, and BMI did not correlate with return to full duty. Combat arms soldiers were less likely to have permanent profile activity restrictions (odds ratio 4.76 [95% confidence interval 1.93 to 11.8]; p = 0.001) and were more likely to return to full duty than soldiers in support roles (OR 0.24 [95% CI 0.09 to 0.65]; p = 0.005), although these findings did not reach statistical significance. Officers were more likely to return to full duty than enlisted soldiers at more than 2 years after surgery (OR 17.44 [95% CI 4.56 to 66.65]; p < 0.001). No surgical variables correlated with return-to-duty endpoints. Conclusions Surgeons should be aware of the low likelihood of return to military duty at more than 2 years after MAT and counsel patients accordingly. Based on this study, MAT does not appear to be compatible with continued unrestricted military duty for most patients. Level of Evidence IV, therapeutic study.