Original Paper
Translation, validation, and cultural adaptation of the HSS-ES scale (Hospital for Special Surgery's [HSS] Shoulder Surgery Expectations Survey)
Traducción, adaptación cultural y validación delcuestionario HSS-ES (Hospital for Special Surgery [HSS] Shoulder Surgery Expectations Survey)
L.F. Calixto, R. Pedreros, J.F. Castañeda
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Unidad de Ortopedia y Traumatología, Universidad Nacional de Colombia, Bogotá, Colombia
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Castañeda" "autores" => array:3 [ 0 => array:2 [ "nombre" => "L.F." "apellidos" => "Calixto" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Pedreros" ] 2 => array:4 [ "nombre" => "J.F." "apellidos" => "Castañeda" "email" => array:1 [ 0 => "drjhonf@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Ortopedia y Traumatología, Universidad Nacional de Colombia, Bogotá, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Traducción, adaptación cultural y validación delcuestionario HSS-ES (<span class="elsevierStyleItalic">Hospital for Special Surgery</span> [HSS] <span class="elsevierStyleItalic">Shoulder Surgery Expectations Survey</span>)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3005 "Ancho" => 2504 "Tamanyo" => 641229 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Questionnaire to assess the expectations of patients who are to undergo shoulder surgery, translated into Spanish.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The outcome of surgical procedures to the shoulder has been determined by postoperative function, diagnostic imaging, range of motion and complications, but has not considered the patient's preoperative expectations for outcomes.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">1–9</span></a> Knowing and establishing patient expectations prior to a procedure involves the patient in making decisions that meet the expectations of the outcomes achievable with the proposed surgery.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The level of preoperative expectations correlates directly with better or worse subjective and objective outcomes.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">6,10,11</span></a> Patients may have very high or low expectations for the outcome of a procedure, which may be unrealistic, affecting the postoperative outcome. Outcomes will be better when expectations are realistic and achievable, and worse when they are very high or unattainable, and unmet expectations are associated with lower satisfaction.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">4,12–15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are several methodologies to assess the clinical and functional outcome of shoulder surgery,<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">16–21</span></a> but few assess patients’ preoperative expectations.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">5,22,23</span></a> The Hospital for Special Surgery (HSS) Shoulder Surgery Expectations Survey (HSS-ES) questionnaire assesses these expectations. The aim of this study is to translate, culturally adapt and validate the HSS-ES questionnaire into Spanish.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methodology</span><p id="par0020" class="elsevierStylePara elsevierViewall">A scale validation study was conducted to translate the HSS-ES questionnaire into Spanish, taking into account the international recommendations of the American Academy of Orthopaedic Surgeons (AAOS).<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">24</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Questionnaire</span><p id="par0025" class="elsevierStylePara elsevierViewall">The HSS-ES questionnaire has 17 items that measure expectations of different aspects, such as pain relief, improvement in function and strength, and psychosocial functions related to activities of daily living. There are five possible answers for each question: “very important”, “somewhat important”, “a little important”, “I do not expect this”, or “this does not apply to me”.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A minimum sample size of 68 patients was determined, with a 95% confidence interval, an approximate correlation coefficient of .8 and an expected loss of 10%. Older patients with shoulder pathologies who were to undergo a surgical procedure were included. Patients with cognitive deficits or neurological disorders that meant they could not understand the questionnaire or patients with previous surgeries were not included. The patients came from the shoulder surgery practice of one of the authors, between January 2020 and May 2020, with different shoulder surgical pathologies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Translation and transcultural adaptation</span><p id="par0035" class="elsevierStylePara elsevierViewall">The original English questionnaire was translated into Spanish by two independent translators with medical and research experience whose native language was Spanish but who were fluent in English, and a third translator whose native language was English, with a concordance in the versions close to 90% of the terms. The translation focused on the concept and not on the literal translation of the text. We sought to use language that was familiar to the target population, without using technical terms that could confuse the interpretation of the questions and/or answers. This was followed by a unification of concepts based on the three translations. The final Spanish questionnaire was defined through a reconciliation of the discrepancies in the versions. Two translators, whose native language was English, back-translated the Spanish version of the questionnaire, to determine semantic or conceptual differences, demonstrating that the translation of the questionnaire had the same meaning in Spanish as in English.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The translated version of the questionnaire was reviewed by three shoulder surgeons and a linguist with expertise in medical translations, who considered it appropriate and correct for use in Spanish. A pilot test was conducted with this version of the questionnaire, where 20 patients evaluated the clarity of the questionnaire. All patients were asked whether they understood the questions and were able to interpret them correctly, to assess the adaptation process, intelligibility, and comprehension of the questions. Based on the comments of the respondents and the research team, the final version of the questionnaire was edited and corrected with these adjustments.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Internal consistency</span><p id="par0045" class="elsevierStylePara elsevierViewall">Cronbach's alpha was used to measure the reliability of the questionnaire, and to determine test–retest reliability the questionnaire was re-tested on the same patients two weeks after the first completion of the questionnaire and the intraclass correlation coefficient (ICC) was determined.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Continuous quantitative variables, such as age, were analysed using measures of central tendency, and qualitative variables, such as gender and education, were assessed using frequency tables and percentages. All statistical analyses were performed with the free statistical software R version 4.1.1 of 2021.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">After the translation process, the applicability-viability pilot test was performed, where 20 patients with shoulder pathology were included: 11 (55%) with rotator cuff pathology, 5 (25%) with glenohumeral arthrosis, 2 (10%) with shoulder instability, and 2 (10%) with other pathologies. The average age for this test was 53.5 years; 50% of the patients were male and the majority (65%) had a low educational level. The feasibility of the questionnaire was analysed and it was determined that the questionnaire can be used without difficulty.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The average time to answer the test was 5<span class="elsevierStyleHsp" style=""></span>min and 30<span class="elsevierStyleHsp" style=""></span>s, with a range of 4.5–7<span class="elsevierStyleHsp" style=""></span>min, with no significant differences with the time standard established for the test in the original language of 5<span class="elsevierStyleHsp" style=""></span>min (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05). All of the patients answered all the test questions within the time described, but it was evident that 5 patients (25%) had problems with one question and one patient (5%) with two questions. Question 4 presented the most problems in responding – in 25% of the patients – due to the term “<span class="elsevierStyleItalic">luxación</span>” (luxation) used in the question, and therefore it was changed to “<span class="elsevierStyleItalic">dislocación</span>” (dislocation) which was more recognised and did not present the aforementioned response problem. In relation to the rest of the questions, one patient (5%) had problems with question 3 and one patient (5%) with question 8; this was considered acceptable as it was below 15% of the total number of those evaluated.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the second phase of the validation, 70 patients were included, predominantly female (57.1%). The questionnaire was answered twice, with an average of 26 points on the first occasion and 25 points on the second occasion after two weeks, with no statistically significant difference between them (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.05). The performance of the questionnaire in Spanish showed very good internal consistency, with a Cronbach's alpha of .94, and very good reproducibility, with a CCI of .99 (95% CI: .97–.99).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The version of the HSS-ES questionnaire translated into Spanish (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed a very good performance, with very good internal consistency and very good reproducibility of the questionnaire, with values higher than the minimum criterion of .80 recommended by Fleiss et al.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">25,26</span></a> All the patients completed the questionnaire without difficulty, which means that the translated questionnaire had good cultural adaptation. Based on the above, we can state that the performance of the questionnaire in Spanish is adequate for its application in patients with shoulder pathologies.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The HSS-ES is a useful instrument to measure patient expectations before shoulder surgery,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">4,5</span></a> but according to the literature review, this widely used tool has not been validated in Spanish. Because of the lack of available information on the internal consistency of the original tool, the results of this Spanish version were not compared with those of the English version.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Shoulder pathologies are common and cause some degree of upper limb disability and pain, requiring surgical intervention in some cases, which require careful preoperative assessment.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">15</span></a> Outcomes are generally determined by the surgeon, diagnostic imaging, postoperative complications, and the clinical course of the patients.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Preoperative patient expectations have been shown to be a major determinant of outcome.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a> Although different questionnaires have been developed, they are not specific and do not assess the expectations of patients with surgical indications for different shoulder pathologies.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">4,5</span></a> In 2002, Mancuso et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a> developed a questionnaire to assess these expectations, demonstrating that it is a useful tool in the surgeon's daily practice and that it allows clear goals to be set for the surgical procedure.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The HSS-ES questionnaire is a very useful tool to learn patients’ real expectations of their surgery, to better understand what is important for them, to have clear and real goals and, therefore, a more objective doctor-patient conversation regarding the expected results and the best treatment, leading to better outcomes and greater postoperative satisfaction.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The study has some limitations, such as the absence of other questionnaires in Spanish that assess preoperative expectations to compare with the HSS-ES. Further studies should be conducted to consider covariates such as race or work activity among the factors that may influence patient expectations and to compare different patient expectations with postoperative outcomes and the impression of the procedure.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The questionnaire can be applied routinely, because it can be completed in a few minutes and provides valuable information, and is a useful tool for different clinical studies and international comparisons of preoperative expectations in shoulder surgery.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The HSS-ES questionnaire has adequate intragroup validation and a strong intergroup correlation according to the internal consistency analysis with Cronbach's alpha and the CCI, and is therefore considered a suitable questionnaire for use in the Spanish-speaking population.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Level of evidence</span><p id="par0110" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iii</span>.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span><span id="sec2050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1110">Approval of the ethics committee</span><p id="par1305" class="elsevierStylePara elsevierViewall">Ethics Committee of the Faculty of Medicine of the National University of Colombia. Evaluation and approval act N̊ 014-150-20.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2130437" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1809297" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2130438" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1809298" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methodology" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Questionnaire" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Translation and transcultural adaptation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Internal consistency" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Level of evidence" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 12 => array:2 [ "identificador" => "sec2050" "titulo" => "Approval of the ethics committee" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-23" "fechaAceptado" => "2022-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1809297" "palabras" => array:4 [ 0 => "Preoperative expectations" 1 => "Questionnaire" 2 => "Shoulder" 3 => "Validation study" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1809298" "palabras" => array:4 [ 0 => "Expectativas preoperatorias" 1 => "Cuestionario" 2 => "Hombro" 3 => "Estudio de validación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The questionnaire Hospital for Special Surgery Shoulder Surgery Expectations Survey (HSS-ES) is a tool used to assess the preoperative expectations of patients with shoulder pathologies. The purpose of this study is to translate, culturally adapt, and validate the Spanish version of the HSS-ES questionnaire to assess preoperative expectations in Spanish-speaking patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Questionnaire validation study, using a structured method where a survey-type tool was processed, evaluated and validated. The study involved 70 patients from the shoulder surgery outpatient clinic of a tertiary care hospital, with shoulder pathologies requiring surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The version of the questionnaire translated into Spanish presented a very good internal consistency with a Cronbach's Alpha of 0.94 and a very good reproducibility with an Intraclass Correlation Coefficient (ICC) of 0.99.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The HSS-ES questionnaire presents an adequate intragroup validation and a strong intergroup correlation according to the internal consistency analysis of the questionnaire and the ICC. Therefore, it is considered an adequate questionnaire to use in the Spanish-speaking population.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cuestionario <span class="elsevierStyleItalic">Hospital for Special Surgery Shoulder Surgery Expectations Survey</span> (HSS-ES) es una herramienta utilizada para evaluar las expectativas preoperatorias de los pacientes con patologías de hombro. El propósito de este estudio es realizar la traducción, la adaptación cultural y la validación a la versión en español del cuestionario HSS-ES para evaluar las expectativas preoperatorias en pacientes hispanoparlantes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Metodología</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio tipo validación de cuestionario mediante un método estructurado donde se procesó, evaluó y validó una herramienta tipo encuesta. En el estudio participaron 70 pacientes de la consulta externa de cirugía de hombro de un hospital de tercer nivel, con patologías de hombro con indicación quirúrgica.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La versión del cuestionario traducida al idioma español presentó una muy buena consistencia interna, con un alfa de Cronbach de 0,94 y una muy buena reproducibilidad, con un coeficiente de correlación intraclase (CCI) de 0,99.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El cuestionario HSS-ES presenta una adecuada validación intragrupo y una fuerte correlación intergrupo según el análisis de consistencia interna del cuestionario y el CCI, por lo cual se considera un cuestionario adecuado para utilizar en la población hispanoparlante.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3005 "Ancho" => 2504 "Tamanyo" => 641229 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Questionnaire to assess the expectations of patients who are to undergo shoulder surgery, translated into Spanish.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior shoulder instability: a systematic review of the quality and quantity of the current literature for surgical treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 0 | 11 |
| 2024 October | 45 | 14 | 59 |
| 2024 September | 62 | 12 | 74 |
| 2024 August | 54 | 23 | 77 |
| 2024 July | 34 | 9 | 43 |
| 2024 June | 32 | 7 | 39 |
| 2024 May | 43 | 6 | 49 |
| 2024 April | 42 | 9 | 51 |
| 2024 March | 17 | 5 | 22 |
| 2024 February | 14 | 4 | 18 |
| 2024 January | 31 | 4 | 35 |
| 2023 December | 29 | 6 | 35 |
| 2023 November | 19 | 6 | 25 |
| 2023 October | 44 | 5 | 49 |
| 2023 September | 26 | 2 | 28 |
| 2023 August | 20 | 0 | 20 |
| 2023 July | 27 | 1 | 28 |
| 2023 June | 25 | 7 | 32 |
| 2023 May | 95 | 11 | 106 |
| 2023 April | 6 | 4 | 10 |
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