Session 3: Shoulder and Elbow
Onsdag den 25. oktober
09:00 – 10:30
Lokale: Helsinki/Oslo
Chairmen: Theis Thillemann og Anne-Kathrine Belling Sørensen
23. Reproducibility of dual x-ray absorptiometry and assessment of changes in regional body composition following shoulder arthroplasty for osteoarthritis
Mustafa Al-Hamdani, Bo S. Olsen, Bo Zerahn, Jeppe V. Rasmussen
Medicinstuderende, Herlev Hospital og Københavns universitet; Ortopædkirurgisk afdeling, Herlev Hospital; Klinisk nuklearmedicinsk, Herlev hospital; Ortopædkirurgisk, Herlev hospital
Background: Measurements of body composition using a DXA may objectively reflect the outcome of various rehabilitation programs and surgical procedures in the upper extremity.
Purpose / Aim of Study: To assess the reproducibility of dual x-ray absorptiometry (DXA) measurements of regional body composition in the shoulder with or without the presence of a shoulder arthroplasty. Furthermore, we used the DXA to assess changes in body composition after shoulder arthroplasty.
Materials and Methods: Body composition was measured in one region of interest (ROI) corresponding to the deltoid muscle. Each patient had two duplicate scans for both the affected and the contralateral arm. Data on functional outcome score (e.g., the Constant Score) and muscle strength were collected preoperatively whereas the body composition scans were collected the day after surgery. The patients were re- examined at 3 and 12 months.
Findings / Results: Intraclass correlation values (ICC) between duplicate scans were 0.991 and 0.996 with and without a shoulder arthroplasty respectively. The Bland-Altman plots showed narrow limits of agreement. Friedman's and Wilcoxon test showed highly significant declines in muscle mass 3 months after surgery, p <0.001 and the muscle mass was not regained at the 12-months follow-up. There was a statistically significant correlation between muscle mass and muscle strength, r=0.23, P=0.03.
Conclusions: DXA is an excellent method for measuring body composition in the upper extremity. The presence of a shoulder arthroplasty did not affect reproducibility. Muscle mass decreased during the first 3 months and was not fully regained a year after surgery. The reason for this is unknown, but the results of the present study underline the importance of a better understanding of factors that influence postoperative recovery programs after shoulder arthroplasty.
Medicinstuderende, Herlev Hospital og Københavns universitet; Ortopædkirurgisk afdeling, Herlev Hospital; Klinisk nuklearmedicinsk, Herlev hospital; Ortopædkirurgisk, Herlev hospital
Background: Measurements of body composition using a DXA may objectively reflect the outcome of various rehabilitation programs and surgical procedures in the upper extremity.
Purpose / Aim of Study: To assess the reproducibility of dual x-ray absorptiometry (DXA) measurements of regional body composition in the shoulder with or without the presence of a shoulder arthroplasty. Furthermore, we used the DXA to assess changes in body composition after shoulder arthroplasty.
Materials and Methods: Body composition was measured in one region of interest (ROI) corresponding to the deltoid muscle. Each patient had two duplicate scans for both the affected and the contralateral arm. Data on functional outcome score (e.g., the Constant Score) and muscle strength were collected preoperatively whereas the body composition scans were collected the day after surgery. The patients were re- examined at 3 and 12 months.
Findings / Results: Intraclass correlation values (ICC) between duplicate scans were 0.991 and 0.996 with and without a shoulder arthroplasty respectively. The Bland-Altman plots showed narrow limits of agreement. Friedman's and Wilcoxon test showed highly significant declines in muscle mass 3 months after surgery, p <0.001 and the muscle mass was not regained at the 12-months follow-up. There was a statistically significant correlation between muscle mass and muscle strength, r=0.23, P=0.03.
Conclusions: DXA is an excellent method for measuring body composition in the upper extremity. The presence of a shoulder arthroplasty did not affect reproducibility. Muscle mass decreased during the first 3 months and was not fully regained a year after surgery. The reason for this is unknown, but the results of the present study underline the importance of a better understanding of factors that influence postoperative recovery programs after shoulder arthroplasty.
24. The prevalence and impact of Diabetes Mellitus on the Frozen Shoulder
Per Hviid Gundtoft, Anne Krog Kristensen, Mikkel Attrup, Jette Wessel Vobbe, Torben Luxhøi, Flemming Gothard Rix, Per Hölmich, Lilli Sørensen
Orthopedic, Kolding Hospital; Orthopedic, Vejle Hospital; Orthopedic, Copenhagen University Hospital Amager-Hvidovre; Orthopedic, Vejle Hospital; Orthopedic, Kolding Hospital; Orthopedic, Kolding Hospital; Orthopedic, Copenhagen University Hospital Amager-Hvidovre; Orthopedic, Vejle Hospital
Background: Numerous studies have shown that Diabetes Mellitus (DM) is a risk factor for Frozen Shoulder (FS), and patients with DM are regarded as being more severely affected by their FS than patients without DM. Furthermore, a high proportion of patients with DM are undiagnosed.
Purpose / Aim of Study: The objective of this study was to estimate the prevalence of undiagnosed DM in patients with newly diagnosed FS and study whether DM increases the severity of the FS disease.
Materials and Methods: Patients with newly diagnosed FS were consecutively included in this case-control study. Patients that were not already diagnosed with DM were invited to be tested with the HbA1c blood sample test. The study population was compared with a control group, consisting of 5 individuals from the general population matched on age and sex. The passive range of motion (ROM), Oxford Shoulder Score, and Visual Analog Scale (VAS) for average and maximum daily pain was recorded for all patients in the study group.
Findings / Results: A total of 235 patients were included of which 34 (14%) were diagnosed with DM prior to examination. Of the reaming 201 patients, 122 (61%) agreed to be tested for DM. None of the tested patients had undiagnosed DM. This was not significantly different from the prevalence in the matched control population (p= 0.09). There was no difference between patients with and without DM in average daily VAS (p= 0.46) nor maximum daily VAS (p= 0.44). The Oxford Shoulder Score was similar in the two groups (p= 0.23) and so was the ROM.
Conclusions: The prevalence of undiagnosed DM is low in patients with FS and does not differ from the general population. DM does not seem to affect the perceived severity of a FS.
Orthopedic, Kolding Hospital; Orthopedic, Vejle Hospital; Orthopedic, Copenhagen University Hospital Amager-Hvidovre; Orthopedic, Vejle Hospital; Orthopedic, Kolding Hospital; Orthopedic, Kolding Hospital; Orthopedic, Copenhagen University Hospital Amager-Hvidovre; Orthopedic, Vejle Hospital
Background: Numerous studies have shown that Diabetes Mellitus (DM) is a risk factor for Frozen Shoulder (FS), and patients with DM are regarded as being more severely affected by their FS than patients without DM. Furthermore, a high proportion of patients with DM are undiagnosed.
Purpose / Aim of Study: The objective of this study was to estimate the prevalence of undiagnosed DM in patients with newly diagnosed FS and study whether DM increases the severity of the FS disease.
Materials and Methods: Patients with newly diagnosed FS were consecutively included in this case-control study. Patients that were not already diagnosed with DM were invited to be tested with the HbA1c blood sample test. The study population was compared with a control group, consisting of 5 individuals from the general population matched on age and sex. The passive range of motion (ROM), Oxford Shoulder Score, and Visual Analog Scale (VAS) for average and maximum daily pain was recorded for all patients in the study group.
Findings / Results: A total of 235 patients were included of which 34 (14%) were diagnosed with DM prior to examination. Of the reaming 201 patients, 122 (61%) agreed to be tested for DM. None of the tested patients had undiagnosed DM. This was not significantly different from the prevalence in the matched control population (p= 0.09). There was no difference between patients with and without DM in average daily VAS (p= 0.46) nor maximum daily VAS (p= 0.44). The Oxford Shoulder Score was similar in the two groups (p= 0.23) and so was the ROM.
Conclusions: The prevalence of undiagnosed DM is low in patients with FS and does not differ from the general population. DM does not seem to affect the perceived severity of a FS.
25. PRECISION OF BONE MODELS IN DYNAMIC RSA OF THE ELBOW AND DISTAL FOREARM
Sepp De Raedt, Janni Thillemann, Chalotte Vestergaard Hemmingsen, Maiken Stilling
Research and Development, Nordic Roentgen Technique; Department of Clinical Medicine, Aarhus University; Orthopedic Research Unit, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University
Background: Dynamic radiostereometric (dRSA) analysis can be used to quantitatively measure changes in the three-dimensional in-vivo movements of bones, which can provide insight in the kinematics. However, analysis of the radius and ulna bones in both the elbow and forearm is challenging due to the long cylindrical shape. Using digitally reconstructed radiograph (DRR) based RSA, the position and orientation of the bones can be determined without markers.
Purpose / Aim of Study: To validate the precision of DRR based RSA compared to marker-based analysis.
Materials and Methods: Custom motorized fixtures to perform clinically relevant wrist (11 arms) and elbow (8 arms) motions were made. Subject specific bone models were created from CT and tantalum markers were inserted. Model- based RSA (RSAcore) was used to calibrate the first frame and initialize the bones. The complete recording was subsequently automatically analyzed by custom developed AutoRSA software. Marker analysis was independently performed in 3 images per dynamic recording. Precision was evaluated as systematic bias (mean difference) and random error (1.96*SD) for translations and rotations.
Findings / Results: In the elbow the mean systematic bias for translations (mm) was <0.17 for the proximal radius (p<0.05), <0.15 for the ulna (p<0.05).and <0.02 for the humerus (p>0.21). No systematic bias was found for rotations. Precision was ≤0.55 mm and ≤1°. In the distal forearm the mean systematic bias (mm/°) was <0.06 for the ulna (p>0.17) and <0.03 for the radius (p>0.26). Precision was ≤0.18mm and ≤1°.
Conclusions: DRR based RSA analysis using bone models provides a good precision for investigation of kinematics in the elbow and forearm. The method can be used for automated analysis of markerless dRSA studies for both pre-operative diagnostics and to evaluate kinematics after ligament or implant surgery.
Research and Development, Nordic Roentgen Technique; Department of Clinical Medicine, Aarhus University; Orthopedic Research Unit, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University
Background: Dynamic radiostereometric (dRSA) analysis can be used to quantitatively measure changes in the three-dimensional in-vivo movements of bones, which can provide insight in the kinematics. However, analysis of the radius and ulna bones in both the elbow and forearm is challenging due to the long cylindrical shape. Using digitally reconstructed radiograph (DRR) based RSA, the position and orientation of the bones can be determined without markers.
Purpose / Aim of Study: To validate the precision of DRR based RSA compared to marker-based analysis.
Materials and Methods: Custom motorized fixtures to perform clinically relevant wrist (11 arms) and elbow (8 arms) motions were made. Subject specific bone models were created from CT and tantalum markers were inserted. Model- based RSA (RSAcore) was used to calibrate the first frame and initialize the bones. The complete recording was subsequently automatically analyzed by custom developed AutoRSA software. Marker analysis was independently performed in 3 images per dynamic recording. Precision was evaluated as systematic bias (mean difference) and random error (1.96*SD) for translations and rotations.
Findings / Results: In the elbow the mean systematic bias for translations (mm) was <0.17 for the proximal radius (p<0.05), <0.15 for the ulna (p<0.05).and <0.02 for the humerus (p>0.21). No systematic bias was found for rotations. Precision was ≤0.55 mm and ≤1°. In the distal forearm the mean systematic bias (mm/°) was <0.06 for the ulna (p>0.17) and <0.03 for the radius (p>0.26). Precision was ≤0.18mm and ≤1°.
Conclusions: DRR based RSA analysis using bone models provides a good precision for investigation of kinematics in the elbow and forearm. The method can be used for automated analysis of markerless dRSA studies for both pre-operative diagnostics and to evaluate kinematics after ligament or implant surgery.
26. Muscle inflammation following supraspinatus tears
Lars Henrik Frich, Kate Lykke Lambertsen, Allan Steensballe, Henrik Daa Schrøder
Orthopadics, Odense UniversitetsHospital; Clinical research, University of Southern Denmark; Health Science and Technology, Aalborg University; Pathology, Odense university Hospital
Background: Rotator cuff (RC) lesions are one of the most common conditions affecting the shoulder. The etiology of RC diseases is multifactorial but the supraspinatus (SS) tendon is particularly vulnerable to become lesioned. In patients with RC tears, increased numbers of inflammatory cells have been demonstrated in the inflamed synovial tissue. Recent studies have suggested that also the RC muscles become inflamed after RC tears and animal models suggest that acute inflammation plays a detrimental role in chronic muscle damage following RC tears.
Purpose / Aim of Study: The aim of this study was to characterize inflammation in humans suffering from a RC tear
Materials and Methods: Tissue samples were taken from the RC tissues at the time of surgery in 9 patients scheduled for surgery. Mean age was 58 years (40-61) years. All patients had a MRI validated SS tear. Control biopsies were obtained from the deltoid muscle. We used multiplex analysis, proteomics, histological and immunohistochemical analyses to study the inflammatory profiles of SS muscle and tendon, deltoid muscle and bursa.
Findings / Results: Multiplex analysis demonstrated differential expression levels of several matrix metalloproteinases. Also several inflammatory mediators were differentially expressed between RC tissues. Immuno-histochemical analyses of SS muscle demonstrated the presence of CD68+ macrophages, and CD3+ and CD8+ T cells. Proteomic analysis demonstrated the presence of inflammatory related proteins in the SS tendon and SS muscle.
Conclusions: We have shown that not only the tendon becomes inflamed following RC tendon tears but also the SS muscle shows sign of inflammation. Chronic inflammation differs between tendon and muscle and between muscles, which suggests that the pathophysiological mechanisms taking place in RC muscles may be a major contributor to RC disease.
Orthopadics, Odense UniversitetsHospital; Clinical research, University of Southern Denmark; Health Science and Technology, Aalborg University; Pathology, Odense university Hospital
Background: Rotator cuff (RC) lesions are one of the most common conditions affecting the shoulder. The etiology of RC diseases is multifactorial but the supraspinatus (SS) tendon is particularly vulnerable to become lesioned. In patients with RC tears, increased numbers of inflammatory cells have been demonstrated in the inflamed synovial tissue. Recent studies have suggested that also the RC muscles become inflamed after RC tears and animal models suggest that acute inflammation plays a detrimental role in chronic muscle damage following RC tears.
Purpose / Aim of Study: The aim of this study was to characterize inflammation in humans suffering from a RC tear
Materials and Methods: Tissue samples were taken from the RC tissues at the time of surgery in 9 patients scheduled for surgery. Mean age was 58 years (40-61) years. All patients had a MRI validated SS tear. Control biopsies were obtained from the deltoid muscle. We used multiplex analysis, proteomics, histological and immunohistochemical analyses to study the inflammatory profiles of SS muscle and tendon, deltoid muscle and bursa.
Findings / Results: Multiplex analysis demonstrated differential expression levels of several matrix metalloproteinases. Also several inflammatory mediators were differentially expressed between RC tissues. Immuno-histochemical analyses of SS muscle demonstrated the presence of CD68+ macrophages, and CD3+ and CD8+ T cells. Proteomic analysis demonstrated the presence of inflammatory related proteins in the SS tendon and SS muscle.
Conclusions: We have shown that not only the tendon becomes inflamed following RC tendon tears but also the SS muscle shows sign of inflammation. Chronic inflammation differs between tendon and muscle and between muscles, which suggests that the pathophysiological mechanisms taking place in RC muscles may be a major contributor to RC disease.
27. Risk factors of infection after shoulder arthroplasty. Incidence, infection-free survival and relative risks in 6877 primary shoulder replacements
Sahar Moeini, Jeppe V. Rasmussen, Stig Brorson
Orthopedic department, Herlev Hospital; Orthopedic department, Herlev Hospital; Orthopedic department, Herlev Hospital
Background: Deep infection after arthroplasty is associated with extensive consequences for patients and health care providers. Nonetheless, scientific data on incidence and risk factors for deep infection after shoulder arthroplasty is limited. Most studies report revision rates in general without focusing on infection.
Purpose / Aim of Study: The purpose of this study was to report the incidence of revision due to infection in primary shoulder arthroplasties and to identify risk factors associated with infection. Thus, the aim was to provide the surgeon with data in clinical decision- making and when informing the patient.
Materials and Methods: We included all primary arthroplasties reported to the Danish Shoulder Arthroplasty Registry (DSR) between 2006 and 2013 – comprising 6877 arthroplasties in 6555 patients. Incidence of infection was reported. We reported infection-free survival with Kaplan Meier and relative risks (RR) with Cox regression according to different risk factors. The risk factors included age, gender, diagnosis, primary arthroplasty design and previous surgery on the same shoulder.
Findings / Results: 55 (0.8%) were revised due to infection. The overall infection-free survival was 98.5 % (standard error = 0.3). Male patients, rotator cuff arthropathy, reverse arthroplasty and previous surgery showed the lowest survival estimates. The adjusted RR for infection was significant higher for male gender, previous surgery and reverse arthroplasty.
Conclusions: The incidence of infection was low. We found an increased RR for reverse arthroplasty, male gender and previous surgery.
Orthopedic department, Herlev Hospital; Orthopedic department, Herlev Hospital; Orthopedic department, Herlev Hospital
Background: Deep infection after arthroplasty is associated with extensive consequences for patients and health care providers. Nonetheless, scientific data on incidence and risk factors for deep infection after shoulder arthroplasty is limited. Most studies report revision rates in general without focusing on infection.
Purpose / Aim of Study: The purpose of this study was to report the incidence of revision due to infection in primary shoulder arthroplasties and to identify risk factors associated with infection. Thus, the aim was to provide the surgeon with data in clinical decision- making and when informing the patient.
Materials and Methods: We included all primary arthroplasties reported to the Danish Shoulder Arthroplasty Registry (DSR) between 2006 and 2013 – comprising 6877 arthroplasties in 6555 patients. Incidence of infection was reported. We reported infection-free survival with Kaplan Meier and relative risks (RR) with Cox regression according to different risk factors. The risk factors included age, gender, diagnosis, primary arthroplasty design and previous surgery on the same shoulder.
Findings / Results: 55 (0.8%) were revised due to infection. The overall infection-free survival was 98.5 % (standard error = 0.3). Male patients, rotator cuff arthropathy, reverse arthroplasty and previous surgery showed the lowest survival estimates. The adjusted RR for infection was significant higher for male gender, previous surgery and reverse arthroplasty.
Conclusions: The incidence of infection was low. We found an increased RR for reverse arthroplasty, male gender and previous surgery.
28. Risk of revision or clinical failure in 2,418 patients with stemmed hemiarthroplasty for acute proximal humeral fracture
Alexander Amundsen, Jeppe V. Rasmussen, Bo S. Olsen, Stig Brorson
Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital
Background: Revision rates are commonly used as primary outcome after shoulder arthroplasty for proximal humeral fractures. However, revision rates do not necessarily reflect the clinical outcome as some failures are never revised due to patient or surgery related factors.
Purpose / Aim of Study: The aim was to report revision rates, seven-year prosthesis survival and to determine the proportion of patients that are not revised despite an unsatisfactory clinical outcome.
Materials and Methods: The Danish Shoulder Arthroplasty Registry was used to obtain patients’ demographics, surgical information and one-year Western Ontario Osteoarthritis of the Shoulder (WOOS) index on all patients who underwent a stemmed hemiarthroplasty for acute proximal humeral fracture between 2006 and 2012. Revision rate was used as primary outcome and the WOOS at one year as secondary outcome. The WOOS score was converted to percentages of a maximum score, with 100 being the best. A WOOS score below 30 was arbitrarily defined as a clinical failure.
Findings / Results: Mean age was 71.9 ± 11.3 years. 1,873 (77.5%) were women. 106 (4.4%) arthroplasties were revised. Luxation and rotator cuff failure were the most common reasons for revision. The cumulative seven-year survival rate was 93.8 %. 154 patients died (6.4%) and 45 were revised (1.9%) before answering WOOS, leaving 2,219 patients available for follow-up. 1,581 (71.2%) patients completed WOOS with a mean score of 54.9 ± 26.1. A WOOS below 30 was reported by 314 (13.0%) patients.
Conclusions: We reported a revision rate of 4.4%. However, 13.0% of patients reported a functional outcome which was regarded as a clinical failure. This indicates that a substantial number of clinical failures are not revised.
Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital; Department of Orthopaedic Surgery, Herlev Hospital
Background: Revision rates are commonly used as primary outcome after shoulder arthroplasty for proximal humeral fractures. However, revision rates do not necessarily reflect the clinical outcome as some failures are never revised due to patient or surgery related factors.
Purpose / Aim of Study: The aim was to report revision rates, seven-year prosthesis survival and to determine the proportion of patients that are not revised despite an unsatisfactory clinical outcome.
Materials and Methods: The Danish Shoulder Arthroplasty Registry was used to obtain patients’ demographics, surgical information and one-year Western Ontario Osteoarthritis of the Shoulder (WOOS) index on all patients who underwent a stemmed hemiarthroplasty for acute proximal humeral fracture between 2006 and 2012. Revision rate was used as primary outcome and the WOOS at one year as secondary outcome. The WOOS score was converted to percentages of a maximum score, with 100 being the best. A WOOS score below 30 was arbitrarily defined as a clinical failure.
Findings / Results: Mean age was 71.9 ± 11.3 years. 1,873 (77.5%) were women. 106 (4.4%) arthroplasties were revised. Luxation and rotator cuff failure were the most common reasons for revision. The cumulative seven-year survival rate was 93.8 %. 154 patients died (6.4%) and 45 were revised (1.9%) before answering WOOS, leaving 2,219 patients available for follow-up. 1,581 (71.2%) patients completed WOOS with a mean score of 54.9 ± 26.1. A WOOS below 30 was reported by 314 (13.0%) patients.
Conclusions: We reported a revision rate of 4.4%. However, 13.0% of patients reported a functional outcome which was regarded as a clinical failure. This indicates that a substantial number of clinical failures are not revised.
29. Predictors of pain six months after arthroscopic shoulder surgery
Lone Dragnes Brix, Theis Muncholm Thillemann, Karen Toftdahl Bjørnholdt, Lone Nikolajsen
Anaesthesiology, Horsens Regional Hospital; Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Surgery, Horsens Regional Hospital; Operation and intensive care North, South and East, Aarhus University Hospital
Background: Arthroscopic shoulder surgery, e.g. subacromial decompression (ASD) and acromioclavicular resection (AC resection ), usually results in significant improvement in pain and shoulder function; however some patients report persistent pain after shoulder surgery.
Purpose / Aim of Study: Thus, the aims of this prospective study were 1) to determine the incidence of pain six months after outpatient ASD and/or AC resection, and 2) to identify risk factors for persistent pain.
Materials and Methods: One-hundred-and-fifty patients completed Western Ontario Rotator Cuff Index (WORC), Single Assessment Numeric Evaluation (SANE), State-Trait Anxiety FORM Y (STAI), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS) and were tested for endogenous pain modulation capacity. Patients with pain six months after surgery (pain intensity ≥3 on a numeric rating scale with impact on daily living) were examined by an experienced orthopaedic surgeon to identify the reasons for persistent pain.
Findings / Results: Data from 101 patients were available for analysis six months after surgery. Thirty-six patients (35.6%) had pain, with the surgeon able to identify reasons for the pain in ten patients (9.9%). Predictors of unexplained persistent pain included unemployment, ongoing insurance case, and a high t-STAI-score.
Conclusions: Persistent pain was prevalent in 35.6% of patients six months after ASD and/or AC resection, but this number was reduced after excluding patients with identified reasons for the pain. Several preoperative risk factors were identified. Thus, the current data highlights the importance of careful patient selection before surgery and of patient follow-up after surgery.
Anaesthesiology, Horsens Regional Hospital; Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Surgery, Horsens Regional Hospital; Operation and intensive care North, South and East, Aarhus University Hospital
Background: Arthroscopic shoulder surgery, e.g. subacromial decompression (ASD) and acromioclavicular resection (AC resection ), usually results in significant improvement in pain and shoulder function; however some patients report persistent pain after shoulder surgery.
Purpose / Aim of Study: Thus, the aims of this prospective study were 1) to determine the incidence of pain six months after outpatient ASD and/or AC resection, and 2) to identify risk factors for persistent pain.
Materials and Methods: One-hundred-and-fifty patients completed Western Ontario Rotator Cuff Index (WORC), Single Assessment Numeric Evaluation (SANE), State-Trait Anxiety FORM Y (STAI), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS) and were tested for endogenous pain modulation capacity. Patients with pain six months after surgery (pain intensity ≥3 on a numeric rating scale with impact on daily living) were examined by an experienced orthopaedic surgeon to identify the reasons for persistent pain.
Findings / Results: Data from 101 patients were available for analysis six months after surgery. Thirty-six patients (35.6%) had pain, with the surgeon able to identify reasons for the pain in ten patients (9.9%). Predictors of unexplained persistent pain included unemployment, ongoing insurance case, and a high t-STAI-score.
Conclusions: Persistent pain was prevalent in 35.6% of patients six months after ASD and/or AC resection, but this number was reduced after excluding patients with identified reasons for the pain. Several preoperative risk factors were identified. Thus, the current data highlights the importance of careful patient selection before surgery and of patient follow-up after surgery.
30. ELBOW BIOMECHANINCS, RADIOCAPITELLAR JOINT PRESSURE, AND INTEROSSOUS MEMBRANE STRAIN BEFORE AND AFTER RADIAL HEAD ARTHROPLASTY
Chalotte Krabbe Hemmingsen, Theis Muncholm Thillemann, Brian Elmengaard, Sepp de Raedt, Emil Toft Nielsen, Sebastian Breddam Mosegaard, Kasper Stent-Olesen, Maiken Stilling
Department of Clinical Medicine, Aarhus University Hospital, Denmark; Department of Orthopedic Surgery, Shoulder and Elbow Section, Aarhus University Hospital, Denmark; Department of Orthopedic Surgery, Shoulder and Elbow Section, Aarhus University Hospital, Denmark; Nordisk Røntgen Teknik, Aarhus Denmark; Department of Clinical Medicine, Aarhus University Hospital, Denmark; University Clinic for Hand, Hip and Knee Surgery, Hospital Unit West, Denmark; Nordisk Røntgen Teknik, Aarhus Denmark; Department of Clinical Medicine, Aarhus University Hospital, Denmark
Background: Complex radial head fractures with associated elbow instability may be treated with a radial head implant (RHA).
Purpose / Aim of Study: To compare the elbow kinematics before and after anatomic RHA in an experimental study.
Materials and Methods: 8 human native elbows (mean age 82 years, range 61-89) were examined with dynamic radiostereometric analysis (dRSA) during forearm flexion with neutral rotation, and further in supination and pronation with/without a 10N varus-valgus stress. Results were compared with dRSA after insertion of an anatomic RHA (Acumed). Translations of the radial head in the x-, y- and z-directions relative to the humerus and to the ulna were measured. The radiocapitellar joint (RCJ) contact pressure and the tension within the interosseous membrane (IOM) was measured using a pressure sensor and a custom-made strain gauge.
Findings / Results: After RHA the radial head was displaced approximately 1.8mm medially and 1.4mm distally compared with the native radial head. During unloaded flexion motion the mean difference in translation between the native radial head and the RHA was <1mm (CI95 +/- 0.5mm) (p=0.00), and with varus- valgus loading the difference was <1.5mm (CI95% +/- 1.5mm) (p=0.00). The mean difference in RCJ contact pressure was <0.30 MPa (CI95% 0.40 MPa) during unloaded flexion motion (p=0.00). The tension in the IOM in supinated (p=0.03) and pronated (p=0.00) forearm position was higher for the RHA compared with native elbows. Varus-valgus stress in supinated and pronated forearm position decreased the IOM tension in the RHA elbows (p=0.00).
Conclusions: There were only submillimeter kinematic changes and small changes in RCJ joint pressure and IOM tension after insertion of an anatomical RHA in an experimental setting.
Department of Clinical Medicine, Aarhus University Hospital, Denmark; Department of Orthopedic Surgery, Shoulder and Elbow Section, Aarhus University Hospital, Denmark; Department of Orthopedic Surgery, Shoulder and Elbow Section, Aarhus University Hospital, Denmark; Nordisk Røntgen Teknik, Aarhus Denmark; Department of Clinical Medicine, Aarhus University Hospital, Denmark; University Clinic for Hand, Hip and Knee Surgery, Hospital Unit West, Denmark; Nordisk Røntgen Teknik, Aarhus Denmark; Department of Clinical Medicine, Aarhus University Hospital, Denmark
Background: Complex radial head fractures with associated elbow instability may be treated with a radial head implant (RHA).
Purpose / Aim of Study: To compare the elbow kinematics before and after anatomic RHA in an experimental study.
Materials and Methods: 8 human native elbows (mean age 82 years, range 61-89) were examined with dynamic radiostereometric analysis (dRSA) during forearm flexion with neutral rotation, and further in supination and pronation with/without a 10N varus-valgus stress. Results were compared with dRSA after insertion of an anatomic RHA (Acumed). Translations of the radial head in the x-, y- and z-directions relative to the humerus and to the ulna were measured. The radiocapitellar joint (RCJ) contact pressure and the tension within the interosseous membrane (IOM) was measured using a pressure sensor and a custom-made strain gauge.
Findings / Results: After RHA the radial head was displaced approximately 1.8mm medially and 1.4mm distally compared with the native radial head. During unloaded flexion motion the mean difference in translation between the native radial head and the RHA was <1mm (CI95 +/- 0.5mm) (p=0.00), and with varus- valgus loading the difference was <1.5mm (CI95% +/- 1.5mm) (p=0.00). The mean difference in RCJ contact pressure was <0.30 MPa (CI95% 0.40 MPa) during unloaded flexion motion (p=0.00). The tension in the IOM in supinated (p=0.03) and pronated (p=0.00) forearm position was higher for the RHA compared with native elbows. Varus-valgus stress in supinated and pronated forearm position decreased the IOM tension in the RHA elbows (p=0.00).
Conclusions: There were only submillimeter kinematic changes and small changes in RCJ joint pressure and IOM tension after insertion of an anatomical RHA in an experimental setting.
31. Longterm clinical results in patients treated with arthroscopic release for elbow stiffness
Taj Haubuf, Janne Ovesen, Hans Viggo Johannsen
Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital; Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital; Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital
Background: Elbow stiffness is most commonly caused by trauma, osteoarthritis, arthritis or infections. Development of arthroscopic technique has made arthroscopic arthrolysis more common for treatment of elbow contractures, although it is a technically demanding technique.
Purpose / Aim of Study: The purpose was to report the long-term functional and radiologic outcomes after arthroscopic surgery in elbow contractures both post-traumatic and degenerative.
Materials and Methods: All patients who received arthroscopic release between 2000 and 2005 where invited for clinical evaluations. So fare 127 patients (out of 197) were reviewed with a mean follow-up of 172 months (134 to 202). We performed the clinical follow-up with clinical examination of ROM, pain score (VAS), Mayo Elbow Performance Score (MEPS) and the Danish version of Oxford Elbow Score (D-OES). Furthermore, conventional x-rays anterior-posterior and side view of the elbow where obtained. Any reoperations and complications where recorded. All perimeters were compared with the patient’s old journals.
Findings / Results: The mean ROM improved 15° in both pronation and supination, 15° in extension and 13° in flexion. The mean D-OES was 83 (48-100) and the average MEPS improved from 65 to 89. VAS improved on average 3,5 and patients reported a 22% better daily function of their elbow after surgery. 79 patients had surgery due to post-traumatic stiffness and 48 patients due to degenerative stiffness. 8 cases had complications, 3 ulnar neuropathy and 2 deep infections and 3 superficial infections. 4 patient had another operation due to complications.
Conclusions: Long term follow-up results shows that arthroscopy surgery for stiff elbow is safe, complications rate is low and it offers a useful improvement in ROM, pain, daily function and subjectively results.
Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital; Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital; Shoulder and Elbow Unit, Orthopedic , Aarhus University Hospital
Background: Elbow stiffness is most commonly caused by trauma, osteoarthritis, arthritis or infections. Development of arthroscopic technique has made arthroscopic arthrolysis more common for treatment of elbow contractures, although it is a technically demanding technique.
Purpose / Aim of Study: The purpose was to report the long-term functional and radiologic outcomes after arthroscopic surgery in elbow contractures both post-traumatic and degenerative.
Materials and Methods: All patients who received arthroscopic release between 2000 and 2005 where invited for clinical evaluations. So fare 127 patients (out of 197) were reviewed with a mean follow-up of 172 months (134 to 202). We performed the clinical follow-up with clinical examination of ROM, pain score (VAS), Mayo Elbow Performance Score (MEPS) and the Danish version of Oxford Elbow Score (D-OES). Furthermore, conventional x-rays anterior-posterior and side view of the elbow where obtained. Any reoperations and complications where recorded. All perimeters were compared with the patient’s old journals.
Findings / Results: The mean ROM improved 15° in both pronation and supination, 15° in extension and 13° in flexion. The mean D-OES was 83 (48-100) and the average MEPS improved from 65 to 89. VAS improved on average 3,5 and patients reported a 22% better daily function of their elbow after surgery. 79 patients had surgery due to post-traumatic stiffness and 48 patients due to degenerative stiffness. 8 cases had complications, 3 ulnar neuropathy and 2 deep infections and 3 superficial infections. 4 patient had another operation due to complications.
Conclusions: Long term follow-up results shows that arthroscopy surgery for stiff elbow is safe, complications rate is low and it offers a useful improvement in ROM, pain, daily function and subjectively results.
32. Good mid-term outcome and few complications after elbow hemiarthroplasty for acute distal humeral fractures in adults
Ali K. K. Al-Hamdani, Jeppe Rasmussen, Anne Kathrine Belling Sørensen, Janne Ovesen, Stig Brorson, Bo Olsen
Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Århus Universitetshospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital
Background: Distal intraarticular and multifragmantary humeral fractures pose a surgical challenge.Total elbow arthroplasty (TEA) is known method for treatment of distal humeral fractures, but the outcome of elbow hemiarthroplasty (EHA) is still limited.
Purpose / Aim of Study: The aim of this study was to report the functional and radiographic outcomes, in a consecutive series of Elbow hemiarthroplasty (EHA) in patients with acute distal humeral fractures.
Materials and Methods: From January 2011 to January 2016 thirty-one patients were treated with EHA for an acute distal humeral fracture. Four patients died before follow-up and 3 patients were unable to participate. Thus, twenty-four patients were included. Mayo Elbow Performance Score MEPS, Oxford Elbow Score OES, pain severity, and range of motion are used to evaluate the clinical outcome. Radiographic outcomes were assessed. The length of sick-leave was recorded.
Findings / Results: Two EHA were revised to a TEA. The remaining 22 patients had a complete follow-up. The mean age was 64 years and 12 patients were under the age of 65 years. The mean follow-up time was 30 months. The median MEPS was 85 and the median OES was 40. The median pain severity score was 2 (range 0-8) on a scale from 0-10. The median flexion/extension and supination/pronation arcs were 112.5 degree and 160 degree respectively. Two patients were re-operated, one because of stiffness and one because of infection (soft-tissue revision). Seven patient were occupationally- active, and six of them returned to the same occupation. The mean sick-leave was 3 months.
Conclusions: The outcome of EHA for the treatment of ureconstructable acute multifragmentary intraarticular distal humeral fractures seems promising in active patients. However ulnar and radia wear and component loosening may lead to a less promising outcome in the long term.
Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Århus Universitetshospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital; Orthopaedics / Shoulder elbow section, Herlev Gentofte Hospital
Background: Distal intraarticular and multifragmantary humeral fractures pose a surgical challenge.Total elbow arthroplasty (TEA) is known method for treatment of distal humeral fractures, but the outcome of elbow hemiarthroplasty (EHA) is still limited.
Purpose / Aim of Study: The aim of this study was to report the functional and radiographic outcomes, in a consecutive series of Elbow hemiarthroplasty (EHA) in patients with acute distal humeral fractures.
Materials and Methods: From January 2011 to January 2016 thirty-one patients were treated with EHA for an acute distal humeral fracture. Four patients died before follow-up and 3 patients were unable to participate. Thus, twenty-four patients were included. Mayo Elbow Performance Score MEPS, Oxford Elbow Score OES, pain severity, and range of motion are used to evaluate the clinical outcome. Radiographic outcomes were assessed. The length of sick-leave was recorded.
Findings / Results: Two EHA were revised to a TEA. The remaining 22 patients had a complete follow-up. The mean age was 64 years and 12 patients were under the age of 65 years. The mean follow-up time was 30 months. The median MEPS was 85 and the median OES was 40. The median pain severity score was 2 (range 0-8) on a scale from 0-10. The median flexion/extension and supination/pronation arcs were 112.5 degree and 160 degree respectively. Two patients were re-operated, one because of stiffness and one because of infection (soft-tissue revision). Seven patient were occupationally- active, and six of them returned to the same occupation. The mean sick-leave was 3 months.
Conclusions: The outcome of EHA for the treatment of ureconstructable acute multifragmentary intraarticular distal humeral fractures seems promising in active patients. However ulnar and radia wear and component loosening may lead to a less promising outcome in the long term.
33. Cuff-Tear Arthropathy: An Historical Review of 19th Century Sources
Stig Brorson
Ortopædkirurgisk Afdeling, Herlev/Gentofte Hospital
Background: The term cuff-tear arthropathy was first introduced by Charles Neer in 1977. It is a widely held belief that the condition was unknown prior to the description in the classical paper by Neer, Craig, and Fukuda in 1983. Cuff-tear arthropathy designates the end stage of a process characterized by massive rotator cuff tear, glenohumeral instability with upward migration of the humeral head, and painful arthritis.
Purpose / Aim of Study: In this historical review it is hypothesized that the pathogenesis and the pathoanatomical changes seen in cuff-tear arthropathy were well described and understood in the pre-radiographical era.
Materials and Methods: 19th century clinical case series, autopsy reports, monographs, dissertations, reviews, articles, editorials, letters, and illustrations were systematically searched from historical bibliographical databases and retrieved for relevance. Historical descriptions, discussions and illustrations were identified, presented and interpreted.
Findings / Results: The typical progressive pathoanatomical changes in bone, cartilage, capsule, muscles, tendons, joint fluid, and bursa were described in details and the pathogenesis was understood within a biomechanical framework. In particular, the consequences of the degeneration, displacement or rupture of the tendon of the long head of the biceps and the superior migration of the humeral head were well understood. Relevant historical nosological terms include ‘chronic rheumatic arthritis of the shoulder’ and ‘partial luxation upwards of the humeral head’.
Conclusions: A thorough pathoanatomical and biomechanical understanding of the condition later termed cuff-tear arthropathy can be found in 19th century sources.
Ortopædkirurgisk Afdeling, Herlev/Gentofte Hospital
Background: The term cuff-tear arthropathy was first introduced by Charles Neer in 1977. It is a widely held belief that the condition was unknown prior to the description in the classical paper by Neer, Craig, and Fukuda in 1983. Cuff-tear arthropathy designates the end stage of a process characterized by massive rotator cuff tear, glenohumeral instability with upward migration of the humeral head, and painful arthritis.
Purpose / Aim of Study: In this historical review it is hypothesized that the pathogenesis and the pathoanatomical changes seen in cuff-tear arthropathy were well described and understood in the pre-radiographical era.
Materials and Methods: 19th century clinical case series, autopsy reports, monographs, dissertations, reviews, articles, editorials, letters, and illustrations were systematically searched from historical bibliographical databases and retrieved for relevance. Historical descriptions, discussions and illustrations were identified, presented and interpreted.
Findings / Results: The typical progressive pathoanatomical changes in bone, cartilage, capsule, muscles, tendons, joint fluid, and bursa were described in details and the pathogenesis was understood within a biomechanical framework. In particular, the consequences of the degeneration, displacement or rupture of the tendon of the long head of the biceps and the superior migration of the humeral head were well understood. Relevant historical nosological terms include ‘chronic rheumatic arthritis of the shoulder’ and ‘partial luxation upwards of the humeral head’.
Conclusions: A thorough pathoanatomical and biomechanical understanding of the condition later termed cuff-tear arthropathy can be found in 19th century sources.