Session 11: Shoulder and Elbow / Sports Orthopedics II
Torsdag d. 24. oktober
13:30 - 15:00
Lokale: Vingsal 1
Chairmen: Michael Rindom Krogsgaard og Jeppe Vejgaard Rasmussen
82. The short-term survival of total stemless shoulder arthroplasty for osteoarthritis is comparable to that of total stemmed shoulder arthroplasty: a Nordic Arthroplasty Register Association study
Rasmussen Jeppe, Jenni Harjula, Erica Arverud, Randi Hole, Steen Lund Jensen, Stig Brorson, Anne Marie Fenstad, Björn Salomonsson, Ville Äärimaa
Department of Orthopaedic Surgery, Herlev and Gentofte Hospital; Department of Orthopaedic Surgery, Turku University and University Hospital, Turku, Finland; Department of Orthopaedic Surgery, Karolinska Institutet, Danderyds Sjukhus AB, Danderyd, Stockholm, Sweden; Department of Orthopaedic Surgery , Haukeland University Hospital, Bergen, Norway; , Aalborg University Hospital; Department of Orthopaedic Surgery, Zealand University Hospital, Køge; Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Orthopaedic Surgery, Karolinska Institutet, Danderyds Sjukhus AB, Danderyd, Stockholm, Sweden; Department of Orthopaedic Surgery, Turku University and University Hospital, Turku, Finland
Background: Despite potential benefits, there are also concerns related to stemless shoulder arthroplasty systems. The metaphyseal fixation relies on adequate bone quality, and the risk of component loosening, especially in elderly patients, could in theory be higher than with stemmed humeral components.
Purpose / Aim of Study: The purpose of this study was to compare the short-term survival rate of total stemless, metaphyseal fixated, shoulder arthroplasty with that of total stemmed shoulder arthroplasty in the treatment of osteoarthritis.
Materials and Methods: Data were collected by the national arthroplasty registries in Denmark, Finland, Norway, and Sweden and merged into one dataset under the umbrella of the Nordic Arthroplasty Register Association. For the present study, we included all patients with osteoarthritis treated with either stemless (n = 761) or stemmed (n = 4398) shoulder arthroplasty from 2011 to 2016.
Findings / Results: A total of 21 (2.8%) stemless and 116 (2.6%) stemmed shoulder arthroplasties were revised. The 6-year unadjusted cumulative survival rates were 0.953 for stemless shoulder arthroplasty and 0.958 for stemmed shoulder arthroplasty, P = .77. The most common indication for revision of both arthroplasty types was infection. Five (0.7%) stemless and 16 (0.4%) stemmed shoulder arthroplasties were revised because of loosening of either the glenoid or the humeral component. In the multivariate cox regression model, which included age, category, gender, year of surgery, previous surgery, and arthroplasty type, the hazard ratio (HR) for revision of the stemless shoulder arthroplasty was 1.00 (95% confidence interval [CI], 0.63-1.61), P = .99, with the stemmed shoulder arthroplasty as reference. Male gender (HR = 1.50 [95% CI, 1.06-2.13], P = .02) and previous surgery (HR = 2.70 [95% CI, 1.82-4.01], P < .001) were associated with increased risk of revision.
Conclusions: The short-term survival of total stemless shoulder arthroplasty appears comparable with total stemmed shoulder arthroplasty, but longer observation time is needed to confirm whether they continue to perform equally.
Department of Orthopaedic Surgery, Herlev and Gentofte Hospital; Department of Orthopaedic Surgery, Turku University and University Hospital, Turku, Finland; Department of Orthopaedic Surgery, Karolinska Institutet, Danderyds Sjukhus AB, Danderyd, Stockholm, Sweden; Department of Orthopaedic Surgery , Haukeland University Hospital, Bergen, Norway; , Aalborg University Hospital; Department of Orthopaedic Surgery, Zealand University Hospital, Køge; Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Orthopaedic Surgery, Karolinska Institutet, Danderyds Sjukhus AB, Danderyd, Stockholm, Sweden; Department of Orthopaedic Surgery, Turku University and University Hospital, Turku, Finland
Background: Despite potential benefits, there are also concerns related to stemless shoulder arthroplasty systems. The metaphyseal fixation relies on adequate bone quality, and the risk of component loosening, especially in elderly patients, could in theory be higher than with stemmed humeral components.
Purpose / Aim of Study: The purpose of this study was to compare the short-term survival rate of total stemless, metaphyseal fixated, shoulder arthroplasty with that of total stemmed shoulder arthroplasty in the treatment of osteoarthritis.
Materials and Methods: Data were collected by the national arthroplasty registries in Denmark, Finland, Norway, and Sweden and merged into one dataset under the umbrella of the Nordic Arthroplasty Register Association. For the present study, we included all patients with osteoarthritis treated with either stemless (n = 761) or stemmed (n = 4398) shoulder arthroplasty from 2011 to 2016.
Findings / Results: A total of 21 (2.8%) stemless and 116 (2.6%) stemmed shoulder arthroplasties were revised. The 6-year unadjusted cumulative survival rates were 0.953 for stemless shoulder arthroplasty and 0.958 for stemmed shoulder arthroplasty, P = .77. The most common indication for revision of both arthroplasty types was infection. Five (0.7%) stemless and 16 (0.4%) stemmed shoulder arthroplasties were revised because of loosening of either the glenoid or the humeral component. In the multivariate cox regression model, which included age, category, gender, year of surgery, previous surgery, and arthroplasty type, the hazard ratio (HR) for revision of the stemless shoulder arthroplasty was 1.00 (95% confidence interval [CI], 0.63-1.61), P = .99, with the stemmed shoulder arthroplasty as reference. Male gender (HR = 1.50 [95% CI, 1.06-2.13], P = .02) and previous surgery (HR = 2.70 [95% CI, 1.82-4.01], P < .001) were associated with increased risk of revision.
Conclusions: The short-term survival of total stemless shoulder arthroplasty appears comparable with total stemmed shoulder arthroplasty, but longer observation time is needed to confirm whether they continue to perform equally.
83. Increased use of total shoulder arthroplasty and improved patient-reported outcome for osteoarthritic patient in Denmark from 2006 to 2015: a nationwide cohort study from the Danish shoulder arthroplasty Registry.
Jeppe Rasmussen, Alexander Amundsen, Anne Kathrine Sørensen, Tobias Klausen, John Jakobsen, Steen Lund Jensen, Bo Sanderhoff Olsen
Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Hematology, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital
Background: Osteoarthritis has become the most common indication for shoulder arthroplasty in Denmark. The outcome have been monitored by the Danish Shoulder Arthroplasty Registry (DSR) since 2004, and data on patient- reported outcome and revision rates have been published in annual reports and in international orthopedic journals
Purpose / Aim of Study: The aims were to investigate the use of different arthroplasty types for osteoarthritis in Denmark from 2006- 2015, to report the patient-reported outcome, and to study if changes in the use of arthroplasty types have changed the overall patient-reported outcome from 2006-2015.
Materials and Methods: We included 2,867 shoulder arthroplasties performed for osteoarthritis between 2006 and 2015 and reported to the DSR. The Western Ontario Osteoarthritis of the Shoulder (WOOS) index at one year was used as outcome. The raw score was converted to a percentage of a maximum score. General linear models were used to analyze differences in WOOS.
Findings / Results: The proportion of anatomical total shoulder arthroplasty and reverse shoulder arthroplasty increased from 3% and 7% in 2006 to 53% and 27% in 2015. The mean WOOS score was 70 (SD26) after resurfacing hemiarthroplasties (n=1.258), 68 (SD26) after stemmed hemiarthroplasty (n=500), 82 (SD23) after anatomical total shoulder arthroplasties (n=815) and 74 (SD23) after reverse shoulder arthroplasties (n=213). The overall WOOS increased with 18 (95%CI 12:22, P<0.001) in the univariate model and 10 (95%CI 5:15, P<0.001) in the multiple model. We found improved WOOS scores for anatomical total shoulder arthroplasty (14, 95%CI: 5-23, P=0.003) from 2006- 2015.
Conclusions: The patient reported outcome of shoulder arthroplasty for osteoarthritis improved from 2006 to 2015. This may be related to different factors: improved outcome of anatomical total shoulder arthroplasty; the increased use of total shoulder arthroplasty towards the end of the study period; and better treatment selection including the use of reverse shoulder arthroplasty in patients with poor rotator cuff function. The reason for the increased use of total shoulder arthroplasty is unknown but may be related to surgeons’ awareness of clinical results through annual reports from the DSR.
Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital; Department of Hematology, Herlev and Gentofte hospital; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Orthopaedic Surgery, Herlev and Gentofte hospital
Background: Osteoarthritis has become the most common indication for shoulder arthroplasty in Denmark. The outcome have been monitored by the Danish Shoulder Arthroplasty Registry (DSR) since 2004, and data on patient- reported outcome and revision rates have been published in annual reports and in international orthopedic journals
Purpose / Aim of Study: The aims were to investigate the use of different arthroplasty types for osteoarthritis in Denmark from 2006- 2015, to report the patient-reported outcome, and to study if changes in the use of arthroplasty types have changed the overall patient-reported outcome from 2006-2015.
Materials and Methods: We included 2,867 shoulder arthroplasties performed for osteoarthritis between 2006 and 2015 and reported to the DSR. The Western Ontario Osteoarthritis of the Shoulder (WOOS) index at one year was used as outcome. The raw score was converted to a percentage of a maximum score. General linear models were used to analyze differences in WOOS.
Findings / Results: The proportion of anatomical total shoulder arthroplasty and reverse shoulder arthroplasty increased from 3% and 7% in 2006 to 53% and 27% in 2015. The mean WOOS score was 70 (SD26) after resurfacing hemiarthroplasties (n=1.258), 68 (SD26) after stemmed hemiarthroplasty (n=500), 82 (SD23) after anatomical total shoulder arthroplasties (n=815) and 74 (SD23) after reverse shoulder arthroplasties (n=213). The overall WOOS increased with 18 (95%CI 12:22, P<0.001) in the univariate model and 10 (95%CI 5:15, P<0.001) in the multiple model. We found improved WOOS scores for anatomical total shoulder arthroplasty (14, 95%CI: 5-23, P=0.003) from 2006- 2015.
Conclusions: The patient reported outcome of shoulder arthroplasty for osteoarthritis improved from 2006 to 2015. This may be related to different factors: improved outcome of anatomical total shoulder arthroplasty; the increased use of total shoulder arthroplasty towards the end of the study period; and better treatment selection including the use of reverse shoulder arthroplasty in patients with poor rotator cuff function. The reason for the increased use of total shoulder arthroplasty is unknown but may be related to surgeons’ awareness of clinical results through annual reports from the DSR.
84. How objective knee laxity correlates with patient-reported outcome after ACL reconstruction
Malthe Fiil Larsen
Orthopedics, Aarhus University hospital
Background: The orthopedic literature has found variable results concerning knee laxity and subjective outcomes after ACL reconstruction.
Purpose / Aim of Study: Therefore, the purpose of this study is to describe the relationship between objective sagittal knee laxity and subjective assessment of function and symptoms using high-volume registry data. The hypothesis of this study is that greater laxity correlates with an inferior patient reported outcome and with a higher risk of revision surgery
Materials and Methods: 13035 patients who underwent primary ACL reconstruction from the Danish Knee Ligament Reconstruction Registry were divided into three groups based on their side-to-side difference on instrumented sagittal laxity 1-year after surgery. Group A (n=10613) with ≤ 2mm, group B (n=2122) with 3-5 mm, and group C (n=300) with >5 mm. The outcome measures were Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scores as well as revision rate.
Findings / Results: The study found that revision surgery was highly correlated to laxity. The group with most laxity (group C: 26%) were more than four times as likely to get revision surgery compared to the group with least laxity (group A: 6%) Furthermore, there were a significant correlation between sagittal laxity and the KOOS QoL sub score in all groups. KOOS-4 score and Tegner activity were both significant different when comparing the group with least (group A) and most laxity (group C).
Conclusions: Increased post-operative sagittal laxity correlates with worse knee related quality of life and with a greatly increased risk of revision surgery.
Orthopedics, Aarhus University hospital
Background: The orthopedic literature has found variable results concerning knee laxity and subjective outcomes after ACL reconstruction.
Purpose / Aim of Study: Therefore, the purpose of this study is to describe the relationship between objective sagittal knee laxity and subjective assessment of function and symptoms using high-volume registry data. The hypothesis of this study is that greater laxity correlates with an inferior patient reported outcome and with a higher risk of revision surgery
Materials and Methods: 13035 patients who underwent primary ACL reconstruction from the Danish Knee Ligament Reconstruction Registry were divided into three groups based on their side-to-side difference on instrumented sagittal laxity 1-year after surgery. Group A (n=10613) with ≤ 2mm, group B (n=2122) with 3-5 mm, and group C (n=300) with >5 mm. The outcome measures were Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scores as well as revision rate.
Findings / Results: The study found that revision surgery was highly correlated to laxity. The group with most laxity (group C: 26%) were more than four times as likely to get revision surgery compared to the group with least laxity (group A: 6%) Furthermore, there were a significant correlation between sagittal laxity and the KOOS QoL sub score in all groups. KOOS-4 score and Tegner activity were both significant different when comparing the group with least (group A) and most laxity (group C).
Conclusions: Increased post-operative sagittal laxity correlates with worse knee related quality of life and with a greatly increased risk of revision surgery.
85. Low agreement on fracture morphology in patients considered for shoulder arthroplasty
Alexander Amundsen, Jeppe Vejlgaard Rasmussen, Bo Sanderhoff Olsen, John Kloth Petersen, Stig Brorson
Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Sjællands Universitetshospital, Køge; Ortopædkirurgisk afdeling, Sjællands Universitetshospital, Køge
Background: The majority of proximal humeral fractures can be treated non-surgically. However, an arthroplasty is often considered in the case of head-split fractures or fracture dislocations. Previous studies have reported a poor to moderate inter- and intra-observer agreement on Neer classification of proximal humeral fractures. However, these studies have not focused on the most complex fracture patterns.
Purpose / Aim of Study: To study the level of agreement between and within shoulder surgeons assessing proximal humeral fracture morphology in patients considered for arthroplasty.
Materials and Methods: Preoperative anterior-posterior and scapular- lateral radiographs of 51 consecutive patients with proximal humeral fractures treated with hemiarthroplasty at two university hospitals were retrospectively obtained. One case of glenoid fracture was excluded. First, 4 shoulder surgeons served as observers and independently reviewed all cases. Each case was first classified according to Neer. Second, the surgeon determined if a fracture dislocation or a head-split fracture was present. This process was repeated in a changed picture sequence 3 weeks later. Inter-observer and intra-observer agreement were calculated using Cohen’s kappa and 95 % confidence intervals. Kappa values were interpreted according to Landis and Koch.
Findings / Results: The overall mean kappa-values for inter-observer agreement on Neer classification were 0.11 and 0.34 in the two rounds. Higher mean kappa-values for inter-observer agreement were found for dislocation (0.59 and 0.72) and head-split (0.56 and 0.65). Mean kappa-values for intra-observer agreement on Neer classification ranged from -0.06 to 0.84 and from -0.38 to 1 for dislocation, while intra-observer agreement on head-split ranged from 0.41 to 0.89.
Conclusions: We found slight to fair agreement on Neer classification between four experienced shoulder surgeons. The level of agreement on dislocation and head-split was moderate to substantial. The agreement within surgeons varied from poor to almost perfect. The classification of these fractures and the diagnosis of headsplit fractures and fracture dislocations remain difficult even for experienced surgeons.
Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Herlev-Gentofte Hospital; Ortopædkirurgisk afdeling, Sjællands Universitetshospital, Køge; Ortopædkirurgisk afdeling, Sjællands Universitetshospital, Køge
Background: The majority of proximal humeral fractures can be treated non-surgically. However, an arthroplasty is often considered in the case of head-split fractures or fracture dislocations. Previous studies have reported a poor to moderate inter- and intra-observer agreement on Neer classification of proximal humeral fractures. However, these studies have not focused on the most complex fracture patterns.
Purpose / Aim of Study: To study the level of agreement between and within shoulder surgeons assessing proximal humeral fracture morphology in patients considered for arthroplasty.
Materials and Methods: Preoperative anterior-posterior and scapular- lateral radiographs of 51 consecutive patients with proximal humeral fractures treated with hemiarthroplasty at two university hospitals were retrospectively obtained. One case of glenoid fracture was excluded. First, 4 shoulder surgeons served as observers and independently reviewed all cases. Each case was first classified according to Neer. Second, the surgeon determined if a fracture dislocation or a head-split fracture was present. This process was repeated in a changed picture sequence 3 weeks later. Inter-observer and intra-observer agreement were calculated using Cohen’s kappa and 95 % confidence intervals. Kappa values were interpreted according to Landis and Koch.
Findings / Results: The overall mean kappa-values for inter-observer agreement on Neer classification were 0.11 and 0.34 in the two rounds. Higher mean kappa-values for inter-observer agreement were found for dislocation (0.59 and 0.72) and head-split (0.56 and 0.65). Mean kappa-values for intra-observer agreement on Neer classification ranged from -0.06 to 0.84 and from -0.38 to 1 for dislocation, while intra-observer agreement on head-split ranged from 0.41 to 0.89.
Conclusions: We found slight to fair agreement on Neer classification between four experienced shoulder surgeons. The level of agreement on dislocation and head-split was moderate to substantial. The agreement within surgeons varied from poor to almost perfect. The classification of these fractures and the diagnosis of headsplit fractures and fracture dislocations remain difficult even for experienced surgeons.
86. Surgical versus non-surgical management of displaced fractures of the proximal humerus in elderly
Stig Brorson, Ilija Ban, Janne Ovesen
Department of Orthopaedic Surgery, Zealand University Hospital; Department of Orthopaedic Surgery, Amager and Hvidovre Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Proximal humeral fractures are the third most common non-vertebral fractures in elderly. Minimally displaced fractures account for about half of the fractures and can be treated non-surgically. However, the optimal treatment of displaced 2-, 3-, and 4-part fractures is disputed.
Purpose / Aim of Study: To determine the clinical outcome after surgical versus non-surgical management of displaced fractures of the proximal humerus in elderly (>60 years).
Materials and Methods: Our search strategy from 2015 was applied. Metaanalyses and randomized trials were assessed for eligibility. Two reviewers independently assessed all systematic reviews with metaanalyses using the AMSTAR tool. Additional randomized clinical trials were assessed using the Cochrane Risk of Bias tool.
Findings / Results: Eight new metaanalyses were identified and assessed. The two highest scoring metaanalyses were included in the guideline. They covered eight randomized trials with a total of 567 patients. No additional randomized trials were identified. There was high quality evidence of no statistically or clinically relevant difference in patient-reported function at one- or two-year follow-up between surgical and non-surgical management. There was moderate quality evidence of a significantly higher risk of additional surgery in the surgery group. No randomized trial comparing outcome after non- surgical management and primary reverse prosthesis were identified. Two network mataanalyses of moderate to low quality recommend the use of reverse prostheses. However, the heterogeneity of populations, indications and interventions does not justify the application of network metaanalyses. Recommendations on the use of reverse prosthesis in acute fractures therefore awaits the reporting from well conducted randomized trials.
Conclusions: We recommend a non-surgical approach to displaced 2-, 3-, and 4-part fractures of the proximal humerus in elderly. Other fracture patterns like fracture-dislocations or articular fractures and fracture in younger patients may benefit from surgical management.
Department of Orthopaedic Surgery, Zealand University Hospital; Department of Orthopaedic Surgery, Amager and Hvidovre Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Proximal humeral fractures are the third most common non-vertebral fractures in elderly. Minimally displaced fractures account for about half of the fractures and can be treated non-surgically. However, the optimal treatment of displaced 2-, 3-, and 4-part fractures is disputed.
Purpose / Aim of Study: To determine the clinical outcome after surgical versus non-surgical management of displaced fractures of the proximal humerus in elderly (>60 years).
Materials and Methods: Our search strategy from 2015 was applied. Metaanalyses and randomized trials were assessed for eligibility. Two reviewers independently assessed all systematic reviews with metaanalyses using the AMSTAR tool. Additional randomized clinical trials were assessed using the Cochrane Risk of Bias tool.
Findings / Results: Eight new metaanalyses were identified and assessed. The two highest scoring metaanalyses were included in the guideline. They covered eight randomized trials with a total of 567 patients. No additional randomized trials were identified. There was high quality evidence of no statistically or clinically relevant difference in patient-reported function at one- or two-year follow-up between surgical and non-surgical management. There was moderate quality evidence of a significantly higher risk of additional surgery in the surgery group. No randomized trial comparing outcome after non- surgical management and primary reverse prosthesis were identified. Two network mataanalyses of moderate to low quality recommend the use of reverse prostheses. However, the heterogeneity of populations, indications and interventions does not justify the application of network metaanalyses. Recommendations on the use of reverse prosthesis in acute fractures therefore awaits the reporting from well conducted randomized trials.
Conclusions: We recommend a non-surgical approach to displaced 2-, 3-, and 4-part fractures of the proximal humerus in elderly. Other fracture patterns like fracture-dislocations or articular fractures and fracture in younger patients may benefit from surgical management.
87. Lost jobs and sick leave are common in patients with subacromial impingement syndrome in secondary care: a consecutive cohort study.
Mikkel Bek Clausen, Mathias Fabricius Nielsen, Mikas Merrild, Per Hölmich, Kristian Thorborg
Department of Physiotherapy and Occupational Therapy, Faculty of Health and Technology, University College Copenhagen; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery,, Copenhagen University Hospital Amager-Hvidovre; Department of Physiotherapy and Occupational Therapy, Faculty of Health and Technology, University College Copenhagen; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery,, Copenhagen University Hospital Amager-Hvidovre
Background: Loss of workdays is the main societal cost related to shoulder disorders, with nine lost workdays per six months in average. It is, however, unknown if loss of workdays is equally common for patients with subacromial impingement syndrome (SIS).
Purpose / Aim of Study: The aim is to investigate the amount of workdays lost due to SIS in secondary care.
Materials and Methods: From 157 consecutive patients diagnosed with SIS, 129 (82%) completed a structured six-month follow- up interview. Job status (fulltime/part- time/no job), average weekly working hours and days on sick leave due to SIS were recorded. Only patients in job (n= 58) and patients who lost their job due to SIS (n=8) were considered at-risk of losing workdays, leaving 66 patients to be further analyzed. Lost worktime due to SIS was calculated separately for sick leave, lost job, and working part-time, and normalized to full-time workdays. Mean lost workdays per 6 months was estimated using Poisson regression analyses.
Findings / Results: In total, 1781 workdays were lost due to sick leave (851 days), lost job (647 days) and part-time work (283 days), for the entire cohort (n=129). Mean lost workdays per six months was 14 (95%CI: 9-21) days for the entire cohort, and 27.0 (95%CI: 18-40) days for patients at-risk (n=66).
Conclusions: In secondary care, the amount of workdays lost due to SIS in patients at-risk of losing workdays was 27 workdays (>5 work- weeks). This is 3 times higher than the 9 days previously reported, indicating that productivity loss in this population is a major concern.
Department of Physiotherapy and Occupational Therapy, Faculty of Health and Technology, University College Copenhagen; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery,, Copenhagen University Hospital Amager-Hvidovre; Department of Physiotherapy and Occupational Therapy, Faculty of Health and Technology, University College Copenhagen; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery,, Copenhagen University Hospital Amager-Hvidovre
Background: Loss of workdays is the main societal cost related to shoulder disorders, with nine lost workdays per six months in average. It is, however, unknown if loss of workdays is equally common for patients with subacromial impingement syndrome (SIS).
Purpose / Aim of Study: The aim is to investigate the amount of workdays lost due to SIS in secondary care.
Materials and Methods: From 157 consecutive patients diagnosed with SIS, 129 (82%) completed a structured six-month follow- up interview. Job status (fulltime/part- time/no job), average weekly working hours and days on sick leave due to SIS were recorded. Only patients in job (n= 58) and patients who lost their job due to SIS (n=8) were considered at-risk of losing workdays, leaving 66 patients to be further analyzed. Lost worktime due to SIS was calculated separately for sick leave, lost job, and working part-time, and normalized to full-time workdays. Mean lost workdays per 6 months was estimated using Poisson regression analyses.
Findings / Results: In total, 1781 workdays were lost due to sick leave (851 days), lost job (647 days) and part-time work (283 days), for the entire cohort (n=129). Mean lost workdays per six months was 14 (95%CI: 9-21) days for the entire cohort, and 27.0 (95%CI: 18-40) days for patients at-risk (n=66).
Conclusions: In secondary care, the amount of workdays lost due to SIS in patients at-risk of losing workdays was 27 workdays (>5 work- weeks). This is 3 times higher than the 9 days previously reported, indicating that productivity loss in this population is a major concern.
88. Dynamic radiostereometric analysis for pre- and postoperative evaluation of range of motion in the femeroacetabular impingement hip joint
Lars Hansen, Sepp de Raedt, Bjarne Mygind-Klavsen, Peter Bo Jørgensen, Kjeld Søballe, Maiken Stilling
Department of Clinical Medicine, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University Hospital; Department of Orthopedic Surgery, Aarhus University Hospital; Orthopedic Research Unit, Aarhus University Hospital; Department of Orthopedic Surgery, Aarhus University Hospital; Orthopedic Research Unit, Aarhus University Hospital
Background: Dynamic RSA (dRSA) enables precise non- invasive 3D motion-tracking of bones. Hereby, the biomechanical effects of arthroscopic cheilectomy and –rim trimming (ACH) can be evaluated in patients with femoroacetabular impingement (FAI).
Purpose / Aim of Study: The aim of this study was to investigate the pre- and postoperative range of motion (ROM) and CT bone volume removed after ACH.
Materials and Methods: 13 patients (6 women) were included. The patient’s hips were CT-scanned and CT- bone models of the proximal femur and pelvis were created. Preoperative dRSA recordings were acquired at 5 frames/sec during flexion to 90°, adduction to stop, and internal rotation to stop (FADIR). ACH was performed, CT and dRSA were repeated 3 months and 1 year post-operatively. dRSA images were analyzed using customized automated software called AutoRSA. Hip joint kinematics before, and 3 months and 1 year after ACH were compared pairwise. The bone volume (BV) removal was quantified and compared to postoperative ROM. The center edge angle, alpha angle, acetabular index and femoral anteversion were measured pre- and postoperatively.
Findings / Results: Mean internal hip rotation was 11.4° before ACH surgery, and 8.1° at 3 months and 9.4° at 1 year after surgery, (p>0.84). Hip adduction was 10.4° preoperatively, and 10.5° and 11.6° after ACH surgery (p>0.87). Mean hip flexion during dRSA tests were 80.3° preoperatively, and 78.5° and 79.3° after ACH surgery (p>0.94). The subluxation of the femoral head in the acetabulum, along the x-axis decreased after surgery (p=0.01). No difference along y- and z-axis translations were observed (p>0.05). The BV was 406-1783 mm3 and was not correlated to ROM. Radiological measures were unchanged.
Conclusions: ACH surgery in FAI patients reduced the subluxation of the femoral head but had no impact of ROM during passive FADIR test at 1 year followup. This indicates that the positive clinical effects of ACH are not brought by increased ROM but rather a reduction in labral stress and cartilage pressure during end-range motion.
Department of Clinical Medicine, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University Hospital; Department of Orthopedic Surgery, Aarhus University Hospital; Orthopedic Research Unit, Aarhus University Hospital; Department of Orthopedic Surgery, Aarhus University Hospital; Orthopedic Research Unit, Aarhus University Hospital
Background: Dynamic RSA (dRSA) enables precise non- invasive 3D motion-tracking of bones. Hereby, the biomechanical effects of arthroscopic cheilectomy and –rim trimming (ACH) can be evaluated in patients with femoroacetabular impingement (FAI).
Purpose / Aim of Study: The aim of this study was to investigate the pre- and postoperative range of motion (ROM) and CT bone volume removed after ACH.
Materials and Methods: 13 patients (6 women) were included. The patient’s hips were CT-scanned and CT- bone models of the proximal femur and pelvis were created. Preoperative dRSA recordings were acquired at 5 frames/sec during flexion to 90°, adduction to stop, and internal rotation to stop (FADIR). ACH was performed, CT and dRSA were repeated 3 months and 1 year post-operatively. dRSA images were analyzed using customized automated software called AutoRSA. Hip joint kinematics before, and 3 months and 1 year after ACH were compared pairwise. The bone volume (BV) removal was quantified and compared to postoperative ROM. The center edge angle, alpha angle, acetabular index and femoral anteversion were measured pre- and postoperatively.
Findings / Results: Mean internal hip rotation was 11.4° before ACH surgery, and 8.1° at 3 months and 9.4° at 1 year after surgery, (p>0.84). Hip adduction was 10.4° preoperatively, and 10.5° and 11.6° after ACH surgery (p>0.87). Mean hip flexion during dRSA tests were 80.3° preoperatively, and 78.5° and 79.3° after ACH surgery (p>0.94). The subluxation of the femoral head in the acetabulum, along the x-axis decreased after surgery (p=0.01). No difference along y- and z-axis translations were observed (p>0.05). The BV was 406-1783 mm3 and was not correlated to ROM. Radiological measures were unchanged.
Conclusions: ACH surgery in FAI patients reduced the subluxation of the femoral head but had no impact of ROM during passive FADIR test at 1 year followup. This indicates that the positive clinical effects of ACH are not brought by increased ROM but rather a reduction in labral stress and cartilage pressure during end-range motion.
89. Complications after nonsurgical management of proximal humeral fractures: a systematic review of terms and definitions
Stig Brorson, Nikola Alispahic, Christian Bahrs, Alexander Joeris, Amir Steinitz, Laurent Audigé
Department of Orthopaedic Surgery, Zealand University Hospital, Department of Clinical Medicine, University of Copenhagen; Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Basel, Switzerland; Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center, Tübingen, Germany; , AO Clinical Investigation and Documentation, Dübendorf, Switzerland; , Crossklinik, Basel, Switzerland; Research and Development Department, Upper Extremities, Schulthess Clinic, Zurich, Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
Background: A majority of proximal humeral fractures can be managed without surgery. Recent randomized clinical trials and meta-analyses even question the benefit of surgical treatment for displaced 3-, and 4- part fractures. However, evidence-based treatment recommendations, balancing benefits and harms, presuppose a common reporting of complications and adverse events, which at the moment is largely missing.
Purpose / Aim of Study: To systematically review the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures.
Materials and Methods: We searched PubMed, EMBASE, Cochrane Library, Scopus and WorldCat (2010-2017) and included articles and book chapters containing complication terms or definitions. Two reviewers independently extracted and grouped terms and definitions according to a predefined scheme. Terms and definitions concerning nonsurgical management were tabulated, grouped and analyzed qualitatively.
Findings / Results: The initial search identified 1,376 references from which 470 articles were selected for full-text retrieval. A total of 69 terms for complications after nonsurgical management were identified. The most commonly reported event terms regarded osteonecrosis, malunion, secondary displacement and rotator cuff problems. Seven individual terms were accompanied by some kind of definition. Most terms and definitions were based on radiographical assessments.
Conclusions: We found no consensus in the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures. Multiple terms, some synonymous, some partly synonymous, some distinct, were used. Few complication terms were explicitly defined. Development and validation of an internationally consensus-based core event set for complications after proximal humeral fractures managed nonsurgically is needed.
Department of Orthopaedic Surgery, Zealand University Hospital, Department of Clinical Medicine, University of Copenhagen; Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Basel, Switzerland; Department of Traumatology and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center, Tübingen, Germany; , AO Clinical Investigation and Documentation, Dübendorf, Switzerland; , Crossklinik, Basel, Switzerland; Research and Development Department, Upper Extremities, Schulthess Clinic, Zurich, Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
Background: A majority of proximal humeral fractures can be managed without surgery. Recent randomized clinical trials and meta-analyses even question the benefit of surgical treatment for displaced 3-, and 4- part fractures. However, evidence-based treatment recommendations, balancing benefits and harms, presuppose a common reporting of complications and adverse events, which at the moment is largely missing.
Purpose / Aim of Study: To systematically review the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures.
Materials and Methods: We searched PubMed, EMBASE, Cochrane Library, Scopus and WorldCat (2010-2017) and included articles and book chapters containing complication terms or definitions. Two reviewers independently extracted and grouped terms and definitions according to a predefined scheme. Terms and definitions concerning nonsurgical management were tabulated, grouped and analyzed qualitatively.
Findings / Results: The initial search identified 1,376 references from which 470 articles were selected for full-text retrieval. A total of 69 terms for complications after nonsurgical management were identified. The most commonly reported event terms regarded osteonecrosis, malunion, secondary displacement and rotator cuff problems. Seven individual terms were accompanied by some kind of definition. Most terms and definitions were based on radiographical assessments.
Conclusions: We found no consensus in the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures. Multiple terms, some synonymous, some partly synonymous, some distinct, were used. Few complication terms were explicitly defined. Development and validation of an internationally consensus-based core event set for complications after proximal humeral fractures managed nonsurgically is needed.
90. Supraspinatus and deltoid muscle fiber diversity in rotator cuff tear conditions
Morten K Ravn, Trine I Østergaard, Henrik Daa Schrøder, Jens R Nyengaard, Kate L Lambertsen, Lars H Frich
Orthopaedics, Odense University Hospital; Orthopaedics, Odense University Hospital; Pathology, Odense University Hospital; Core Centre for Molecular Morphology, Aarhus University Hospital; Neurobiology Research, University of Southern Denmark; Orthopaedics, Odense University Hospital
Background: Rotator cuff (RC) tears are associated with RC muscle atrophy and changes in composition that are crucial to the prognosis of RC repair.
Purpose / Aim of Study: The aim of this study was to characterize muscle fiber composition in the supraspinatus (SS) muscle under tear conditions
Materials and Methods: Muscle biopsies were obtained from 21 patients undergoing surgery for RC tendon tear. Biopsies were obtained from the musculotendinous junction of the SS muscle and control biopsies were harvested from the deltoid muscle (DT). Biopsies were immunohistochemically processed for detection of type 1 (slow type) and type 2 (fast type) fibers and analyzed using design-unbiased, stereological principles. We counted the total numbers of type 1 and 2 muscle fibers/mm2 and fiber diameter was used to estimate muscle fiber atrophy and hypertrophy
Findings / Results: We found significantly more type 2 cells/mm² in the SS compared to the DT (p<0.01). In addition, we found a significantly higher fraction of type 1 fibers than type 2 fibers in the DT (p<0.01), whereas both fiber types were equally present in the SS. The diameters of SS cells were generally smaller than those of DT cells. Atrophy of especially SS type 2 fibers was also demonstrated. Fiber atrophy was more pronounced in men than women
Conclusions: The changes in the composition of SS muscle cell types suggest a shift from type 1 to type 2 muscle fibers and atrophy of both type 1 and 2 fibers. This composition indicates loss of endurance and rapid fatigue of the SS muscle under RC tear conditions
Orthopaedics, Odense University Hospital; Orthopaedics, Odense University Hospital; Pathology, Odense University Hospital; Core Centre for Molecular Morphology, Aarhus University Hospital; Neurobiology Research, University of Southern Denmark; Orthopaedics, Odense University Hospital
Background: Rotator cuff (RC) tears are associated with RC muscle atrophy and changes in composition that are crucial to the prognosis of RC repair.
Purpose / Aim of Study: The aim of this study was to characterize muscle fiber composition in the supraspinatus (SS) muscle under tear conditions
Materials and Methods: Muscle biopsies were obtained from 21 patients undergoing surgery for RC tendon tear. Biopsies were obtained from the musculotendinous junction of the SS muscle and control biopsies were harvested from the deltoid muscle (DT). Biopsies were immunohistochemically processed for detection of type 1 (slow type) and type 2 (fast type) fibers and analyzed using design-unbiased, stereological principles. We counted the total numbers of type 1 and 2 muscle fibers/mm2 and fiber diameter was used to estimate muscle fiber atrophy and hypertrophy
Findings / Results: We found significantly more type 2 cells/mm² in the SS compared to the DT (p<0.01). In addition, we found a significantly higher fraction of type 1 fibers than type 2 fibers in the DT (p<0.01), whereas both fiber types were equally present in the SS. The diameters of SS cells were generally smaller than those of DT cells. Atrophy of especially SS type 2 fibers was also demonstrated. Fiber atrophy was more pronounced in men than women
Conclusions: The changes in the composition of SS muscle cell types suggest a shift from type 1 to type 2 muscle fibers and atrophy of both type 1 and 2 fibers. This composition indicates loss of endurance and rapid fatigue of the SS muscle under RC tear conditions
91. Reliability testing of the Baseline® Hydraulic Wrist Dynamometer for supination strength after distal biceps tendon injury
Muhammed Bakhtiyar, Christian Dippmann
Section of Sports Traumatology 51, Bispebjerg Hospital University Hospital of Copenhagen, Denmark; Section of Sports Traumatology 51, Bispebjerg Hospital University Hospital of Copenhagen, Denmark
Background: Rupture of the distal biceps’ tendon (DBT) is a rare injury with a reported incidence of 1.2 ruptures per 100.000 patients per year. Untreated a rupture of the DBT results in a reduction of flexion and supination strength up to 50%. Data from patient related outcome measures (PROMS) show significant increase after operation. Precise measures of the effect of operation on strength are rarely reported, probably because strength testing requires access to a biomechanical testing machine.
Purpose / Aim of Study: This aim of this study was to analyse, if a handy strength measurement tool: the Baseline® Hydraulic Wrist Dynamometer is useful for testing peak torque of supination. The reliability of repeated measurements with the device was investigated. Both arms were measured to study, if the opposite side can be used as reference.
Materials and Methods: A power analysis showed that 6 subjects would be needed to achieve 80 % power and an alpha value of 5 %. The design of the study was a test-retest reliability with at least 48 hours between the two testing sessions. Six Subjects without any history of upper extremity pathology were enrolled and performed supination peak torque in two different positions (neutral and 90degrees supination) with both arms.
Findings / Results: The mean age of the subjects was 26.67 +/- 4.75 years. The measurements for neutral position (thumbs up) were discarded because the readings surpassed the maximal threshold of the dynamometer. The ICC, used to access reliability, for the right and dominant upper extremity was 0.949 corresponding to excellent reliability, and 0.791 for the left extremity corresponding to good reliability. No significant difference was detected between the dominant and non-dominant upper extremity (P-value 0.145)
Conclusions: The Baseline® Hydraulic Wrist Dynamometer is a reliable device to measure supination peak torque, although testing should be performed in 90degrees supination in order to avoid a ceiling effect. Furthermore, we could show that the dominant and non-dominant upper extremities demonstrate similar supination peak torque and therefor can be used as reference to compare supination strength following a rupture of the distal biceps’ tendon.
Section of Sports Traumatology 51, Bispebjerg Hospital University Hospital of Copenhagen, Denmark; Section of Sports Traumatology 51, Bispebjerg Hospital University Hospital of Copenhagen, Denmark
Background: Rupture of the distal biceps’ tendon (DBT) is a rare injury with a reported incidence of 1.2 ruptures per 100.000 patients per year. Untreated a rupture of the DBT results in a reduction of flexion and supination strength up to 50%. Data from patient related outcome measures (PROMS) show significant increase after operation. Precise measures of the effect of operation on strength are rarely reported, probably because strength testing requires access to a biomechanical testing machine.
Purpose / Aim of Study: This aim of this study was to analyse, if a handy strength measurement tool: the Baseline® Hydraulic Wrist Dynamometer is useful for testing peak torque of supination. The reliability of repeated measurements with the device was investigated. Both arms were measured to study, if the opposite side can be used as reference.
Materials and Methods: A power analysis showed that 6 subjects would be needed to achieve 80 % power and an alpha value of 5 %. The design of the study was a test-retest reliability with at least 48 hours between the two testing sessions. Six Subjects without any history of upper extremity pathology were enrolled and performed supination peak torque in two different positions (neutral and 90degrees supination) with both arms.
Findings / Results: The mean age of the subjects was 26.67 +/- 4.75 years. The measurements for neutral position (thumbs up) were discarded because the readings surpassed the maximal threshold of the dynamometer. The ICC, used to access reliability, for the right and dominant upper extremity was 0.949 corresponding to excellent reliability, and 0.791 for the left extremity corresponding to good reliability. No significant difference was detected between the dominant and non-dominant upper extremity (P-value 0.145)
Conclusions: The Baseline® Hydraulic Wrist Dynamometer is a reliable device to measure supination peak torque, although testing should be performed in 90degrees supination in order to avoid a ceiling effect. Furthermore, we could show that the dominant and non-dominant upper extremities demonstrate similar supination peak torque and therefor can be used as reference to compare supination strength following a rupture of the distal biceps’ tendon.
92. Computer tomography acquired hip angles and patient reported outcomes in patients with femoroacetabular impingement syndrome
Signe Kierkegaard, Lone Rømer, Bent Lund, Ulrik Dalgas , Kjeld Søballe, Inger Mechlenburg
H-Hip, Department of Physio and Occupational Therapy and Orthopaedic Surgery, Horsens Hospital; Department of Radiology, Horsens Hospital; Department of Orthopaedic Surgery, Horsens Hospital; Department of Publich Health, Section for Sport, Aarhus University; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Patients with femoroacetabular impingement syndrome (FAIS) experience pain, decreased function and quality of life. Patients present with cam and/or pincer morphology of their hip joint. In the literature, several studies have focus on diagnosis via imaging but recent literature suggests that FAIS should be diagnosed via imaging, clinical signs and symptoms. Associations between patient reported outcomes and specific hip angles might highlight which radiological parameters affect outcomes experienced by the patients.
Purpose / Aim of Study: The aims of the study were 1) to describe computer tomography (CT) acquired angles in patients with FAIS 2) to investigate the association between hip angles in patients with FAIS and the Copenhagen Hip and Groin Outcome Score (HAGOS).
Materials and Methods: Patients were eligible for inclusion if they were scheduled for primary hip arthroscopic surgery for FAIS. The study was approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-239-14) and the Danish Data Protection Agency (1-16-02- 499-14). The CT images of the hip were acquired on a Philips Brilliance 64 (Philips Medical Systems, Best, the Netherlands) scanner with low-dose radiation. All patients completed the HAGOS. Associations between patient reported outcomes and hip angles was tested with linear regression.
Findings / Results: Sixty patients aged 36 ±9, 63% females were included in the study. The following mean ±standard deviation was found: alpha angle 51.7 ±9.6, femoral anteversion angle 27.5 ±10.5, lateral centre edge angle 33.1 ±5.6, acetabular index angle 2.8 ±6.0, anterior acetabular sector angle 59.2 ±6.6, posterior acetabular sector angle 94.9 ±6.8, acetabular anteversion 18.0 ±4.7. Hip angles were not associated with any of the HAGOS scores.
Conclusions: Patients presented with a high femoral anteversion angle and many patients had a low acetabular index angle. There was no overall association between HAGOS scores and hip angles which highlights that patients with FAIS should be diagnosed using other diagnostic criteria than only scans.
H-Hip, Department of Physio and Occupational Therapy and Orthopaedic Surgery, Horsens Hospital; Department of Radiology, Horsens Hospital; Department of Orthopaedic Surgery, Horsens Hospital; Department of Publich Health, Section for Sport, Aarhus University; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Patients with femoroacetabular impingement syndrome (FAIS) experience pain, decreased function and quality of life. Patients present with cam and/or pincer morphology of their hip joint. In the literature, several studies have focus on diagnosis via imaging but recent literature suggests that FAIS should be diagnosed via imaging, clinical signs and symptoms. Associations between patient reported outcomes and specific hip angles might highlight which radiological parameters affect outcomes experienced by the patients.
Purpose / Aim of Study: The aims of the study were 1) to describe computer tomography (CT) acquired angles in patients with FAIS 2) to investigate the association between hip angles in patients with FAIS and the Copenhagen Hip and Groin Outcome Score (HAGOS).
Materials and Methods: Patients were eligible for inclusion if they were scheduled for primary hip arthroscopic surgery for FAIS. The study was approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-239-14) and the Danish Data Protection Agency (1-16-02- 499-14). The CT images of the hip were acquired on a Philips Brilliance 64 (Philips Medical Systems, Best, the Netherlands) scanner with low-dose radiation. All patients completed the HAGOS. Associations between patient reported outcomes and hip angles was tested with linear regression.
Findings / Results: Sixty patients aged 36 ±9, 63% females were included in the study. The following mean ±standard deviation was found: alpha angle 51.7 ±9.6, femoral anteversion angle 27.5 ±10.5, lateral centre edge angle 33.1 ±5.6, acetabular index angle 2.8 ±6.0, anterior acetabular sector angle 59.2 ±6.6, posterior acetabular sector angle 94.9 ±6.8, acetabular anteversion 18.0 ±4.7. Hip angles were not associated with any of the HAGOS scores.
Conclusions: Patients presented with a high femoral anteversion angle and many patients had a low acetabular index angle. There was no overall association between HAGOS scores and hip angles which highlights that patients with FAIS should be diagnosed using other diagnostic criteria than only scans.