Session 11: Shoulder/elbow
17. November
13:30 - 15:00
Lokale: Vingsal 2
Chair: Rie Nyholm and Lars H. Frich
Andreas Haubjerg Qvist¹, Steen Lund Jensen²
Department of Orthopedics, Aarhus University Hospital¹; Department of Orthopedics and Orthopaedic Research Unit, Aalborg University Hospital²
Background: There is substantial evidence that operative treatment of displaced midshaft clavicular fractures reduces the risk of non- union, but the summarized data from randomized studies has failed to demonstrate long term functional gains compared with nonoperative treatment. In some studies, however, the advantage of faster functional recovery is used as an argument for operative treatment.
Aim: The aim of this meta-analysis of randomized controlled trials was to investigate the possible early functional gains (= 6 months) after operative treatment of displaced midshaft clavicular fractures compared with non- surgical treatment.
Materials and Methods: A systematic search was performed to identify randomized controlled trials comparing plate osteosynthesis with nonoperative treatment. We evaluated shoulder function outcomes measured by Constant Score (CS) or Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Other outcomes of interest were sick leave and return to previous activity (work, leisure).
Results: 10 studies including 1333 patients were included. The mean difference in DASH score after 6 weeks was 9.4 points (95% Confidence Interval (CI) 13.7 to 5.1) in favor of operative treatment. At 3 months the difference was 3.6 points (95% CI 6.9 to 0.4) and at 6 months the difference was 3.2 points (95% CI 5.2 to 1.1), both in favor of operative treatment. Results for CS were similar to that of DASH score.
Interpretation / Conclusion: This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. The gain, however, is barely clinically relevant for the average patient. At three and six months, the functional gain is lesser and not clinically relevant.
Department of Orthopedics, Aarhus University Hospital¹; Department of Orthopedics and Orthopaedic Research Unit, Aalborg University Hospital²
Background: There is substantial evidence that operative treatment of displaced midshaft clavicular fractures reduces the risk of non- union, but the summarized data from randomized studies has failed to demonstrate long term functional gains compared with nonoperative treatment. In some studies, however, the advantage of faster functional recovery is used as an argument for operative treatment.
Aim: The aim of this meta-analysis of randomized controlled trials was to investigate the possible early functional gains (= 6 months) after operative treatment of displaced midshaft clavicular fractures compared with non- surgical treatment.
Materials and Methods: A systematic search was performed to identify randomized controlled trials comparing plate osteosynthesis with nonoperative treatment. We evaluated shoulder function outcomes measured by Constant Score (CS) or Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Other outcomes of interest were sick leave and return to previous activity (work, leisure).
Results: 10 studies including 1333 patients were included. The mean difference in DASH score after 6 weeks was 9.4 points (95% Confidence Interval (CI) 13.7 to 5.1) in favor of operative treatment. At 3 months the difference was 3.6 points (95% CI 6.9 to 0.4) and at 6 months the difference was 3.2 points (95% CI 5.2 to 1.1), both in favor of operative treatment. Results for CS were similar to that of DASH score.
Interpretation / Conclusion: This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. The gain, however, is barely clinically relevant for the average patient. At three and six months, the functional gain is lesser and not clinically relevant.
Marie Louise Jensen, Steen Lund Jensen, Matthijs Bolder, Klaus Hanisch, Anne Kathrine Belling Sørensen, Bo Sanderhoff Olsen, Thomas Falstie-Jensen, Jeppe Vejlgaard Rasmussen
Department of Orthopaedics, Gentofte and Herlev University Hospital; Department of Orthopaedics, Aalborg University Hospital; Department of Orthopaedics, Odense University Hospital; Department of Orthopaedics, Hospital South West Jutland; Department of Orthopaedics, Aarhus University Hospital.
Background: Previous studies have indicated an increased risk of periprosthetic joint infection in patients treated with reverse shoulder arthroplasty. The reason for this may be related to a high prevalence of previous rotator cuff repair in these patients.
Aim: The purpose was to determine the risk of periprosthetic joint infection for patients with previous rotator cuff repair compared to patients with no previous surgery and report the rates of revision due to infection after reverse shoulder arthroplasty for cuff tear arthropathy or osteoarthritis.
Materials and Methods: Data was retrieved from the Danish Shoulder Arthroplasty Registry and medical records. We included 2,217 patients who had reverse shoulder arthroplasty for cuff tear arthropathy or osteoarthritis between 2006 and 2019. Periprosthetic joint infection was defined as at least 3 out of 5 tissue samples positive for the same bacteria or as definite or probable infection evaluated from the International Consensus Meeting. The Kaplan-Meier method was used to illustrate the unadjusted 14-year cumulative rates of revision. The Cox regression model was used to report hazard for revision due to periprosthetic joint infection. Results were adjusted for previous non-arthroplasty surgery, gender, diagnosis, and age.
Results: Revision was performed in 88 (4.0%) shoulders of which 40 (1.8%) were due to periprosthetic joint infection. There were 272 (12.3%) patients who had previous rotator cuff repair of which 11 (4.0%) were revised due to periprosthetic joint infection. The 14- year cumulative rate of revision due to periprosthetic joint infection for patients with previous rotator cuff repair was 14.1% and for patients without previous surgery it was 2.7%. The adjusted hazard ratio for revision due to periprosthetic joint infection for patients with previous rotator cuff repair was 2.2 (95% CI 1.04 to 4.60) compared to patients without previous surgery
Interpretation / Conclusion: There is an increased risk of revision due to periprosthetic joint infection after reverse shoulder arthroplasty for patients with previous rotator cuff repair. We recommend that patients with previous rotator cuff repair to be regarded as high-risk patients when considering reverse shoulder arthroplasty.
Department of Orthopaedics, Gentofte and Herlev University Hospital; Department of Orthopaedics, Aalborg University Hospital; Department of Orthopaedics, Odense University Hospital; Department of Orthopaedics, Hospital South West Jutland; Department of Orthopaedics, Aarhus University Hospital.
Background: Previous studies have indicated an increased risk of periprosthetic joint infection in patients treated with reverse shoulder arthroplasty. The reason for this may be related to a high prevalence of previous rotator cuff repair in these patients.
Aim: The purpose was to determine the risk of periprosthetic joint infection for patients with previous rotator cuff repair compared to patients with no previous surgery and report the rates of revision due to infection after reverse shoulder arthroplasty for cuff tear arthropathy or osteoarthritis.
Materials and Methods: Data was retrieved from the Danish Shoulder Arthroplasty Registry and medical records. We included 2,217 patients who had reverse shoulder arthroplasty for cuff tear arthropathy or osteoarthritis between 2006 and 2019. Periprosthetic joint infection was defined as at least 3 out of 5 tissue samples positive for the same bacteria or as definite or probable infection evaluated from the International Consensus Meeting. The Kaplan-Meier method was used to illustrate the unadjusted 14-year cumulative rates of revision. The Cox regression model was used to report hazard for revision due to periprosthetic joint infection. Results were adjusted for previous non-arthroplasty surgery, gender, diagnosis, and age.
Results: Revision was performed in 88 (4.0%) shoulders of which 40 (1.8%) were due to periprosthetic joint infection. There were 272 (12.3%) patients who had previous rotator cuff repair of which 11 (4.0%) were revised due to periprosthetic joint infection. The 14- year cumulative rate of revision due to periprosthetic joint infection for patients with previous rotator cuff repair was 14.1% and for patients without previous surgery it was 2.7%. The adjusted hazard ratio for revision due to periprosthetic joint infection for patients with previous rotator cuff repair was 2.2 (95% CI 1.04 to 4.60) compared to patients without previous surgery
Interpretation / Conclusion: There is an increased risk of revision due to periprosthetic joint infection after reverse shoulder arthroplasty for patients with previous rotator cuff repair. We recommend that patients with previous rotator cuff repair to be regarded as high-risk patients when considering reverse shoulder arthroplasty.
Stig Brorson¹ ², Signe Amalie Borg¹, Kenneth Brian Holtz¹, Zaid Issa¹
¹ Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Køge ² Department of Clinical Medicine, University of Copenhagen
Background: Randomized trials have failed to demonstrate superiority of surgical management in displaced proximal humeral fractures (PHF). Little is known about patient reported outcome after non-surgical management outside control groups in randomized trials.
Aim: To report short-term outcome in a large consecutive cohort of geriatric patients with displaced PHF managed non-surgically.
Materials and Methods: A prospective cohort study performed at a Danish university hospital. All patients aged 60 years or above with an acute (< 3 weeks from injury) displaced PHF (according to Neer’s definition) were followed for 6 months with Oxford Shoulder Score (OSS) and health-related quality of life (EQ 5D-3L). Patients were offered usual rehabilitation in their municipalities. Minimally displaced fractures were referred to primary care and not included in the cohort.
Results: Within a 10-month period 141 patients (77% females) with a displaced PHF were managed. Median age was 75 (interquartile range (IQR) 70- 81). The most common fracture patterns were 2- part (n=75), 3-part (n=40) and 4-part (n=12). We excluded 50 patients: 12 (8.5%) managed surgically (4 primary surgeries, 8 secondary, all with reverse arthroplasty), 11 with concomitant fractures, 9 referred to local hospital, 7 deaths, 6 suffering dementia, 5 other specified reasons. We lost 3 patients to follow-up leaving 88 for final evaluation. Median Oxford Shoulder Score was 37 (IQR 29- 43) which equals 77% of a full shoulder function. Median EQ 5D-3L was 0.60 (IQR 0.43-0.71). A ceiling effect was found for both outcomes. No statistically significant difference in outcome was found between 2-, 3-, and 4-part fractures for either OSS (p=0.22) or EQ 5D-3L (p=0.67) (Kruskal-Wallis test).
Interpretation / Conclusion: Short-term outcome in a large consecutive cohort of geriatric patients with displaced PHF managed non- surgically was reported. Data can be used in patient counseling, clinical decision making and future research.
¹ Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Køge ² Department of Clinical Medicine, University of Copenhagen
Background: Randomized trials have failed to demonstrate superiority of surgical management in displaced proximal humeral fractures (PHF). Little is known about patient reported outcome after non-surgical management outside control groups in randomized trials.
Aim: To report short-term outcome in a large consecutive cohort of geriatric patients with displaced PHF managed non-surgically.
Materials and Methods: A prospective cohort study performed at a Danish university hospital. All patients aged 60 years or above with an acute (< 3 weeks from injury) displaced PHF (according to Neer’s definition) were followed for 6 months with Oxford Shoulder Score (OSS) and health-related quality of life (EQ 5D-3L). Patients were offered usual rehabilitation in their municipalities. Minimally displaced fractures were referred to primary care and not included in the cohort.
Results: Within a 10-month period 141 patients (77% females) with a displaced PHF were managed. Median age was 75 (interquartile range (IQR) 70- 81). The most common fracture patterns were 2- part (n=75), 3-part (n=40) and 4-part (n=12). We excluded 50 patients: 12 (8.5%) managed surgically (4 primary surgeries, 8 secondary, all with reverse arthroplasty), 11 with concomitant fractures, 9 referred to local hospital, 7 deaths, 6 suffering dementia, 5 other specified reasons. We lost 3 patients to follow-up leaving 88 for final evaluation. Median Oxford Shoulder Score was 37 (IQR 29- 43) which equals 77% of a full shoulder function. Median EQ 5D-3L was 0.60 (IQR 0.43-0.71). A ceiling effect was found for both outcomes. No statistically significant difference in outcome was found between 2-, 3-, and 4-part fractures for either OSS (p=0.22) or EQ 5D-3L (p=0.67) (Kruskal-Wallis test).
Interpretation / Conclusion: Short-term outcome in a large consecutive cohort of geriatric patients with displaced PHF managed non- surgically was reported. Data can be used in patient counseling, clinical decision making and future research.
Lars Henrik Frich (1,2), Julie Dybdal (1), Marie Nolsøe Helles (1), Eva Kildall Heibøl (1,2), Stephanie Carlsen (1), Henrik Daa Schrøder (3), Kate Lykke Lambertsen (1),
1. Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark 2. Dept of Orthopaedics, Hospital Sønderjylland, Aabenraa, Denmark 3. Dept. of Pathology, Odense University Hospital, Odense, Denmark
Background: The success of rotator cuff tendon repair is dependent of both tendon healing and muscle recovery. The regenerative capacity of the muscle is primarily driven by muscle stem cells, also known as satellite cells (SCs) that are quiescent cells located under the basal lamina of muscle fibers. The SCs express the transcription factor paired box protein pax7 (Pax7). When a muscle is exposed to injury the SCs break quiescence and reenter the cell cycle in which Pax7 is involved in myogenic cell lineage determination and specification. When SCs are activated, primary myogenic regulatory factors (MRF) like MyoD1 and the secondary MRF myogenin function downstream in terminal differentiation. Pax7+, MyoD1+ and myogenin+ cells in a muscle fiber can therefore be interpreted as an expression of the SC’s presence, activity and stage of differentiation
Aim: to quantify stem cell markers Pax7, MyoD1 and Myogenin+ as an expression of the regenerative potential of the supraspinatus (SS) muscle in RC tear conditions
Materials and Methods: Biopsies were obtained from the SS muscle in 26 patients undergoing surgery for RC tear (RCT). Control biopsies were harvested from the deltoid (DT) muscle. Biopsies were immunohistochemically processed for detection of myogenic precursor marker proteins (Pax7+, MyoD1+ and myogenin+ cells) and analyzed using stereological principles. Total number of Pax7+, MyoD1+ and myogenin+ cells/mm2 was counted to estimate the myogenic potential of the muscle. Statistical adjustments were made for age, lesion age and gender
Results: Our results revealed an unchanging number of satellite cells (Pax7+ expression) in all age groups. However, we showed increased expression of MyoG and MyoD1 in younger patients. A lesion age dependent influence was indicated by a rise in MyoG expression up to 6 month after lesion
Interpretation / Conclusion: The difference in the expression of stem cell markers between the SS muscle and the ipsilateral DT muscle indicates a preserved myogenic potential in the RC muscle during early tear conditions. Treatment opportunities in elderly patient with RCT needs rethinking and enhancement of the myogenic potential of the supraspinatus muscle is a possible therapeutic target to improve rotator cuff repair
1. Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark 2. Dept of Orthopaedics, Hospital Sønderjylland, Aabenraa, Denmark 3. Dept. of Pathology, Odense University Hospital, Odense, Denmark
Background: The success of rotator cuff tendon repair is dependent of both tendon healing and muscle recovery. The regenerative capacity of the muscle is primarily driven by muscle stem cells, also known as satellite cells (SCs) that are quiescent cells located under the basal lamina of muscle fibers. The SCs express the transcription factor paired box protein pax7 (Pax7). When a muscle is exposed to injury the SCs break quiescence and reenter the cell cycle in which Pax7 is involved in myogenic cell lineage determination and specification. When SCs are activated, primary myogenic regulatory factors (MRF) like MyoD1 and the secondary MRF myogenin function downstream in terminal differentiation. Pax7+, MyoD1+ and myogenin+ cells in a muscle fiber can therefore be interpreted as an expression of the SC’s presence, activity and stage of differentiation
Aim: to quantify stem cell markers Pax7, MyoD1 and Myogenin+ as an expression of the regenerative potential of the supraspinatus (SS) muscle in RC tear conditions
Materials and Methods: Biopsies were obtained from the SS muscle in 26 patients undergoing surgery for RC tear (RCT). Control biopsies were harvested from the deltoid (DT) muscle. Biopsies were immunohistochemically processed for detection of myogenic precursor marker proteins (Pax7+, MyoD1+ and myogenin+ cells) and analyzed using stereological principles. Total number of Pax7+, MyoD1+ and myogenin+ cells/mm2 was counted to estimate the myogenic potential of the muscle. Statistical adjustments were made for age, lesion age and gender
Results: Our results revealed an unchanging number of satellite cells (Pax7+ expression) in all age groups. However, we showed increased expression of MyoG and MyoD1 in younger patients. A lesion age dependent influence was indicated by a rise in MyoG expression up to 6 month after lesion
Interpretation / Conclusion: The difference in the expression of stem cell markers between the SS muscle and the ipsilateral DT muscle indicates a preserved myogenic potential in the RC muscle during early tear conditions. Treatment opportunities in elderly patient with RCT needs rethinking and enhancement of the myogenic potential of the supraspinatus muscle is a possible therapeutic target to improve rotator cuff repair
Stig Brorson¹, Joanne Elliott², Theis Thillemann³, Patricia Aluko4, Helen Handoll5
Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark¹; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom²; Department of Orthopaedics, Shoulder and Elbow Unit, Aarhus University Hospital, Aarhus N, Denmark³; National Institute for Health Research (NIHR) Innovation Observatory, Newcastle University, Newcastle Upon Tyne, United Kingdom4; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester and Department of Orthopaedics and Trauma, The University of Edinburgh, Manchester, United Kingdom5
Background: Fractures of the proximal humerus are common injuries, especially in older people. The indication for surgery remains a key treatment question for displaced fractures - surgical interventions are still used widely despite accumulating evidence that surgery may not result in a better outcome. We updated our Cochrane review to include the new evidence for non-pharmacological interventions for treating these fractures. This presentation focuses on surgical versus non- surgical treatment comparison.
Aim: To assess the benefits and harms of surgical versus non-surgical treatment for proximal humeral fractures.
Materials and Methods: A systematic review and meta-analysis. We conducted a comprehensive search in multiple bibliographical databases in November 2021. We considered all randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.
Results: We included 47 randomised trials (3,179 participants) that tested one of 26 comparisons. Ten trials, (717 participants) evaluated surgical versus non-surgical treatment for displaced fractures. We found high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (SMD 0.10, 95% CI -0.07 to 0.27; 552 participants, 7 studies) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 423 participants, 5 studies). We found high-certainty evidence of no clinically important between- group difference in quality of life at one year (EuroQol: MD 0.01, 95% CI -0.02 to 0.04; 502 participants, 6 studies). Low-certainty evidence of a higher risk of additional surgery in the surgery group was found (RR 2.06, 95% CI 1.21 to 3.51; 667 participants, 9 studies).
Interpretation / Conclusion: There is high-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury. Surgery may increase the need for subsequent surgery.
Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark¹; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom²; Department of Orthopaedics, Shoulder and Elbow Unit, Aarhus University Hospital, Aarhus N, Denmark³; National Institute for Health Research (NIHR) Innovation Observatory, Newcastle University, Newcastle Upon Tyne, United Kingdom4; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester and Department of Orthopaedics and Trauma, The University of Edinburgh, Manchester, United Kingdom5
Background: Fractures of the proximal humerus are common injuries, especially in older people. The indication for surgery remains a key treatment question for displaced fractures - surgical interventions are still used widely despite accumulating evidence that surgery may not result in a better outcome. We updated our Cochrane review to include the new evidence for non-pharmacological interventions for treating these fractures. This presentation focuses on surgical versus non- surgical treatment comparison.
Aim: To assess the benefits and harms of surgical versus non-surgical treatment for proximal humeral fractures.
Materials and Methods: A systematic review and meta-analysis. We conducted a comprehensive search in multiple bibliographical databases in November 2021. We considered all randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.
Results: We included 47 randomised trials (3,179 participants) that tested one of 26 comparisons. Ten trials, (717 participants) evaluated surgical versus non-surgical treatment for displaced fractures. We found high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (SMD 0.10, 95% CI -0.07 to 0.27; 552 participants, 7 studies) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 423 participants, 5 studies). We found high-certainty evidence of no clinically important between- group difference in quality of life at one year (EuroQol: MD 0.01, 95% CI -0.02 to 0.04; 502 participants, 6 studies). Low-certainty evidence of a higher risk of additional surgery in the surgery group was found (RR 2.06, 95% CI 1.21 to 3.51; 667 participants, 9 studies).
Interpretation / Conclusion: There is high-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury. Surgery may increase the need for subsequent surgery.
Catarina Malmberg¹, Kristine R Andreasen¹, Stefan E Jensen¹, Benjamin Michaud², Per Hölmich¹, Kristoffer W Barfod¹, Jesper Bencke¹ ³
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager & Hvidovre, Denmark¹; Laboratoire de simulation et modélisation du mouvement (S2M), École de kinésiologie et des sciences de l’activité physique, Université de Montréal, Québec²; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager & Hvidovre, Denmark³
Background: Primary or secondary scapular dyskinesis is characterized by abnormal scapular rotations. It can be painful and impair the shoulder function. A skin marker-based motion capture model providing information about the rotations of the scapula was recently developed and can potentially be used to diagnose and monitor scapular dyskinesis.
Aim: To investigate the concurrent validity and the interrater reliability of a new model for analysis of scapular kinematics.
Materials and Methods: Twelve infrared cameras were used to track reflections from moving skin markers in the motion capture model. A strict protocol for placement of the skin markers was followed. Shoulder range of motion (ROM) and activities of daily living (ADL) were tested. To investigate the validity, the skin marker-based model was compared to gold standard through simultaneous data collection from markers fitted to an intracortical pin in the scapula of healthy volunteers. Reliability was tested by comparing two investigators performing the skin marker- based protocol in a different group of healthy volunteers. The mean Root Mean Square Error (RMSE) was calculated for each tested motion to determine the validity. The interrater reliability was determined as Intraclass Correlation (ICC2,1) for each tested motion.
Results: Eight subjects were included in the validity test: F/M=2/6, mean age 34 (range 29-38), mean BMI 23.4 (SD3.3). The mean RMSE of all scapular rotations ranged 2.4-7.6° during shoulder ROM and 2.2-8.7° during ADL. The highest errors were seen for movements in front of the body: sagittal/scapular plane flexion, hair combing and eating. In the reliability test, 20 subjects were included: F/M=8/12, mean age 31 (range 23-37), mean BMI 22.9 (SD1.74). ICC for measuring protraction ranged 0.64-0.83 during ROM and 0.71-0.76 for ADL. Correspondingly, ICC ranged 0.15-0-70 and (-0.01)-0.72 for upward rotation, and 0.37-0.77 and 0.57-0.76 for anterior tilt.
Interpretation / Conclusion: Our results indicate that the model’s validity and reliability are task dependent and interpretation should be made with caution. Taking the inherent limitations of the method into consideration, the model is promising for clinical use.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager & Hvidovre, Denmark¹; Laboratoire de simulation et modélisation du mouvement (S2M), École de kinésiologie et des sciences de l’activité physique, Université de Montréal, Québec²; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager & Hvidovre, Denmark³
Background: Primary or secondary scapular dyskinesis is characterized by abnormal scapular rotations. It can be painful and impair the shoulder function. A skin marker-based motion capture model providing information about the rotations of the scapula was recently developed and can potentially be used to diagnose and monitor scapular dyskinesis.
Aim: To investigate the concurrent validity and the interrater reliability of a new model for analysis of scapular kinematics.
Materials and Methods: Twelve infrared cameras were used to track reflections from moving skin markers in the motion capture model. A strict protocol for placement of the skin markers was followed. Shoulder range of motion (ROM) and activities of daily living (ADL) were tested. To investigate the validity, the skin marker-based model was compared to gold standard through simultaneous data collection from markers fitted to an intracortical pin in the scapula of healthy volunteers. Reliability was tested by comparing two investigators performing the skin marker- based protocol in a different group of healthy volunteers. The mean Root Mean Square Error (RMSE) was calculated for each tested motion to determine the validity. The interrater reliability was determined as Intraclass Correlation (ICC2,1) for each tested motion.
Results: Eight subjects were included in the validity test: F/M=2/6, mean age 34 (range 29-38), mean BMI 23.4 (SD3.3). The mean RMSE of all scapular rotations ranged 2.4-7.6° during shoulder ROM and 2.2-8.7° during ADL. The highest errors were seen for movements in front of the body: sagittal/scapular plane flexion, hair combing and eating. In the reliability test, 20 subjects were included: F/M=8/12, mean age 31 (range 23-37), mean BMI 22.9 (SD1.74). ICC for measuring protraction ranged 0.64-0.83 during ROM and 0.71-0.76 for ADL. Correspondingly, ICC ranged 0.15-0-70 and (-0.01)-0.72 for upward rotation, and 0.37-0.77 and 0.57-0.76 for anterior tilt.
Interpretation / Conclusion: Our results indicate that the model’s validity and reliability are task dependent and interpretation should be made with caution. Taking the inherent limitations of the method into consideration, the model is promising for clinical use.
Kristoffer Weisskirchner Barfod, Anja Ussing, Theis Muncholm Thillemannd, Anne Kathrine Belling Sørensen, Steen Lund Jensen, Behnam Liaghat, Henning Keinke Andersen, Simon Tarp, Birgitte Holm Petersen, Martin Bach Jensen, Morten Hoegh, Stig Brorson
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Denmark.* Danish Health Authority, Copenhagen, Denmark. The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark. Department of Orthopedic Surgery, Aarhus University Hospital, Denmark; Department of clinical medicine, Aarhus University, Denmark Department of Orthopedic Surgery, Copenhagen University Herlev, Denmark fDepartment of Orthopedic Surgery, Aalborg University Hospital; Department of Clinical Medicine, Aalborg University. Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. Center for General Practice at Aalborg University, Aalborg, Denmark. Musculoskeletal Health and Implementation, Department of Medicine, Aalborg University, Aalborg, Denmark. Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Background: No reviews have investigated the effect of artroscopic subacromial decompression (ASAD) in patients who have failed best evidence non- operative treatment
Aim: To investigate the effect of artroscopic subacromial decompression (ASAD) in adult patients with long- lasting subacromial pain syndrome (SAPS) (more than 6 months), and not responding to structured exercise therapy (minimum 3 months).
Materials and Methods: A systematic review and meta-analysis. Certainty of evidence was evaluated using GRADE. Data sources were: Embase, MEDLINE, Cochrane Library, Cinahl, and Pedro (inception to March 2020). Eligible studies were randomised controlled trials comparing ASAD with a) non-surgical treatment or b) no treatment.
Results: No studies fulfilled the inclusion criteria. Four studies (n=487) provided indirect information as a majority of the included populations was assumed to have had long-lasting SAPS and have failed non-surgical treatment. ASAD compared to non-surgical treatment showed a satistically significant but clinically irrelevant effect on pain (3 RCTs; n = 315; mean difference (MD) 0.69, 95% CI 0.08;1.3 (on a 0- 10 visual analogue scale (VAS) MCID 1.5), and function (constant score (CS)) (3 RCTs; n=314; MD 5.53, 95% CI 2.09;12.79 (on a 0-100 scale, MCID 8.3) at 6 months. No difference was found for risk of serious adverse events. ASAD compared to no treatment showed no satistically significant nor clinically relevant effect on pain at 6 months (1 RCT; n = 120; MD 0.02, 95% CI -0.85;0.89 (on a 0-10 VAS,), and a statistically significant, but clinically irrelevant negative effect on function (CS) at 6 months (1 RCT; n=120; std. MD -6.2, 95% CI -12.02;-0.38. No difference was found in the risk of serious adverse events.
Interpretation / Conclusion: No trial has been limited to patients failing non- operative treatment why research is needed to establish the value of ASAD in this population. Based on indirect evidence, ASAD was not superior to non-surgical treatment (very low certainty of evidence) or no treatment (low certainty of evidence). These findings support a weak recommendation against the use of ASAD in this group of patients.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Denmark.* Danish Health Authority, Copenhagen, Denmark. The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark. Department of Orthopedic Surgery, Aarhus University Hospital, Denmark; Department of clinical medicine, Aarhus University, Denmark Department of Orthopedic Surgery, Copenhagen University Herlev, Denmark fDepartment of Orthopedic Surgery, Aalborg University Hospital; Department of Clinical Medicine, Aalborg University. Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. Center for General Practice at Aalborg University, Aalborg, Denmark. Musculoskeletal Health and Implementation, Department of Medicine, Aalborg University, Aalborg, Denmark. Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Background: No reviews have investigated the effect of artroscopic subacromial decompression (ASAD) in patients who have failed best evidence non- operative treatment
Aim: To investigate the effect of artroscopic subacromial decompression (ASAD) in adult patients with long- lasting subacromial pain syndrome (SAPS) (more than 6 months), and not responding to structured exercise therapy (minimum 3 months).
Materials and Methods: A systematic review and meta-analysis. Certainty of evidence was evaluated using GRADE. Data sources were: Embase, MEDLINE, Cochrane Library, Cinahl, and Pedro (inception to March 2020). Eligible studies were randomised controlled trials comparing ASAD with a) non-surgical treatment or b) no treatment.
Results: No studies fulfilled the inclusion criteria. Four studies (n=487) provided indirect information as a majority of the included populations was assumed to have had long-lasting SAPS and have failed non-surgical treatment. ASAD compared to non-surgical treatment showed a satistically significant but clinically irrelevant effect on pain (3 RCTs; n = 315; mean difference (MD) 0.69, 95% CI 0.08;1.3 (on a 0- 10 visual analogue scale (VAS) MCID 1.5), and function (constant score (CS)) (3 RCTs; n=314; MD 5.53, 95% CI 2.09;12.79 (on a 0-100 scale, MCID 8.3) at 6 months. No difference was found for risk of serious adverse events. ASAD compared to no treatment showed no satistically significant nor clinically relevant effect on pain at 6 months (1 RCT; n = 120; MD 0.02, 95% CI -0.85;0.89 (on a 0-10 VAS,), and a statistically significant, but clinically irrelevant negative effect on function (CS) at 6 months (1 RCT; n=120; std. MD -6.2, 95% CI -12.02;-0.38. No difference was found in the risk of serious adverse events.
Interpretation / Conclusion: No trial has been limited to patients failing non- operative treatment why research is needed to establish the value of ASAD in this population. Based on indirect evidence, ASAD was not superior to non-surgical treatment (very low certainty of evidence) or no treatment (low certainty of evidence). These findings support a weak recommendation against the use of ASAD in this group of patients.
Stig Brorson¹ ², Bjarke Viberg³, Per Gundtoft³ 4, Bamo Jalal¹, Søren Ohrt-Nissen5
¹ Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Køge; ² Department of Clinical Medicine, University of Copenhagen; ³ Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding; 4 Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital; 5 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen
Background: Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates has been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery.
Aim: To describe the epidemiology and trends in management of acute PHF in adults in Denmark from 1996 to 2018 with focus on changes in 1) incidence of PHF, 2) proportion of surgical and non- surgical cases, and 3) preferred surgical techniques.
Materials and Methods: This is a national registry-based study with data on diagnoses and interventions retrieved from The Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as diagnosis code on PHF (DS422) combined with a surgical procedure code within 3 weeks of injury. HA was defined as KNBB0* and KNBB1* while RSA was defined as KNBB20, 30, 40, or 59. Plating was defined as KNFJ60 and other techniques as other KNB* procedures. Non-surgical was defined as no surgical procedure code within 3 weeks or KNBJ0*. Statistics Denmark provided background population data for incidence estimation.
Results: Between 1996 and 2018, 137,429 PHF were registered. Women accounted for 72%. The overall incidence was 139/100,000/year (497 for women 60 years or above). The incidences were stable over the period. Non-surgical treatment accounted for 119,966 (87%) of the fractures. The 17,470 surgical procedures included 7,331 (42%) locking plates, 5,850 (34%) arthroplasties and 4,289 (25%) other techniques (K-wires, intramedullary nails, screws and combined techniques). In 2013, 17% of all PHF were treated surgically, the rate gradually declined to 11% in 2018. In patients above 60 years, the rate of locking plates remained stable (51%) from 2013 to 2018 while the use of RSA increased from 1% to 13% and the rate of HA decreased from 38% to 24%.
Interpretation / Conclusion: The incidence of PHF has remained stable between 1996 and 2018. The approach to PHF remains predominantly non-surgical and the number of surgeries in Denmark have decreased since 2013. RSA is increasingly used in acute PHF.
¹ Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Køge; ² Department of Clinical Medicine, University of Copenhagen; ³ Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding; 4 Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital; 5 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen
Background: Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates has been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery.
Aim: To describe the epidemiology and trends in management of acute PHF in adults in Denmark from 1996 to 2018 with focus on changes in 1) incidence of PHF, 2) proportion of surgical and non- surgical cases, and 3) preferred surgical techniques.
Materials and Methods: This is a national registry-based study with data on diagnoses and interventions retrieved from The Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as diagnosis code on PHF (DS422) combined with a surgical procedure code within 3 weeks of injury. HA was defined as KNBB0* and KNBB1* while RSA was defined as KNBB20, 30, 40, or 59. Plating was defined as KNFJ60 and other techniques as other KNB* procedures. Non-surgical was defined as no surgical procedure code within 3 weeks or KNBJ0*. Statistics Denmark provided background population data for incidence estimation.
Results: Between 1996 and 2018, 137,429 PHF were registered. Women accounted for 72%. The overall incidence was 139/100,000/year (497 for women 60 years or above). The incidences were stable over the period. Non-surgical treatment accounted for 119,966 (87%) of the fractures. The 17,470 surgical procedures included 7,331 (42%) locking plates, 5,850 (34%) arthroplasties and 4,289 (25%) other techniques (K-wires, intramedullary nails, screws and combined techniques). In 2013, 17% of all PHF were treated surgically, the rate gradually declined to 11% in 2018. In patients above 60 years, the rate of locking plates remained stable (51%) from 2013 to 2018 while the use of RSA increased from 1% to 13% and the rate of HA decreased from 38% to 24%.
Interpretation / Conclusion: The incidence of PHF has remained stable between 1996 and 2018. The approach to PHF remains predominantly non-surgical and the number of surgeries in Denmark have decreased since 2013. RSA is increasingly used in acute PHF.
Christian Cavallius, Kenneth Quaade Szkopek, Theis M. Thillemann, Steen Lund Jensen
DOT, DSSAK
Background: ..
Aim: The aim of this short clinical guideline was to assess the evidence for treatment of isolated Mason type III fractures of the radial head not amenable for osteosynthesis: which is better; substitution with a metallic radial head prosthesis or a simple radial head resection?
Materials and Methods: A systematic search of relevant literature for guidelines, systematic reviews and randomized controlled trails (RTC) was conducted on Pubmed on March 8th, 2022. The evidence was rated by standardized forms (AMSTAR2, Cochrane Risk of Bias-tool and GRADE).
Results: From a total of 292 studies, 258 were excluded based on titles and abstracts, and 29 studies were excluded after reading full text by at least two of the authors. Of the remaining five studies, three were excluded due to a low score on AMSTAR2. Finally, two studies were included: a network meta-analysis and a quasi-randomized controlled trial. Both studies assessed functional outcome by Mayo Elbow Performance Index, but disagreed as to which treatment was better. Rate of reoperation was not reported in either study, but overall, radial head resection led to fewer complications compared to arthroplasty. This finding was not statistically significant.
Interpretation / Conclusion: It is not recommended to use radial head arthroplasty instead of simple radial head excision in isolated Mason type III fracture not amenable to internal fixation if there are no associated lesions. The evidence to support the conclusion is very weak.
DOT, DSSAK
Background: ..
Aim: The aim of this short clinical guideline was to assess the evidence for treatment of isolated Mason type III fractures of the radial head not amenable for osteosynthesis: which is better; substitution with a metallic radial head prosthesis or a simple radial head resection?
Materials and Methods: A systematic search of relevant literature for guidelines, systematic reviews and randomized controlled trails (RTC) was conducted on Pubmed on March 8th, 2022. The evidence was rated by standardized forms (AMSTAR2, Cochrane Risk of Bias-tool and GRADE).
Results: From a total of 292 studies, 258 were excluded based on titles and abstracts, and 29 studies were excluded after reading full text by at least two of the authors. Of the remaining five studies, three were excluded due to a low score on AMSTAR2. Finally, two studies were included: a network meta-analysis and a quasi-randomized controlled trial. Both studies assessed functional outcome by Mayo Elbow Performance Index, but disagreed as to which treatment was better. Rate of reoperation was not reported in either study, but overall, radial head resection led to fewer complications compared to arthroplasty. This finding was not statistically significant.
Interpretation / Conclusion: It is not recommended to use radial head arthroplasty instead of simple radial head excision in isolated Mason type III fracture not amenable to internal fixation if there are no associated lesions. The evidence to support the conclusion is very weak.