Session 19: Sports and Shoulder/elbow

18. November
12:45 - 13:35
Lokale: Vingsal 3
Chairmen: Jeppe V. Rasmussen and Christian Dippmann

142. Level of pain catastrophizing determines if patients with longstanding subacromial impingement benefit from more resistance exercise: pre-defined secondary analyses (SExSI-Trial)
Mikkel Bek Clausen¹ ², Michael Skovdal Rathleff³ 4, Thomas Graven-Nielsen5, Thomas Bandholm6 7, Karl Bang Christensen8, Per Hölmich¹, Kristian Thorborg¹ 6
Sports Orthopaedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Institute for Clinical Medicine, Copenhagen University, Denmark¹; Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy, Faculty of Health, University College Copenhagen, Copenhagen, Denmark²; Center for General Practice at Aalborg University, Denmark³; Department of Health Science and Technology, Faculty of Medicine, Aalborg University4; Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Denmark5; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark6; Clinical Research Centre, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark7; Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark8

Background: More resistance exercise does not improve nonoperative care for subacromial impingement (SIS) but further analyses are needed to explore the impact of exercise adherence, facilitated or disrupted pain mechanisms and catastrophizing.
Aim: To investigate 1) if adding a large resistance exercise dose to usual care is superior to usual care alone for improving pain mechanisms and catastrophizing in patients with longstanding SIS, 2) the modifying effect of pain mechanisms and catastrophizing on intervention effectiveness in improving shoulder strength and disability, and 3) the impact of strengthening exercise dose and pain mechanisms on changes in shoulder strength and disability from baseline to four-month follow up.
Materials and Methods: 200 consecutive patients with longstanding SIS were randomly allocated to usual exercise-based care or the same plus additional elastic-band exercise to increase total exercise dose. Completed add-on exercise dose was captured using a sensor. Outcome measures included Shoulder Pain and Disability Index (SPADI), pain catastrophizing (PCS), and pain mechanisms (local pressure pain threshold at the deltoid (PPT-deltoid), temporal summation of pain (TSP), conditioned pain modulation (CPM) assessed at the lower leg).
Results: Additional elastic band exercise was not superior to usual care in improving pain catastrophizing or pain mechanisms (TSP, CPM and PPT-deltoid). Interaction analyses showed that pain catastrophizing (median split) modified the effectiveness of additional exercises (effect-size 0.95, P=.0029), with superior results in the additional exercise group compared to the usual care group in patients with less pain catastrophizing. Within-group analyses showed that for every hour completed of the additional elastic-band exercise, SPADI improved by 3 points (95%CI -4.1 to -1.1, P<.001).
Interpretation / Conclusion: Additional resistance exercise added to usual care is not superior to usual care alone in improving pain mechanisms or catastrophizing. Additional exercise is, however, superior in improving self-reported disability in patients with lower levels of pain catastrophizing at baseline. Larger completed add-on exercise dose is associated with larger improvements in shoulder disability.

143. 91% satisfactory results after non-operative treatment of type II-V Acromioclavicular dislocation – a prospective cohort study
Haugaard KB¹, Bak K², Ryberg D¹, Muharemovic O³, Hölmich P¹, Barfod KW¹
1. Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Denmark; 2. Adeas Private Hospital, Øster Allé 42, Copenhagen, Danmark; 3. Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre.

Background: Acromioclavicular (AC) joint dislocations account for 9-12% of all injuries to the shoulder girdle. The injuries are, according to Rockwood, classified in type I-VI depending on the severity.
Aim: To evaluate non-operative treatment of acute acromioclavicular joint dislocation and identify prognostic factors.
Materials and Methods: This was a prospective cohort study of patients with acute (< 3 weeks) AC joint dislocation type II-V. Patients, aged 18-60 years with no concomitant injury to the upper extremity, were identified through review of x-rays from the emergency departments at 3 hospitals. Patients were treated non-operatively with a 3 months supervised training program. Follow up was at 6w, 3m, 6m and 1y. Patients with unsatisfactory progression (i.g. decreased ROM and/or reduced ADL) at 6 weeks or later were referred for surgery (OP-group). The primary outcome measure was the Western Ontario Shoulder instability Index (WOSI (%)) at 3 months. Outcome in patients with a satisfactory result from non- OP treatment was compared with the OP- group using appropriate statistics.
Results: More than 7000 x-rays were screened, 104 patients were eligible, 100 patients mean (SD) age 39 (13), male/female 11/89 were included and 96 patients contributed data for the primary outcome analysis. There were 5 type II, 57 type III and 38 type V injuries. 91/100 patients had a satisfactory result without surgery. 9 patients (7 type III and 2 type V injuries) were referred for surgery. A statistically significant between- group difference was found at 6w (mean difference 31 [95% CI 18;44], p<0.001) and 3m (32 [19;46], p<0.001). Patients with a satisfactory result from non-operative treatment had significantly higher WOSI 3 months after the injury compared to 3 months after surgery in the OP-group with mean WOSI scores of 74% (20) and 57% (22), respectively (p=0.048). There was no significant difference in WOSI between patients with type III and V injuries at any time-point.
Interpretation / Conclusion: Non-operative treatment of AC joint dislocation was successful in 91% of cases. Patients referred for surgery had an average of 31% and 32% lower WOSI at 6 and 12 weeks, respectively. The Rockwood classification was not prognostic for the result.

144. Interrater and intrarater reliability of four classification methods for evaluating acromial morphology on standardized radiographs
Thomas Wagenblast Mayntzhusen¹, Adam Witten¹, Jens Gramkow¹, Sanja Somodi², Shefali Anup Chatterjee², Per Hølmich¹, Kristoffer Weisskirchner Barfod¹
Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre¹; Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark²

Background: Three classification methods exist for evaluation of acromial morphology: Bigliani, Modified Epstein, and The acromial angle classification. Their reliability varies considerably across studies, and have not yet been compared in a single clinical study, or using standardized radiographs. Consequently, the evaluation of acromial morphology is currently not validated though its widespread use in clinical decision- making across the world. We have developed a novel evaluation: the Acromial curve classification.
Aim: To investigate the interrater and intrarater reliability of the three known classifications, and the novel Acromial curve classification.
Materials and Methods: Three experienced clinicians (one senior orthopedic shoulder surgeon and two senior radiologists) classified 102 standardized supraspinatus outlet view radiographs. Each radiograph was rated with the four classification methods by all raters in two separate and blinded sessions a month apart. Reliability was assessed using Kappa and ICC statistics for the categorial and continuous classification methods, respectively. With an expected kappa and ICC > 0,7 (+/- 0,15), the target sample size was 87 radiographs.
Results: The Bigliani classification had interrater and intrarater reliability ranging from fair to good (Kappa 0.32-0.41 and 0.26-0.62). The modified Epstein classification had fair to good interrater and intrarater reliability (Kappa 0.24-0.69 and 0.57-0.63). The acromial angle classification had moderate to good interrater and intrarater reliability (Kappa 0.53-0.60 and 0.59-0.72). The novel Acromial curve classification showed moderate to good interrater and intrarater reliability (ICC 0.66-0.71 and 0.75-0.78, respectively).
Interpretation / Conclusion: The novel Acromial curve classification method met, as the only of the four tested classification methods, our hypothesis with an ICC value > 0.7. The popular Bigliani method had the worst reliability. The Acromial curve classification yields numerical data, as opposed to the other three classification methods. This could potentially be utilized in future research to establishing cut-off values for treatment stratification.

145. Patient-reported outcomes of Hip Arthroscopy after Periacetabular Osteotomy (PAO) in dysplastic patients compared with a matching femoroacetabular impingement (FAIS) cohort. A minimum of two-year follow-up data from the Danish Hip Arthroscopy Registr
Bjarne Mygind-Klavsen, Bent Lund, Torsten Grønbech Nielsn, Martin Lind
Bjarne Mygind-Klavsen: (MD), Department of Orthopedics, Aarhus University Hospital; Bent Lund: (MD), Dept. of Orthopedics, H-HiP Research Unit, Horsens Regional Hospital; Torsten Grønbech Nielsen: (PT), Department of Orthopedics, Aarhus University Hospital; Martin Lind: (MD, DMSc, PhD), Department of Orthopedics, Aarhus University Hospital.

Background: In theory, the purpose of the osteotomy is to reorientate the acetabulum and thereby unloading the acetabular rim and resolve symptoms from the intraarticular abnormalities. Unfortunately, the risk of additional hip arthroscopy after the PAO procedure, due to intraarticular symptoms, has been reported between 2-11%.
Aim: The purpose of this study was to report a minimum of two-year follow-up of additional hip arthroscopy after PAO and compare patient-reported outcome with a matched cohort of patients treated with hip arthroscopy due to FAIS with data from DHAR.
Materials and Methods: Inclusion criteria in the study cohort were PAO-surgery resulting in an additional hip arthroscopy procedure. The control group consisted of FAIS patients in DHAR undergoing primary FAIS hip arthroscopy procedure, defining the FAIS cohort. The FAIS patients were assessed for eligibility according to radiological findings such as cam, pincer, or mixed type impingement. In the two cohorts, the Copenhagen Hip and Groin Outcome Scores, HAGOS, were evaluated. Other non-FAIS patients treated with hip arthroscopy or other hip related surgery, previous hip conditions such as Legg-Calvé-Perthes disease, avascular necrosis, patients without baseline and/or two-year follow-up patient-reported outcome measures or otherwise lost to follow-up, were excluded.
Results: A total of 65 patients were included in the study cohort and the FAIS cohort consisted of 260 patients after matching. HAGOS improved significantly in all subscales from preoperatively to two-year follow-up between 8.3 and 15.7 points in the study cohort. The improvement was inferior to FAIS improvements, 15.8 and 25.9 points. According to HAGOS subscales, 44.6- 56.9% and 24.6-36.9% achieved Minimal Important Clinical Difference, MCID, and Patient Acceptable Symptom State, PASS respectively and inferior compared to FAIS cohort.
Interpretation / Conclusion: This study demonstrates, in PAO treated patients, significant HAGOS improvements after additional hip arthroscopy. Unfortunately, only 50% and 30% achieved MCID and PASS respectively. These results are inferior to results after FAIS surgery.

146. Strength, function and overall health before and after surgical or conservative treatment of proximal hamstring avulsion.
Kasper Spoorendonk(1), Jens Ole Storm(2), Bohn Marie Bagger(2), Bent Lund(2), Signe Kierkegaard(1)
Department of Physio and Occupational Therapy, Horsens Regional Hospital(1) Department of Orthopedic Surgery, Horsens Regional Hospital(2)

Background: Proximal Hamstring Avulsion (PHA) is a rare injury and happens with hyperextended knee and hyper flexed hip as seen in waterskiing, football and slipping injuries. Symptoms are a large hematoma on the back of the thigh, stiffness and pain during walking and sitting and surgical repair is a treatment option. The effect of the treatment with regard to pain, function and quality of life is not well described.
Aim: The aim of the study was to investigate the effect of surgical and conservative treatment of PHA.
Materials and Methods: Patients with MRI-verified PHA were included and had either surgery or training. At baseline, at 6- and 12-months follow-up, all patients answered Perth Hamstring Assessment Tool (PHAT), Hip Sports Activity Scale (HSAS), an overall-health Visual Analog scale and had their knee flexion strength measured at 30 degrees using a handheld dynamometer.
Results: 13 patients had surgery (mean age 51±15, 46% females, 15 days after injury) and 13 patients had supervised training (mean age 50±17, 46% females, 64 days after injury). In the surgical group, the median PHAT score increased from 41 to 70 to 82 (p<0.001), their overall health: 50 to 80 to 80 (p=0.025) and their HSAS: 0 to 3 to 3 (p<0.01). In the training group, the PHAT score increased from 51 to 68 to 77 (p<0.001). Overall health improved from 69 to 75 to 80 (p=0.025), while HSAS went from 0 to 1 to 1 (p<0.01). Median knee strength improved in the surgical group from 0.22 to 0.67 to 1.07 Nm/kg (<0.001) and in the training group from 0.24 to 0.44 to 0.48 Nm/kg (p<0.001).
Interpretation / Conclusion: At 12 months follow-up, both groups improved PHAT and overall health. However, the surgical group improved more in knee flexion strength and were able to participate in sports at a higher level than the conservative treated group.

147. Is the Femoral-Epiphyseal Acetabular Roof (FEAR) index associated with hip pain in patients with hip dysplasia?
Lisa Urup Tønning¹², Markus Schmid³, João Barroso4, Benedicte Hovind¹, Dunia Hessain¹, Marie Balling¹, Stig Storgaard Jakobsen¹², Inger Mechlenburg¹²5
Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark¹; Department of Clinical Medicine, Aarhus University, Denmark²; Department of Radiology, Aarhus University Hospital, Denmark³; Orthopaedic Department, ULSM – Hospital Pedro Hispano, Portugal4; Department of Public Health – Sport, Aarhus University, Denmark5

Background: Micro instability of the hip joint has been suggested to cause pain in patients with hip dysplasia. Recently, the Femoral-Epiphyseal Acetabular Roof (FEAR) index has been developed to evaluate hip instability in patients with dysplasia.
Aim: To investigate associations between the FEAR index and patient-reported outcomes before and six months after periacetabular osteotomy (PAO).
Materials and Methods: Radiographs of patients with hip dysplasia who underwent PAO between 2018 and 2020 were retrospectively assessed by a radiologist and an orthopedic surgeon. Radiographic measurements indicative of hip instability (Shenton’s line, FEAR index, centre-edge angle of Wiberg, acetabular index of Tönnis and the femoral neck-shaft angle) were measured. Data on hip pain, function, and quality of life were collected prospectively using the Hip dysfunction and Osteoarthritis Outcome Score (HOOS).
Results: A total of 222 patients were included in the study. All radiographic measurements and patient- reported outcomes improved significantly from preoperative to 6 months postoperative (p<0.001). There were no differences in the change score of patient-reported outcomes between patients with a FEAR index >2o (indicative of hip instability) and patients with a FEAR index =2o.
Interpretation / Conclusion: The FEAR index was not associated with hip pain, function, and quality of life among patients with hip dysplasia. This study did not find evidence supporting that instability defined by the FEAR index caused pain in patients with hip dysplasia.

148. Impaired hip muscle strength, function and patient reported outcomes in patients with hip abductor tendon tears: a cross sectional study of 69 patients and 25 healthy volunteers
Marie Bohn, Signe Kierkegaard, Kasper Spoorendonk, Stian Jørgensen, Bent Lund, Jeppe Lange
H-HiP, Department of Orthopaedic Surgery, Horsens Regional Hospital H-HiP, Department of Physio and Occupational Therapy, Horsens Regional Hospital Department of Clinical Medicine, Aarhus University

Background: In patients with hip abductor tendon tears (HAT), knowledge of hip muscle strength is lacking. We investigated isometric hip muscle strength in patients with magnetic resonance imaging (MRI) verified HAT scheduled for surgical reconstruction and compared them with age and gender matched healthy volunteers.
Aim: The aim of the study was to investigate the functional impairments in patients with magnetic resonance imaging (MRI) proven tears of the hip abductor (gluteus medius and/or minimus) tendon(s) scheduled for surgery, and compare these findings with healthy volunteers without current hip pain or previous hip or spine surgery.
Materials and Methods: Isometric hip muscle strength was assessed with a handheld dynamometer in 69 females with MRI verified HAT before surgery and in 25 healthy female volunteers. Copenhagen Hip and Groin Outcome score (HAGOS) and Oxford Hip Score (OHS) was used to measure self-reported outcome. The 30second sit-to-stand test (STS) was used to assess functional capacity.
Results: Patients and healthy volunteers had a mean±SD age of 56±13 and 53±6 years, respectively. Both the affected and contralateral hip of the patients demonstrated lower isometric hip muscle strength compared with healthy volunteers. A significant association between number of completed STS and isometric hip abduction (p<0.001), extension (p=0.008) and external rotation strength (p=0.018) was found. Furthermore, there was a clear association between number of completed STS’s and HAGOS pain (p=0.006) and activities of daily living (p=0.007) together with OHS total score (p=0.011). We found no association between patient reported outcomes and maximal hip muscle strength.
Interpretation / Conclusion: Compared with age and gender matched healthy volunteers, patients with HAT demonstrate substantial impairments in hip strength, function and self-reported outcomes.