Session 17: Sport and Shoulder/Elbow

17. November
12:45 - 13:45
Lokale: 102-105
Chair: Anne Kathrine B Sørensen and Stig Brorson

142. Open knotless suture-staples procedure for partial, low-grade gluteus medius tendon repair - a promising novel technique
Patrick Korsgaard, Jeppe Lange, Bent Lund, Marie Bagger Bohn
All authors are employed at Department of Orthopaedics, Horsens Regional hospital.

Background: In 2018 an endoscopic “suture staples” technique for partial thickness hip abductor tendon (HAT) repair was reported by Domb et al.1 We have adopted the technique, but perform surgery as an open procedure. The technique is potentially beneficial in selected cases of HAT, due to the minute iatrogenic soft tissue injury.
Aim: To report 1-year follow-up on our first cases of an open “suture staples” procedure.
Materials and Methods: From our database on HAT repairs (n>120), we extracted cases with a “suture staples” procedure, who had a minimum of 1-year follow- up. Patients were selected for this procedure, if presenting with Lateral Hip Pain and had HAT pathology on MRI, but no bony changes at the anterior footprint and with an intact gluteus minimus tendon. During surgery the tendon complex had to appear intact, but display “wave sign”. In all other cases a standardized detachment of the tendon complex was performed. Bursectomy was not performed, but the bursa was divided to access the tendon complex. Oxford Hip Score (OHS), Numeric Rating Scale (NRS), The Euro-Qol Visual Analogue Scale (EQ-VAS) and Copenhagen Hip and groin outcome score (HAGOS) were filled out before surgery at baseline and 12 months post-surgery. Global Rating of change score (GROC) were collected at 12 months. Data are presented as median with 25-75% interquartile range. All patients gave consent to participate in this study.
Results: 6 patients (5 females), age 55 years (49-58), Body Mass Index 28 (22-29), had reached a 1-year follow- up. The duration of surgery was 31 minutes (27-36). At 1-year 6 of 6 (100%) reported success on GROC. OHS improved from 20 (17-24) to 43 (40-45) (p=0.03). HAGOS improved statistically significant in all sub-scales. Pain during activity decreased on NRS from 9 (8-10) to 1 (0-2) (p=0.03). EQ-VAS went from 55 (50-60) to 95 (90-99) (p=0.03). All index hips tested stronger at 12 months follow up.
Interpretation / Conclusion: We present a novel surgical procedure for minor HAT pathologies with excellent 1-year results. Due to the technical simplicity of the procedure, our novel technique appears of value in selected HAT cases. More research into this procedure is warranted.

138. Shoulder instability following recurrent traumatic anterior dislocations measured with radiostereometry during apprehension-relocation test.
Josephine Olsen Kipp1,3, Emil Toft Petersen1,2, Thomas Falstie-Jensen2, Johanne Frost Teilmann1, Anna Zejden4, Rikke Jellesen Åberg4, Maiken Stilling1,2,3, Theis Muncholm Thillemann2,3
1 AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital 2 Department of Orthopedic Surgery, Aarhus University Hospital 3 Department of Clinical Medicine, Aarhus University 4 Department of Radiology Aarhus University Hospital

Background: Anterior shoulder instability (ASI) is characterized by recurrent dislocations of the glenohumeral joint (GHJ) and may induce glenoid bone defects. Apprehension- relocation test is the preferred clinical test to evaluate shoulder instability. To our knowledge, the GHJ kinematics during apprehension-relocation test has not previously been studied in patients with ASI.
Aim: The aim of this study was to examine the GHJ kinematics during an apprehension- relocation test in patients with ASI scheduled for a Latarjet procedure with radiostereometry (RSA).
Materials and Methods: Twenty patients (16 males, mean age 31 years (21-40)) with severe ASI and glenoid bone loss scheduled for the Latarjet procedure on one side, and a healthy shoulder on the contralateral side, were included at Aarhus University Hospital. Three consecutive static RSA recordings were performed bilaterally on the patient's shoulders during 1) relaxation (abducted and externally rotated), 2) apprehension test, and 3) relocation test. Double examination was performed to examine the repeatability of the tests. Bone models from CT scans were aligned on the RSA recordings. Anatomical coordinate systems were applied to describe the GHJ kinematics.
Results: Preliminary results for the first eight patients showed that for the unstable shoulder, the mean anterior humeral head translation during apprehension was 0.31 mm (SD=0.88) compared to the relaxed position. For the contralateral healthy shoulder, the humeral head translated 2.11 mm (SD=1.08), which was significantly more than the unstable shoulder. No statistically significant difference was found between the healthy and the anterior unstable shoulder for the relocation test. For the double examinations, no significant differences were found in any of the positions.
Interpretation / Conclusion: RSA is a feasible method to assess GHJ kinematics. Anterior translation is lower in ASI compared to the patient’s healthy shoulder during apprehension test, which may be explained by patient’s increased muscle guard during apprehension due to smaller glenoid size and translation distance to dislocation.

139. Evaluation of glenohumeral joint kinematics following a simulated bony Bankart lesion. A dynamic radiosteometric cadaver study.
Josephine Olsen Kipp1,3, Emil Toft Petersen1,2, Theis Muncolm Thillemann2,3, Thomas Falstie-Jensen2, Lindgren Lars4, Maiken Stilling1,2,3
1 AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital 2 Department of Orthopedic Surgery, Aarhus University Hospital 3 Department of Clinical Medicine, Aarhus University 4 Department of Radiology, Aarhus University Hospital

Background: During anterior shoulder dislocation, the anterior rim of the glenoid may be damaged with a combined labral and bone lesion (bony Bankart lesion). This leads to a reduced contact surface in the glenohumeral joint (GHJ) and may result in anterior shoulder instability. Instability symptoms typically occur during active abduction and external rotation. Dynamic evaluation of GHJ kinematics during motion has not previously been described.
Aim: The aim of this study was to establish an experimental setup to measure the GHJ translation before and after a 15% anterior glenoid bone lesion using dynamic radiostereometric analysis (dRSA).
Materials and Methods: Nine human donor arms were fixed in a motorized fixture allowing a controlled 90 degrees external rotation of the GHJ positioned at 60 degrees of abduction. Dynamic radiostereometry recordings were performed before and after inducing a bony Bankart lesion (15% of the glenoid width). All shoulders were tested before and after bony Bankart lesion and both stages with and without a 10N anterior directed load. Bone models from computed tomography scans were aligned on the dynamic radiostereometry recordings and anatomic coordinate systems were applied to describe GHJ kinematics during motion.
Results: Without loading, the maximal anterior- posterior translation range of the humeral head increased with a mean of 0.56 mm (SD=1.68) after the bony Bankart lesion. With a 10N anterior directed load, the maximal anterior-posterior translation range increased by a mean of 1.32 mm (SD=1.53) after the bony Bankart lesion compared to the native joint. After the bony Bankart lesion, the humeral head position was 0.62 mm (SD = 1.04) more inferior for the unloaded joint. With a 10N anterior load, the humeral head position was 1.18 mm (SD = 1.16) more inferior for the loaded joint, as compared with the intact glenoid.
Interpretation / Conclusion: After 15 % bony Bankart lesion the humeral head translated anteriorly and inferiorly compared to the intact glenoid during active rotation in 60 degrees abduction. However, the 10N anterior directed load was not sufficient to demonstrate statistical significance of the pathomechanics.

140. Ultrasonographic findings in patients with isolated unilateral subacromial pain syndrome and intact rotator cuff tendons.
Adam Witten1, Mikkel Bek Clausen2, Kristian Thorborg1, Per Hölmich1, Kristoffer Weisskirchner Barfod1,
1. Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark; 2. Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy, Faculty of Health, University College Copenhagen, Copenhagen, Denmark

Background: The aetiology of subacromial pain syndrome (SAPS) remains enigmatic. It is theorized that the supraspinatus tendon (SUPRA) and the subacromial bursa (BURSA) are the primary pain-generating structures. SUPRA and BURSA are generally considered to be thickened in patients with SAPS, but this assumption lacks validation. Some consider mechanical impingement of the subacromial structures to be the primary cause of pain, others do not. There is a trend to abandon the term impingement, though it has never been investigated if it can be visually observed.
Aim: To measure SUPRA, BURSA and acromiohumeral distance (AHD), and assess the presence of mechanical impingement in patients with SAPS, and compare it to their asymptomatic side.
Materials and Methods: Patients were recruited from the outpatient clinic, Hvidovre Hospital, using validated criteria for SAPS. Patients with contralateral shoulder pain, acromioclavicular osteoarthrosis, rotator cuff tears, biceps tendon or labral pathology, or calcified tendinitis were excluded. Validated ultrasonographical measurements methods were used. Thickness (mm) of SUPRA and BURSA were measured perpendicular to the tendon longitudinal axis, 2 cm from the lateral border of the SUPRA footprint, with the shoulder in slight internal rotation. AHD (mm) was measured as the shortest distance from the anterolateral acromion to humerus with the shoulder in neutral position. Impingement was defined as visual bulging (Yes/No) of BURSA in active shoulder abduction.
Results: We examined 56 patients with unilateral SAPS from 01.09.21 to 31.12.22. We found significantly more cases of ultrasonographic impingement in painful shoulders compared to the pain-free (45 vs 18, Chi-Square p = 0.04). Mean measurements of painful and pain-free shoulders did not differ: SUPRA 5.4 vs 5.5 mm; BURSA 1.9 vs 1.9 mm; AHD 11.1 vs 11.0 mm.
Interpretation / Conclusion: In this cohort of patients with isolated unilateral SAPS, we found more cases of ultrasonographic impingement in painful shoulders compared to the pain-free, but no significant differences in SUPRA, BURSA or AHD between painful and pain-free shoulders. These findings question the dogma of thickened subacromial structures being the primary aetiological explanation.

141. TITLE Patients with subacromial pain syndrome often present with varying combinations of concomitant shoulder pathology. A cross-sectional study in a secondary care setting.
Adam Witten1, Mikkel Bek Clausen2, Kristian Thorborg1, Per Hölmich1, Kristoffer Weisskirchner Barfod1
1. Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark; 2. Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy, Faculty of Health, University College Copenhagen, Copenhagen, Denmark

Background: Subacromial pain syndrome (SAPS) lacks recognized diagnostic criteria. This could lead to variations in concomitant shoulder pathology across patient populations. It is possible that the presence of concomitant pathology can explain why some patients do not benefit from a typical non-surgical approach, or from surgery aimed at SAPS. It is not known how often SAPS is seen in combination with concomitant pathology or in which pattern. Knowledge of this could be valuable to stratify treatment and in the design and interpretation of future studies.
Aim: To investigate how often, and in which pattern, SAPS is seen with associated concomitant shoulder pathology.
Materials and Methods: Patients with insidious onset of shoulder pain, referred to the outpatient clinic, Hvidovre Hospital, were eligible for inclusion. Patients were systematically screened for SAPS using validated criteria and for 7 predefined concomitant pathologies. We used 18 standardized physical examination tests performed by experienced orthopedic specialists and radiographs, ultrasound and/or MR when indicated. Patients with frozen shoulder, cervical pathology, glenohumeral osteoarthritis (OA) or previous fractures/surgery/radiotherapy in the shoulder girdle, were excluded.
Results: We identified and examined 741 patients, with insidious onset of shoulder pain, from 01.09.21 to 31.12.22. 408 (55%) were diagnosed with SAPS. 160 (39%) had at least one type of concomitant pathology (acromioclavicular OA 76 (48%), full-thickness rotator cuff tears 60 (38%), biceps tendon pathology 54 (34%), labral pathology 17 (11%), minor shoulder instability: 14 (9%), calcified tendinitis: 6 (4%). A combination of concomitant pathology, with two or more different types, were seen in 53 (33%) patients. In total, 18 different combinations of concomitant pathology were seen.
Interpretation / Conclusion: Patients with SAPS constitute an etiological heterogenic group, presenting with many different patterns of concomitant shoulder pathology. The clinical importance of individual concomitant pathologies remains uncertain, but the high prevalence underpins the need for a systematic and transparent approach in future studies to ensure qualified interpretation and comparison of studies.

143. Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: A systematic review and meta-analysis of randomized controlled trials
Troels Kjeldsen1,2,3, Katrine Jessen Hvidt1, Marie Bagger Bohn4, Bjarne Mygind-Klavsen1, Martin Lind1,2, Adam Ivan Semciw5,6, Inger Mechlenburg1,2,7
1 Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark, 2 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark, 3 The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Denmark, 4 H-HiP, Department of Orthopaedic Surgery, Horsens Regional Hospital, Denmark, 5 Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, La Trobe University, Australia, 6 Department of Allied Health, Northern Health, Australia, 7 Department of Public Health, Aarhus University, Aarhus, Denmark.

Background: Greater trochanteric pain syndrome (GTPS) is a regional pain syndrome involving pathology of several potential anatomical structures. It is believed that the primary causes of GTPS are tendinosis or tears of the hip abductors, and a shift in focus of GTPS treatment to address these structures has previously been proposed. However, no review has performed meta-analyses focused specifically on exercise compared with a control condition or other conservative treatments across multiple clinical outcomes in this condition.
Aim: To estimate the effectiveness of exercise at end of treatment and at long-term follow-up compared with a control condition or other conservative treatment in patients with GTPS.
Materials and Methods: Randomized controlled trials comparing exercise interventions for patients with GTPS with a control condition; corticosteroid injection; shock wave therapy; or other types of exercise programs were included. Risk of bias was assessed using the Cochrane ROB2 tool. Meta- analyses were performed using a random-effects model. The certainty of the evidence was rated by the GRADE approach.
Results: Meta-analyses showed that in the long term, exercise reduces hip pain and disease severity while improving patient-reported physical function and global rating of change compared with a control condition. Compared with corticosteroid injection, exercise improves long- term global rating of change. No serious adverse events from exercise therapy were reported.
Interpretation / Conclusion: The current evidence supports the implementation of exercise as first-line treatment in patients with GTPS. Compared with corticosteroid injection, exercise is superior in increasing the likelihood that patients experience meaningful global improvement.

144. Ten years’ experience with a local allograft bank - optimizing the treatment for 552 patients.
Helia Azkia1, Lene Holm Harritshøj2, Connie Nielsen2, Niels Agerlin3, Mette Gotlieb Jensen4, Pia Charlotte Andersen1, Michael Rindom Krogsgaard1
1. Department of Orthopedic Surgery, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark, 2. Department of Clinical Immunology, (Rigshospitalet), Copenhagen University Hospital, 3. Department of Neurosurgery, (Rigshospitalet), Copenhagen University Hospital, 4. Transplantation coordinator, (Rigshospitalet), Copenhagen University Hospital

Background: In 2011 the Danish National Board of Health (DNBH) centralized treatment of multi- ligament injury and revision ligament surgery of the knee, meniscus transplantation, and advanced cartilage procedures to few departments with the purpose to increase experience and quality of these challenging procedures. This increased the need for allogeneic connective tissue (grafts). It is possible to obtain grafts from tissue banks in other countries, but from an ethical point of view Denmark should be self-providing, and there are differences in how grafts are obtained and preserved, which might affect tissue quality. Therefore, a local tissue bank was established in 2014.
Aim: To report experience from this tissue bank.
Materials and Methods: Various logistic models were explored. It was decided to connect allograft donation to the organ donor program. The age limit for donors is 50 years for tendons, 40 for menisci, and 30 for hyaline cartilage. After permission from relatives is obtained the transplantation coordinator contacts the orthopedic team (two surgeons and two nurses), and after organ donation the musculoskeletal tissue is removed. The tissue is handled and stored by dept. of clinical immunology. The donor is tested for contagious disease and the grafts are cultured for contamination. After negative results, the grafts are released for use.
Results: Since June 2014 there has been 31 donations, resulting in 1160 grafts. 40 grafts had a positive bacteria culture and were discarded. Until April 2023, 552 recipients have been treated by use of these allografts: 175 knee multi-ligament reconstructions (Rs), 226 revision ligament Rs, 44 meniscal transplantations (Ts), 18 fresh cartilage Ts, 3 tibial plateau+meniscal Ts, 2 ulnar Rs, 5 AC joint, 9 SC joint and 1 PTF joint stabilizations, 4 quadriceps Rs, 9 labral Rs (hip) 2 pectoralis major tendon Rs, 1 revision ankle stabilization, 45 one ligament Rs (knee). There are no recorded transplantation related complications. During the period it was necessary in addition to buy 245 grafts from tissue banks in Belgium.
Interpretation / Conclusion: Through the established donation program it has been possible to offer optimal treatment for several highly specialized musculoskeletal conditions.