Session 6: Shoulder / Elbow

16. November
09:30 - 11:00
Lokale: 01+02
Chair: Dennis Karimi and Thomas F Jensen

44. Weight-adjusted cefuroxime dosing provides sufficient surgical site concentrations in reverse shoulder arthroplasty - A clinical microdialysis study
Sara Kousgaard Tøstesen1, Thomas Falstie-Jensen2, Mats Bue1,2, Pelle Hanberg1, Mikkel Tøttrup2, Janne Ovesen2, Maiken Stilling1,2, Theis Thillemann2
1. Aarhus Denmark Microdialysis Research Group (ADMIRE), Aarhus University Hospital 2. Department of Orthopedic Surgery, Aarhus University Hospital

Background: For reverse shoulder arthroplasty (RSA) the periprosthetic joint infection (PJI) rate is higher than that of anatomic shoulder arthroplasty and other joint replacement surgeries. RSA leaves a larger peri implant deadspace due to the deficient rotator cuff. The deadspace is defined as the residual tissue void after tissue loss with a presumable sparse vascularization. A compromised deadspace perfusion may promote inadequate concentrations of prophylactic antibiotics increasing the risk of PJI.
Aim: To assess the time with cefuroxime concentrations above the clinical breakpoint minimal inhibitory concentration (fT>MIC) for Staphylococcus aureus of 4 µg/mL in deadspace, bone, muscle, subcutaneous tissue and plasma during two dosing intervals (8 h x 2), following RSA surgery.
Materials and Methods: Ten patients, undergoing RSA surgery, were included. Cefuroxime was dosed according to weight (20 mg/kg), administered as an intravenous bolus infusion 30 min prior to surgery, and readministered after 8 h. Before wound closure, microdialysis catheters were placed for sampling in deadspace in the glenohumeral joint, cancellous bone of the coracoid process, in the deltoid muscle, and subcutaneous tissue in relation to the incision. Blood samples were drawn for reference. Continuous sampling was performed during two dosing intervals (16 hours). Cefuroxime concentrations were quantified using high-performance liquid chromatography.
Results: In the first dosing interval, a mean %fT>MIC (95%CI) of 90% (78-100) was found in deadspace which was comparable to bone 86% (74-98), deltoid muscle 85% (73-97) and subcutaneous tissue 83% (71-95), but longer than plasma 78% (66-90). All compartment specific fT>MIC results were similar between the first and the second dosing interval.
Interpretation / Conclusion: Weight-adjusted cefuroxime provided homogeneous target distribution demonstrated by comparable target tissue fT>MIC (4 µg/mL) for deadspace, cancellous bone, skeletal muscle, and subcutaneous tissue. Importantly, sufficient cefuroxime concentrations were achieved in the surgical deadspace. Consequently, it seems unlikely that the increased infection rates found in RSA can be explained by insufficient antibiotic distribution to the deadspace.

45. Variation in surgical trends and outcome following isolated proximal humerus fracture - A comparative longitudinal cohort study of 37,189 patients from Denmark and England
Helle K. Østergaard1, Jennifer Lane2,3, Antti P. Launonen4, Inger Mechlenburg5,6, Marianne Toft1, Merete N. Madsen7, Richard Craig8, Dominic Furniss3, Matt Costa3, Stephen Gwilym3, Jonathan Rees3
1. Department of Orthopaedic Surgery, Viborg Regional Hospital; 2. Barts Bone and Joint Health, Queen Mary, University of London; 3. NDORMS, University of Oxford; 4. Department of Orthopaedics, Tampere University Hospital; 5. Department of Orthopaedics, Aarhus University Hospital; 6. Department of Public Health, Aarhus University; 7. Elective Surgery Centre, Silkeborg Regional Hospital; 8. Milton Keynes University Hospital.

Background: Management of proximal humerus fractures (PHF) is controversial and can vary internationally. However, over the last decade high-level evidence from randomized trials has shown that for most of these fractures, surgical treatment is not superior to non-surgical treatment.
Aim: To estimate the incidence rates and temporal trends in the surgical treatment of PHF in Denmark and England, the risk of serious adverse events (SAE) and to evaluate the impact of large-scale surgical trial evidence upon clinical practice.
Materials and Methods: This was a multinational population-based cohort study using routinely collected data from England (Hospital Episode Statistics) and Denmark (National Patient Registry) from 1998 to 2018. All adult patients with an isolated PHF combined with predefined surgical procedure codes were included. Age and sex specific incidence rates were calculated along with incidence rates of each surgical procedure per calendar year. Furthermore, the cumulated incidence proportion of SAEs within 30 days of surgery was computed. Lastly, multivariable logistic regression analysis was undertaken to determine the impact of age, sex and comorbidity with SAE at 30 days and the risk of mortality at 30 and 90 days, and one year.
Results: A total of 37,189 patients were included (11,453 Denmark; 25,736 England). The median age was 68 years in Denmark and 63 years in England. The overall incidence rate of surgery in Denmark was 10 times higher for women aged 80 years than that observed in England. Plate fixation was the leading surgical procedure in Denmark from 2005 peaking in 2011, while arthroplasty remained the most frequent procedure in England. The cumulated incidence proportions of SAEs within 30 days of surgery were low in both countries, however higher in Denmark. In both countries, men had a significant higher risk of mortality at all time points compared to women.
Interpretation / Conclusion: We found considerable variation in the surgical management of PHF between Denmark and England, despite high- certainty evidence from surgical trials. We have yet to understand and learn from the interplay of hospital, surgeon, and evidence based factors that lead to these variations in surgical practice between countries.

46. Impact of radial head arthroplasty diameter on elbow joint kinematics evaluated by dynamic radiostereometric analysis
Johanne Frost Teilmann1,2, Emil Toft Petersen1,3, Theis Muncholm Thillemann3, Chalotte Krabbe Hemmingsen1, Josephine Olsen Kipp1,2, Thomas Falstie-Jensen3, Maiken Stilling1,3
1. AutoRSA Research Group, Orthopedic Research Unit, Aarhus University Hospital 2. Department of Clinical Medicine, Aarhus University 3. Department of Orthopedic Surgery, Aarhus University Hospital

Background: Radial head arthroplasty (RHA) is a hemiprosthesis used in the treatment of complex elbow dislocation fractures. Improper RHA diameter and length may result in pain, joint stiffness, and osteoarthritis, which is likely caused by unfavorable biomechanical changes. The ideal size of the RHA is unknown and knowledge concerning elbow stability after different head sizes is warranted.
Aim: The aim of this experimental study was to evaluate the elbow kinematics of different sizes of radial head implants after RHA using dynamic radiostereometric analysis (dRSA)
Materials and Methods: Eight human donor arms were examined with dRSA during a motor-controlled elbow flexion-extension with the forearm in unloaded neutral position, and in supinated- and pronated position without and with 1kg either varus or valgus load, respectively. The elbows were examined before and after RHA with head diameters of anatomical size, -2mm (undersized), and +2mm (oversized). The length of the stem was not changed throughout tests. The ligaments were kept intact by use of a step-cut humerus osteotomy for repeated RHA exchange. Bone models were obtained from CT and AutoRSA software was used to match the bone models with dRSA recordings. To describe elbow kinematics, anatomic coordinate systems were applied to the humerus and radius.
Results: Compared to the native radial motion during elbow flexion-extension, the anatomical-sized RHA shifted the radius 2mm ulnar (p<0.001) in unloaded pronated position. The undersized RHA shifted the radius 1mm posterior (p<0.001) and 2mm ulnar (p<0.01) in unloaded pronated position and increased the varus angle by 2.5° (p<0.001) in supinated loaded position. The oversized RHA shifted the radius 2mm radially (p<0.001) in both supinated positions.
Interpretation / Conclusion: The anatomically sized RHA maintained the kinematics of the native elbow the best, but the kinematic changes with oversized and undersized RHA diameters were small, which could suggest some tolerance variation for the RHA diameter size. However, a few degrees or mm changes in elbow kinematics could potentially increase stress to the interosseous membrane and contact pressure within the joint, and evaluation of these parameters are encouraged.

47. Clavicle fractures does not increase the occurrence of later subacromial pain syndrome. A registry-based case-control study with 15-25 years follow-up of 131.838 persons from the Danish National Patient Register.
Anne Marie Nyholm1, Adam Witten 2, Kristoffer Weisskirchner Barfod2
1. Department of Orthopaedics, Herlev and Gentofte Hospital; 2. Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre

Background: A clavicle fracture changes the mechanical axes of the shoulder girdle, potentially leading to scapular protraction and decreased subacromial space. If protraction of the scapula is a major risk factor for developing subacromial pain syndrome (SAPS), a previous clavicle fracture could increase the risk of later SAPS.
Aim: The purpose of this study was to investigate if a clavicle fracture was correlated with a higher occurrence or earlier diagnosis of SAPS.
Materials and Methods: In this retrospective case-control study with data from the Danish National Patient Register, all persons aged 18-60 years, with a hospital contact due to a clavicle fracture (DS420) between 1.1.1996 and 31.12.2005 were identified as cases. For each case, five controls, matched on age and sex, were identified. Primary outcome was the first hospital contact with a SAPS diagnosis (DM751-755) registered more than 180 days following a clavicle fracture. Persons were followed until 01.11.2021.
Results: 21.973 cases and 109.865 controls were included. The incidence of a clavicle fracture was 76 fractures per 100.000 persons per year. 23% were female. 1.640 (7.46%) cases and 8.072 (7.35%) controls later received a SAPS diagnosis, demonstrating no significant difference in occurrence of SAPS diagnosis (p=0.56). Mean time from fracture to SAPS diagnosis was shorter for cases compared to controls (4040 vs. 4442 days, p<0.001), and cases were slightly younger when receiving the diagnosis (mean age 51.3 vs 53.6 years, p<0.001). 1614 cases underwent surgical fixation. This subgroup had a statistically significant higher occurrence of later SAPS diagnosis (205 cases, 13%, p<0.001).
Interpretation / Conclusion: Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial impingement syndrome (SAPS). However, the diagnosis was given 1-2 years earlier for people with a previous fracture. Surgical fixation of the clavicle was correlated significantly with a higher occurrence of later SAPS diagnosis. Based on these findings no strong argument for protraction of the scapula as a major risk-factor for the development of SAPS was found. Surgery of a clavicle fracture to reduce the risk of later SAPS cannot be recommended.

48. The incidence and treatment trends of 23,917 humeral shaft fractures: Data from the Danish National Patient Registry from 1996 to 2018
Dennis Karimi1, Søren Wacher Qvistgaard1, Per Hviid Gundtoft2, Stig Brorson3, Bjarke Viberg1, 4
1. Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital: University Hospital of Southern Denmark 2. Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 3. Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen 4. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Denmark

Background: Humeral shaft fractures (HSF) can be treated surgically or non-surgically. National trends and distributions are sparsely reported.
Aim: We present the epidemiology of HSFs in Denmark (i) to report incidences and temporal trends, (ii) to report the distribution of treatment options.
Materials and Methods: The diagnosis (ICD-10: S42.3) and surgical procedure codes (NOMESCO: external fixation [KNBJ21], K-wire fixation [KNBJ41], screw fixation [KNBJ71], combined fixation [KNBJ81], and arthroplasty [KNBB0*, KNBB1*]) for HSF were obtained from the Danish National Patient Registry (DNPR) covering 1996-2018. The diagnosis code for HSF is validated in the DNPR. Patients aged 18 years and above were included. Surgical treatment was defined as a diagnosis of HSF combined with a surgical procedure within 3 weeks of injury. Non-surgical treatment was defined as a diagnosis and no relevant procedure registered within 3 weeks.
Results: A total of 23,917 HSFs (63% females) were identified. The overall mean incidence was 26/100,000/year. The overall age-specific rate was stable around 10 fractures until the age of 50 years, where the rate increased per five years with an average of 15 fractures/100,000/year. This resulted in a maximum rate of 141 fractures/100,000/year at the highest age range. A total of 78% of all HSFs were above 50 years. The incidences and treatment distribution remained stable over 23 years. Non-surgical treatment accounted for 86% (n= 20,534). Temporal changes occurred in surgical procedures. Intramedullary nail fixation decreased from 54% to 24% of all surgeries while plate fixation increased from 19% to 63%.
Interpretation / Conclusion: The overall incidence for HSF remained stable from 1996 to 2018. The majority of cases were females aged 50 years and above, suggesting there could be an association with osteoporosis in this group. The preferred treatment for HSF was non-surgical for all ages. Plating became more popular than nailing over the period under study.

49. Minimal important change (MIC) of the Western Ontario Osteoarthritis of the Shoulder index (WOOS) in patients with glenohumeral osteoarthritis and rotator cuff tear arthropathy
Josefine B. Larsen1,2, Theis M. Thillemann1,2, Antti P. Launonen 3, Helle K. Østergaard2,4, Thomas Falstie-Jensen1, Srdjan Zivanovic4, Steen L. Jensen5,6, Inger Mechlenburg1,2, Ville Ponkilainen3
1Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark 2Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark 3Department of Orthopaedic Surgery, Tampere University Hospital, Tampere, Finland 4Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark 5Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark 6Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

Background: The Minimal Important Change (MIC) for patient- reported outcomes (PRO) is the value that describes the smallest improvement considered worthwhile by patients. To our knowledge, no MIC of the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score has been reported using the anchor-based predictive MIC calculation method. Additionally, no studies have reported a MIC for the Disabilities of the Arm Shoulder and Hand (DASH) based on patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy, treated with an anatomical total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RSA), respectively.
Aim: The aim of this study was to determine MIC for WOOS and DASH in a cohort of patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy treated with TSA or RSA.
Materials and Methods: Data on 217 patients were collected at four hospitals in Denmark and Finland. Data were collected at baseline, and at 12 and 14 weeks after surgery. At 12 weeks the patients were asked about their perceived overall improvement after surgery measured by the Global Rating of Change Score (GRCS). The MIC estimate for the WOOS and DASH was calculated using logistic regression with the GRCS as an anchor with a predictive modeling approach.
Results: Patients had a mean age of 69.9 years and 55% were women. Our sample consisted of 46% with glenohumeral osteoarthritis and 53% with rotator cuff tear arthropathy. 85 patients had complete data. The estimated MIC for the WOOS score was 30.7 (95% CI 19.6; 42.4) and 5.1 (95% CI -2.8; 13.1) for the DASH.
Interpretation / Conclusion: The estimated MIC for WOOS was higher than shown in previous studies. For patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy, treated with a TSA or RSA, the MIC values were 30.7 for WOOS and 5.1 for DASH. The estimated MIC for WOOS and DASH show wide confidence intervals, which could be due to the low sample size but also indicate a large heterogeneity within the patient group. For PRO measures such as WOOS and DASH, there is a need for further investigation of their psychometric properties in relation to their utility and interpretability in clinical trials.

50. Patient reported outcome after displaced two-part surgical neck fractures treated without surgery: a consecutive, prospective cohort of 174 geriatric patients
Stig Brorson1,2, Signe Borg1, Kenneth Holtz1, Zaid Issa1
1. Centre for Evidence-Based Orthopaedics, Department of Orthopaedic Surgery, Zealand University Hospital 2. Department of Clinical Medicine, University of Copenhagen

Background: The two-part fracture of the surgical neck is the most common displaced fracture pattern in geriatric shoulder fractures. Randomized trials have failed to demonstrate superiority of surgery. Little is known about outcome outside control groups in experimental settings.
Aim: To evaluate short-term patient reported outcome in a consecutive, prospective cohort of geriatric patients with displaced two-part surgical neck fractures managed without surgery.
Materials and Methods: Patients aged 60 years or above referred to a Danish university hospital with a fracture of the proximal humerus within three weeks from injury were screened for eligibility. Fractures were classified according to Neer. Only two-part surgical neck fractures were included. We excluded patients with other fracture patterns, concomitant fractures, dementia or pathological fractures. All patients were followed in the outpatient clinic after two weeks, six weeks and six months post-injury. Prior to the six months visit all patients completed Oxford Shoulder Score (OSS)(0-48; 48 best) and EuroQoL-3D (-0.624 – 1; 1 best) and general health self- assessment, (0-100; 100 best). We report demographics, summary statistics, mean and standard deviations.
Results: We assessed 174 patients with two-part fractures for eligibility. Mean age was 77 years (SD 8.55), 77 % were females. We excluded 71 patients due to concomitant fractures (25), dementia (12), death (11) and other specified reasons (19). Reverse arthroplasty on pain indication was performed in four patients (2 %). Three patients were lost to follow-up. Patient reported outcome was available for 100 patients. Mean OSS at six months was 37.15 (SD 8.25) equal to 76 % of a full shoulder function. Normal value for females aged 71-80 is 82 %. Mean EuroQoL-3D index was 0.83 (SD 0.23). Population norm for Danish females aged 71-80 is 0.82. Mean general health self-assessment was 72.1 (SD 16.6).
Interpretation / Conclusion: At six months, patient reported shoulder function and quality of life was close to reference values for the background population. The healing potential in geriatric patients with displaced two-part surgical neck fractures is good, even when severe displacement and subsequent malunion are present.

51. Positive predictive value of humeral fractures in the Danish National Patient Registry
Dennis Karimi1, Line Houkjær2, Per Hviid Gundtoft3, Stig Brorson2, Bjarke Viberg1, 4
1. Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt – University Hospital of Southern Denmark 2. Centre for Evidence-Based Orthopaedics, Zealand University Hospital 3. Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 4. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark

Background: National patient registers are a key tool in healthcare planning. To ensure a meaningful use and interpretation of data, validity is essential.
Aim: The purpose of this study was to validate humeral fracture diagnoses for adults in the Danish National Patient Registry (DNPR).
Materials and Methods: A validation study, including adults (=18 years) with a humeral fracture seen at the emergency department in twelve Danish hospitals from March 2017 to February 2020. Administrative data were retrieved on 12,912 patients from the hospital databases. We extracted information on discharge and admission diagnoses based on the International Classification of Diseases, tenth version. Data from 100 cases were randomly sampled from each of the specific humeral fracture diagnoses (S42.2-S42.9). If less than 100 cases were registered for one of the specific diagnoses, all cases for that specific diagnosis were included. The positive predictive value (PPV) was calculated for each diagnosis. Radiographic images from the emergency departments were reviewed and assessed as the gold standard. The PPVs with 95% confidence intervals (CI) were estimated according to the Wilson method.
Results: In total, 661 patients were sampled between all available diagnosis codes. Overall, the PPV for humeral fracture was 89.3% (95% CI: 86.6- 91.4%). PPVs were 91.0% (95% CI: 84.0- 95.0%) for proximal humeral fractures, 89.0% (95% CI: 81.0-94.0%) for humeral diaphyseal fractures and 78.0% (95% CI: 68.9-84.9%) for distal humeral fractures. Out of the 661 cases, 361 patients were diagnosed with an unspecified humeral fracture code and the distribution of fractures were 66% for proximal humeral fractures, 16% for humeral diaphyseal fractures, 3% for distal humeral fractures.
Interpretation / Conclusion: The validity of the humeral fracture diagnosis and the classifications of proximal and diaphyseal fractures in the DNPR is high. This ensures that DNPR contains good data for register-based research on humeral fractures, but the diagnosis of distal humeral fractures has a lower validity and should be used with caution.

52. High rate of clinical improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis
Marc R K Nyring1, Bo S Olsen1, Alexander Amundsen1, Jeppe V Rasmussen1
1. Department of Orthopaedic Surgery, Gentofte and Herlev Hospital

Background: The minimal clinically important difference (MCID) is defined as the smallest meaningful change in a health domain that a patient would identify as important. Thus, an improvement that exceeds the MCID can be used to define a successful treatment for the individual patient.
Aim: The aim of this study was to quantify the rate of clinical improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis.
Materials and Methods: Patients were treated with the Global Unite total shoulder platform arthroplasty between March 2017 and February 2019 at Herlev and Gentofte Hospital, Denmark. The patients were evaluated preoperatively and 3, 6, 12 and 24 months postoperatively using the Western Ontario Osteoarthritis of the Shoulder index (WOOS), Oxford Shoulder Score (OSS) and Constant- Murley Score (CMS). The rate of clinically relevant improvement was defined as the proportion of patients who had an improvement 24 months postoperatively that exceeded the MCID. Based on previous literature, MCID for WOOS, OSS and CMS was defined as 12.3, 4.3 and 12.8 respectively.
Results: 49 patients were included for the final analysis. One patient was revised within the two years follow-up. The rate of clinically relevant improvement was 87% using WOOS, 94% using OSS and 88% using CMS.
Interpretation / Conclusion: Based on three shoulder-specific outcome measures we found that 87% to 94% of patients had a clinically relevant improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis. This is a clear and distinct message that together with information about implant survival can be used to inform patients about their prognosis.

53. Persistet opioid use after elective shoulder arthroplasty
Alexander Scheller Madrid1, Jeppe Vejlegaard Rasmussen1
1. Department of Orthopaedics, Herlev and Gentofte University Hospital, Denmark

Background: Surgical procedures have shown to have a substantial number of patients receiving prolonged opioids.
Aim: We wanted to show the pre-and postoperative utilization of opioids after elective shoulder arthroplasty.
Materials and Methods: Patient data were collected through the Danish Shoulder Arthroplasty Registry, only patients with a diagnosis of rotator cuff disease, arthrosis, or caput necrosis were selected. Patients with a previous fracture or contralateral operation were excluded. Potential risk factors were collected from The Danish National Patient registry. From The Danish National Health Service Perscription Database, preoperative and postoperative drug use was gathered. Preoperative opioid use is defined as receiving 1 or more prescriptions within 90 days before surgery. Postoperative opioid utilization is shown as the number of patients dispensing opioids within each quarter of the first postoperative year.
Results: Of 5600 patients included 2029(36%) were using opioids preoperatively. For preoperative opioid users, 91% dispensed opioids within the first quarter of the year (Q1), which decreased to 60% in Q2, 57% in Q3, and 56% in Q4. For patients with no opioid use 3 months before surgery in Q1 72% of patients dispensed opioids, in Q2 12%, Q3 10%, and Q4 11%.
Interpretation / Conclusion: A substantial amount of patients treated with elective shoulder arthroplasty were still receiving opioids up to 1 year postoperatively. Further studies are needed to understand the underlying mechanism and potential interventions that might reduce prolonged opioid consumption.