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.