Session 7: Shoulder/elbow

Josephine Olsen kipp^1,2, Theis Mucholm Thillemann^2,3, Emil Toft Petersen^1,2,3, Sepp de Raedt¹, Anna Zejden⁴, Rikke Jellesen Åberg⁴, Thomas Falstie-Jensen³, Maiken Stilling^1,2,3
1. AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark 2. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark 3. Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus N, Denmark 4. Department of Radiology Aarhus University Hospital, Aarhus N, Denmark

Background: The Latarjet procedure is the preferred choice for patients with anterior shoulder instability and glenoid bone loss. However, the glenohumeral joint (GHJ) kinematics and, thereby, knowledge about the stabilizing effect of the Latarjet procedure in patients are sparse.
Aim: To evaluate the GHJ kinematics during an apprehension and relocation test in patients with anterior shoulder instability one year after their Latarjet procedure.
Materials and Methods: Twenty patients scheduled for the Latarjet procedure were enrolled. The patients were examined preoperatively with bilateral static radiostereometric (RSA) recordings and on the operated shoulder one year after their Latarjet procedure during a repeated apprehension-relocation test. Patient- specific bone models were obtained from computed tomography and were aligned with the RSA images using digitally reconstructed radiographs. The GHJ kinematics were evaluated with two methods: 1) the humeral head center location relative to the glenoid center and 2) the GHJ contact point. Paired differences (mean (95%CI)) between pre- and postoperative unstable shoulders and the contralateral healthy shoulders were calculated.
Results: In the anterior-posterior direction for the apprehension and relocation test, no differences in the postoperative location of the humeral head center or contact point were found compared with the healthy shoulder. Compared to the preoperative shoulder, the postoperative humeral head center was 0.8 mm (0.1;1.4) more superior and 0.5 mm (0.0;1.1) more posterior. In the superior-inferior direction during the apprehension test, the postoperative humeral head center was 0.8 mm (1.0;1.4) more superior compared to the preoperative shoulder.
Interpretation / Conclusion: The Latarjet procedure was able to restore the humeral head center compared to the healthy contralateral shoulder. The Latarjet procedure stabilized the humeral head center in a more superior and posterior direction during the apprehension test compared to the preoperative unstable shoulder. Understanding GHJ kinematics and, thereby, the stabilizing effect following the Latarjet procedure is crucial for identifying failures and optimizing the surgery in the future.

Anna Normann Rasmussen¹, Martin Wyman Rathcke¹, Tim Houbo Pedersen¹, MICHAEL RINDOM KROGSGAARD¹
1. Section for Sports Traumatology, Department of Orthopedics, Copenhagen University Hospital Bispebjerg.

Background: Sterno-clavicular arthroscopic surgery offers good visualisation of the posterior part of the sternoclavicular joint (SCJ), minimizing the risk of damaging the structures in the mediastinum posterior to the joint. In literature, results of the procedure have only been reported in few, small series.
Aim: The aim was to present the outcome of SCJ arthroscopic treatment in a large prospective cohort of patients..
Materials and Methods: The SCJ as source of pain was confirmed by reduction of symptoms following an intraarticular injection of analgesics. A two-portal technique and a 2.9 mm arthroscope was used. DASH and Oxford Shoulder Score (OSS) were completed before the operation and after 1, 2 and 5 years. Results of similar open procedures were achieved from literature.
Results: Since 2009 86 patients (56 female/30 male) with a mean age of 45,6 years (17-79) had a SCJ-arthrocopy: Resection of a torn or degenerated disc (55 cases), synovectomy (19), resection of the medial clavicle end (29) and removal of loose bodies (17). 17 cases were converted to open surgery. There were no operative or infectious complications. Mean operation time was 48 minutes (21-89). The DASH-score and the "worst pain", "usual pain" and "pain at night" from OSS had all improved (p<0.05) at 1- and 2-year follow-up. Three patients had a re-arthroscopy and one had an interposition arthroplasty with a gracilis tendon for persisting pain despite resection of the medial clavicle end. One case of instability after resection of osteophytes was treated by an open stabilizing procedure.
Interpretation / Conclusion: Arthroscopic treatment of degenerative and traumatic conditions in the SCJ is a safe procedure with minimal surgical burden, and outcomes are as least as good as for open procedures.

Marc Randall Kristensen Nyring¹, Jeppe Vejlgaard Rasmussen¹, David Gill³, Dylan Harries^{2, 3}, Bo Sanderhoff Olsen¹, Richard Page^{3, 4}
1. Department of Orthopedic Surgery, Herlev and Gentofte Hospital, Hellerup, Denmark 2. South Australia Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia 3. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia 4. Barwon Centre for Orthopaedic Research and Education (B-CORE), St John of God Hospital and Deakin University, Geelong, VIC, Australia

Background: The stemmed anatomical total shoulder arthroplasty is the gold standard in the treatment of glenohumeral osteoarthritis. However, the use of stemless total shoulder arthroplasties has increased in recent years. The number of revision procedures are relatively low and therefore it has been recommended that national joint replacement registries should collaborate when comparing revision rates.
Aim: We aimed to compare the revision rates of stemmed and stemless TSA used for glenohumeral osteoarthritis using data from both the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Danish Shoulder Arthroplasty Registry (DSR).
Materials and Methods: We included all patients registered in the AOANJRR and the DSR from 2012 to 2021 with an anatomical total shoulder arthroplasty used for osteoarthritis. Revision was used as the primary outcome. We used the Kaplan-Meier method to illustrate the cumulative revision rates and a multivariate cox regression model to calculate the hazard ratios. All analyses were performed separately for data from AOANJRR and DSR.
Results: 13066 arthroplasties from AOANJRR and 2882 arthroplasties from DSR were included. The hazard ratio for revision of stemmed TSA with stemless TSA as reference, adjusted for age and gender, was 1.67 (95% CI 1.34-2.09, p<0.001) in AOANJRR and 0.57 (95% CI 0.36-0.89, p=0.014) in DSR. When including glenoid type and fixation, surface bearing and hospital volume in the cox regression the hazard ratio for revision of stemmed TSA compared to stemless TSA was 1.22 (95% CI 0.85-1.75, p=0.286) in AOANJRR and 1.50 (95% CI 0.91-2.45, p=0.109) in DSR. The adjusted hazard ratio for revision of total shoulder arthroplasties with metal backed glenoid components compared to all- polyethylene glenoid components was 2.54 (95% CI 1.70-3.79, p < 0.001) in AOANJRR and 4.1 (95% CI 1.92-8.58, p<0.001) in DSR.
Interpretation / Conclusion: Based on data from two national shoulder arthroplasty registries, we found no significant difference in risk of revision between stemmed and stemless total shoulder arthroplasties after adjusting for the type of glenoid component. We advocate that metal-backed glenoid components should be used with caution and not on a routine basis.

Marie Louise Jensen¹, Epaminondas Markos Valsamis², Alexander Scheller Madrid¹, Bo Sanderhoff Olsen¹, Jeppe Vejlgaard Rasmussen¹
1. Department of Orthopedics, Herlev and Gentofte Hospital, Denmark 2. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom

Background: The use of total shoulder arthroplasties have increased over time as well as improvement in Western Ontario Shoulder Score (WOOS).
Aim: The purpose of the study was to evaluate the association between socioeconomic status and postoperative, patient-reported Western Ontario Shoulder Score (WOOS) at 1 year after shoulder arthroplasty due to osteoarthritis or rotator cuff arthropathy.
Materials and Methods: All patients having a shoulder arthroplasty for osteoarthritis or cuff tear arthropathy were identified using linked data from the Danish Shoulder Arthroplasty Registry and Statistics Denmark between April 2012 and April 2019. Multiple linear regression was used to identify socioeconomic factors associated with patients’ WOOS score at 1 year following primary surgery after adjusting for a number of patient, centre and surgical confounding variables. We examined several societal determinants, job status, marital status, education and income.
Results: A total of 2,292 patients were identified with a mean WOOS score of 76.2 (SD 24.1). The mean WOOS score was 53.9 (SD 29.0) for patients who were unemployed, 72.3 (SD 25.0) for patients with a low-level job, 79.4 (SD 20.7) for patients with a high-level job and 77.1 (SD 23.6) for patients who were retired. After confounding adjustments, patients with any employment status (including retired) had a clinically important and statistically significant (coefficients between 14.5% and 19.1%) increased 1-year postoperative WOOS score compared to unemployed patients. Educational level was associated with a statistically significant, but not clinically important difference, while income and marital status were not found to be statistically significantly associated with the outcome.
Interpretation / Conclusion: Unemployment was associated with a clinically important reduction in patient-reported postoperative WOOS score up to 19.1% at 1 year following primary shoulder arthroplasty when compared to patients who were employed or retired. This highlights the need for awareness of specific patient groups before and after surgery.

Andreas Kristian Pedersen¹, Jacob von Bornemann Hjelmborg², Christian Backer Mogensen¹, Lars Henrik Frich^1,3
1. Dept. of Regional Health Research, University of Southern Denmark, Odense, Denmark 2. Dept. of Epidemiology, Biostatistics and Biodemography, Institute of Public Health, University of Southern Denmark 3. Department of Orthopedics, Hospital Sønderjylland, Denmark

Background: Rotator cuff disease is a widespread musculoskeletal pathology ranging from tendinopathy to full-thickness tear. The effect of the disease can result in disability and severe pain for the patient. The etiology behind the disease is multifaceted and resulting from an interplay between intrinsic and extrinsic factors. Studies on familial predisposition suggest that genetic plays a role in the pathogenesis of rotator cuff disease. Family members of patients with rotator cuff disease may have a significantly higher risk of rotator cuff tears than the general population. Genetic predisposition may play a role also in clinical presentation and progression of rotator cuff tears. A population-based study of family factors behind rotator cuff disease based on treatment diagnosis and long follow up is there for needed.
Aim: The aim is to study genetic and environmental determinants of rotator cuff diagnosis
Materials and Methods: We included all Danish twin pairs born from 1910–1980 and identified them using the Danish twin registry. The primary outcome was rotator cuff tear and based on the ICD-10 DS460, DS467, DM751 and ICD8 code 90500. To assess familial risk, time-to-event analysis for bivariate twin data was applied taking censoring and competing risk of death into account
Results: This population based study consist of 16749 (24.6 %) monozygotic (MZ) and 51247 (75.4 %) dizygotic twins (DZ). The lifetime familial risk of a rotator cuff diagnosis in a MZ twin, if diagnosed in a co-twin was 10% (95%CI [3.0-16%]). For DZ twins the familial risk of rotator cuff disease was significantly lower at 6.0% (95%CI [3.0- 9.0%]). The lifetime risk of rotator cuff disease for the dizygotic twin was 4.3% (95%CI [4.3-4.8%]). Biometric analyses showed a lifetime heritability of rotator cuff risk at 7.48% (95%CI [-6.8-21.8%]) and the influence of shared environmental factors was 2.74% (95%CI [-11.7%, 17.3%]). Increased genetic influence during 50-70 years of age were indicated
Interpretation / Conclusion: This, largest ever family study show that moderate genetic influence governs the risk of rotator cuff tear while substantial environmental influences are present that could potentially be targeted in prevention strategies

Andreas Falkenberg Nielsen¹, Ali Al-Hamdani¹, Jeppe Vejlgaard Rasmussen¹, Peter Kraglund Jacobsen³, Theis Muncholm Thillemann², Bo Sanderhoff Olsen¹
1. Department of Orthopeadic Surgery, Herlev & Gentofte Hospital, Copenhagen, Denmark 2. Department of Orthopeadic Surgery, Aarhus University Hospital, Aarhus, Denmark 3. Department of Orthopeadic Surgery, Odense University Hospital, Odense, Denmark

Background: Elbow arthroplasty is an established treatment of distal humeral fractures not amenable to internal fixation. Total elbow arthroplasty (TEA) is the most common modality, but it is still unclear which option produces the best results. We hypothesize that elbow hemiarthroplasty (EHA) leads to a higher revision rate than TEA, due to ulnar erosion.
Aim: The primary aim of this study was to evaluate and compare revision rates after TEA and EHA in the treatment of acute distal humeral fracture. Secondary aims were to describe reasons and risk factors for revision.
Materials and Methods: We identified all elbow arthroplasties nationwide in patients with distal humeral fractures in the period of January 1, 2008 to December 1, 2021. Data was collected retrospectively and audited on the level of individual patients to ensure completeness of data. Kaplan-Meier analyses were conducted to estimate the cumulative implant survival of TEA and EHA. Hazard ratios (HR) were calculated using the Cox-proportional hazards model with mutual adjustment for age, sex, time to surgery, and implant type (TEA or EHA).
Results: 225 primary TEA and 141 primary EHA procedures were included. All TEAs were semi-constrained (136 Coonrad-Morrey [Zimmer], 4 Latitude [Tornier], 37 Nexel [Zimmer], and 48 Discovery [Lima]). All EHAs were of the Latitude Elbow System [Tornier]. The 5- and 10-year revision rates were 8.6% (95% CI 4.4%, 12.8%) and 20.5% (95% CI 9.2%, 31.9%) for TEA, and 9.3% (95% CI 3.0%, 15.6%), and 18.7% (95% CI 4.8%, 32.7%) for EHA. 21 TEAs and 11 EHAs were revised. The most common cause for revision of TEA was aseptic loosening (n=11, 52.4%), where loosening of the humeral component was the cause in 10 cases. For EHA, the most common cause of revision was ulnar erosion (n=5, 45.5%). After adjustment, the HR for male patients was 3.24 (95% CI 1.37, 7.66). The HR for EHA was 0.77 (95% CI 0.36, 1.65).
Interpretation / Conclusion: Revision rates were comparable, with increased risk of revision for males. Although the size of the presented data is small, EHA does not seem to produce inferior results compared to TEA. EHA might bridge the gap between internal fixation and TEA, but results on patient related outcomes are necessary for further evaluation.

Hamzah Ayub^1,2, Dennis Karimi², Per Hölmich¹, Adam Witten¹
1. Sports Orthopedic Research Center - Copenhagen (SORC-C). Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre. 2. Trauma Orthopedic Research Copenhagen Hvidovre (TORCH). Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre

Background: Subacromial pain syndrome (SAPS) is the most common cause of shoulder pain, and mechanical impingement, supposedly linked to acromial morphology, is thought to be an important etiological factor. However, the evidence supporting this theory is lacking. The Copenhagen Acromial Curve (CAC) and the Critical Shoulder Angle (CSA) are two reliable, well-described methods for evaluating acromial morphology on standardized radiographs.
Aim: To investigate the differences in CAC and CSA between patients with and without SAPS.
Materials and Methods: Cross-sectional study of a consecutive cohort of 777 patients recruited during a 27-month period from a secondary care unit. Inclusion criteria: Insidious onset of shoulder pain. Exclusion criteria: Shoulder radiograph lacking or low quality. Patients were divided into two groups: patients with SAPS and without SAPS, according to standardized criteria. Standardized radiographs were used to evaluate CAS and CSA. Linear regression models were used for analyses. Analyses were adjusted for age and sex. Aiming for 90% power, a total sample size of 24 and 60 patients were required for CSA and CAC, respectively.
Results: Results: 301 patients (women: 54%, mean age: 56 years) were included in the analyses: 209 with SAPS and 92 without. Patients with SAPS had a higher CSA in the unadjusted analysis (1.5° [95% CI: 0.4-2.5]) and the adjusted analysis (1.3° [95% CI: 0.2-2.4]) compared to patients without SAPS. There were no significant differences in CAC between patients with and without SAPS. Post-hoc analyses of the subgroup of SAPS-patients with full-thickness supraspinatus tears (n=36) showed a higher CSA compared to patients without SAPS in both the unadjusted (2.1° [95% CI 0.6-3.6]) and the adjusted analysis (1.9° [95% CI 0.4-3.5]). No significant difference for CAC was found in the post-hoc analyses. For all 301 patients, the mean CSA was 33.9°, and the mean CAC was 27.4°.
Interpretation / Conclusion: Patients with SAPS had a higher CSA compared to patients without SAPS. No difference in CAC between patients with and without SAPS was found. The findings do not seem to support acromial morphology being an important etiological factor in SAPS.

Josefine Beck Larsen^1,2, Martin Bækgaard Stisen^1,2, Theis Muncholm Thillemann^1,2, Pia Kjær Kristensen^1,2, Antti P. Launonen³, Inger Mechlenburg^1,2
1Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark 2Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark 3Department of Orthopaedic Surgery, Tampere University Hospital, Tampere Finland

Background: Internationally reported rates of serious adverse events after shoulder arthroplasty vary between 0.8- 5.6%. As serious adverse events are rare after shoulder arthroplasty, it is important to know the rates.
Aim: This study aimed to estimate the all-cause mortality and serious adverse events at 30 and 90 days after discharge in patients treated with shoulder arthroplasty compared to the background population.
Materials and Methods: We identified patients who underwent shoulder arthroplasty from 2006-2021 in the Danish Shoulder Arthroplasty Registry . Data from the Danish Shoulder Arthroplasty Registry were linked to data from the Danish National Patient Register and the Danish Civil Registration System and Statistics Denmark . Patients identified in the Danish Shoulder Arthroplasty Registry were matched (1:10) on age, sex, and year of birth to the Danish background population. Data on first serious adverse events and mortality were estimated at 30 and 90 days after discharge.
Results: 14187 patients with a shoulder arthroplasty procedure were identified. This resulted in 141870 controls from the background population. All-cause mortality for shoulder patients within 30 days was 0.6% and within 90 days 1.4%. All-cause mortality for the background population within 30 days was 0.3% and 0.8% within 90 days of the index date. Overall, serious adverse events were 2.6% within 30 days and 3.9% within 90 days of surgery for the patients.
Interpretation / Conclusion: Patients treated with shoulder arthroplasty had an overall 30-day all-cause mortality of 0.6%, which is higher than the rates in the background population. Serious adverse events within 30 days were within the reported rates in international studies. Our results may be used to inform the shared decision- making process and develop a treatment plan.

Josephine Olsen Kipp^1,2, Theis Muncholm Thillemann^2,3, Thomas Falstie-Jensen³, Lærke Borgen¹, Annemarie Brüel⁴, Emil Toft Petersen^1,2,3, Maiken Stilling^1,2,3
1. AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark 2. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark 3. Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus N, Denmark 4. Department of Biomedicine, Aarhus University, Aarhus, Denmark

Background: Patients with anterior shoulder instability typically experience symptoms during active abduction and external rotation of the shoulder. In cases of a glenoid bone lesion, bone grafting procedures such as the Eden- Hybinette procedure with tricortical iliac crest bone graft (EH) and the Latarjet procedure (LP) can be performed to stabilize the glenohumeral joint (GHJ).
Aim: To evaluate the GHJ kinematics throughout an external shoulder rotation following the EH and LP.
Materials and Methods: Eight human specimens were examined with dynamic radiostereometry (dRSA) during an automated 85 o external rotation of the GHJ at a 30- and 60-degree GHJ abduction. The test was performed with anteriorly directed loads of 0, 10, 20, and 30 N in four stages: 1) the native joint, 2) 15% anterior glenoid bone lesion, 3) the EH, and 4) the LP. Specimen-specific bone models from computed tomography scans were aligned with dRSA images using digitally reconstructed radiographs. The GHJ kinematics (maximum differences) were described by anatomical coordinate systems applied to the bone models.
Results: The anterior glenoid bone lesion resulted in an anterior and inferior humeral head translation. Both the EH and LP restored the GHJ kinematics towards the native GHJ. Compared to the glenoid bone lesion, maximum posterior translation was 7.8 mm (95%CI 0.0-15.5) and 9.7 mm (95%CI 0.5- 18.8), and maximum superior translation was 7.9 mm (95%CI 0.5-15.6) and 7.4 mm (95%CI 0.3-14.3) with the EH and LP, respectively. Comparing the EH and the LP, the humeral head position was up to 7.6 mm (95%CI 3.6-11.5) more posterior for the LP during the last part of the external rotation at all loads in 60 degrees of abduction.
Interpretation / Conclusion: Following the infliction of anterior shoulder instability with a glenoid bone lesion on human specimens, the EH and LP restored the GHJ kinematics towards the native GHJ kinematics during a loaded external shoulder rotation. However, during the last part of the external rotation with 60 degrees of GHJ abduction, the LP procedure provided more posterior stabilization of the humeral head than the EH, which may be ascribed to the “sling effect” from the conjoined tendon.

Tazio Maleitzke^1,2,3,4, Nicolas Barthod-Tonnot¹, Nina Maziak¹, Natascha Kraus⁵, Mark Tauber^6,7, Alexander Hildebrandt^1,2, Jonas Pawelke¹, Larissa Eckl¹, Lukas Mödl⁸, Kathi Thiele^1,9, Doruk Akgün¹, Philipp Moroder^1,10
1. Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany 2. Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Julius Wolff Institute, Berlin, Germany 3. Department of Orthopaedic Surgery, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark 4. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark 5. Department of Orthopaedics, University Clinic, Greifswald, Germany 6. Department for Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany 7. Department for Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria 8. Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany 9. Department of Shoulder and Elbow Surgery, Auguste Viktoria Hospital, Berlin, Germany 10. Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland

Background: Treatment of acromioclavicular joint (ACJ) separations remains controversial. Yet, conservative treatment has become common even for high-grade injuries. In a recent case report, we introduced the concept of restoring ACJ integrity by non-invasively bracing a RW type V injury.
Aim: The purpose of this study was to prospectively evaluate the clinical and radiological efficacy of a novel ACJ brace and compare it to early functional rehabilitation and surgery for RW III and V injuries after a minimum of 12 months.
Materials and Methods: Patients with acute RW III injuries (n=18) and patients with RW V injuries who refused surgery (n=7) were prospectively enrolled and treated with an ACJ brace and followed up clinically and radiologically for 12 months. Endpoint results were compared to injury grade-, sex-, age-, and follow-up-period-matched patients treated with early functional rehabilitation (n=23) and surgical TightRope® stabilization (n=23). Clinical outcomes included Constant Score (CS), Subjective Shoulder Value (SSV), Taft Score (TS), and modified Acromioclavicular Joint Instability Score (mAJIS) and radiological outcome included coracoclavicular (CC) index.
Results: CS, SSV, TS, and mAJIS improved in RW III and CS and SSV in RW V patients treated with the ACJ brace. Significance was only reached in RW III patients (p < 0.001). Radiological indices did not improve over time in RW III and V patients. No differences were found when comparing functional and cosmetic outcomes (CS, SSV, TS, mAJIS) after a minimum of 12 months between bracing, surgery, and early functional rehabilitation in RW III and V patients. The CC index was most improved in patients treated by surgery compared to bracing after a minimum of 12 months (p=0.0011 for RW III).
Interpretation / Conclusion: Brace treatment led to comparable clinical and cosmetic outcomes as early functional rehabilitation and surgery in patients with high grade ACJ injuries after a minimum of 12 months. However, no sustainably improved reduction of the ACJ resulted from bracing, when compared to early functional rehabilitation, thus questioning its utility. While surgery ensured radiological improvement compared to bracing, no benefit was seen over early functional rehabilitation.