Session 5: Shoulder/elbow

Torsdag den 23. oktober
09:30 – 10:30
Lokale: Stockholm/Copenhagen
Chairmen: Theis Tillemann / Steen Lund Jensen

45. Physiotherapy improves patient reported shoulder function and health status in patients with subacromial impingement syndrome
Filip Holst Storgaard, Christina Gravgaard Pedersen, Majbritt Lykke Jensen, Steen Lund Jensen
Physiotherapy, Aalborg University Hospital; Orthopaedic, Aalborg University Hospital

Background: Physiotherapy may be as effective as surgery in the treatment of subacromial impingement syndrome (impingement). According to National Clinical Guidelines, patients with impingement should have recieved at least three months of physiotherapy before surgery is considered.
Purpose / Aim of Study: To report the outcome of a standardized physiotherapy based treatment regimen for impingement.
Materials and Methods: An orthopaedic shoulder specialist provisionally selects patients from referrals. The physiotherapist makes a final diagnosis of impingement based on clinical findings and radiographs, and initiates a 3-6 months rehabilitation program including rotator cuff strengthening, posture correction and scapula setting. Treatment efficacy is monitored by Oxford Shoulder Score (OSS) and EQ- 5D-5L, using web based software and email communication (Procordo).
Findings / Results: The first year 222 patients (mean age 53 years, 121 males) were included for physiotherapy and patient reported outcome. Home-based response rates were 92% and 82% after 4 and 12 months. The mean OSS scores at inclusion, after 4 months and after 12 months were 30.3, 35.3 and 38.4 respectively (p<0.001). The corresponding EQ-5D-5L index values were 0.79, 0.82 and 0.86 (p<0.001). 31 had clinically unsatisfactory results, and were seen by shoulder surgeon (mean OSS improvement at 4 months -1.3 compared with 5.9 for those treated exclusively by physiotherapist); 24 had surgery.
Conclusions: Patients with impingement managed by a physiotherapy regimen improve self- perceived shoulder function and health status. Improvement continues during the first year, even after formal physiotherapy is stopped. Only few patients need evaluation for surgery. Measuring patient reported outcome with a web based software and email is feasible and provide high response rates in this patient group.

46. Persistent pain after shoulder replacement: A nationwide questionnaire study.
Karen Toftdahl Bjørnholdt, Birgitte Brandsborg, Kjeld Søballe, Lone Nikolajsen
Department of Orthopaedic Surgery, Horsens Hospital; Department of Anaesthesiology, Aarhus University Hospital; Danish Pain Research Center/Department of Anaesthesiology, Aarhus University Hospital

Background: Persistent postsurgical pain is a well- recognized problem after various types of surgery such as amputation, thoracotomy and inguinal hernia repair. The prevalence of persistent pain, and to which degree it involves neuropathic pain, is highly dependent on the type of surgery. Persistent pain following shoulder replacement has not previously been investigated.
Purpose / Aim of Study: This study aimed to investigate the prevalence, characteristics and risk factors of persistent pain 1-2 years after shoulder replacement surgery performed in Denmark.
Materials and Methods: A questionnaire was sent to patients who had undergone primary shoulder replacement between April 2011 and April 2012, and whose operations had been reported to the Danish Shoulder Arthroplasty Register. Patients who had undergone reoperation or bilateral replacements were excluded. The outcome of persistent pain was defined as pain experienced daily or constantly within the last month at a level that interfered much or very much with daily activities. A multivariate logistic regression model was used to assess risk factors.
Findings / Results: 538 patients were available for analysis. The prevalence of persistent pain was 22% (CI 18-25%), and the prevalence of neuropathic pain was 13% (CI 10-16%). Risk factors were pain intensity the first postoperative week, pain elsewhere, diagnosis of fracture, and previous osteosynthesis, but not age or sex. Also, prosthesis type and supplemental cuff reconstruction seemed to influence the risk of persistent pain, but these findings may have various explanations.
Conclusions: Persistent pain occurs in a considerable amount of patients after shoulder replacement, and this study emphasizes the need to intensify early postoperative pain management and to further study patients at risk, so possible causes can be identified and treatment can be engaged.

47. Pitfalls in the self-management of pain after outpatient surgery: An exploratory analysis
Karen Toftdahl Bjørnholdt, Lone Dragnes Brix, Lone Nikolajsen
Department of Orthopaedic Surgery, Horsens Hospital; Department of Anaesthesiology, Horsens Hospital; Danish Pain Research Center/Department of Anaesthesiology, Aarhus University Hospital

Background: Adequate pain treatment is important for postoperative recovery. Studies have shown that many outpatients fail to obtain adequate pain control at home, but knowledge of the extent of the problem and the pitfalls that occur is limited.
Purpose / Aim of Study: We aimed to find possible problem areas in analgesic consumption after discharge, in order to direct future interventions to improve pain control.
Materials and Methods: Data were obtained during a randomised clinical trial of dexamethasone involving outpatients undergoing minor arthroscopic shoulder surgery at Horsens Hospital. Patients received preoperative dexamethasone (40 mg, 8 mg, or placebo) and intraoperative local bupivacaine. In the recovery room, patients received fentanyl as needed and initiated the post-discharge regime of paracetamol around-the-clock and ibuprofen and morphine as needed. Patients recorded pain scores and analgesic use until the third postoperative day.
Findings / Results: 75 patients were available for analysis. The average pain intensity was successfully kept <4 out of 10 in 27 patients. Undertreatment occurred, as 16 patients experienced days or nights with average pain intensity >7 out of 10. Moreover, 6 of these refrained from any rescue analgesics. Overtreatment also occurred, as 18 patients consumed morphine when their worst pain intensity was <4. Rescue doses between 0:00 and 6:00 a.m. were consumed by 32 patients. Some patients exceeded the maximal daily dose of paracetamol (n=7) and ibuprofen (n=14). Overdoses were mostly due to other brand names or strengths compared to patients’ usual medication.
Conclusions: Problems in the self-management of pain after discharge include overdoses, under-/overtreatment, and nightly failures. Attention should be directed toward improving patient education and/or providing further assistance to patients after discharge.

48. Frozen shoulder - appearance in the electron microscope
Mads Okholm, Abigail Mackey, Klaus Qvortrup, Jens Jakobsen, Thomas Hansen, Michael Krogsgaard
Ortopædkirurgisk Afd. M, Bispebjerg Hospital; Institute of Sports Medicine Copenhagen, Bispebjerg Hospital; Core Facility for Integrated Microscopy, University of Copenhagen; Ortopædkirurgisk Afd., Idrætskirurgisk Enhed M51, Bispebjerg Hospital

Background: Primary frozen shoulder (PFS) has been thoroughly described clinically as well as histologically. To our knowledge, only a single study has ever described the electron microscopic appearance of PFS capsule tissue, and no study has ever compared the different phases of the disease.
Purpose / Aim of Study: To evaluate and describe capsular tissue appearance with the transmission electron microscope (TEM) in the 3 phases of PFS compared to controls.
Materials and Methods: Tissue samples from PFS capsules were taken during arthroscopic capsular release. 8 samples were randomly selected from a larger pool of tissue samples – these included two from each of the three phases and two from controls (patients with subacromial impingement syndrome). Samples were prepared for TEM, and two experienced observers evaluated the images on a Philips CM 100 TEM. Tissue cellularity, collagen architecture and fibril appearance was described.
Findings / Results: In general, the collagenous tissue was very dense in all samples. Fibril diameter varied between 30 and 70 nm. In all phases, areas of cross-sectioned fibrils with irregular, “hairy” edges were seen. In the phase 1 frozen shoulder samples, an abundance of large, irregularly shaped fibroblasts with clearly dilated organelles (golgi apparatus, rough endoplasmic reticulum) and intracellular lipid inclusions was noted. In phase 2 the cellular abundance was still present, but without the same enlargement of cell size and organelles. In phase 3 the cellularity was clearly reduced, and fibroblasts were small and rounded with modest organelle size.
Conclusions: In PFS, very active fibroblasts produce a densely packed collagenous tissue with many thick and irregular collagen fibrils. The morphology is phase-related: The earlier the phase, the larger, more irregularly shaped and dilated fibroblasts.

49. Anatomical changes in the aging sternoclavicular joint
Martin Wyman Ratchke, Jørgen Tranum-Jensen, Michael R. Krogsgaard
Section for Sportstraumatology M51, Bispebjerg Hospital; (1) Department of Cellular and Molecular Medicine , Copenhagen University

Background: The prevalence of degenerative changes of the sternoclavicular joints (SCJ) is unknown. Some cases are so painful that surgical treatment is indicated. Degeneration of the intraarticular disc with a central hole and the cartilage on the clavicle is reported in cadaver studies, but in sternoclavicular arthroscopies we often find detachment of the disc from the anterior capsule and marked disintegration of the disc.
Purpose / Aim of Study: To study the anatomy of the SCJ in detail and describe occurrence of conditions, that are potentially surgically accessible.
Materials and Methods: Both SCJs from 39 formalin embalmed (age mean: 79, range: 59-96, 13 F/26 M) were frozen and divided frontally with a thin band saw, so both SCJs were opened through the centre of the disc. Examination of the joints was performed after the specimens had been thawed and stored in 30% ethanol.
Findings / Results: We found a typical pattern: detachment of the disc inferior from the manubrium and from anterior and posterior capsule, in connection with thinning and fragmentation of the inferior part of the disc. Generally the disc was thickest superior and thinnest inferior. With inferior detachment we found a marked supero-medial instability of the medial clavicular end. In all cadavers but one there were cartilage changes on the clavicle and sternum. The manubrium joint surface was much smaller that the clavicular surface.
Conclusions: The superior part of the clavicular cartilage is only in contact with the cartilage of manubrium during extensive elevation off the clavicle, e.g. in abduction of the arm. Therefore it is mainly the inferior part of the discus that is compressed between articular surfaces and subject to age related degenerative tearing. This disc pathology can be trimmed but not reinserted. If instability is symptomatic, the joint can be stabilized.

50. Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears. A retrospective study of 38 Cases
Magnús Pétur Bjarnason Obinah, Theis Muncholm Thillemann, Janne Ovesen, Brian Elmengaard, Hans Viggo Skjeldborg Johannsen
Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Aarhus University Hospital

Background: Latissimus Dorsi Transfer (LDT) was proposed by Gerber in 1988 for treating irreparable posterosuperior rotator-cuff tears involving the supraspinatus and infraspinatus. These injuries can cause superior migration of the humeral head, which may lead to glenohumeral cartilage degeneration due to excentric wear, and ultimately cuff tear arthropathy.
Purpose / Aim of Study: The aim of this retrospective study was to evaluate the 1-11 years results after LDT in a consecutive series of 38 cases.
Materials and Methods: We included 38 LDT procedures in 38 patients treated in the period from 2003-2013. Pre- and peroperative information was collected by review of medical reports. The primary outcome was failure defined as graft rupture or revision surgery (shoulder arthroplasty). Secondary outcomes obtained at follow-up included range of motion (ROM), Constant score, Oxford Shoulder Score (OSS), simple shoulder value (SSV) and radiographic evaluation.
Findings / Results: Mean follow-up was 76.5 months (19 - 137). Mean age at operation was 58,3 (49 – 69). Eight patients had revision surgery, with a median interval between index and revision surgery of 45 months (8 – 96). One patient had a graft-failure. The cumulative 5 year survival rate was 83,9% (95% CI: 67,5 – 92,4). At follow-up mean active flexion was 105º (95% CI: 85 – 126), abduction 102º (95% CI: 81 – 122) and external rotation 28º (95% CI: 21 – 34). Mean Constant score was 44 (95% CI: 37 – 50), mean OSS was 32 (95% CI: 28-37) and mean SSV was 50 (95% CI: 39 – 60). When asked if they would choose a LDT again if given the same preoperative circumstances; 90% answered yes.
Conclusions: Latissimus Dorsi Transfer is a satisfactory treatment for irreparable posterosuperior rotator-cuff tears. At long term follow-up we found acceptable functional outcome and pain relief with good overall patient satisfaction.

51. Revision total elbow arthroplasty using the linked Coonrad-Morrey implant.
Hans Viggo Skjeldborg Johannsen, Janne Ovesen
Shoulder and Elbow Unit, Orthopaedic Dept, Aarhus University Hospital

Background: Total elbow arthroplasty is not a common procedure, and reports on revision elbow arthroplasty are rare.
Purpose / Aim of Study: The objective of the present study was to report our experience with revision elbow arthroplasty using a semiconstrained Coonrad-Morrey prosthesis and to review the functional outcome after revisions.
Materials and Methods: From 2000 to 2010, 58 patients (58 elbows) had a revision elbow arthroplasty using a linked Coonrad-Morrey implant. Forty-five patients were revised because of aseptic loosening and 13 because of infection. There were 27 women and 31 men with a mean age 63 (range 35 to 83) years at the time of revision. Thirteen had died from unrelated causes at a mean of 38 months (range 16 to 61 months) post-operatively, in all except one patient the implant was in place. Five of the surviving 45 patients were unable to return for follow-up. Mean follow-up was 5,3 (range 1 to 12) years. Follow-up included Mayo Elbow Performance Score and Oxford Elbow core, radiographs and clinical examination.
Findings / Results: Forty elbows in 40 patients had a full follow-up.The mean Oxford Elbow score was 26.8 (8 to 48). According to the Mayo Elbow Performance Score, 31 elbows had a satisfactory outcome (6 excellent, 8 good, 17 fair). The mean score was 70.5 (range 45 to 100). Eight of the 40 patients had been re-revised; five because of infection and three because of aseptic loosening. Complications included ulnar nerve palsy, intraoperative fracture, triceps failure, deep infection and aseptic loosening.
Conclusions: Revision elbow arthroplasty is a technically challenging procedure and both the short term and long term complication rates sre high. A number of different surgical options should be considered and the treatment individualized. Satisfactory results can be achieved in most cases.There is a high incidence of progressive radiolucency and patients should be monitored closely.

52. Complications and revision surgery of the reverse shoulder arthroplasty
Janne Ovesen, Thomas Falstie Jensen, Hans Viggo Skjeldborg Johannsen
Shoulder and Elbow Clinic. Department of Orthopaedic Surgery., Aarhus Universityhospital

Background: The indications for reverse total shoulder arthroplasty (RTSA) have expanded, but there is relatively limited knowledge regarding longterm results after revisions of the RTSA.
Purpose / Aim of Study: To identify and understand the most common complications and reasons for failure in RTSA.
Materials and Methods: Between 2003 and 2014, 37 patients with RTSA had revision surgery. Clinical and radiographic examinations were performed preoperatively, postoperatively and analyzed retrospectively. Revision was defined as a surgical intervention with exchange or removal of one or more components. Causes for revision were identified and the patients were reviewed with a mean of 56 months follow-up after the first intervention.
Findings / Results: 37 patients with a mean age of 70.1 years (51 to 83), needed at least one additional intervention to treat a complication of RTSA. Additional interventions after RTSA were needed between the second day of the RTSA and 11 years thereafter, with mean of 21.4 months postoperatively. The most common causes for revision were infection (62.2%), prosthetic instability (24.3%), humeral loosening, fracture (5.4%), glenoid loosening (5.4%) and other reasons (2.7%). At follow-up 17 patients had retained a RTSA, 17 patients had undergone conversion to hemiartroplasty and 3 patients had chosen to keep the cementspacer. Previous surgery was found to be a potential cause of low-grade infection.
Conclusions: The most frequent causes for revision of a failed RTSA were infection and instability. Previous failed surgery was a risk factor for revision RTSA, in particular failed treatment for fracture (hemiarthroplasty or osteosynthesis) and failed cuffrepair. Revision of RTSA may lead to several surgical procedures in the same patient. Preservation or replacement of the RTSA, allowing a functional shoulder, was in most cases possible.