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.