Thursday May 12th
12:00 – 13:00
Chairmen: Michael Krogsgaard (DK) & Sigurd Liavaag (N)
Sami Elamo1, Liisa Selänne1, Kaisa Lehtimäki1, Juha Kukkonen2 and Ville Äärimaa1
1 Division of musculoskeletal diseases, Turku University hospital and University of Turku, Finland
2 Satakunta Central Hospital, Pori, Finland
Background: Arthroscopic Bankart operation is the most common operative procedure to treat shoulder instability. However, failure of stabilization and recurrence of instability is relatively common. In case of recurrence both Bankart and Latarjet operations are used as revision procedures. The purpose of this study was to compare the re-recurrence rate of instability and clinical results after revision Bankart and revision Latarjet operations.
Methods: Files of consecutive patients operatively treated for shoulder instability at Turku University Hospital, between years 2003-2013, were analyzed. Patients with a primary Bankart operation followed by a recurrence of instability, and a subsequent arthroscopic Bankart or open Latarjet revision operation, with a minimum of one-year follow-up, were called for follow-up. The re-recurrence rate of instability and Western Ontario Instability Index (WOSI) were used as outcome measures.
Results: 43 patients out of 78 (drop-out rate 44%) were available for follow-up (mean 4.2 years). There were 7 (16%) females and 36 (84%) males. After a failed Bankart repair, 28 were revised with an arthroscopic Bankart operation and 15 with an open Latarjet operation. 11 (39%) patients re-dislocated after the revision Bankart, and 10 (36%) were re-re-operated, whereas none re-dislocated after the revision Latarjet operation. Among patients without re-dislocation there was a statistically and clinically significant difference in the mean WOSI scores between the revision Bankart and revision Latarjet groups, 67% vs. 88%, respectively (p=0.0145).
Birgitte Hede Christensen1,2, Kathrine Skov Andersen2,3, Sten Rasmussen2,4, Elizabeth Lykholt Andreasen1, Lotte Mejlvig Nielsen1, Steen Lund Jensen4
1: Fysio- og Ergoterapi, Aalborg Universitetshospital
2: Ortopædkirurgisk Forskningsenhed, Aalborg Universitetshospital
3: Neurologisk Afdeling, Regionshospitalet Viborg
4: Ortopædkirurgisk afdeling, Aalborg Universitetshospital
Baggrund og formål: Rotator cuff ruptur er associeret med dysfunktion, smerter og nedsat styrke relateret til overekstremiteten (1). Der findes enkelte studier, som understøtter brugen af øvelsesterapi til patientgruppen, men der mangler viden omkring, hvilke øvelser der giver størst mulig effekt samt hvordan den fysioterapeutiske intervention skal tilrettelægges (2-4). Observationsstudier indikerer at m. deltoideus anterior og m. teres minor er særligt vigtige muskler for at kompensere for den manglende funktion i de afficerede muskler i rotator cuffen (5).
Formålet med studiet var derfor at undersøge effekten af styrketræning af m. deltoideus anterior og m. teres minor til patienter med irreparabel rotator cuff ruptur.
Metode: Patienter med irreparabel ruptur af minimum m. supraspinatus og m. infraspinatus identificeret ved ultralydsscanning, blev inkluderet i studiet og gennemgik 5 måneders øvelsesterapi med fokus på at centrere caput humeri i cavitas glenoidale og øge styrken i m. deltoideus anterior og m. teres minor. Det primære effektparameter var Oxford Shoulder Score, som blev udfyldt af patienterne ved baseline, 3 og 5 måneders follow-up. De sekundære effektparametre var måling af livskvalitet ved brug af EQ-5D, måling af bevægelighed og styrke samt måling af muskelaktivitet ved brug af elektromyografiske målinger. De sekundære effektparametre blev udført ved baseline og 5 måneders follow-up.
Resultater: 30 patienter blev inkluderet i studiet og 24 patienter gennemførte træningen. Årsag til manglende gennemførsel var for to patienter vanskeligheder ved at komme til træningsstedet, én patient blev genhenvist til ortopædkirurgerne og for de resterende tre var årsagen ukendt. Patienterne havde i gennemsnit haft deres symptomer i 38,6 måneder (varierede fra 3-216 måneder) og 53% rapporterede, at de havde haft symptomer i over 1 år.
Efter 5 måneders træning var der sket en bedring både på det primære og de sekundære effektparametre. Ved baseline var middelværdien på Oxford Shoulder Score 25,6 (SD 8,1) og steg signifikant efter 3 måneder til 33,8 (SD 8,7) (p=0,004) og efter 5 måneder til 37,2 (SD 8,2) (p<0,001). Bevægelighed målt ved abduktion og styrke målt ved flektion steg også signifikant fra baseline til 5 måneders follow-up. Endvidere rapporterede patienternes en forbedret livskvalitet og en reduktion i smerter efter 5 måneder. Der blev ikke observeret nogen signifikante ændringer i de elektromyografiske målinger som følge af træningen.
Diskussion og perspektiv: Patienterne inkluderet i studiet trænede to simple øvelser i 5 måneder og trods en gennemsnitlig lang symptomvarighed, lykkedes det at bedre funktionen i den symptomatiske skulder, reducere smerter og øge livskvaliteten hos patienterne.
Patienterne blev ikke sammenlignet med en kontrolgruppe, hvilket er en svaghed ved studiet.
Da flere patienter havde symptomer over længere tid, vurderes det, at spontan bedring som årsag til den observerede effekt er mindre sandsynlig. Derudover havde 17 ud af de 24 patienter forsøgt andre non-operative behandlinger inklusiv fysioterapi uden effekt. Endelig afklaring af træningsprogrammets effekt kræver randomiserede studier, men på baggrund af studiets positive resultater på både objektive og subjektive effektparametre anbefaler vi, at træningsprogrammet tilbydes til patienter med irreparabel rotator cuff ruptur.
1: Downie B, Miller B. Treatment of rotator cuff tears in older individuals: a systematic review. J Shoulder Elbow Surg. 2012;21:1255–61.
2: Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev.2003;2.
3: Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med. 2007;41(4):200–10.
4: Lin J, Weintraub N, Aragaki D. Nonsurgical Treatment for Rotator Cuff Injury in the Elderly. J Am Med Dir Assoc. 2008;9:626–32.
5: Ainsworth R. Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskeletal Care. 2006;4:140–51.
Jón Rói Jacobsen BSc, Carsten Moss Jensen MD, Søren Rasmussen Deutch MD PhD
Shoulder impingement (SI) is the most common shoulder disorder. Even though conservative treatment is the primary choice of treatment, surgery has increased substantially in several countries during the last 20 years. In Denmark, the National clinical guidelines for treatment of SI were initiated in 2011.
The aim of this study was to investigate the effectiveness of an Arthroscopic Subacromial Decompression (ASD) in 244 patients selected for surgery according to the Danish national Clinical Guidelines.
Materials and Methods:
Patients were included from an internet-based shoulder/elbow database. They were asked to complete two questionnaires consisting of the Oxford Shoulder Score (OSS) and EQ-5D-3L –VAS preoperatively and at 6 months follow-up. All patients were carefully selected for surgery according to the National Guidelines with persisting symptoms for at least 6 months where conservative means had failed to relieve symptoms. Furthermore, patients were divided into 3 groups according to the Pre-operative Oxford Shoulder Score.
For the complete study group, an OSS-change of 10 [8,8 ; 11,2], p=0.0001 was found at 6 months follow-up. No significant difference was found between the genders (p=0,17).
The largest clinical effect from the intervention was found in the low Pre-OSS group where a median-change of 19 was found. The moderate/high Pre-OSS groups had median changes of 15 and 6, respectively.
Similarly, according to the EQ-5D-3L-VAS the largest improvements were seen in the Low/Moderate Pre-OSS groups.
An ASD is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish National Guidelines.
Johanne M. Lyhne, Jon R. Jacobsen, Søren J. Hansen, Carsten M. Jensen, Søren R. Deutch
Department of Orthopaedic Surgery, Regional Hospital Randers, Denmark
Frozen shoulder is a painful shoulder joint disease. Patients with diabetes seem to have worse clinical symptoms and surgery in this patient population is believed to be more common.
The objective postoperative evaluation indicates inferior results when treating diabetic patients, but no previous studies have investigated the subjective satisfaction of arthroscopic capsular release on an unbiased basis.
Materials and methods
93 patients were included. All had remained unresponsive to conservative treatment for at least 6 months. The patients were retrospectively divided in two groups based on diabetes status: Group 1 consisted of patients with type 1 or type 2 diabetes (18) and group 2 consisted of the remaining patients (75). Evaluation was performed prior to arthroscopic capsular release and at 6 months follow-up. The web-based questionnaire consisted of 2 different evaluation forms: An Oxford Shoulder Score (OSS) and a visual quality scale (VQS).
Both groups had a statistically significant improvement in both evaluations. OSS in group 1 improved by 11.5 [95 % CI: 6.2 ; 16.4] and by 15.8 [95 % CI: 13.6 ; 17.9] in group 2. Although the improvement was larger in group 2, it was not statistically significant (p = 0.09). The VQS improved 39.6 in group 1 and 44.5 in group 2, (p = 0.50).
Our study indicates that diabetic patients are as equally satisfied following arthroscopic capsular release for frozen shoulders as non-diabetics when patients are selected for operation with no regard to diabetic status. We will continue to select patients for arthroscopic release without differences in preoperative counseling between diabetics and non-diabetics.
Juha Kukkonen1, Antti Joukainen2, Janne Lehtinen3 and Ville Äärimaa4
1 Satakunta Central Hospital, Pori, Finland
2 Hatanpää Hospital, Tampere, Finland
3 Kuopio University Hospital, Kuopio, Finland
4 Turku University Hospital and University of Turku, Finland
Backround: Optimal treatment for symptomatic, non-traumatic rotator cuff tear is unknown. This trial was set out to compare the effectiveness of physiotherapy, acromioplasty and rotator cuff repair in treatment of symptomatic, non-traumatic supraspinatus tear.
Methods: 180 shoulders (173 patients, mean age 65 years) with symptomatic, non-traumatic supraspinatus tears were randomized into one of three cumulatively designed intervention groups: physiotherapy only (Group 1), arthroscopic acromioplasty and physiotherapy (Group 2), and rotator cuff repair, acromioplasty and physiotherapy (Group 3). The Constant score was the primary outcome measure. Secondary outcome measures were visual analogue scale (VAS) for pain, patient satisfaction, rotator cuff integrity in control MRI investigation and cost of treatment.
Results: 167 shoulders were available for analysis at two years. There were no statistically significant differences in the mean change of Constant score: 18.4 (95% CI 14.2 – 22.6) in Group 1, 20.5 (95% CI 16.4 – 24.6) in Group 2, and 22.6 (95% CI 18.4 – 26.8) in Group 3 (p = 0.38). There were no statistically significant differences in pain VAS scores and patient satisfaction between the groups (p=0.45, p=0.28 respectively). At two years the mean sagittal size of the tendon tear was significantly smaller in Group 3 than in Group 1 and 2 (4 mm vs. 11 mm, p<0.0001). Rotator cuff repair and acromioplasty were significantly more expensive than physiotherapy only (p<0.01).
Conclusion: There were no significant differences in clinical outcome between the three interventions at two-year follow-up. Conservative treatment should be considered as primary treatment for symptomatic, non-traumatic supraspinatus tears.
Pelle Petersen1,2, Jes Bruun Lauritzen1, Michael Rindom Krogsgaard2
1Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen,
København NV, Denmark.
2 Department of Sports Traumatology M51, Bispebjerg Hospital, University of Copenhagen,
København NV, Denmark.
Stærevej 45, 2.th
2400 København NV
Background: Complex regional pain syndrome is a challenging condition including a broad spectrum of sensory, autonomic and motor features predominantly in extremities recovering a trauma. Surgical and non-surgical treatments are known risk-factors. Few large-scale studies have addressed occurrence of and factors associated with CRPS following orthopedic treatment. The present study aimed to identify factors associated to post-treatment development of CRPS.
Methods: Using the Danish Patient Compensation Association’s database (DPCA), we identified 647 patients with post-treatment CRPS (DM89.0), between January 1, 1992 and March 5, 2015. Age, gender, initial diagnosis, treatment, debut date of CRPS, severity of CRPS and size of compensation were extracted. A multiple logistic regression was performed to assess variables with association to approval of the claim made to DPCA. In the cases of CRPS in patients with carpal tunnel syndrome we analyzed bilateral vs. unilateral symptoms and whether neurophysiological changes prior to treatment were seen.
Results: The following variables were excessively represented; woman gender 4:1, primary diagnosis to the upper limb 2½:1 and surgical treatment 3:1. Mean age was 47.5±13.7, no difference between gender. Colles’ fracture (12%) and carpal tunnel syndrome (9%) were the most common diagnoses. Conservative treatment was negatively associated with approval of the claim (OR 0.29). Among CTS patients with unilateral symptoms 71.4% had normal neurophysiology prior to surgery.