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Abstract: Shoulder disorders are very common musculoskeletal conditions. Few studies have focused on the costs associated with shoulder disorders, and the economic burden has never been established in a nationwide cost-of-illness study. We aimed to evaluate the healthcare costs and costs of productivity loss (sick leave) and to evaluate if costs were higher for specific subgroups. Using national Danish registers, we identified individuals with shoulder disorders (subacromial pain, stiffness, fracture, or dislocation) diagnosed between 2005 and 2017 and controls matched on age and gender without shoulder disorders. Health care usage, sick leave, and related costs were estimated. During the 13-year inclusion period, 617,334 unique individuals were identified and the incidence rate was 1215 per 100,000 person-years in 2017. The expected additional societal costs were €1.21 billion annually. The mean additional total costs for the 6-year period were €11,334 (11,014-11,654) for individuals aged ≥65 years and €25,771 (25,531-26,012) for individuals aged <65 years. For individuals in the working age, the costs of sick leave accounted for approximately 70% of the total costs. Individuals aged ≥65 years had healthcare costs that were twice as high as individuals aged <65 years. Additionally, the 20% of cases accruing the highest costs accounted for 66% of the total costs. In conclusion, incidence rates of shoulder disorders were high and costs of sick leave accounted for a large proportion of total costs associated with illness in working age people. Furthermore, a minority of patients accounted for a substantial share of the total costs., (Copyright © 2022 International Association for the Study of Pain.)

Introduction: Adequate responsiveness and knowledge of the minimal important change (MIC) is essential when using patient-reported outcome measures to assess treatment efficacy., Objective: The objective of this study was to evaluate the responsiveness and MIC of common outcomes in patients with subacromial impingement syndrome undergoing arthroscopic subacromial decompression., Methods: At baseline and 6 months after surgery, patients completed the Oxford Shoulder Score (OSS), EQ-5D 5-level utility index, EQ visual analogue scale, Fear-Avoidance Belief Questionnaire Physical Activity subscale (FABQ-PA), assessed pain (pain visual analogue scale), and Subjective Shoulder Value. Furthermore, at the 6-month follow-up, patients assessed the overall change with a Global Rating of Change Scale. Responsiveness was examined by analyzing the area under the receiver operating characteristics curve and correlations between the change scores. MIC was assessed using the optimal cutoff point at the receiver operating characteristics curve., Results: Area under the receiver operating characteristics curve estimates were 0.96 (95% confidence interval [CI] 0.91,1.00) for OSS, 0.82 (95% CI 0.66,0.99) for EQ-5D 5-level utility index, 0.73 (95% CI 0.58,0.87) for EQ visual analogue scale, and 0.74 (95% CI 0.58,0.90) for FABQ-PA. MIC were 6.0 points for OSS, 0.024 points for EQ-5D 5-level utility index, 10.0 points for EQ visual analogue scale, and -5.0 points for FABQ-PA., Conclusion: Responsiveness of the OSS, EQ-5D, and FABQ-PA was sufficient to measure improvement after arthroscopic decompression surgery., (© 2021 The Authors.)

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour. At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results.

Background: The purpose of this study was to evaluate the clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum., Materials and Methods: Between 2003 and 2007, 10 patients (6 female and 4 male patients), with a mean age at surgery of 18 years (range, 13 to 27 years), with advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The surgical technique involves transplanting small-sized cylindrical osteochondral grafts from the lateral periphery of the femoral condyle at the level of the patellofemoral joint to the defect of the capitellum. At a mean follow-up of 30 months, all elbows were assessed with the Mayo Elbow Performance Score and a modified functional elbow score (Constant)., Results: Postoperative radiographs and control magnetic resonance imaging/computed tomography images showed incorporation of the subchondral cortex in all patients. All but 2 patients were completely pain free after surgery. Of the patients, 8 (80%) had no reduction in range of motion. By use of the Mayo Elbow Performance Score, the injured elbow had a preoperative mean score of 71 points (range, 55 to 85 points) and increased significantly to a mean score of 93.5 points (range, 85 to 100 points) postoperatively (P = .0005, paired t test). The nonoperative elbows had a mean score of 100 points, whereas the operated elbows had a mean score of 93.5 points. The functional elbow score showed a mean difference of 7.5 points between the operated and nonoperative elbows. No infection or neurologic deficit developed after surgery in any case., Conclusions: Autologous osteochondral mosaicplasty for advanced lesions of capitellar osteochondritis dissecans can provide satisfactory clinical and radiographic results., (Crown Copyright © 2011. Published by Mosby, Inc. All rights reserved.)

Background: Fractures of the proximal humerus are common injuries and account for 4-5 percent of all fractures, second only to hip and wrist fractures. The incidence is positively correlated with age and osteoporosis, and is likely to increase. Displaced four-part fractures are among the most severe injuries, accounting for 2-10 percent of proximal humeral fractures. The optimal intervention is disputed. Two previous randomised trials were very small and involved a noticeable risk of bias, and systematic reviews consequently conclude that there is inadequate basis for evidence-based treatment decisions. We aim to compare the effect of osteosynthesis with angle-stable plate with non-surgical management, and the effect of primary hemiarthroplasty with both osteosynthesis and non-surgical management., Methods/design: We will conduct a randomised, multi-centre, clinical trial including patients from ten national shoulder units within a two-year period. We plan to include 162 patients. A central randomisation unit will allocate patients. All patients will receive a standardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation. Patients will be followed at least one year. The primary outcomes will be the overall score on the Constant Disability Scale, and its pain subscale, measured at 12 months. A blinded physiotherapist will carry out the assessments. Other secondary outcomes are Oxford Shoulder Score, and general health status (Short Form-36).

Purpose: The purpose of this study was to compare long-term results after surgical and conservative primary treatment of first-time traumatic anterior shoulder dislocation., Methods: Arthroscopic diagnosis after first-time traumatic anterior shoulder dislocation was performed, and in cases of a Baker type 1, 2, or 3 lesion, patients were randomized either to conservative treatment with a fixed sling for 1 week followed by a rehabilitation program or to open repair with a similar rehabilitation program., Results: In this study 76 patients (14 female and 62 male patients), aged 15 to 39 years, were randomized to surgical repair (n = 37) or conservative treatment (n = 39). Of the patients, 6.6% had Baker type 1 lesions, 13.2% had type 2 lesions, and 80.3% had type 3 lesions. After a minimum of 2 years' follow-up, 56% had recurrence after conservative treatment and 3% after open repair (P < .005). Among nondislocators, 39% in the conservative group and 7% in the repair group had a positive apprehension test. When evaluated after 10 years by use of the Oxford self-assessment score, 72% of patients in the surgical group had good or excellent results. Of the conservatively treated patients, 75% had unsatisfactory results because of recurrence, instability, and pain or stiffness., Conclusions: Arthroscopic evaluation after first-time anterior shoulder dislocation revealed a Baker type 2 or 3 lesion in 93.5% of patients. At 2 years' follow-up, 21 (54%) of the conservatively treated patients had recurrence, as compared with 1 patient with recurrence (3%) after open surgical repair. After 8 years, a further 3 patients in the conservatively treated group had redislocations, 1 had subjective instability, and 4 had pain or stiffness, resulting in 74% having unsatisfactory results according to the Oxford score. Of the patients who had surgical repair, 72% had good or excellent results after 10 years. Because open repair produces superior results compared with conservative treatment, we recommend that the surgeon consider performing primary repair in active patients to reduce the risk of recurrence., Level of Evidence: Level I, high-quality prospective, randomized controlled trial.

From 1992 to 1993, 17 elbows were replaced with the unlinked Kudo type 3 total elbow arthroplasty in 16 patients with arthritic joint destruction. Of these elbows, 8 were available for clinical examination after a mean of 9.5 years. Of the 17 elbow implants, 5 were revised: 2 because of loosening of the ulnar component, 1 because of dislocation, 1 because of a periprosthetic fracture, and 1 because of a late deep infection. At 9.5 years' follow-up, 67.9% of the prostheses had survived, and the mean survival of the implant was 8.7 years (95% confidence interval, 7.5-10 years). In this study, we observed high rates of progressive valgus tilting of the ulnar component. This valgus tilting is of major concern because it provides more stress to a smaller area on the polyethylene. It may, therefore, cause an increased degree of polyethylene wear and, thereby, reduce the final implant survival rate.

We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked relief of pain, but the range of movement showed no overall improvement. Two patients had a second revision because of infection and two for aseptic loosening. The estimated five-year survival rate of the prosthesis was 83.1% (95% confidence interval 61.1 to 93.3). Revision elbow arthroplasty using the Coonrad-Morrey implant provided satisfactory results but with complications occurring in 13 cases.

Between 1994 and 2000, 51 capitellocondylar elbow replacements were inserted in 41 patients. All patients had late-stage rheumatoid arthritis. The mean age at operation was 56 years (range, 25-78 years). There were 12 men and 29 women. At follow-up, 6 patients had died of unrelated causes with the implant in situ and without radiographic loosening, and 1 patient was lost to follow-up. The remaining 43 elbows in 34 patients were followed up clinically and radiographically at a mean of 6.9 years (range, 26-119 months). Relief of pain was complete in 91% of the surviving elbows, and in 9%, there was only mild pain. Pain-free range of motion at follow-up was significantly improved. Flexion increased a mean of 43 degrees ; extension, 16 degrees ; supination, 24 degrees and pronation, 26 degrees . Of the elbows, 7 underwent revision, 3 because of deep infection, 1 for aseptic loosening, and 3 because of instability. Other complications included 2 maltracking elbows, 2 triceps tendon ruptures, 2 cases of operative olecranon bursitis, and 2 ulnar nerve palsies. One elbow showed radiolucent lines of more than 1 mm in the circumference of the ulnar component; none of the other elbows showed any signs of progressive radiographic loosening. At a mean follow-up of 6.9 years, a functional prosthesis was retained in 82.7% of the elbows, and the mean survival of the implant was 8.6 years (95% CI, 7.8-9.5 years).

Patients with a displaced muscle belly because of rupture of the long head biceps tendon were investigated for local pain and other disabilities, together with strength and endurance loss. Eleven patients (median age 59 years, minimum follow-up 6 months) were included, and minimum follow-up was 6 months. Magnetic resonance imaging (MRI) of both upper arms allowed investigation of muscle atrophy and evaluation of any other degenerative signs in the displaced muscle. All patients reported pain or disability locally in the displaced muscle in certain situations, and strength and endurance were reduced by 25%. MRI revealed the displaced muscle to be unreduced in size and with no signs of degeneration. Generally, operative reattachment of the displaced muscle is not advocated in middle-aged or older patients. In order to elucidate this subject, we present a retrospective consecutive series of patients with considerable disabilities in the displaced muscle belly independent of shoulder disabilities.

Rheumatoid arthritis of the shoulder is a progressive and destructive joint disease, and similar to arthritis in other joints, progression of the disease is unpredictable and may stop at any stage of involvement. Between 1983 and 1996, more than 500 shoulder prostheses were implanted in patients at the authors' institution. Total shoulder replacement yields satisfactory short and long term results even in patients with severely destructed joints. Pain relief is reliable and significant as reported in short and long term studies. In most patients the functional result is good or acceptable. Although range of motion is only slightly increased, a satisfactory overall range of motion is achieved by most patients because of the unaffected scapulothoracic motion. However, deteriorating results, emphasizing the complexity of shoulder arthroplasty, were seen with increasing observation time in patients with rheumatoid arthritis. Proximal migration of the humeral prosthesis attributable to rotator cuff failure, with secondary eccentric glenoid loading and progressive loosening, is latent in patients with chronic progressive rheumatoid disease and was by far the most common complication (42%) in the present series.

The aim of this study was to investigate tendon integrity after surgical repair of single-tendon rotator cuff lesions. In 31 patients, 31 single-tendon repairs were evaluated. Thirty-one patients were available for clinical assessment and magnetic resonance imaging (MRI) at follow-up. A standard series of MR images was obtained for each. The results of functional assessment were scored according to the system of Constant. According to MRI evaluation, 21 (68%) patients had an intact or thinned rotator cuff and 10 (32%) had recurrence of a full-thickness cuff defect at follow-up. Patients with an intact or thinned rotator cuff had a median Constant score of 75.5 points; patients with a full-thickness cuff defect had a median score of 62 points. There was no correlation between tendon integrity on postoperative MR images and functional outcome. Patients with intact or thinned cuffs did not have significantly better functional results than patients with retorn cuffs. Because of the presence of metal artifacts and the difficulty in distinguishing postoperative scar tissue from partial tears or thinning, MRI is of minor diagnostic value in assessing the shoulder after cuff repair. However, full-thickness tears are readily diagnosed after operation with MRI.

In a controlled clinical prospective study, 43 consecutive patients (43 shoulders) with subacromial impingement resistant to conservative therapy and without full-thickness rotator cuff tears underwent arthroscopic subacromial decompression. The patients were randomized to either self-training or physiotherapist-guided rehabilitation for immediate postoperative rehabilitation. Postoperative follow-up was performed by an independent observer after 3, 6, and 12 months. With the use of the Constant score for evaluation of functional outcome, patients training themselves improved from a mean 53 points (range 26 to 81 points) to a mean 79 points (range 45 to 100) points after 12 months. Physiotherapist-supervised patients improved from a mean 54 points (range 20 to 90 points) to a mean 80 points (range 40 to 100 points). The self-training patients returned to work after a mean 8.5 weeks (range 1 to 14 weeks), whereas the physiotherapist-supervised patients returned to work after a mean 8 weeks (range 3 to 13 weeks). No statistical difference was found between the 2 rehabilitation methods. This study was unable to show any beneficial effect of physiotherapist-supervised rehabilitation after arthroscopic subacromial decompression of the shoulder.

During a 15-month period, 24 patients with arthroscopically verified frozen shoulders were treated with manipulation while under general anesthesia and early passive motion. The minimum follow-up was 12 months, and the average duration from onset of the disease until treatment was 8 months. All patients had moderate to severe pain, and the average range of motion was less than 40% of the opposite shoulder. During the follow-up period, 75% of the patients obtained normal or almost full range of motion, and 79% had slight pain or no pain at all. Eighteen (75%) patients returned to work 9 weeks (mean) after treatment. There was no relationship between the end result and the initial pathologic condition. We believe that manipulation combined with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment has failed.

The aim of this prospective study was to evaluate the results of arthroscopic subacromial decompression (ASAD) in the treatment of impingement syndrome in patients without full thickness rotator cuff tears. Sixty patients (64 operative procedures) underwent ASAD during the study period; 37 men and 23 women, average age 46 years (range 28-63), average duration of symptoms 37 months (range 8-132). Patients with calcifying tendintis were not included. Evaluation preoperatively and one year postoperatively included: Constant score, clinical examination and radiological evaluation (supraspinatus outlet view). All follow-up examinations were done by an independent observer. Fifty-six patients (60 procedures) were available for follow-up. The average length of follow-up was 13 months (range 10-23). Forty-six patients (77%) achieved a good or excellent result according to Constant score criteria. Preoperatively twenty-four patients had applied for worker's compensation benefits (WCB). Only half of the patients in the WCB group achieved a satisfactory result, whereas 94% of the non-WCB patients had a good or an excellent result. Arthroscopic subacromial decompression is an effective procedure for the majority of patients with stage II impingement syndrome. In this study WCB claims were associated with inferior results.

Over a 15 month period 20 patients with 20 arthroscopically verified frozen shoulders were treated with manipulation under general anaesthesia and early passive motion. The study had a minimum of six months follow-up. The average duration of the disease before treatment was eight months. Prior to treatment all patients suffered from moderate to severe pain and the average range of motion was less than 40% of the normal shoulder. During the follow-up period 55% had obtained a normal or almost full range of motion and 75% suffered from only slight pain or had no pain at all. Fourteen patients returned to prior work within a mean of nine weeks after treatment. We found no relation between the end-result and the prior pathology. We believe that manipulation with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment fails.

A prospective study of 62 Neer mark II total shoulder arthroplasties performed during the period from 1981 to 1990 on 51 patients with rheumatoid arthritis was undertaken to evaluate factors associated with component loosening and proximal humeral migration. Thirty-two (51%) showed proximal migration of the humerus before surgery was performed. The mean follow-up time was 92 months (range 52 to 139 months). The results revealed proximal migration in 55% of the patients (34 shoulders), and 40% (25 shoulders) showed progressive radiographic loosening of the glenoid component. Five of 12 press-fit humeral components demonstrated progressive radiographic loosening, whereas no signs of loosening were found in 50 cemented humeral components. In spite of progressive component loosening and progressive migration, this study demonstrated good pain relief in 89% of the patients (55 shoulders) and also a significant improvement in range of movement and function. The presence of proximal humeral migration did not significantly influence the average results-neither pain relief, range of movement, abduction force, nor function. Also, component loosening did not significantly influence the average pain relief, range of movement, abduction force, or function. The risk of clinical asymptomatic loosening is a relatively late complication that is eventually followed by pronounced bone destruction related to the loose component. Long-term radiographic control of total shoulders with rheumatoid arthritis is recommended. Hemiarthroplasty with a cemented humeral prosthesis may be a better treatment in the end stage of rheumatoid arthritis of the shoulder.

Forty patients (40 knees) with acute isolated or combined lesions of the anterior cruciate ligament treated by means of primary suture without reinforcement were followed-up 4-5 years postoperatively. In 75% of the patients, follow-up examination revealed clinical instability of the anterior cruciate ligament but only 25% of these had noteworthy subjective complaints (Lysholm knee score less than 83) and no significant difference was observed between the median knee scores for the group of patients with unstable knees and those with stable knees. On the other hand, however, a significant decrease in the level of activity (Tegner activity scale) was observed in patients with unstable knee joints as compared with patients with stable knees. These patients compensated for the defective stability by reducing the level of activity. Primary suture without plastic reinforcement cannot be recommended as the method of treatment of acute lesions of the anterior cruciate ligament because it does not provide long-term stability in the majority of patients.

Arthroscopy of the knee was carried out under local anaesthesia in 313 outpatients, with arthroscopic surgery in 81. The procedure had to be abandoned because of apprehension in only 0.9%. With increasing experience, the number of arthroscopic meniscectomies increased from 5% to 64% of the lesions found. The method was particularly valuable in the assessment of patello-femoral pain since dynamic evaluation of patellar alignment, and the localisation of sensitive structures by palpation, was possible. The method is a safe, reliable and inexpensive alternative to the use of spinal or general anaesthesia for arthroscopy.

In a double-blind, randomised controlled cross-over study the effects of perineuronal (perifemoral) injections of morphine were compared with epidural injections with the same amount of morphine in patients after knee surgery. Better pain scores were achieved during treatment with epidural morphine. We have not been able to confirm the hypothesis of neuro-axonal transport of morphine from the periphery to the spinal cord.

The purpose of the study was to analyse the effect of knuckle protection on the type and incidence of injuries in traditional karate contests. Knuckle protection was mandatory at the Danish karate championships 1983 and 1986 (290 matches, 0.26 injuries per match), and prohibited at the championships 1984 and 1985 (620 matches, 0.25 injuries per match). Head injuries were more common in the tournaments where fist pads were used. The incidences of transitory psychomotor disturbances following blows to the head were comparable. The severity of head injuries, however, decreased; minor head injuries dominated when fist pads were used (66%, compared with 44% without fist pads, p less than 0.01) and there were fewer lacerations and fractures. Injuries to the fingers or hands were also fewer--1.3% compared with 11% without protection (p less than 0.01). The use of fist pads reduced considerably the number of injuries requiring treatment (from 42% to 16%, p less than 0.01). In conclusion; fist pads offer some protection against injuries, especially to the hands, but additional measures are needed.

This study evaluates the role of arthroscopy in the diagnosis of acute injuries to the knee. One hundred and fifty four patients with a suspected ligament injury or effusion of the knee joint underwent arthroscopy. A haemarthrosis was present in 82% and a bloodless effusion in 10%. Meniscal tears were found in 19% of the knees. Fresh ligament ruptures were present in 71% and an associated haemarthrosis in 95% of these; 65% were partial tears. The commonest isolated lesion was a complete or partial tear of the anterior cruciate, which occurred in 15% of cases. More than one ligament injury occurred in 56%, the commonest combination being tears of the anterior cruciate and medial collateral ligaments. In a high percentage of cases, arthroscopy revealed unsuspected injuries of significance in management. In 39%, an open or closed procedure followed arthroscopy. There were no complications from the diagnostic arthroscopy. We conclude that arthroscopy provides a more accurate diagnosis than clinical examination alone, and is especially valuable for assessing the patient with a haemarthrosis of the knee.

Twenty-nine patients underwent meniscal repair using an inside-to-out technique and instruments developed in our department. The tears were more than 1.5 cm in length, vertical, and located in the outer third of the meniscus. The torn segment was mobile, the remainder of the meniscus stable. After six months, fourteen out of sixteen patients achieved a good or excellent Lysholm knee score. We conclude that the technique is safe and reliable and allows better access than an arthrotomy. Care must be taken to avoid neurovascular injury.

The objectives of this study were to evaluate the effect of exercise on knee joint laxity. If exercise induced laxity is physiological, incorporation of this quality into a ligament replacement material would be indicated. Twenty recreational long distance runners average age 41 (range 24 to 50 yr) were tested before and immediately after 30 minutes of running. Using a computerized goniometer type instrument (Acufex KSS), knee flexion, axial tibial rotation and anterior-posterior tibial displacement were simultaneously recorded, while the runners underwent tests of static as well as dynamic knee joint laxity. At 30 degrees of knee flexion, a maximum increase of 16 per cent in mean total anterior-posterior laxity post-exercise was found. At the examination 30 minutes post-exercise, laxity at 30 degrees of knee flexion was still increased. However, laxity at 90 degrees of knee flexion had decreased to pre-exercise levels or below. Anterior tibial displacement, recorded during eccentric quadriceps activity (0 to 90 degrees of knee flexion) with weights attached to the foot, showed a maximum of 18 per cent increase in total anterior-posterior laxity post-exercise. It is suggested that the laxity increase is caused in part by a true ligamentous laxity increase, and in part by a decreased resting tone of the fatigued muscles.