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Background: The minimal clinically important difference (MCID) is an important instrument in the interpretation of changes in patient-reported outcome measures (PROM). To our knowledge, no MCID of the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score has ever been reported and no studies have reported an MCID for the Oxford Shoulder Score (OSS) based on patients with glenohumeral osteoarthritis, treated with an anatomical total shoulder arthroplasty (aTSA). The aim of this study was to determine MCID for WOOS and OSS in a cohort of patients with glenohumeral osteoarthritis treated with an aTSA.Methods: All patients treated with an aTSA for glenohumeral osteoarthritis at our institution between March 2017 and February 2019 were included. Each patient completed the WOOS and the OSS preoperatively and one year postoperatively. At one year, the patients were asked to rate their overall improvement on a 7-point scale. We used an anchor-based method as our primary method to calculate the MCID, supported by two different distribution-based methods.Results: A total of 45 primary aTSA were included. The MCID of WOOS was 12.3 according to the anchor-based method and 14.2 and 10.3 according to the two distribution-based methods. The MCID of OSS was 4.3 according to the anchor-based method and 5.8 and 4.3 according to the two distribution-based methods.Conclusion: The anchor-based method is considered superior to the distribution-based method, and therefore we advocate to use this as MCID. For patients with glenohumeral osteoarthritis treated with an aTSA, the MCID values were 12.3 points for WOOS and 4.3 points for OSS. To our knowledge, this is the first study to report a MCID value for WOOS and the first study to report a MCID value for OSS in this subgroup of patients.

Marc Randall Kristensen Nyring, Bo Sanderhoff Olsen, Alexander Amundsen, Jeppe Vejlgaard Rasmussen Department of Orthopedic Surgery, Herlev and Gentofte Hospital, Hellerup, 2900, DenmarkCorrespondence: Marc Randall Kristensen NyringDepartment of Orthopedic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte Hospitalsvej 12, Hellerup, 2900, DenmarkTel +45 38673840Email marc.randall.kristensen.nyring@regionh.dkBackground: The minimal clinically important difference (MCID) is an important instrument in the interpretation of changes in patient-reported outcome measures (PROM). To our knowledge, no MCID of the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score has ever been reported and no studies have reported an MCID for the Oxford Shoulder Score (OSS) based on patients with glenohumeral osteoarthritis, treated with an anatomical total shoulder arthroplasty (aTSA). The aim of this study was to determine MCID for WOOS and OSS in a cohort of patients with glenohumeral osteoarthritis treated with an aTSA.Methods: All patients treated with an aTSA for glenohumeral osteoarthritis at our institution between March 2017 and February 2019 were included. Each patient completed the WOOS and the OSS preoperatively and one year postoperatively. At one year, the patients were asked to rate their overall improvement on a 7-point scale. We used an anchor-based method as our primary method to calculate the MCID, supported by two different distribution-based methods.Results: A total of 45 primary aTSA were included. The MCID of WOOS was 12.3 according to the anchor-based method and 14.2 and 10.3 according to the two distribution-based methods. The MCID of OSS was 4.3 according to the anchor-based method and 5.8 and 4.3 according to the two distribution-based methods.Conclusion: The anchor-based method is considered superior to the distribution-based method, and therefore we advocate to use this as MCID. For patients with glenohumeral osteoarthritis t

Traumatic ruptures of the subscapularis tendon in children are rare and often missed. In this case report, a 70 kg person landed on a 13-year-old boy with his arm abducted and rotated, causing pain and restricted motion. An MRI showed a total rupture of the subscapularis with avulsion of the minor tubercle and subluxation of the biceps tendon. The avulsion was fixed to the foot print and the biceps tendon in the bicipital groove, by delto-pectoral approach, using three anchors. It is important to avoid missing these injuries. They may cause chronic shoulder pain and decreased motion if left untreated.

Osteoarthritis of the shoulder is common in elderly, and arthroplasty surgery is increasing in Denmark. This review summarises the current knowledge. Results are good, and revision rates are low at ten years. Symptomatic osteoarthritis in the acromioclavicular joint are common. Most patients can be treated conservatively. Resection arthroplasty complications are rare, and the results are good. Osteoarthritis of the elbow is rare, and only a few arthroplasties are performed. Complications are common, but revision rates are relatively low, and results are improving.

BackgroundReverse shoulder arthroplasty has been proven to improve function in shoulders with cuff-tear arthropathy, but existing studies are primarily single-center studies with a small number of patients, which limits their ability to identify patients who have an increased risk of revision or a worse functional outcome.Questions/purposes(1) What is the estimated 10-year cumulative revision rate after reverse shoulder arthroplasty for cuff-tear arthropathy, and what factors are associated with the risk of revision? (2) What is the patient-reported outcome 1 year after surgery, and what factors are associated with a worse patient-reported outcome?MethodsWe included all patients treated with reverse shoulder arthroplasty for cuff-tear arthropathy reported in the Danish Shoulder Arthroplasty Registry from 2006 to 2015. During the study period, the completeness of reporting was 93% for both primary and revision arthroplasties. Estimated revision rates were illustrated using the Kaplan-Meier method, and hazard ratios were calculated using a Cox regression model. Patient-reported outcome was measured with a postal survey at 12 months (range 10-14 months) postoperatively using the Western Ontario Osteoarthritis of the Shoulder (WOOS) index. The WOOS is a patient-administered questionnaire that measures the quality of life of patients with glenohumeral osteoarthritis. A visual analog scale that ranges from 0 to 100 is used for each question. There are 19 questions, giving a total score ranging from 0 to 1900, with 1900 being the worst. For simplicity of presentation, raw scores were converted to a percentage of the maximum score, with 100 being the best. There is no defined minimal clinically important difference of the WOOS, but the Danish Shoulder arthroplasty registry has for many years regarded an arbitrary difference of 10 or above as being clinically relevant. The rate of response to the WOOS was 71%.ResultsThe estimated 10-year cumulative revision rate was 8.5%

Background and purpose — It is unclear whether previous osteosynthesis is a risk factor for inferior outcome following shoulder arthroplasty for a proximal humeral fracture. We used data from the Danish Shoulder Arthroplasty Registry (DSR) to examine this question. Patients and methods — All 285 patients treated with a shoulder arthroplasty after failed osteosynthesis of a proximal humeral fracture reported to DSR from 2006 to 2013 were included. Each case was matched with 2 controls (570) treated with a primary shoulder arthroplasty for an acute proximal humeral fracture. Patient reported outcome was assessed using the Western Ontario Osteoarthritis of the Shoulder index (WOOS) and the relative risk of revision was reported. Results — The mean WOOS was 46 (SD 25) for a shoulder arthroplasty after failed osteosynthesis and 52 (27) after a primary shoulder arthroplasty. The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. In a separate analysis of patients treated by locking plate the mean WOOS was 46 (24), with a relative risk of revision at 1.5 with a primary arthroplasty as reference. Interpretation — Compared with primary arthroplasty for proximal humeral fracture, we found an inferior patient-reported outcome and a substantial risk of revision for patients treated with a shoulder arthroplasty after failed osteosynthesis for a proximal humeral fracture. The risk and burdens of additional surgery should be accounted for when deciding on the primary surgical procedure.

PURPOSE: To examine associations between retinal vascular geometry (tortuosity, branching coefficient [BC] and length-diameter ratio [LDR]) and diabetic proliferative retinopathy (PDR), nephropathy, and peripheral neuropathy in patients with type 1 diabetes mellitus (T1DM).METHODS: A cohort of patients with T1DM participated in a clinical examination in 2011. Blood and urine analyses were done and retinal images taken. PDR was defined as Early Treatment Diabetic Retinopathy Study level 61 or above, nephropathy as albumin-creatinin ratio ≥300 mg/g, and neuropathy as vibration perception threshold >25 Volt. Retinal vessel parameters were measured using semi-automated software. Multiple logistic regressions were performed to investigate correlations between retinal vascular parameters and outcomes. Models were adjusted for other variables (sex, age, duration of diabetes, systolic and diastolic blood pressure, HbA1c, and presence of microvascular complications). Odds ratios were given per standard deviation in retinal vascular parameter.RESULTS: Retinal vascular analyses were performed in 181 patients. Mean age and duration of diabetes were 37.0 years and 29.4 years respectively, and 50.8% were male. Prevalence of PDR, nephropathy, and neuropathy were 26.5%, 6.8%, and 10.1% , respectively. Patients with increased arteriolar BC had a higher risk of nephropathy (OR: 3.10, 95% CI: [1.01-9.54]). Patients with increased venular BC had a higher risk of neuropathy (OR: 2.11, 95% CI: [1.11-4.03]). No associations were found in patients with PDR.CONCLUSIONS: By analyzing the retinal vascular tree in patients with T1DM, we found a higher risk of complications in kidneys and nerves when BC was increased. This might indicate a suboptimal construction of the vascular tree in these patients.

BACKGROUND: The primary aim was to quantify the 30-day, 90-day, and 1-year mortality rates after primary shoulder replacement. The secondary aims were to assess the association between mortality and diagnoses and to compare the mortality rate with that of the general population.METHODS: The study included 5853 primary operations reported to the Danish Shoulder Arthroplasty Registry between 2006 and 2012. Information about deaths was obtained from the Danish Cause of Death Register and the Danish Civil Registration System. Age- and sex-adjusted control groups were retrieved from Statistics Denmark.RESULTS: The mean age was 69.3 ± 11.6 years, and 69.2% of patients were women. Of the patients, 39 (0.7%) died within 30 days, 88 (1.5%) within 90 days, and 222 (3.8%) within 1 year. Fracture patients had an incidence rate of 1256 per 100,000 within 30 days, which was significantly higher than the incidence rate of 182 per 100,000 in the general population (P < .001), whereas osteoarthritis patients had an incidence of 111 per 100,000, which was significantly lower than the incidence rate of 125 per 100,000 in the general population.CONCLUSIONS: Fracture patients had a 6 times higher incidence of death within 30 days than the general population. However, the difference was equalized during the first year. This finding indicates that the injury and arthroplasty procedure are associated with an increased risk of death for these patients. Pulmonary, cardiac, and abdominal causes of death were common, and for fracture patients in particular, close postoperative monitoring of pulmonary, cardiac, and abdominal conditions seems important.

In this study, we evaluated patient-reported outcomes, the rate of revision and the indications for revision following resurfacing hemiarthroplasty of the shoulder in patients with osteoarthritis. All patients with osteoarthritis who underwent primary resurfacing hemiarthroplasty and reported to the Danish Shoulder Arthroplasty Registry (DSR), between January 2006 and December 2010 were included. There were 772 patients (837 arthroplasties) in the study. The Western Ontario Osteoarthritis of the Shoulder (WOOS) index was used to evaluate patient-reported outcome 12 months (10 to 14) post-operatively. The rates of revision were calculated from the revisions reported to the DSR up to December 2011 and by checking deaths with the Danish National Register of Persons. A complete questionnaire was returned by 688 patients (82.2%). The mean WOOS was 67 (0 to 100). A total of 63 hemiarthroplasties (7.5%) required revision; the cumulative five-year rate of revision was 9.9%. Patients aged < 55 years had a statistically significant inferior WOOS score, which exceeded the minimal clinically important difference, compared with older patients (mean difference 14.2 (8.8; 95% CI 19.6; p < 0.001), but with no increased risk of revision. There was no significant difference in the mean WOOS or the risk of revision between designs of resurfacing hemiarthroplasty.

AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus.METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo.RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt.CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.

Jeppe V Rasmussen,1 John Jakobsen,2 Bo S Olsen,1 Stig Brorson1 1Department of Orthopedic Surgery, Herlev University Hospital, Herlev, Denmark; 2Department of Orthopedic Surgery, Aalborg University Hospital, Thisted, Denmark Background and purpose: The Western Ontario Osteoarthritis of the Shoulder (WOOS) index is a patient-reported, disease-specific questionnaire for the measurement of the quality-of-life in patients with osteoarthritis. The purpose of this study was to describe the process used to translate the WOOS into Danish and to test the translation in a Danish population, in terms of validity, reliability, and responsiveness. Material and methods: The translation of the WOOS was done according to international standardized guidelines. The psychometric properties were tested in 20 consecutive patients. The eligibility criteria were: a diagnosis of osteoarthritis without symptomatic rotator cuff pathology and treated with primary shoulder replacement. Patients were excluded only in the case of other pathology of the upper extremity or in the case of cognitive or linguistic impairment compromising the ability to complete the questionnaires. Results: The Pearson's correlation coefficient between the WOOS and the Constant-Murley score (CMS), preoperatively was 0.62 (P = 0.004) and the correlation between the changes of score for the WOOS and CMS was 0.73 (P < 0.001). The correlation coefficient between the WOOS and the CMS, SF-36, and the Oxford Shoulder Score postoperatively was 0.82 (P < 0.001), 0.48 (P = 0.03), and 0.82 (P < 0.001), respectively. There were no floor and ceiling effects. The Cronbach's alpha was 0.98. The intraclass correlation coefficient between test and retest was 0.96. The standardized response mean was 1.41, and effect size was 2.32. Conclusion: We have shown that the Danish version of the WOOS, translated according to international standardized guidelines, has substantial statistical and clinical psych

Orthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus. However, the clinical implications of low observer agreement remain unclear. The purpose of the study was to compare the agreement on Neer classification with the agreement on treatment recommendations.

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.

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).

INTRODUCTION: Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus. METHODS: We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently. RESULTS: Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%. CONCLUSIONS: Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures.

The purpose of this study was to evaluate the clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum.

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).

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).

Inferior dislocation of the shoulder (luxatio erecta) is a rare type of shoulder dislocation. In this short article we review a case of a 56-year-old man who sustained a subcoracoid inferior dislocation of the right shoulder after accidental axial loading of the right arm. Post-reduction magnetic resonance scan showed supraspinatus tendon rupture. Such type of shoulder dislocation is associated with significant complications (such as rotator cuff tears) and also late complications (including instability, chronic pain and reduced motion). A brief description of presentation, diagnosis and management of this injury is presented. Udgivelsesdato: 2009-Aug, Inferior dislocation of the shoulder (luxatio erecta) is a rare type of shoulder dislocation. In this short article we review a case of a 56-year-old man who sustained a subcoracoid inferior dislocation of the right shoulder after accidental axial loading of the right arm. Post-reduction magnetic resonance scan showed supraspinatus tendon rupture. Such type of shoulder dislocation is associated with significant complications (such as rotator cuff tears) and also late complications (including instability, chronic pain and reduced motion). A brief description of presentation, diagnosis and management of this injury is presented.