The Os centrale carpi is a relatively rare accessory carpal bone of the wrist that infrequently has been reported to cause symptoms. This report describes 2 cases where an apparently mobile Os centrale carpi caused painful clicking and crepitus and where the symptoms disappeared after arthroscopic removal of the ossicles.

Arthroscopic synovectomy is a safe outpatient procedure with minimal postoperative morbidity. In patients who have rheumatoid arthritis and possibly also in patients who have JRA, SLE, and postinfectious arthritis, a long period of increased comfort and improved function can be anticipated. The procedure may be considered in post-traumatic cases with joint contracture and as an adjunct to other measures for certain osteoarthritic disorders. In patients who have septic arthritis with insufficient clinical improvement after systemic antibiotics and lavage, arthroscopic synovectomy seems advantageous. © 2005 Elsevier Inc. All rights reserved.

Arthroscopic synovectomy is safe and reliable, with mild postoperative morbidity. The rationale of a surgical synovectomy is to excise inflamed synovium and thereby, remove as much effusion and inflammatory substrate as possible. In most cases, arthroscopic synovectomy is performed as an outpatient procedure. The technique has also been used for other diagnoses causing wrist arthritis, but very few results have been reported and the indications remain to be defined. In rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), systemic lupus erythematosus (SLE), and post-infectious monoarthritis, a long period of increased comfort and improved function can be anticipated.

This stndy comprising six separate papers, is concerned with the techniques of, and bevaluation of arthroscopy as a diagnostic and therapeutic tool in different pathologic conditions in the upper extremity.

Arthroscopy proved to increase diagnostic accuracy in 177 examined patients with anterior shoulder instability or shoulder pain. Previously not well described patterns of pathological morphology in the ventral joint capsule after anterior shoulder dislocations were disclosed. A new classification system of rotator cuff pathology to be used for arthroscopy in the subacromial impingement syndrome is suggested. Different stages of rotator cuff pathology were found to influence the clinical results after arthroscopic acromioplasty in 79 patients.

An anatomical stndy on 16 cadaver elbows revealed the close proximity between commonly used arthroscopic portals and important neurovascular structures. The usefulness and potential risks of each portal were demonstrated and a preferred procedure for diagnostic elbow arthroscopy was suggested.

Wrist arthroscopy was performed in 30 patients with long-standing post-traumatic pain and resulted in increased diagnostic accuracy. In patients where clinical examination and radiography had shown no abnormality, arthroscopy demonstrated serious carpal ligament injuries and related instability.

A technique for arthroscopic wrist synovectomy was described in patients with rheumatoid arthritis. In 18 wrists of 16 patients, a reasonably radical synovectomy could be achieved with this atraumatic method. Primary results showed decreased pain and increased grip-strength in all patients and an increased range of motion in some.

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This important reference textbook covers the surgical management of all major orthopaedic and traumatological conditions. The book will act as the major source of education and guidance in surgical practice for surgeons and trainees, especially those preparing for higher surgical examinations and the Board of Orthopaedics and Traumatology examinations within and beyond Europe. The emphasis throughout is on the application of current knowledge and research to technical problems, how to avoid operative problems, and how to salvage complications if they occur. The didactic text is complemented by abundant illustrations that highlight the essentials of each clinical scenario. The authors are all recognized international authorities active at congresses and workshops as well as in universities and hospitals across the world. ​

Synovectomy may be considered for the treatment of chronic wrist arthritis. The indications for wrist synovectomy are, however, not clearly defined. Open synovectomy has been reported to provide good pain relief for a relatively long time but can be associated with loss of mobility. Arthroscopic synovectomy seems equally reliable in terms of symptom reduction and no adverse effects have been reported. © 2006 Elsevier B.V. All rights reserved.

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.

The gleno-humeral joint is by far the most mobile in the human body but also afflicted by dislocations, predominantly anterior. Surgical stabilisation is often successful but failures not uncommon. The following review describes potential causes of failure and highlights the need of adapting surgical methods to pathomorphology.

We treated 4 female patients (mean age 80) with complex intraarticular acute fracture of the distal humerus with a Kudo humeral component, i.e. a hemiarthroplasty. All fractures were considered impossible to treat with open reduction and internal fixation. At mean 10 (3-14) months, 3 patients had an excellent result and 1 a good result according to the Mayo elbow performance score. We conclude that a hemiarthroplasty may be a valuable alternative in eldery patients with complex fractures of the distal humerus. Copyright© Taylor & Francis 2006.

Background and purpose: Age and gender have been regarded important for surgical decision making and used as inclusion criteria for clinical trials. Individual demands and level of activity have been less considered. A self-administered scale, defining subjectively assessed level of activity involving the upper extremities was therefore developed. The primary purpose of this study was to present the scale. Secondarily to investigate its reliability and correlation with age and gender.

Patients and Methods: A scale with 8 categories ranging from extremely demanding to non-demanding activities, separated according to hand dominance, was constructed. Reliability testing was performed on 103 healthy individuals of both genders with a wide age range (20-86). 241 patients, median age 58 years (range 18-97), with different upper extremity injuries completed the scale. Participants were instructed to mark activities representative for their normal activity level. Correlation with age and gender was then investigated using Spearman Correlation Coefficient (SCC).

Results: The level of activity ranged from 1, corresponding tominimal use of the arm, to 8 defined as elite sports. For test-retest Intraclass Correlation Coefficient (ICC) was 0.89 for the dominant and 0.90 for the non-dominant arm. Correlations between gender, age and level of activity were weak.

Interpretation: The scale was found reliable and feasible to use. Age and gender were weakly correlated with level of activity and patients with low and high activities found in all ages and both genders. The activity scale allows improved description of patients included in clinical trials and can aid in treatment decision making but is primarily not intended for measurement of treatment outcome.

Background: Treatment of intra-articular fractures of the distal humerus in the elderly is challenging. In patients with very distal fractures and severe comminution, primary arthroplasty has been advocated. Recently, a few reports have described promising results of hemiarthroplasty. This study describes the medium-term results of using the Kudo humeral implant (Biomet Ltd, Bridgend, U. K.) as replacement of the distal humerus. less thanbrgreater than less thanbrgreater thanMaterial and methods: Eight women (mean age, 79 years) were treated. Follow-up was conducted at a mean of 4 years after the procedure and consisted of the Mayo Elbow Performance Score (MEPS), radiographic images, and range of motion (ROM). less thanbrgreater than less thanbrgreater thanResults: All patients had a good or excellent outcome according to the MEPS. Mean ROM was 31 degrees to 126 degrees. Radiographic signs of attrition of the ulna were observed in 3 patients but did not correlate with the functional outcome. A periprosthetic fracture occurred in 1 patient 3 years after the index operation, and ROM was unsatisfactory in 1 patient. No other complications were observed. less thanbrgreater than less thanbrgreater thanConclusion: The use of the Kudo humeral implant as a hemiarthroplasty resulted in a reasonable functional outcome in the medium-term, but the radiographic signs of attrition suggest that the implant is not recommended as a hemiprosthesis.

This study assessed the role of diagnostic arthroscopy following a wrist injury in patients with normal standard radiographs, an unclear clinical diagnosis and persistent severe pain at 4 to 12 weeks. Forty-three patients were included after conservative management had failed to improve their wrist pain so that a stability test could be performed satisfactorily and underwent arthroscopy within 12 weeks. Arthroscopy revealed recent pathology in 41 wrists, of which 17 had significant ligament lesions that might have benefited from acute repair. We conclude that patients with marked persistent post-traumatic symptoms despite conservative management are likely to have sustained ligament injuries despite normal radiographs. We therefore recommend that under these circumstances an arthroscopy is carried out within 4 weeks if the patient and surgeon wish to acutely repair significant ligament injuries.

Background and purpose:Extracellular matrix remodelling is altered in rotator cuff tears,16partly due to altered expression of matrix metalloproteinases (MMPs) and their inhibitors. It is unclear if this altered expression can be traced as changes in plasma protein levels.

The purposes were to measure the plasma level of MMPs and their tissue inhibitors (TIMPs) inpatients with rotator cuff tears and to relate changes in the pattern of MMP and TIMP levels with the extent of the rotator cuff tear.

Methods: Blood samples were collected from 17 patients, median 61 (range 39-77) years, with sonographically verified rotator cuff tears (partial- or full-thickness). These were compared with 16 gender and age matched control persons with sonographically intact rotator cuffs. Plasma levels of MMPs and TIMPs were measured simultaneously using Luminex technology and ELISA.

Results: The plasma level of TIMP-1 was elevated in patients with rotator cuff tears, especially in those with full-thickness tears. The levels of TIMP-1, TIMP-3 and MMP-9 were higher in patients with full-thickness tears compared to those with partial-thickness tears, but only TIMP-1 was different from controls.

Interpretation: The observed elevation of TIMP-1 in plasma might reflect local pathological processes in or around the rotator cuff, or a genetic predisposition in these patients. That levels of TIMP-1 and certain MMP´s was found to differ between partial and full thickness tears may reflect the extent of the lesion or different aetiology and pathomechanisms.

Background: A specific exercise strategy focusing on eccentric exercises, for treating sbacromial pain has in a previous study been found effective at three-month followup.

The aim of the present study was to investigate if the positive short-term results were maintained after one year. A further aim was to examine if baseline clinical score, rotator cuff status and radiological findings influenced the choice of surgery.

Methods: 97 patients on the waiting-list for arthroscopic subacromial decompression were in the first study randomized to a three-month specific exercise strategy or unspecific exercises (controls). Patients were examined with radiology, ultrasound and assessed with clinical scores: primary Constant-Murley score. After three months of exercises the patients were asked if they still wanted surgery and this option was available until the one-year follow-up. All patients were re-assessed with clinical scores one year after inclusion or one year after surgical intervention and the number of patients that had chosen surgery in each group was compared. The baseline Constant-Murley score and the status of subacromial structures were analyzed in relation to patient's choice of surgery.

Results: The positive short-term effect (improved shoulder function and pain) of the specific exercises was maintained after one-year. Compared to the three-month followup all patients had improved significantly (p < 0.0001) in Constant-Murley score. The number of patients that had chosen surgery in the control exercise group (63%) was significantly larger (p < 0.0001) than in the specific exercise group (24%). Patients that had chosen surgery had a significantly lower baseline Constant-Murley score and significantly more often a full-thickness tear. Patients with partial-thickness tears did not differ from those with intact cuff tendons.

Conclusions: The positive short-term outcomes after specific exercises were maintained after one year and reduced the need of surgery significantly more than the unspecific control exercises. Patients with low baseline clinical score and/or a full-thickness tear significantly more often chose surgery.

Level of evidence: I, Randomized controlled trail according to Consort statement.

Background and purpose A programme based on eccentric exercises for treating subacromial pain was in a previous study found effective at 3-month follow-up. The purposes of the present study were to investigate whether the results were maintained after 1 year and whether the baseline Constant-Murley score, rotator cuff status and radiological findings influenced the outcome. Patients and methods 97 patients on the waiting list for arthroscopic subacromial decompression had been randomised to a specific exercise programme or unspecific exercises (controls). After 3 months of exercises, the patients were asked whether they still wanted surgery and this option was available until a 1-year follow-up. 1 year after inclusion or 1 year after surgery, the number of patients who decided to have surgery in each group was compared. The choice of surgery was related to the baseline Constant-Murley score, ultrasound and radiographs taken at inclusion. Results All patients had improved significantly (pless than0.0001) in the Constant-Murley score at the 1-year follow-up. Significantly more patients in the control group decided to have surgery (63%) than those in the specific exercise group (24%; pless than0.0001). Patients who decided to have surgery had a significantly lower baseline Constant-Murley score and more often a full-thickness tear. Patients with partial tears did not differ from those with intact tendons. Interpretation The positive short-term results of specific exercises were maintained after 1 year, and this exercise strategy reduces the need for surgery. Full-thickness tear and a low baseline Constant-Murley score appear to be a predictive marker for a less good outcome.

Background and purpose Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome. Patients and methods 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6-91) days. Follow-up at a mean of 39 (12-108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score. Results At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired. Interpretation A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

Background: A successful clinical result is reported in 75% to 85% of impingement patients after arthroscopic subacromial decompression. The result is maintained over time, but few studies have investigated the integrity of the rotator cuff in these patients. Materials and methods: Using ultrasonography, we examined the integrity of the rotator cuff in 70 patients 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at the index procedure. Results: Tendons were still intact in 57 patients (82%), 10 (14%) had partial-thickness tears, and 3 (4%) had full-thickness tears. Discussion: The total number of 18% tears (partial and full thickness) in this study, including patients clinically diagnosed with subacromial impingement at a mean age of 60 years, is unexpectedly low compared with 40% degenerative tears reported in asymptomatic adults of the same age. Conclusion: Arthroscopic subacromial decompression seems to reduce the prevalence of rotator cuff tears in impingement patients. This appears attributable to elimination of extrinsic factors such as mechanical wear and bursitis. The potential effect of surgery on intrinsic cuff degeneration is unknown, but intrinsic factors may explain tears still developing despite decompression.

We studied regeneration distance of rat sciatic nerve, with the sensory pinch reflex test and immunocytochemical staining for neurofilaments, four to 21 days after transsection, repair, and enclosure of the repair site in either a non-absorbable silicone tube or an absorbable polyglycolic acid (PGA) tube. The size of both tube-types was carefully selected so that they did not compress the repaired nerve. The opposite nerve was repaired and not inserted in a tube (control). The regeneration distances in repaired nerves enclosed in silicone tube were significantly longer than the control side at all time points, a result not seen when PGA tube was used. The number of proliferating non-neuronal cells (incorporation of 5-bromodeoxyuridine (BrdU)) was studied just proximal to the site of nerve repair after six days. Numerous stained cells were seen, but there where no significant differences between the groups. We conclude that outgrowth of sensory axons after transsection and repair of rat sciatic nerve with sutures can be increased by enclosing the site of repair in a silicone tube but not in a PGA tube. The effect is probably not related to the number of proliferative non-neuronal cells.

BACKGROUND: Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes, benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection.

QUESTIONS/PURPOSES: After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin?

METHODS: Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model.

RESULTS: When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31).

CONCLUSION: Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method.

LEVEL OF EVIDENCE: Level Ⅲ, therapeutic study.

OBJECTIVE: To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.

DESIGN: Randomised, participant and single assessor blinded, controlled study.

SETTING: Department of orthopaedics in a Swedish university hospital.

PARTICIPANTS: 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.

INTERVENTIONS: The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.

MAIN OUTCOME MEASURES: The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients' global impression of change because of treatment and decision regarding surgery.

RESULTS: Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients' global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).

CONCLUSION: A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.

TRIAL REGISTRATION: Clinical trials NCT01037673.

STUDY QUESTION Can a specific exercise strategy improve shoulder function and pain in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression? SUMMARY ANSWER Compared with a control exercise group, patients in the specific exercise group had significantly greater improvements in shoulder function and pain and fewer patients needed surgery at the three month assessment. WHAT IS KNOWN AND WHAT THIS PAPER ADDS Different exercise programmes are used as first line treatment in patients with subacromial impingement syndrome, but conclusive evidence to support the efficacy for these programmes is lacking. This specific exercise strategy proved effective in improving shoulder function and pain in patients in whom earlier conservative treatment had failed.

Study question

Can a specific exercise strategy improve shoulder function and pain in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression?

Summary answer

Compared with a control exercise group, patients in the specific exercise group had significantly greater improvements in shoulder function and pain and fewer patients needed surgery at the three month assessment.

What is known and what this paper adds

Different exercise programmes are used as first line treatment in patients with subacromial impingement syndrome, but conclusive evidence to support the efficacy for these programmes is lacking. This specific exercise strategy proved effective in improving shoulder function and pain in patients in whom earlier conservative treatment had failed.

Objective: The purpose of this study was to determine the minimal important change (MIC) of improvement in the Constant‐Murley score (CM score) in patients with longstanding subacromial pain and in subgroups of patients with subacromial pain with and without rotator cuff ruptures.

Method: The MIC was estimated by using the visual anchor‐based MIC distribution method, which integrates an anchor‐ and distribution‐based approach: the optimal cut‐off point of the receiver operator characteristic curve (MIC ROC) and the 95% limit cut‐ off point (MIC 95%limit). The study population consisted of 93 patients included in a randomized clinical trial evaluating the effect of a specific exercise strategy in patients with longstanding subacromial pain.

Results: The MIC ROC was found at a mean change of 17 points in the CM score. The MIC 95% limit was found at a mean change of 24 points. In the subgroup analysis the MIC ROC was found at a mean change of 19 points and the MIC 95% limit at 18 points in patients with an intact rotator cuff. In patients with rotator cuff ruptures the MIC ROC was found at a mean change of 15 points and the MIC 95% limit at 30 points.

Conclusion: The CM score is able to detect the minimal important change in individual patients with long‐standing subacromial pain when the rotator cuff is intact. In all patients with longstanding subacromial pain, the MIC value was dependent on the subgroup as well as the choice of statistical analysis. The estimated MIC values could be used as an indication for relevant changes in the CM score in clinical practice and guide the clinician in how to interpret the results of specific treatments for patients with longstanding subacromial pain.

Purpose: The aim of the study was to examine triangular fibrocartilage (TFCC) injury patterns associated with unstable, extra-articular dorsally displaced distal radius fractures.

Methods: Twenty adult patients with an Arbeitsgemeinschaft für Osteosynthesefragen (AO), type A2 or A3, distal radius fracture with an initial dorsal angulation greater than 20° were included. Nine had a tip fracture (distal to the base) of the ulnar styloid and 11 had no such fracture. They were all openly explored from an ulnopalmar approach and TFCC injuries were documented. Eleven patients also underwent arthroscopy and intra-articular pathology was recorded.

Results: All patients had TFCC lesions of varying severity, having an extensor carpi ulnaris subsheath avulsion in common. Eighteen out of 20 also displayed deep foveal radioulnar ligament lesions, with decreasingly dorsal fibres remaining. The extent of this foveal injury could not be appreciated by radiocarpal arthroscopy.

Conclusions: Severe displacement of an extra-articular radius fracture suggests an ulnar-sided ligament injury to the TFCC. The observed lesions concur with findings in a previous cadaver study. The lesions follow a distinct pattern affecting both radioulnar as well as ulnocarpal stabilisers.

Injury to the triangular fibrocartilage complex associated with distal radius fracture may cause symptoms of ulnar instability. Assessed by a radioulnar stress test, increased laxity of the distal radio-ulnar joint has in two previous studies been depicted to be associated with poorer outcome. This prospective study of 40 adults investigates the correlation of this test with functional outcome as measured by DASH. No clinically significant difference was found in relation to this test at two and five years after injury. Therefore using this test alone to decide whether or not to perform an acute repair of the TFCC cannot be recommended.

This study evaluates the standardized strength test in the Constant-Murley shoulder assessment of adults with healthy shoulders in a randomized, single-blind design. The following questions were to be answered: (1) Can the spring balance and a digital dynamometer both yield the same result? (2) What is the intraobserver and interobserver reliability of the strength test? (3) Is the strength test sensitive to change in technique or affected by calculation with mean or maximum values? Ten subjects were included in a comparison of the Handyscale (digital dynamometer) and the mechanical spring balance for concurrent validity, resulting in intraclass correlation coefficient values ranging from 0.96 to 0.99. For intraobserver and interobserver reliability, 2 observers tested 20 subjects with the Handyscale and retested them after 2 weeks. Regardless of technique during testing, this resulted in almost perfect agreement (intraclass correlation coefficient range, 0.89–0.98). The digital dynamometer can replace the conventional spring balance. The standardized strength test in the Constant-Murley shoulder assessment is reliable in young subjects with healthy shoulders, independent of technique or whether calculated with mean or maximum values.

Objective. We aimed to describe the attitudes among GPs and physiotherapists toward the diagnostic approach and management of patients with a common shoulder disorder.

Method. A questionnaire was sent out to 188 GPs and 71 physiotherapists. The total response rate was 71.8%. The questions were based on a written case simulation with cues about history and symptoms.

Results. The results showed a unanimous opinion of the diagnosis. Rotator cuff tendinitis was marked as the most probable. The two groups showed similarities in the way that they would examine the patient. The GPs referred the patients to the physiotherapists significantly more often than the other way around. The most probable choice of treatment made by the GPs was non-steroidal anti-inflammatory drugs (NSAIDs) and by the physiotherapists, movement exercises together with ergonomics. Most treatment alternatives had at least 20% of the responders marking a neutral attitude, and few treatments were disregarded.

Conclusions. We conclude that in Swedish primary care GPs and physiotherapists have a uniform diagnostic approach towards patients with subacromial pain, but their choice of treatment reflects an uncertainty about the effectiveness of conservative treatments. The questioned pathogenesis of the suggested diagnosis and lack of research regarding the efficacy of conservative treatments could explain this uncertainty.

Background and Purpose. There is no definitive evidence for the efficacy of the physical therapy interventions used for patients with impingement syndrome. The purpose of this study was to compare manual acupuncture and continuous ultrasound, both applied in addition to home exercises, for patients diagnosed with impingement syndrome.

Subjects and Methods. Eighty-five patients with clinical signs of impingement syndrome were randomly assigned to either a group that received acupuncture (n=44) or a group that received ultrasound (n=41). Both interventions were given by physical therapists twice a week for 5 weeks in addition to a home exercise program. Scores from 3 shoulder disability measures, combined in the analysis, measured change during a period of 12 months.

Results. Both groups improved, but the acupuncture group had a larger improvement in the combined score.

Discussion and Conclusion. The results suggest that acupuncture is more efficacious than ultrasound when applied in addition to home exercises.

The aim of the study is to determine which treatments for patients with subacromial pain are trusted by general practitioners (GPs) and physiotherapists, and to compare trusted treatments with evidence from a systematic critical review of the scientific literature. A two-step process was used: a questionnaire (written case simulation) and a systematic critical review. The questionnaire was mailed to 18 GPs and 71 physiotherapists in Sweden. The total response rate was 72% (186/259). The following treatments were trusted: ergonomics/adjustments at work, corticosteroids, non-steroidal anti-inflamatory drugs, movement exercises, acupuncture, ultrasound therapy, strengthening exercises, stretching, transcutaneous electric nerve stimulation, and superficial heat or ice therapy. The review, including efficacy studies for the treatments found to be trusted, was conducted using the CINAHL, EMBASE and MEDLINE databases. Evidence for efficacy was recorded in relation to methodological quality and to diagnostic criteria that labelled participants as having subacromial pain or a non-specific shoulder disorder. Forty studies were included. The methodological quality varied and only one treatment had definitive evidence for efficacy for non-specific patients, namely injection of corticosteroids. The trust in corticosteroids, injected in the subacromial bursa, was supported by definitive evidence for short-term efficacy. Acupuncture had tentative evidence for short-term efficacy in patients with subacromial pain. Ultrasound therapy was ineffective for subacromial pain. This is supported by tentative evidence and, together with earlier reviews, this questions both the trust in the treatment and its use. The clinicians' trust in treatments had a weak association with available scientific evidence.

BACKGROUND: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions in weight-bearing as opposed to TEA. These two treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS: This was a multicenter RCT. Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥ 60 years and independent living. The final follow-up took place after ≥ 2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation and supination) and grip strength.

RESULTS: 40 patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = 0.30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = 0.39), a difference of -5.6 points (95% CI: -18.6-7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = 0.59), EQ-5D index (0.92 vs. 0.86, P = 0.13), extension (29° vs. 29°, P = 0.98), flexion (126° vs. 136°, P = 0.05), arc of flexion-extension (97° vs. 107°, P = 0.25), supination (81° vs. 75°, P = 0.13), pronation (78° vs. 74°, P = 0.16) or grip strength (17.5 kg vs. 17.2 kg, P = 0.89). There were 6 adverse events in each treatment group.

CONCLUSION: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

The Oxford Elbow Score (OES) is a well-validated, elbow-specific, patient-reported outcome measure (PROM), originally assigned a 4-week recall period. For PROMs, short recall periods could have some advantages, such as optimizing validity by minimizing the negative effects of inaccurate recollection and temporal trends (increase or decrease) in symptoms over the course of the recall period. Temporal trends in elbow function can, for example, be expected to occur over 4 weeks in patients recovering from an injury or surgery. The purpose of this study was to evaluate the measurement properties of the OES using a shortened, 7-day, recall period (OES-7d).

Introduction Fractures of the distal ulna, excluding the styloid, are rare. The cause of injury is often a fall on an outstretched hand with an extended wrist, and in most cases there is a concomitant distal radius fracture. The aims of this retrospective study were to investigate the results of the current treatment of distal ulna fractures in adults, with or without a concomitant distal radius fracture, and if a recently presented fracture classification could predict outcome. Materials and methods Patients, 18 years or older, treated for a fracture of the distal third of ulna in our county, were included. Fractures of the styloid tip were excluded. The radiographs of the fractures were independently classified by two specialists in radiology according to the 2018 AO/OTA classification. Follow-up was performed 5-7 years after the injury, through the questionnaire Patient-Rated Wrist Evaluation (PRWE) and new radiographs of both wrists. Results Ninety-six patients with 97 fractures were included and filled out the PRWE. 65 patients also had new radiographs taken. 79 patients were women and the mean age at the time of injury was 63 years (SD 14.5). The most common fracture class was the extra-articular transverse fracture, 2U3A2.3 (42%). We found that 40% of the fractures had been treated by internal fixation and only 2 fractures had not healed, one conservatively treated and one operated. The median PRWE was 15 (IQR 33.5). The PRWE score was significantly worse in the operated ulna fractures (p = 0.01) and this was also true for extra-articular transverse fractures 2U3A2.3 (p = 0.001). Initial displacement was more common in operated transverse fractures, but it could not be proven that this was the reason for the inferior result. Conclusions Distal ulna fractures almost always unite and the result is comparable to that of isolated distal radius fractures when measured by PRWE. Based on the opinions of the radiologists and how often a consensus discussion was needed for classification, we found the updated AO classification system difficult to use, if dependent only on standard radiographic views. In the present study, transverse extra-articular ulna fractures did not benefit from internal fixation regardless if associated with a distal radius fracture or isolated.

Background and purpose - Fractures of the distal ulna can occur in isolation or in conjunction with a distal radius fracture. They may result in incongruence and instability of the distal radioulnar joint. We investigated the incidence of distal ulna fractures, whether any fracture types were more common, and the methods of treatment used. Patients and methods - Data were collected from patients 18 years or older, treated for a fracture of the distal ulna in ostergotland, Sweden, during 2010-2012. Patients were identified in the patient registry. The fractures were classified according to the AO comprehensive classification of fractures. Results - The incidence of distal ulna fractures was 74/100,000 person-years. The most common fracture type was that of the ulnar styloid Q1 (79%), followed by the ulnar neck Q2 (11%). Rarest was ulna head fracture, type Q4 (1%). Incidental findings were a mean age of 63 years (SD 18), a concomitant distal radius fracture in 92% of the patients and that 79% were caused by falling from standing height. Internal fixation was performed in 30% of the Q2-Q6 fractures. This indicates that most were considered stable without internal fixation or stable after fixation of a concomitant radius fracture. Interpretation - Our results show that fractures of the distal ulna are not very common, and some fracture types are even rare. There seem to be no consensus on treatment.

Background and purpose - Classification of fractures can be valuable for research purposes but also in clinical work. Especially with rare fractures, such as distal ulna fractures, a treatment algorithm based on a classification can be helpful. We compared 3 different classification systems of distal ulna fractures and investigated their reliability and reproducibility. Patients and methods - patients with 97 fractures of the distal ulna, excluding the ulnar styloid, were included. All fractures were independently classified by 3 observers according to the classification by Biyani, AO/OTA 2007, and AO/OTA 2018. The classification process was repeated after a minimum of 3 weeks. We used Kappa value analysis to determine inter- and intra-rater agreement.

Results - The inter-rater agreement of the AO/OTA 2007 classification was judged as fair,. 0.40, whereas the agreement of AO/OTA 2018 and Biyani was moderate at. 0.42 and 0.43 respectively. The intra-rater agreement was judged as moderate for all classifications. Interpretation - The differences between the classifications were small and the overall impression was that neither of them was good enough to be of substantial clinical value. The Biyani classification, being developed specifically for distal ulna fractures, was the easiest and most fitting for the fracture patterns seen in our material, but lacking options for fractures of the distal diaphysis. Standard radiographs were considered insufficient for an accurate classification. A better radiographic method combined with a revised classification might improve accuracy, reliability, and reproducibility.

Background: Despite new 3-dimensional imaging modalities, 2-dimensional fluoroscopy remains the standard intraoperative imaging modality. The elbow has complex anatomy, and defined standard fluoroscopic projections are lacking. Therefore, the aim of this study was to define standard projections of the elbow for intraoperative fluoroscopy. Methods: This study consisted of 2 parts. In part I, dissected cadaveric elbows were examined under fluoroscopy, and their radiographic anatomical features were assessed, with focus on projections showing defined anatomical landmarks. In part II, projections from part I were verified on entire cadavers to simulate intraoperative imaging. Standard projections for anteroposterior (AP) and lateral views as well as oblique and axial views were recorded. Results: Eight standardized projections could be defined and included 3 AP, 1 lateral, 2 oblique, and 2 axial views. By applying these specific projections, we could visualize the epicondyles, the trochlea with its medial and lateral borders, the capitellum, the olecranon, the greater sigmoid notch, the coronoid process including its anteromedial facet, the proximal radioulnar joint with the radial tuberosity, and the anterior and posterior joint lines of the distal part of the humerus. These standard projections were reliably obtained using a specific sequence. Conclusions: Knowledge about radiographic anatomy and standard projections is essential for visualizing important landmarks. With the presented standard projections of the elbow, important anatomical landmarks can be clearly examined. Thus, fluoroscopic visualization of anatomical fracture reduction and correct implant placement should be facilitated. Clinical Relevance: This basic science cadaveric study defines fluoroscopic standard projections of the elbow essential for visualization of anatomical landmarks during surgery. 

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5 degrees (0 degrees to 60 degrees) and mean flexion was 126.8 degrees (90 degrees to 145 degrees) giving a mean arc of 105.5 degrees (60 degrees to 145 degrees). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Fractures of the greater tuberosity comprise 14-15 percent of all proximal humeral fractures according to the Swedish National Fracture database. This fracture type can lead to prolonged pain and functional impairment if treated suboptimally. The purpose of this article is to describe the anatomy and the injury mechanisms, summarize present literature and guide through the diagnosis and treatment of this fracture. The literature that addresses this injury is limited and treatment consensus is not clearly defined. This fracture can occur isolated as well as associated with glenohumeral dislocations, rotator cuff ruptures and humeral neck fractures. In some cases diagnosis may be difficult. Patients with pain out of proportion despite normal X-ray should be further assessed both clinically and radiologically. Missed fractures can lead to long term pain and functional impairment, especially among young overhead athletes. It is consequently important to identify such injuries, understand the pathomechanics and adapt the treatment based on the patient's activity level and functional needs.

Background: The DASH 7 is a recently published activity-related 7-item short form of the disability of the arm, shoulder, and hand (DASH) questionnaire developed to assess shoulder function in patients with subacromial pain. Before implementation in both intervention studies and in clinical practice, it is essential to evaluate its responsiveness. The objective of this study was to determine the minimal important change (MIC) in the DASH 7 questionnaire for patients with subacromial pain after a 3 months exercise intervention in a primary care context.

Methods: In this psychometric study the anchor-based MIC-distribution method was used to establish the MIC. The Patient Global Impression of Change (PGIC) was used as external criterion. Data from a clinical implementation study, aimed to implement a specific exercise strategy for patients with subacromial pain among physiotherapists in primary care, were used. Data from 70 patients were included in the analyses.

Results: The correlation coefficient between Patient Global Impression of Change and the DASH 7 score change was 0.67 and the area under the curve was 0.94 (95% confidence interval: 0.88-1.0). The MIC_ROC for improvement was detected at a mean change in 6.5 points with the sensitivity at 0.98 (98%) and the specificity at 0.78 (78%), and the MIC_{95% limit} for improvement was detected at a mean change of 25.7 points. There were 77% of the patients who reached at least this MIC_ROC and 51% who reached at least the MIC_{95% limit} after 3 months of exercise intervention_.

Conclusion: The DASH 7 is responsive to change over time and can discriminate between patients considered to be improved and patients considered not improved. These MIC values for patients with subacromial pain in the primary care setting can be used in clinical practice and in intervention studies as an indication on the patients clinically important level of score change for improvement.

Background Subacromial pain is a common cause of shoulder dysfunction that negatively affects quality of life. Currently, most outcome measures for shoulder pain are applied to a heterogeneous group of patients. Of these measures, the Disabilities of the Arm, Shoulder, and Hand (DASH) is the most widely recognized test with which to assess patients with subacromial pain. The primary aim of this study was to assess the content validity of DASH for patients with subacromial pain, with a secondary aim to test responsiveness to a modified set of DASH items tailored to these patients. Methods There were 129 patients who reported activities in the Patient-Specific Functional Scale (PSFS). To assess validity, 5 independent physiotherapists matched PSFS activities to the most appropriate DASH item. DASH items identified as being of greatest importance to patients were those corresponding to the highest number of PSFS-matched activities. Calculations were made for responsiveness and internal consistency. Results Physiotherapists matched DASH items to 271 PSFS activities, reaching agreement for almost 80%. Seven DASH items (DASH 7) were identified as being particularly important. Effect size data (Cohen's d) were 0.93 for DASH 7, 0.92 for DASH 30, and 0.85 for QuickDASH; the corresponding Cronbach's α values (for DASH 7, DASH 30, and QuickDASH) were 0.84, 0.94, and 0.86, respectively. Conclusions DASH 7 is a short, patient-centered, and activity-related scale that can measure shoulder function in patients with subacromial pain using a quarter of the original DASH items. DASH 7 demonstrated responsiveness, with a satisfactory level of internal consistency.

Objective: The primary aim was to describe the variability within clinical presentation of patients with subacromial pain in primary care, secondly to investigate associations between clinical presentation and self-reported pain intensity, shoulder function, level of anxiety and depression, and health-related quality of life. Design and setting A cross-sectional study based on data from two clinical studies in primary care, one randomized controlled trial and one implementation study. Three components: active range of motion (AROM), rotator cuff function and scapular kinematics were analyzed to describe variability within clinical presentation and patient-reported measurements were used to investigate the impact on daily life. Participants Patients aged 30-67 years, describing pain for more than two weeks, and positive signs for a minimum of three out of the following five clinical tests: impingement sign according to Neer, impingement test according to Hawkins-Kennedy, Pattes maneuver, Jobe’s test, and painful arc. Results Among the 164 patients included, 24% displayed dysfunction in one, 50% two and 24% in all three components. Limited AROM was seen in 46%, rotator cuff dysfunction in 91% and scapular dyskinesia in 57% of the patients. Conclusions These results reveal a heterogeneity among primary care patients with subacromial pain confirming a large variability regarding the components AROM, rotator cuff function and scapular kinematics. All three components appear unique (not significantly correlated) where a rotator cuff dysfunction is very frequent while limited AROM and scapular dyskinesia are more inconsistent. There are significant, but rather weak, associations between clinical presentation and impact on daily life.

A consecutive series of 181 patients with clinical signs of subacromial impingement underwent arthroscopic subacromial decompression (ASD). All patients had the same surgical procedure, and all pathological findings at the arthroscopy were recorded. Ten to 13 years (mean, 11.2) after the procedure, 162 patients (91%) were available for follow-up consisting of clinical examination and the Constant-Murley and DASH scores. The overall mean value of the age correlated Constant score was 77 points. Men had significantly better Constant score than women. The state of the rotator cuff at the index procedure was found to affect the outcome significantly. Patients with isolated full-thickness supraspinatus tears had the best results, followed by those with partial tears, intact cuffs, or large tears involving more than 1 tendon. ASD in the treatment of subacromial impingement yields good long-term results. Small full-thickness supraspinatus tears had the best results, indicating that the ASD might prevent further cuff deterioration and that repair of these lesions may be unnecessary. © 2008 Journal of Shoulder and Elbow Surgery Board of Trustees.

Background and purpose - Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure. Patients and methods - We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing. Results - Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04). Interpretation - When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

Background and purpose: Mechanisms of injury to ulnar sided ligaments, stabilizing the distal radioulnar joint and the ulna to the carpus, associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods: Fresh frozen human cadaver arms were used. A dorsal open wedge osteotomy was made in the distal radius. In 8 specimens pressure was applied to the palm with the wrist in dorsiflexion and ulnar sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 more specimens the triangular fibrocartilage complex was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results: Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16-34^o). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6/8 specimens.

Interpretation: A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.

Aim: To evaluate the outcome of using tricalcium phosphate (TCP) as void filler and structural support in corrective opening-wedge osteotomy of the distal radius.

Methods: A consecutive series of 17 patients with malunited dorsally angulated distal radius fracture postoperatively with DASH at 6 months with radiography at 8-12 weeks and 0.5-3.5 years.

Results: Mean DASH score improved from 52 (S.D. 22) preoperatively to 30 (S.D. 22) postoperatively. There was one non-union. There was also a mean loss of radial length of 1.1 mm (S.D. 1.0 mm) between the first postoperative radiograph and final follow-up. Radiolucent zones were observed around the TCP grafts after 6-8 weeks in 10/14 cases, but could not be statistically correlated with the slight loss of reduction.

Conclusions: TCP seems to be an alternative to iliac crest bone grafting in corrective osteotomies of the distal radius. The shortening observed over time may be attributable to inflammation induced by the TCP.