To Örebro University

The 'terrible triad' injury of the elbow is defined as a dislocation of the elbow with concomitant fractures of the radial head and coronoid process. The term was based on reports of poor outcomes following this pattern of injury. However, the 'terrible triad' concept has meant that some very complex elbow fracture-dislocations are considered alongside more benign injuries, leading to problems with our understanding and interpretation of the literature. This annotation explores how our knowledge of elbow stability has evolved, and how the importance of the coronoid to this is becoming increasingly clear. It suggests how we best define, classify, and manage fractures of the coronoid as part of these complex injuries.

Arthroscopy has evolved significantly with advancements in instrumentation and surgical techniques. The introduction of needle arthroscopy represents a promising minimally invasive alternative and, has for the wrist proven to offer a reduced soft tissue trauma with still maintained diagnostic and therapeutic efficacy. The purpose of this study was to evaluate the safety and visualization capabilities of needle arthroscopy of the elbow using cadaveric specimens. Six fresh-frozen cadaveric elbows (three right, three left) were examined using a needle arthroscope, followed by dissection to assess portal safety and proximity to neurovascular structures. The arthroscopic portals evaluated included the proximal anteromedial (PAMP), anteromedial (AMP), mid-anterolateral (MALP), postero-lateral (PLP), direct lateral, and direct posterior portals. The visualization quality of the needle arthroscope was found satisfactory and the smaller diameter (1.9 mm), allowed enhanced maneuverability. Needle arthroscopy offers improved access and acceptable visualization, potential risks remain, particularly concerning neurovascular structures. Notably, the anteromedial portal was in close proximity to the median nerve and medial antebrachial cutaneous nerve (MABCN), with one documented case of PBMACN (Posterior Branch of the MA-BCN)injury. Our results support the use of the needle arthroscope for elbow arthroscopy. However, caution is required to minimize neurovascular injury. Further studies are needed to establish standardized protocols and confirm the long-term safety and efficacy of needle arthroscopy in clinical practice.

BACKGROUND AND PURPOSE: Periprosthetic joint infection (PJI) after elbow arthroplasty is a serious complication. Evidence of the best antibiotic prophylaxis for elbow arthroplasty is lacking. We aimed to investigate the regimens presently used in Sweden, incidence of PJI, and the bacteria most frequently found in elbow PJI.

METHODS: A questionnaire was sent out to all Swedish units performing elbow arthroplasty in 2019 asking about antibiotic prophylaxis routines. The Swedish Elbow Arthroplasty Register (SEAR) and national inpatient and outpatient registers (NPR) from the National Board of Health and Welfare were searched for procedures related to all primary total- or hemi-elbow arthroplasties performed during 2019-2021. Results of microbiological analyses of the suspected PJI cases were collected from the respective laboratory.

RESULTS: Most centers used only cloxacillin (44%) or cloxacillin together with benzylpenicillin (44%), as prophylaxis. 250 primary procedures were performed between 2019 and 2021, and the most used antibiotic prophylaxes were cloxacillin (61%) and cloxacillin with benzylpenicillin (23%). In the NPR, 20 patients (8%) with a diagnosis that could indicate PJI were found and 9 (3.6%) had a confirmed PJI. The most common bacteria were Staphylococcus epidermidis, Cutibacterium acnes, and Staphylococcus aureus.

CONCLUSION: Most centers used cloxacillin antibiotic prophylaxis for elbow arthroplasty. The incidence of PJI was 3.6%. The most frequent diagnosed pathogen was Staphylococcus epidermidis.

Background: Subacromial pain is a common and disabling condition with multifactorial etiology. Increasing evidence supports exercises as first-line treatment and need of surgery is debated. Long-term follow-ups after surgical-and nonsurgical treatment are scarce. The primary aim of the present study was to investigate the 10-year outcomes after a study comparing specific and nonspecific exercise treatment and the need for surgery. Secondarily we compared patients who had undergone exercise treatment, to those having surgery and explored the importance of rotator cuff status in relation to given treatment and outcomes.

Methods: At enrollment 2009-2010, 97 patients with long-standing subacromial pain were on the waiting list for arthroscopic subacromial decompression (ASD). They were randomized to specific exercises focusing on strengthening of the rotator cuff and scapula stabilizers (n = 51) or control: unloaded range of motion exercises (n = 46). ASD was optional during the entire observation time. Eligible patients from either group constitute the present 10-year cohort with nonoperated (n = 42) or operated (n = 41) patients. The primary outcome was shoulder function and pain after 10 years assessed by the Constant-Murley score (CMS). Secondary outcomes were proportion of patients choosing surgery and rotator cuff status related to treatment and primary outcome.

Results: At the 10-year follow-up, 83 of 97 patients (86%) participated. All patients significantly improved in CMS from baseline to 10-year follow-up, mean improvement of 37 (95% confidence interval 33-41, P <.0001). Nonoperated patients had significantly better CMS compared to operated with mean difference 11(95% confidence interval 4-18) (P = .003). Significantly more patients in the control exercise group 65% (26 of 40) had chosen surgery compared to 35% (15 of 43) in the specific exercise group up until 10 years (P = .006). At 10 years, 55% of the patients had a partial or full-thickness rotator cuff tear compared to 28% at baseline. There was no difference in tear progression between operated and nonoperated patients (P = .494). In the contralateral shoulder, 51% of the patients (39 of 76) had a cuff tear compared to 3% at baseline.

Conclusions: Specific exercise treatment for patients with subacromial pain was effective and reduced the need for surgery with maintained results after 10 years. Responders to exercise treatment had the best long-term outcomes and ASD yielded satisfying outcome in nonresponders. A rotator cuff tear was equally common in patients having undergone surgery as in those treated nonoperatively and in the contralateral shoulder.

INTRODUCTION: Quality registers are used for quality assessment, cost analyses, and research regarding outcomes of surgical and non-operative treatments. As the Swedish Fracture Register (SFR) expands, and is used as a platform for randomized trials, assuring reliability and accuracy of the data is essential. AIM: This study aimed to investigate the accuracy of the radiographic classification data for proximal humerus fractures recorded in the SFR.

METHOD: All radiographic images of 171 patients with a proximal humerus fracture registered in the SFR between 2019 and 03-01 and 2019-08-31 at 3 hospitals were included. The radiographs were independently assessed at 2 occasions >3 weeks apart by 1 surgeon at each center and IRR was calculated to validate the modification of the AO/OTA classification used in the register. A "gold standard" classification for each patients' images was then established with a consensus discussion involving 4 shoulder surgeons. The gold standard classification was compared with the classification registered in the SFR.

RESULTS: Intra-rater reliability was moderate (kappa 0.549-0.596) with percent agreement (PA) 61-66 %. Inter-rater reliability was also moderate (kappa 0.508-0.557) with PA 58-62 %. Accuracy of the SFR recordings compared with gold standard was fair with kappa 0.36 (95 % CI 0.297-0.425) and PA 44 %.

CONCLUSION: For registers to be of use the accuracy of data is essential as well as coverage, completeness, validity and reliability. The modified AO/OTA classification for proximal humerus fractures used in the SFR had moderate reliability but registered data only fair accuracy compared with a gold standard. This questions its value as a base for scientific research and clinical decisions.

The imprecise definition of terms used to describe pathological diagnosis in clinical medicine can lead to imprecise treatment concepts and inaccurate recording of outcomes. In this article, we explore the meaning of common terms applied to the pathology of the rotator cuff, and demonstrate how the imprecise use of words entails a risk of leading to a poor definition of the clinical condition being treated. We suggest improvements in the accuracy of the definition of what constitutes the rotator cuff. We suggest the use of 'defect' to describe the most common presentation of a degenerative lesion of the rotator cuff, rather than perpetuate the use of the term 'tear', which has a different, injurious aetiology. We suggest that the term 'repair' should be reserved for the condition in which an acutely injured tendon (with a 'tear') can be expected to heal, using the correct definition of the term 'to heal'. We recommend reserving the use of the term 'healed' for the condition of an acute lesion of the rotator cuff (a 'tear') to which the histological process of regenerating a near-normal enthesis can be reasonably applied. We further suggest that degenerative lesions ('defects') of the rotator cuff, which do not have the biological capacity to heal in the true sense when brought back to bone, should be described as having 'closure' of the defect.

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 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.

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.

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.