Postersession III

Anders Ploug Boesen, Kasper Dideriksen, Peter Schjerling, Christian Couppe, Michael Kjaer, Henning Langberg
Deptartment Ortopaedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, Faculty ; Department of Public Health, Faculty of Health and Medical Sciences , CopenRehab, University of Copenhagen, Denmark

Background: Counteracting the loss of muscle and tendon function during periods of immobilization and recovery of this during rehabilitation represents a challenge in clinical medicine
Purpose / Aim of Study: The aim of the study was to examine the effect of growth hormone (GH) on connective tissue of tendon and skeletal muscle during immobilization and retraining in humans
Materials and Methods: Young men (20-30 years; n=20) were randomly assigned to daily recombinant GH (rhGH) (33-50µg/kg/d) or placebo (Plc), and had one leg immobilized for two weeks followed by six weeks of strength training. Cross sectional area (CSA), maximal isometric muscle strength (MVC) and biomechanical properties of m.quadriceps and patellar tendon were determined. Muscle and tendon biopsies were analysed for mRNA of collagen (COL 1A1/3A1), insulin-like growth factors (IGF-1Ea/Ec) and lysyloxidase (LOX).
Findings / Results: In skeletal muscle the CSA and MVC declined with immobilization, and recovered with rehabilitation similar in both groups. Likewise, both groups increased in IGF-1Ea/Ec and COL 1A1/3A1 expression in muscle during retraining after immobilization compared to baseline, and the rise was more pronounced when subjects received rhGH (p<0.05). The tendon CSA did not change during immobilization, but increased in both groups during six weeks of rehabilitation (GH: +17%, Plc: +11, p<0.05). A decline in tendon stiffness after immobilization was observed only in Plc (p<0.05), and an increase during six weeks rehabilitation was observed only in GH (p<0.05). IGF- 1Ea and COL 1A1/3A1 mRNA increased with immobilization in the GH group only (p<0.05), and LOX mRNA was after immobilization higher in the GH group vs. Plc (p<0.05).
Conclusions: In conclusion, GH stimulates collagen expression in both skeletal muscle and tendon and abolishes the normal inactivity related decline in tendon stiffness and in tendon LOX, and results in an increased tendon CSA and stiffness during rehabilitation. GH has a matrix stabilizing effect during periods with inactivity and rehabilitation in humans.

Inger Mechlenburg, Thomas Klebe, Kaj Døssing, Kjeld Søballe, Maiken Stilling
Orthopaedic Research, Aarhus University Hospital; Orthopaedic Department, Regional Hospital Silkeborg

Background: Humeral head resurfacing implants (HHRI) are used to preserve bone stock and restore normal anatomy in the osteoarthritic shoulder joint.
Purpose / Aim of Study: To examine the clinical results, implant migration and bone density changes in proximity of the Copeland (Biomet Inc.) and the Global C.A.P. (DePuy Int) HHRI.
Materials and Methods: 31 patients (12 females) mean age of 63 (39-82) years with shoulder osteoarthritis were randomly allocated to a Copeland (n=13) or Global C.A.P. implant (n=18). Post-op, 6, 12, 24 weeks 1 and 2 years migration of the implants was measured with radiostereometry (RSA). Bone mineral density (BMD) was measured with DXA. Pre-op, 3,6,12 and 24 months Constant Shoulder Score (CSS) and Western Ontario Osteoarthritis of the Shoulder Index (WOOS) were recorded.
Findings / Results: 2 patients were lost to follow-up and 5 implants were revised (3 Copeland, 2 Global C.A.P.) At 2 years total translation (TT) was 0.60mm (SD 0.41) for the Copeland and 1.01mm (SD 0.66) for the Global C.A.P. (p=0.18). Between 1 and 2 years TT for the Global C.A.P. increased (p=0.02) whereas the Copeland HHRI had no significant migration (p=0.15). At 6 months BMD had decreased from 0.59 to 0.42 g/cm2 (p=0.01) around the Copeland implant and from 0.44 to 0.37 g/cm2 (p=0.21) around the Global C.A.P. No differences between groups. Copeland: CSS increased from 57, 61, 71, 72, 77 and WOOS improved from 939, 645, 296, 295, 113. Global C.A.P: CSS increased from 35, 51, 65, 73, 73 and WOSS improved from 1088, 568, 383, 381, 300. Both groups improved significantly over time (p<0.01) with no differences between the groups.
Conclusions: No difference in TT between the groups. Bone was lost in proximity of both implants. Patient-assessed scores improved comparably in both Groups.

Thomas Falstie-Jensen, Janne Ovesen, Viggo S. Johannsen
Orthopaedic, Aarhus University Hospital

Background: During the recent years proprionibacterium acne is reported to be an common pathogen in shoulder surgery. We reviewed our revisions to judge if any change in diagnostic approach was needed
Purpose / Aim of Study: The aim of the study was to retrospectively evaluate the prevalence of positive cultures obtained at revision shoulder arthroplasty.
Materials and Methods: From January 2009 to December 2012 we revised 104 shoulder arthroplasties because of pain, stiffness and functional limitations. In 69 patients biopsies were cultured either because of suspected deep infection or as a routine precaution. All results from cultures and preoperative blood samples were recorded.
Findings / Results: Cultures were positive in 31 out of the 69 sample sets. The most frequent pathogen was Proprionibacterium Acnes, which was identified in 19 of the 31sets. In the remaining cultures a variety of pathogens were found, primarily of low virulence The main symptoms for patients with positive cultures especially of the Proprionibacterium subgroup were pain and stiffness and very rarely the classical signs of infection. Blood samples displayed normal CPR, ESR and leucocyte counts in many cases During revision surgery membrane formation around the prosthetic components, severe stiffness, cloudy fluid and osteolysis were associated with an increased likelihood of infection.
Conclusions: Proprionibacterium Acnes is a very common pathogen in revision shoulder arthroplasty and should be suspected in painful and stiff shoulders. Suspicion of deep infection is of clinical importance in decision making regarding prosthesis retention or removal and close collaboration with a microbiology department is important in detecting and treating these infections. . Selection of appropriate antibiotics treatment should take into consideration that propionibacteriae are among the most common pathogens.

Kajsa Lindberg, Joanne Boelskifte, Jimmy Johansson, Mie Rinaldo, Morten Tange Kristensen
Rehabilitation Center Vanløse, Community of Copenhagen; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical Therapy and, Copenhagen University Hospital Hvidovre

Background: Subjects surviving a major lower limb amputation (LLA) are quite often provided with prosthesis for optimised function in daily life, but there is a lack of knowledge about the effect of rehabilitation programs, as to which tests to be used to show progress.
Purpose / Aim of Study: To examine construct validity and internal responsiveness of performance-based measures of functional mobility and endurance after LLA.
Materials and Methods: Eighteen subjects with a recent below knee amputation (BKA), and 15 with an above knee amputation (AKA), 6 women and 27 men with a mean age of 63.6 (SD, 12.4). All subjects followed a rehabilitation program (twice weekly), focused at improving balance, strength and prosthetic function, and performed the Timed Up and Go (TUG), the 10 meter fast speed walking test (10MWT) and 2 minute walking test (2MWT) at baseline and at end of the program. Pearson´s r assessed construct validity, while internal responsiveness was assessed by calculating the effect size I (ESI) as the mean change in performance scores / by the baseline SD, and effect size II (ESII) as the mean change in scores / by the SD of changes.
Findings / Results: The three outcome measures were highly correlated (r>0.66, P<0.001) after the program, while effect size was high to medium; 10MWT (ESI 1.03, ESII 1.06), 2MWT (ESI 1.0, ESII 1.15) and TUG (ESI 0.63, ESII 0.94). Performances improved from 39-99% and subjects with a BKA performed all tests significantly faster (P=0.01) than those with an AKA. Eleven subjects walked 1.0 m/s or faster at end of training.
Conclusions: Construct validity and internal responsiveness of the three measures were high, and is recommended be used by other centres. Still, only one third walked faster than 1m/s, supporting the need for studies examining the effect of e.g. progressive strength training for improvements.

Taj Haubuf, Klaus Kjær Petersen , Kurt Fuursted, Alex Lund Laursen, Johnny Keller
Orthopedic, Aarhus University Hospital; Microbiology, Aarhus University Hospital; Infectious Disease , Aarhus University Hospital

Background: Symmetrical Peripheral Gangrene - SPG (also known as Purpura Fulminans) caused by Streptococcus pneumonia (SP) is an uncommon, though very severe and potential lethal complication to septicemia.
Purpose / Aim of Study: To describe our experience with patients with SPG.
Materials and Methods: Between 2003 and 2013 eleven patients SPG due to SP where treated at Aarhus University Hospital. Patient’s files were retrospectively studied regarding clinical status, predispositions, multi-organ involvement, days of admission, surgical treatment and prostheses status.
Findings / Results: Eleven patients, median age 55 years (range 38-71 years) admitted with septicemia developed SPG. Four patients had earlier undergone splenectomy and one patient had no spleen, due to SLE. Six were smokers and only one patient had no obvious predisposing conditions. SP sensitive to penicillin was found in blood samples in all patients. All had purpura and eight had skin necrosis of lips and nose. All patients received high doses of penicillin and intensive care, three patients died during hospitalization, one prior to surgical intervention. Ten patients required extensive surgical intervention resulting in four humeral-, four antebrachium-, 28 digits and hand- , four femoral-, three through knee-, eleven crural and one toe amputations. Nine patients underwent dialysis and seven received vasopressors. Median time from onset of symptoms to amputation was 21,7 days (range 5- 100 days). After a protracted rehabilitation period six patients were mobilized on bilateral leg prostheses. One patient became wheelchair bound.
Conclusions: Symmetrical Peripheral gangrene is a serious complication to Streptococcus pneumonia septicaemia with at high mortality- and complication rate with risk of extensive amputations, resulting in long admissions and loss of daily functions.

Damgaard Jacob , Hauge Hansen Bjarne , Holmberg Jørgensen Peter , Keller Johnny, Hellfritzch Michel , Baad-Hansen Thomas
Center for Bone and Soft Tissue Sarcomas, Aarhus University Hospital, Denmark; Dept. of Radiology, Aarhus University Hospital, Denmark

Background: Surgical biopsies have until recently been the preferred method for diagnosis of tumors arising form peripheral nerve tissue. Ultrasound guided core needle biopsy (UGCNB) has within the last few years been introduced in diagnosis of these tumours. Fewer complications, less unpleasantness for the patients, faster recovery, and quicker diagnostic work-up have been reported.
Purpose / Aim of Study: The aims of the study were to identify causes of UGCNB complications, to evaluate diagnostic strength of UGCNB in terms of grading between benign and malignant specimens, and finally, to describe time consumption using this diagnostic method.
Materials and Methods: We retrospectively reviewed 69 patients who underwent UGCNB between January 2004 and December 2012. Complications due to the procedure were assessed. Sensitivity, specificity; positive predictive value (PPV) and negative predictive value (NPV) were calculated based on the current dataset. Furthermore, time from referral to final diagnosis was calculated.
Findings / Results: A single patient described mild pain after the procedure, which resolved after 2 days. No permanent injuries were reported. In 82% of the cases, UGCNB was able to distinguish between malignant and benign material. Sensitivity was 0.8, specificity was 1.0, PPV was 1.0, and NPV was 0.97. Mean time from referral to UGCNB was 7 days (range 0-43 days). Mean time from UGCNB until the final diagnosis was 7 days (range 1-21 days).
Conclusions: UGCNB of PNST is a safe method. However, UGCNB cannot stand alone in the clinical work-up due to the risk of false negative results. The results shows, that time from referral to decision of treatment is acceptable and in accordance with the National Danish Cancer Patient Pathway for soft tissue sarcomas.

Elinborg Mortensen, Thea Hovgaard, Michael Mørk Petersen
Department of Orthopaedic Surgery, Rigshospitalet, Denmark

Background: Surgical treatment of desmoid fibromatosis is still the standard treatment but oncologic treatment with medicine or radiation therapy is increasingly applied.
Purpose / Aim of Study: To determine the local recurrence rate among surgically excised desmoid fibromatosis.
Materials and Methods: We retrospectively assessed all tumours (34 patients (F/M = 25/9, mean age 38 (12 – 67) years)) of the extremities, spine and trunk wall (abdominal wall/ other locations=13/21) with the histology desmoid fibromatosis surgically excised at our clinic between 1995 and 2005. Patients primarily operated on in other clinics or operated on for a local recurrence were excluded. Data were extracted from the patient files and from the Danish National Pathology Registry (DNPR). Statistics: Data are presented as mean (range). Kaplan Meir survival analysis.
Findings / Results: Mean tumor size was 6.1 (2-15) cm and the surgical margins obtained were: wide (n=28), intralesional (n=3) or inconclusive (n=3). 7 patients had a local recurrence 21.5 (5-51) months after initial tumour excision (mean DNPR follow-up for patients without recurrences was 119 (96-220) months) corresponding to a probability of 5-year local recurrence free survival of 79%. Local recurrences were seen in 6 patients with wide margin and 1 patient with intralesional margin. The majority of local recurrences were seen in patients with tumours of the extremities and paraspinal location (n=5) and 2 abdominal wall tumour recurred.
Conclusions: Overall the treatment seemed reasonable with a 79% probability avoiding local recurrences after 5 years. The recurrences did not seem to depend on the surgical margin, thus a less aggressive approach not always aiming at wide tumour resection could be considered.

Peter Horstmann, Werner Hettwer, Tomas Grum-Schwensen, Michael Mørk Petersen
Department of Orthopaedic Surgery, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denma

Background: Persistent post-operative wound drainage is associated with an increased incidence of periprosthetic infection and occurs in about 4% of conventional total hip arthroplasties. Similar data is not available for endoprosthetic reconstruction of the proximal femur after tumor resection.
Purpose / Aim of Study: To determine the duration of postoperative surgical wound drainage, administration of antibiotics and date of discharge, and to establish if a change in the wound closure routine could improve these variables.
Materials and Methods: We performed a retrospective review of all adult patients (n=41, mean age = 63 (37-86) years) who received a proximal femoral tumor arthroplasty in our department in 2012 and collected similar data prospectively from 2013 (n=5, mean age = 72 (54-86) years), where routine wound closure with staples was substituted with intradermal suture, application of Steristrips and an occlusive skin adhesive (Liquiband Flex).
Findings / Results: In 2012 mean duration of post operative wound drainage was 8 (2-45) days, mean duration of administration of postoperative antibiotics was 8.2 (1-45) days and mean hospital stay was 9.4 (3-45) days. Nineteen (45%) had prolonged wound drainage (7 days or longer). The preliminary first 5 patients, who underwent skin closure with a skin adhesive, all had dry wounds at the first scheduled post operative dressing change (mean 2.9 (2-4) days), mean duration of post operative administration of antibiotics was reduced to 3.6 (2-7) days and mean hospital stay was reduced to mean 6.5 (3-10) days.
Conclusions: Our small sample showed a high prevalence of prolonged drainage from the surgical site. A simple change in the wound closure routine appears to show a promising reduction in wound drainage, postoperative antibiotic administration, and hospital stay. Further studies are warranted.

Ture Karbo, Stig Sonne-Holm, Christian Wong
Pediatric orthopaedic section, Hvidovre University Hospital

Background: Fractures of the lower arm in children are the most common, comprising about 40% of all pediatric fractures. Generally there is consensus regarding treatment, but the displaced distal dia-metaphyseal fractures (DDMF) are there no apparent adequate surgical option. A new type of combined internal elastic nail and external fiksation (MIROS@) was applied in 10 patients compared with 10, age and fracture type matched, children.
Purpose / Aim of Study: To compare MIROS@ to the conventional osteosynthesis methods in treatment of children with DDMF of the antebrachium.
Materials and Methods: The prospective case-control study including 20 children, age 4-15, operated on with standard treatment - with elastic nails / Kirschner wires or MIROS@ for DDMF. Follow-up at 3 month after removal of osteosynthesis material including x-rays of both antebrachii, systematic testing of bilateral range of motion, visual analogue pain scale and strength measurements.
Findings / Results: There were minor differences in clinical and radiological outcome after 3 month follow up. Operating for insertion and removal time of the MIROS was faster with a smaller surgical incision. All Miros@ had a plaster-cast-free aftercare.
Conclusions: MIROS@ is as good as conventional osteosynthesis methods at 3 month follow- up, though having advantages – faster operating time, less surgical scaring, faster removal, no plaster cast and early movement of elbow-/wrist-joints. However, prospective randomized trials should be performed.

Line Kjeldgaard Pedersen, Ahmed Abdul-Hussein Abood, Ole Rahbek, Bjarne Møller-Madsen
Department of Children’s Orthopedics, Aarhus University Hospital

Background: Measurement of seating balance is a promising method for analysis and evaluation of children’s seating balance in relation to orthopedic conditions such as hip dislocation and scoliosis. Furthermore seating balance can be used to evaluate postural control in children with neurodevelopmental diseases such as Cerebral Palsy.
Purpose / Aim of Study: To develop a normal distribution of seating balance in healthy Danish Children for comparison with children with orthopedic disorders.
Materials and Methods: Sixty-six children aged 7-14 years from the 1th, 3 th, 5th and 7th levels were included at a Danish primary school after informed consent were obtained. Tekscan CONFORMat Research was used and the measurements of seating position were analyzed with the Tekscan Sway Analysis Module. Three consecutive measurements of both normal seating and seating in up-right position were used to calculate the average result for each of the 5 parameters of balance. The percentage of pressure distribution on the left and right side were calculated.
Findings / Results: Data were stratified according to age, weight and height. For the 1th level (n=15) two of five parameters for balance showed improvement in the up-right position (p˂0,0003, p˂0,013) and primarily for females. Furthermore a significant correlation was found between seated balance and both height and weight. Statistical analysis with STATA 11 was used, and Spearman correlation and students t- test was calculated.
Conclusions: We measured the effect of BMI, age, gender and back position on seating balance and have established a normal distribution for seating balance in healthy Danish children. This normal distribution can be used as reference data for comparison of seating balance in children with orthopedic disorders in a clinical setting.

Lauge Østergaard, Gert Rahbek Andersen
Orthopedic Department U, Rigshospitalet

Background: Crouch gait among CP patients are caused by hip and knee flexion contractures. Crouch gait can be treated by lengthening of the hamstrings. Hamstring lengthening is usually done by open surgery.
Purpose / Aim of Study: This study examines whether there is any statistical significant difference between making hamstring lengthening by open surgery or by hypodermic needle tenotomy.
Materials and Methods: Data were collected retrospectively by looking through medical records. 59 patients (93 limbs) were included in this study and all the patients had undergone hamstring lengthening. The population was subdivided into two groups. Group 1 (44 patients, 65 limbs) had their hamstring lengthened by tenotomy with a hypodermic needle. Group 2 (15 patients, 28 limbs) had their hamstring lengthened by open surgical procedure.
Findings / Results: Of the 44 patients in group 1 there was one adverse effect. This patient had pain postoperatively in the lateral hamstring on the operated leg. Of the 15 patients in group 2 there was one adverse effect as well. This patient experienced pain around the area of the ischiadic tubercle. In group 1 there was one relapse in the follow up period and in four situations the surgical procedure had no effect. In group 2 there was no effect of the surgical procedure in two cases.
Conclusions: There was no statistical significant difference (0,5>p>0,25) between the rate of complications in the two groups. Furthermore there was no statistical difference on the missing effect or relapse of the surgical procedure between the two groups. Hamstring lenthening by hypodermic nedle tenotomy is safe and outcome is comparable to open surgery; is easy to perform in supine position and thus offers perioperative evaluation of the effectiveness of the lenthening.