Session 10: Tumor/ Pediatrics

Fredag den 25. oktober
09:00 – 10:30
lokale: Stockholm/Copenhagen
Chairmen: Thomas Baad-Hansen / Bjarne Møller-Madsen

94. The Prevalence and Prognostic Impact of Comorbidity in Soft Tissue Sarcoma: A Population-Based Cohort Study
Katja Maretty-Nielsen, Ninna Aggerholm-Pedersen, Akmal Safwat, Steen Baerentzen, Alma Pedersen, Johnny Keller
Department of Experimental Clinical Oncology, Aarhus University Hospital; Department of Oncology, Aarhus University Hospital; Department of Pathology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital

Background: The incidence of soft tissue sarcoma increases with increasing age, and more elderly patients with comorbidity is expected in the future. Comorbidity is an important prognostic factor for survival in other cancers. The prevalence and significance of comorbidity has not yet been investigated in a larger population-based series of soft tissue sarcoma.
Purpose / Aim of Study: The aim of this study was to estimate the prevalence and impact of comorbidity on mortality in soft tissue sarcoma patients.
Materials and Methods: 1210 adult patients with soft tissue sarcoma in the extremities or trunk were identified through the Aarhus Sarcoma Registry, a validated population-based database. Comorbidity data was obtained through the National Patient Registry, and a Charlson Comorbidity score was calculated for each patient. The prevalence was assessed overall, as well as according to age and year of diagnosis. The prognostic impact of comorbidity on overall and disease- specific mortality was estimated uni- and multivariately using proportional hazard models.
Findings / Results: The overall comorbidity prevalence was 25%. The prevalence increased with increasing age, and patients with comorbidity had a larger proportion of adverse prognostic factors compared to patients without comorbidity. The 5-year disease-specific mortality was 26% (95% CI 24-29) for patients without comorbidity, compared to 33% (95% CI 24-42), 41% (95% CI 32-50), and 44% (95% CI 33-55) for patients with mild, moderate, and severe comorbidity, respectively. After adjusting for important prognostic factors, comorbidity was associated with increased overall and disease-specific mortality.
Conclusions: Patients with comorbidity had significantly increased overall and disease-specific mortality compared to patients without comorbidity, even when adjusting for known important prognostic factors.

95. Predictors for functional outcome and health related quality of life following limb sparing surgery for soft-tissue sarcomas
Casper Sæbye, Hanna Maria Fuglø, Tine Nymark, Akmal Safwat, Michael Mørk Petersen, Johnny Keller
Department of Experimental Clinical Oncology, Sarcoma Centre of Aarhus University Hospital; Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital; Department of Oncology, Sarcoma Centre of Aarhus University Hospital; Department of Orthopedic Surgery E5, Sarcoma Centre of Aarhus University Hospital

Background: Patient function can be conceptualized by different clinical aspects such as disability, impaired mobility and health status.
Purpose / Aim of Study: To identify tumour and patient related predictors (age, gender, depth, size, malignancy, comorbidity, location and radiotherapy) for functional outcome and quality of life after limb sparing surgery in sarcoma patients.
Materials and Methods: The study included 131 patients (mean age = 58, F/M = 57/74), that were treated with limb-sparring surgery without bone-resection for soft tissue sarcomas in 3 Danish sarcoma centers during the period 1/1-2009 to 31/12- 2011. Patients were asked to participate at least 1 year after surgery, and patients that had experienced local recurrence or metastatic disease were excluded. Functional disability was measured by the Toronto Extremity Salvage Score (TESS), and functional impairment by the Musculoskeletal Tumour Society Score (MSTS), and Quality of Life by EORTC QLQ-C30. A questionnaire was used to gather relevant data about physiotherapy. Statistics: Multivariate logistic regression analysis with calculation of odds ratio (OR).
Findings / Results: We found in the multivariate analysis that women, lower extremity tumours and radiotherapy had a significantly negative effect on TESS score (OR = 3.76, 9.49 and 4.50, respectively). However the predictors had no significant effect on the MSTS score and quality of life. There was a strong correlation between functional outcome and quality of life. Patients who had physiotherapy had a lower functional outcome compared to patients who did not receive physiotherapy, and there was no difference found in quality of life.
Conclusions: Female sex, lower extremity tumours, and radiotherapy were related to a low TESS score and there was a strong relation between functional outcome and quality of life.

96. Influence of the Extent of Surgery on Patient Survival after Total Joint Replacement because of Metastatic Bone Disease
Michala Skovlund Sørensen, Kristine Grubbe Gregersen, Hindsø Klaus, Petersen Michael Mørk
Ortopædkirurgisk afdeling, Rigshospitalet

Background: In patients with a pathological fracture or painful lesions because of metastatic bone disease (MDB) in the extremities various treatment modalities are available ranging from conservative treatment with radiation therapy over minimal invasive osteosynthesis to extensive bone resection and reconstruction with tumour prosthesis.
Purpose / Aim of Study: To evaluate if extent of surgery influence patient survival after total joint replacement because of MBD.
Materials and Methods: We included a consecutive series of patients (n=130, mean age 64(30-85) years, F/M=76/54) that received a joint replacement operation due to MBD (metastases/haematological disease =114/16) during the period January 2003 to December 2008. The cohort was followed until marts 29th 2011 or until death. The following data were registered: duration of operation, blood loss, bone resection performed (yes/no), age, gender, the American Society of Anaesthesiologists (ASA) score, and primary type of cancer (divided into 3 groups depending on median survival found in the present study). Statistics: Kaplan-Meier survival analysis with log-rank test and Cox proportional hazard regression analysis. P < 0.05 was considered statistical significant.
Findings / Results: The probability of patient survival was 51%, 39%, and, 29% after 6, 12 and 24 months respectively. Duration of surgery (mean 164 min; range 60 – 360 min), blood loss (mean 1273 ml; range 100 – 7000 ml), bone resection (yes/no=102/28) did not influence survival (p=0.83, p=0.39 and p=0.76 respectively) while ASA-score and cancer type was significant predictors for survival (p<0.01 for both variables).
Conclusions: Major surgery did not influence survival in patients treated with joint replacement surgery due to MBD. Survival was determined by co-morbidity and cancer type.

97. Local recurrence rate of Giant Cell Tumors of Bone
Peter Horstmann, Michael Mørk Petersen
Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Background: Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor and metastatic spread to the lungs is possible.
Purpose / Aim of Study: To determine the local recurrence rate of GCT of bone, the rate of lung metastases and the rate of malignant transformation.
Materials and Methods: Retrospective collection of data from patients with GCT of bone treated in our clinic from 1997 to 2012. Thirty- four patients (mean age 34 (14-68) years, F/M = 20/14) were included; 4 patients with GCT in the spine were excluded because treatment routines were significantly different to other anatomical locations. A high percentage (62%) of GCT’s was localized in close relation to the knee joint. Data were collected from patient files and the Danish National Pathology Registry (DNPR). Statistics: Data are presented as mean (range). Kaplan Meier Survival analysis.
Findings / Results: Intralesional curettage and bone grafting was performed primarily in 32 patients (94%) and wide resection in 2 patients (6%). Mean follow-up was 81 (11-194) months. Thirteen patients (38%) had local recurrence of GCT 16 (4-58) months postoperatively, and the 5-year recurrence free survival was 57%. Local recurrence was found in 1 case of wide excision. Five patients who primarily were treated with curettage were later treated with wide excision. Four patients needed more than one curettage after local recurrence. Malignant transformation where found in 1 case and that patient later developed lung metastases. No other lung metastases were found.
Conclusions: The choice of treating GCT’s with curettage seems reasonable in spite of a relatively high recurrence rate because lung metastases and malignant transformation is rare and complications related to wide excisions are avoided.

98. Adaptive bone remodeling of the femoral bone after tumor resection arthroplastry with an uncemented proximally hydroxyapatite coated GMRS stem.
Mikkel Rathsach Andersen, Michael Mørk Petersen
Department of Ortopaedics, Rigshospitalet; Derpartment of Ortopaedics, Rigshospitalet

Background: Loss of bone stock as a response to bone trauma, postoperative immobilisation and stress shielding often leads to pronounced bone loss of the affected bones after joint replacement surgery.
Purpose / Aim of Study: The aim of the present study was to investigate the adaptive bone remodelling of the femoral bone after implantation of a tumour prosthesis using an uncemented press fit stem.
Materials and Methods: We performed 1 year follow up of 6 patients (mean age 54,6 (26-78) years, F/M= 3/3) who underwent bone tumour resection surgery of the femur. Reconstruction were done using GMRS (Stryker) tumour prostheses, with a 125 mm uncemented press-fit titanium alloy stem, with hydroxyapatite (HA) coating of the proximal part of the stem. Measurements of bone mineral density (BMD) were done postoperatively and after 3, 6, and, 12 months. BMD was measured in 3 regions of interest (ROI) of the femur bone containing the GMRS. Statistics: non-parametric analysis of variance (Friedmann test) for evaluation of changes in BMD over time. P-values below 0.05 were considered significant.
Findings / Results: BMD decreased in all 3 ROI with time. In ROI 1(p=0.01) BMD was already decreased by 10% after 3 months and ended with a total decrease of 14% after 1 year. In ROI 2 (p=0.006) BMD was decreased by 6% after 3 and 6 months; after 1 year of follow-up BMD was 9% below the postoperative value. In ROI 3 (p=0.009) BMD was decreased by 6% after 3 and 6 months; after 1 year of follow-up BMD was 8% below the postoperative value.
Conclusions: A bone loss of 8-9% during the first postoperative year was seen of the bone along the femoral stem, but in the bone close to the resection surface containing the HA coated part of the stem the decrease in BMD was 14%, thus indicating that stress shielding of this part of the bone may play a role for the adaptive bone remodelling.

99. Through knee amputation associated with high risk of reamputation
Nikolaj Sode, Steen Vigh Buch, Troels Riis, Søren Kring, Annette Sylvest, Benn Duus
Department of Orthopedic Surgery, Bispebjerg Hospital

Background: Non-traumatic through knee amputation (TKA) is used when below knee amputation is not possible due to insufficient healing potential, or in order to avoid contractures. The patients are often frail and multimorbid. Recent studies show reamputation rates of 6-20% for TKA and 3-48% for above knee amputation (AKA).
Purpose / Aim of Study: The aim of this study is to review the reamputation rates for primary TKA or AKA and identify factors associated with risk of reamputation.
Materials and Methods: Patients who underwent a primary TKA or AKA at Bispebjerg Hospital, Copenhagen, in the period from February 2009 to February 2013 were included. 154 patients (82 male, 72 female) with 69 TKA and 85 AKA were identified. Mean age was 74.0 years (ST.D. ±11,3). P<0.05 was considered significant. Patient records, and blood results were reviewed retrospectively.
Findings / Results: Reamputation rate within 90 days (R90) of primary TKA were 34,8% with hazard ratio 3,80 (1,55-9,32 95% C.I.) compared to a R90 of 9,4% for primary AKA. Each increase in ASA classification level increased hazard ratio for R90 with 2,78 (1,34-5,79 95% C.I.) and a potassium level above 4,3 mmol/L increased hazard ratio for R90 with 3,30 (1,42-7,69 95% C.I.). We found no significant difference for sex, age, BMI, diabetes, prior vascular reconstruction or history of tobacco or alcohol use. For bloodsamples we found no significant difference for elevated levels of creatinine, leucocytes, CRP or low levels of hemoglobin or albumin.
Conclusions: In this study we found a high rate of reamputation after primary TKA and a low rate of reamputation for AKA, and therefore we will evaluate our treatment strategy for these patients. We found an increased risk of reamputation with each increase in ASA group, and with potassium levels within normal physiological range and above.

100. Clinical outcome after treatment of paediatric elbow fracture; a comparison of supracondylar, lateral condyl and medial epicondyl fractures; is physiotherapy mandatory as adjuvant treatment?
Pernille Bovbjerg, Zaid Al-Aubaidi
Orthopeadic, Odense University Hospital

Background: Fractures involving the distal humerus are very common in the paediatric population. The most frequently of those being: supracondylar (SC), lateral condyle (LC) and medial epicondyle fractures (ME).
Purpose / Aim of Study: To analyze the outcome after operative treatment and see the impact of adjuvant physiotherapy (Phys). We expected to find the worse range of motion (ROM) for ME because of the elbow dislocation.
Materials and Methods: The cohort was found at a single institution searching FPAS using ICD and treatment code in the years 2000- 2010.We compared ROM registered in the charts at the last post operative follow up. ROM was divided into 5 groups; 1: normal, 2: having defect in extension less than 10°, 3: having defect in extension and flexion less then 10°, 4: having extension or flexion more than 10° and 5: unknown. We chose to classify group 3 and 4 to be bad ROM.
Findings / Results: In total 221 patients; 158 SC, 35 MC and 28 LC. The mean age in years was 11[5-15] for ME, 7 [4-14] for SC and 7.8 [5-13] for LC. ROM was not registered in the medical charts for 17.5% of those who received Phys and for 23.9% who didn't. For ME there was no positive impact on ROM in patients who received phys, although 50% of the patients with elbow dislocation were sent to phys. For LC the ROM was worse for patients who received phys. For SC we found a better ROM for patients who did receive adjuvant phys. 34.5% of Gartland 3 were sent to phys while only 20% of Gartland 1 and 2. There was no difference in ROM between Gartland 1, 2 and 3.
Conclusions: Although ROM for a big part was not registered in the chart in our cohort, we could not conclude that physiotherapy has a positive impact on post-operative ROM. Further research is needed to illuminate the role of physiotherapy as a mandatory part of treatment in elbow fractures in the pediatric population.

101. Can the Ottawa Ankle Rules be applied in children with ankle injury? A prospective MRI study.
Mikael Hofsli, Trine Torfing, Zaid Al-Aubaidi
Department of Orthopedic Surgery, Odense University Hospital; Department of Radiology , Odense University Hospital

Background: Clinical evaluation of the paedaitric ankle injuries can be challenging. The validation of Ottawa Ankle Rules (OAR) for the paediatric patients could help in the decision making, whether radiographs should be obtained. To the best of our knowledge, there are no prospective studies utilizing magnetic resonance imaging (MRI) to verify OAR in children.
Purpose / Aim of Study: The aim of this study was to validate OAR in children by the use of MRI.
Materials and Methods: 391 with acute ankle trauma, from September 2012 to May 2013 at one institution. 37 patients suspected of ankle fracture were included and underwent an initial clinical examination with OAR and radiography. Patients were then referred for an MRI within few days. All images were reviewed and data were recorded prospectively. All patients were seen for a clinical follow-up and informed about the MRI results. The clinical data and the initial radiographs were blinded to the senior radiologist, whom interpreted the MRI.
Findings / Results: 37 (100%) met the criteria to obtain radiographs by OAR. 3 patients (8%) were excluded due to dropout and 3 (8%) had a fracture on the initial radiography. This resulted in a total of 31 patients referred to MRI without a fracture on initial radiography, 18 males and 13 females, mean age 10±2.86. The time between the injury and the initial radiological examination was 0.4±0.88 days and the MRI was obtained on an average of 6.9±2.87 days.1 patient (3.2%) had a bony flake fracture of the lateral malleolus verified on the MRI, making a total of 4 patients (10.8%) with fractures.
Conclusions: In this study OAR recommended radiographical evaluation of all patients. However, only 3 had fractures verified on initial x-ray and 1 on subsequent MRI, According to this study, OAR is not recommended for clinical evaluation in children, due to a high false-positive rate.

102. The proportion of distal fibula Salter Harris type I epiphyseal fracture in the pediatric population with acute ankle injury. A prospective MRI study.
Mikael Hofsli, Trine Torfing, Zaid Al-Aubaidi
Department of Orthopedic Surgery, Odense University Hospital; Department of Radiology , Odense University Hospital

Background: Ankle injuries are common among the pediatric population and may result in fractures, ligaments or osteochondral injury. There are few prospective studies utilizing magnetic resonance imaging (MRI) to diagnose a clinically suspected Salter-Harris type 1 of the distal fibula (SH1DF).
Purpose / Aim of Study: The aim of this study was to examine the proportion of clinically suspected SH1DF in children.
Materials and Methods: 391 patients with ankle injury, seen at the emergency room (ER) from September 2012 to May 2013 at single institution. All underwent a standardized clinical examination and radiographs was obtained if found necessary. Initial radiographs were reviewed by an orthopedic specialist and a radiologist specialist and data was recorded prospectively. Patients suspected of having SH1DF were referred for an MRI of the ankle joint within few days. All patients were seen for a clinical follow-up and informed about the MRI results. The clinical data and the initial radiographs were blinded to the senior radiologist, whom interpreted the MRI.
Findings / Results: 38 patients had a clinical suspicion of SH1DF. 7 patients were excluded from the study. 3 were excluded, as there was fracture on the initial radiography. One due to closed physis and 3 due to drop out. A total of 31 patients, 18 male and 13 female, mean age 10±2.86. The time between the injury and the initial radiological examination was 0.4±0.88 days. MRI was obtained on an average of 6.9±2.87 days. None of the included patients had evidence of SH1DF on MRI imaging.
Conclusions: According to this study, the clinical diagnosis of SH1DF was incorrect in all of the cases. This study and review of the literature verifies the high false-positive rate of clinically suspected SH1DF. These results may influence the management of clinically suspected SH1DF.

103. Pitfalls in the treatment of pediatric supracondylar fractures of the humerus – a partial root core analysis of 101 cases from the Danish Patient Insurance
Folkvardsen Steffen , Baslev-Clausen Andreas , Krogh Christoffersen Jens , Sonne Holm Stig , Wong Christian
Department of Orthopaedic Surgery , University Hospital of Hvidovre; , The Patient Insurance Association; Department of Pediatric Orthopaedic Surgery , University Hospital of Hvidovre

Background: The supracondylar fracture of the humerus is the most common fracture in the pediatric elbow. Danish Patient Insurance Association (DPIA) receives complaints from patients who believe they have sustained injuries due to potential malpractice or unfortunate circumstances.
Purpose / Aim of Study: Case files from DPIA were assessed to identify causality and factors contributing to complaints and potential malpractices of supracondylar fractures in children.
Materials and Methods: A partial root core analysis was performed of a total of 101 cases. Case files for supracondylar fractures were retrieved from the DPIA database for the diagnose codes DS 42.4 and DS 42.4C for patients under the age of 16.
Findings / Results: The boy:girl ratio was 3:2 and with an average age of 6,7 years. According to the Gartland classification: Six were classified as type 1, 49 as type 2, 41 as type 3 and five cases of flexion type fractures. The main complaints were related to malpractice (47), poor functional outcome (45), cubitus varus (38) and neurological symptoms (18). 38 of the cases were operated on by a specialist in orthopaedics. 32 were treated conservatively with cast including 9 cases supplemented by closed reduction. 69 were operated by either closed (19) or open (50) reduction supplemented by k-wire fixation. The rate of complications increased with fracture severity by the Gartland classification and almost all flexion type fractures had reoperations. Half of the injuries were evaluated as minor injury by the DPIA, but a total number of 48 cases were acknowledged.
Conclusions: Malpractice in surgical technique seemed to be overrepresented in the severe fractures even when operated on by an orthopaedic specialist. In order to optimize treatment, operating doctors would need to be especially trained to deal with these kinds of fractures when severe.

104. Outcome of distal tibial physeal fractures; a comparison of Triplane, Tillaux and medial malleolus SH-III and IV fractures. A retrospective study.
Helene Højsgaard Jensen, Sidsel Hald Rahlf, Niels Wicbech Pedersen, Zaid Al-Aubaidi
Ortopædkirurgisk Afdeling, Odense Universitetshospital (OUH)

Background: Ankle fractures occur frequently in adolescent patients. Fractures that involve the physis can result in Tillaux (TI), Triplane (TR) or medial malleolus fracture (MM). Those can result in growth arrest, which can lead to deformity and shortening of the distal tibia. We expected that medial malleolus fractures have the highest risk of developing growth arrest, as it occurs in a younger age group, with more growth potential.
Purpose / Aim of Study: To examine the outcome and distribution of growth arrest after the physeal fractures of the distal tibia.
Materials and Methods: A retrospective study where the study population was identified through analysis of medical records and x-rays of all adolescent patient with a distal tibia fracture registered at a single institution in the period from 2003 – 2012.
Findings / Results: 51 patients, 53% female and 47% male. 71% of the fractures were located to the right ankle (n=36). There were 15 TR, 9 TI and 27 MM fractures. The mechanisms of injury were: sprain (56.9%), fall from height (15.7%), motor vehicle accident (11.8%) and undefined (15.6%). The mean age was: 13.5 TR (10-16), 13.2 TI (12-15) and 12.9 years MM (8- 16). There were no significant statistical differences between the 3 groups regarding incidence of growth arrest: MM vs. TR p=0,47 (NS), MM vs. TI p=0,56 (NS) and TR vs. TI = NA.
Conclusions: This study shows a trend towards higher risk of developing growth arrest when suffering from a MM compared to the other transitional fractures. However this clinical trend should be interpreted with the scope of this study and further research is necessary to illuminate this aspect of physeal fractures and their complications.