Session 13: Foot/ankle

Fredag den 25. oktober
11:00 – 12:00
lokale: Helsinki/Oslo
Chairmen: Jeannette Østergaard Penny / Lasse Danborg

124. Dynamic non-operative treatment of acute Achilles tendon rupture: The influence of early weight-bearing on clinical outcome. A blinded, randomized, controlled trial.
Kristoffer W Barfod, Jesper Bencke, Hanne Bloch Lauridsen, Ilija Ban, Lars Ebskov, Anders Troelsen
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Gait Analysis Lab, dep. of Ortopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark; Ortopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark

Background: Weight-bearing (WB) during rehabilitation of acute Achilles tendon rupture (ATR) has positive impact on the health related quality of life, and it might allow for quicker return to work. WB after surgical repair of ATR has shown no detrimental effects, but there are no clinical studies examining the role of WB in non-operative, dynamic treatment of ATR.
Purpose / Aim of Study: To compare the functional outcome of patients randomized to early WB or non-WB in non-operative, dynamic treatment of ATR.
Materials and Methods: The study was conducted as a blinded, randomized controlled trial (RCT). 60 patients were randomized. In both groups patients were treated non-operatively with dynamic rehabilitation. The intervention group was allowed full WB from day 1 of treatment. The control group was non-WB for 6 weeks. Outcome at 6 and 12 months was evaluated using the Achilles tendon Total Rupture Score (ATRS), the Heel-rise-work-test and the rerupture rate (RR). Data were evaluated using unpaired T-tests.
Findings / Results: There were no statistically significant differences between the WB and the non- WB groups. Mean ATRS at six months was 59 for the WB group and 67 for the non-WB group (p=0.16). At 12 months the ATRS was 73 WB and 75 non-WB (p=0.72). The Heel- rise-work-test showed a total work performed of the injured limb compared to the uninjured limb of 40% for the WB group and 37% for the non-WB group at six month (p=0.58). At 12 months it was 53% WB and 57% non-WB (p=0.52). There were 3 RR in the WB group and 2 RR in the non-WB.
Conclusions: There were no significant differences between the groups in ATRS or Heel-rise- work-test at one-year follow-up. Both groups had significant functional deficits in the injured limb compared with the uninjured limb. Immediate weight-bearing is a recommendable option in the non-operative treatment of ATR.

125. High volume injection, autologous conditioned plasma and placebo treatment in patients with chronic Achilles tendinopathy– A single blinded prospective study
Anders Ploug Boesen, Morten Boesen, Rudi Hansen, Peter Malliaras , Otto Chan, Henning Langberg
Department Ortopaedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Denmark; , Teres Parkens Privat Hospital, Denmark; Department of Public Health, Faculty of Health Sciences University of Copenhagen, CopenRehab, Section of Social Medicine

Background: Chronic Achilles tendinopathy (AT) is a commen and impairing disorder. Only sparse scientific evidence exists for the present used treatments and no golden standard treatment exists.
Purpose / Aim of Study: The aim of the study was in AT patients to examine and compare the effect of high volume injection (HVI) or autologous conditioned plasma (ACP) in combination with eccentric training to placebo (Plc) treatment (sham treatment and eccentric exercises).
Materials and Methods: Healthy males (21-59 years; n=55) with AT were randomly assigned to HVI (10 mls 0.5% Marcain and 20 mg Depomedrol followed by 40 mls saline), ACP (4 mls) or Plc (sham) treatment. Participants were treated 4 times with 2 wk interval (HVI only once a baseline). All underwent a 12-wk eccentric training program. Outcome measures were assessed at 12 and 24 wk follow-up by VISA-A and VAS score, ultrasound thickness and muscle function (heel-rise test).
Findings / Results: Increase in VISA-A was seen in all follow- ups for every group (p<0.05). The increase was higher in HVI vs ACP and Plc at 12-wks follow-up (p<0.01), with no difference between ACP vs Plc. At 24 wks follow-up a higher increase was found in the HVI and ACP vs Plc (p<0.05). VAS score decreased in all follow-ups for every group (p<0.05). The decrease was higher in HVI and ACP vs Plc at 12-wks follow-up (p<0.05) , with no differences between HVI and ACP. At 24 wks follow-up a higher decrease was found in HVI and ACP vs Plc (p<0.05). Tendon thickness showed a significant decrease in HVI and ACP in all follow- ups. The decrease in thickness at 12 wks follow-up was greater in HVI vs ACP (p<0.01), and ACP vs Plc (p<0.05). At 24 wks follow-up a higher decrease was found in HVI and ACP vs Plc with no differences between HVI and ACP. Muscle function improved in the entire cohort (p<0.01) with no group interaction observed.
Conclusions: Treatment with HVI or ACP in combination with a 12-wk eccentric training regime in AT seems more effective reducing pain, improving activity level and reducing tendon thickness than eccentric training, per se. HVI was found more effective than ACP in this short-term study.

126. Modified Lapidus arthrodesis – Plantar plating and compression screw Retrospective evaluation of fusion rate and IM-1 angle correction
Kim Hegnet Andersen, Anna Kathrine Pramming, Jens Kurt Johansen, Jeannette Østergaard Penny
Foot and Ankle department, Koege Hospital

Background: The Lapidus procedure for treating metatarsus primus varus or instability of the TMT-1 joint is well established. Nonunion rates of 4-25% are reported. Crossed screws or medial or dorsal plating in addition to a compression screw are standard techniques. A plantar plate adds the advantage of tension band effect over the fusion site which has been shown in a biomechanical study.
Purpose / Aim of Study: To report fusion- and complication rates for the Lapidus procedure with plantar plating, and secondly the correction of the IM-1 angle in metarsus primus varus.
Materials and Methods: All patients operated at our department using the Darco LPS plate were evaluated (n=41). Indications were: Metatarsus primus varus(33pts), revision hallux valgus surgery, instability of TMT-1 in midfoot dysfunction/forefoot driven hindfoot valgus and/or arthritis of the TMT-1 joint. All patients were evaluated clinically and radiographically 3-4 and 6-8 weeks postoperatively. The post-op regime was full/partial weightbearing in a post-op shoe. IM1-angle measured pre- and postoperatively, independently by first 3 authors. Means compared by a paired t- test, and agreement by interclass correlation coefficient(ICC).
Findings / Results: All patients fused both clinically and radiographically. IM-1 angle reduced from 16, 5 to 7, 8 degrees (pre/postoperative) (p < 0.0001). Pre ICC (95%CI) = 0.83 (0.74-0.92) and post ICC (95%CI) = 0.85 (0.77- 0.93). 6 patients had minor complications, including 2 screw removals due to malpositioning. 1 patient had (traumatic) rupture of tibialis anterior tendon.
Conclusions: The use of the Darco LPS plate yields good short term results with high fusion rate and low rate of complications. When indicated the IM- 1 angle was corrected significantly and the angle measurements were valid. Long term follow-up as well as prospective studies are needed.

127. Surgical treatment of lesser-toe- MTP joint instability: Plantar plate repair using a plantar approach.
Anna Kathrine Pramming, Jens Kurt Johansen, Kim Hegnet Andersen, Jeanette Østergaard Penny
Foot and Ankle Department, Koege Hospital

Background: The plantar plate (PP) is the principle stabilizing structure of the lesser toe- MTPJ. There is to this point no golden standard treatment for the instable lesser MTPJ. Few clinical studies have been published, some recommending a dorsal approach through a Weil osteotomy. This however changes the center of rotation, and cadaver studies find that anatomical repair reestablishes stability and alignment. The plantar approach allows direct anatomical repair, but has been avoided by many due to fear of painful scarring.
Purpose / Aim of Study: To evaluate the use of a plantar approach in surgical repair of the plantar plate.
Materials and Methods: All patients at our institution (n=19), treated with PP repair only or combined with additional procedures, were examined at a median 24 weeks (8 to 50) postoperatively using the AOFAS forefoot-scale, VAS-FA and a standardized clinical evaluation. 8 were revision cases. The PP rupture was debrided and sutured or reinserted using anchor fixation to the base of the proximal phalanx.
Findings / Results: All plantar incisions healed with minimal scarring. Post operative VAS-FA scored a mean 77.9 (sd 15.8) points and AOFAS forefoot scored a mean 77.5 (sd 15) points. Compared to the opposite side dorsiflexion was reduced by 17° (p<0.01). 3 patients were failures (malalignment/elevation) at follow-up. One was a rheumatoid patient and two did not present a typical plantar plate rupture at surgery, but rotation of the joint capsule and luxation of the flexor tendon complex. 2 reported tenderness at the plantar incision, 4 had pain or tenderness at the dorsal incision.
Conclusions: Surgical repair using a plantar approach yields good results regarding realignment and foot function. The failure risk regarding rheumatic arthritis needs further investigation. Plantar scar complications do not seem to be significant.

128. Development and validation of a novel ultrasonographic method for evaluation of Achilles tendon elongation after rupture
Kristoffer W Barfod, Anja Falck Riecke, Anders Boesen, Philip Hansen, Jens Friedrich Maier, Anders Troelsen
Orthopedic surgery, Copenhagen University Hospital, Køge, Denmark; Institute of Sports Medicine, Copenhagen University Hospital, Bispebjerg, Denmark; Radiology, Copenhagen University Hospital, Bispebjerg, Denmark; Ortopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark

Background: Elongation of the Achilles tendon after acute rupture is associated with inferior functional outcome. A clinically applicable, accurate and easy to perform method for evaluating Achilles tendon elongation is needed.
Purpose / Aim of Study: To develop and validate an ultrasonographic (US) method that accurately measures the length of the Achilles tendon-aponeurosis complex.
Materials and Methods: Both legs of 19 non-injured subjects were examined by MRI and US. The length of the Achilles tendon- aponeurosis complex (calcaneus to the medial head of m. gastrocnemius) was measured by three independent US examiners. Repeated US measurements were performed and compared to MRI measurements. Intra-rater and inter-rater reliability was determined and the agreement between MRI and US was determined. Data were evaluated using the Bland-Altman method and the Inter Correlation Coefficient (ICC), the Standard Error of the Measurement (SEM) and the Minimal Detectable Change (MDC).
Findings / Results: Intra-rater reliability showed no significant systematic differences between test days (p=0.45); ICC 0.96, SEM 3.7mm and MDC 10.3mm. Inter-rater reliability showed a systematic difference between US observers of 2.1mm – 4.5mm (p=0.001- 0.036); ICC 0.97, SEM 3.3mm and MDC 9.3mm. MRI measurements were on average 3.8mm longer than US (p=0.001); ICC 0.98, SEM 2.7mm and MDC 7.6mm. We found no systematic difference in length of the left and the right Achilles tendon (p=0.95); ICC 0.94, SEM 4.1mm and MDC 11.5mm.
Conclusions: The novel US method showed good reliability. For comparison between groups of non-injured subjects differences of more than 4mm can be detected. For repeated assessment of individual subjects differences of more than 10mm can be detected. The novel US method is a promising clinical tool to be further assessed in the setting of acute Achilles tendon rupture.

129. Achilles Tendon ruptures – treatment and complications: A systematic review
Christina Holm, Pernilla Eliasson
Idrætsmedicinsk Institut, Bispebjerg Hospital

Background: Achilles tendon rupture is a frequent sports injury with increasing incidence. Until now there is no consensus regarding the optimal treatment for acute Achilles tendon ruptures.
Purpose / Aim of Study: The purpose of this study was to illuminate and summarize randomized controlled trials comparing surgical and non-surgical treatment of Achilles tendon ruptures.
Materials and Methods: We systematically searched MEDLINE database for randomized prospective controlled trials on humans, comparing surgical and non-surgical treatment of Achilles tendon rupture, for the last 10 years. Six articles were found acceptable according to international quality assessment guidelines. Primary outcomes were re-ruptures, complications of treatment, and functional outcomes.
Findings / Results: All studies used early mobilization in both groups. There was no significant difference in re-rupture rate, but a trend favoring surgery patients. No significant differences in other types of complications, was found, although one study found a increased risk for soft-tissue related complications in the surgery group, that did not affect functional outcome. Patient satisfaction and time to return to work were significant different in favor of surgery in one study and there were better functional outcomes for surgery patients, at early time-points.
Conclusions: We found no significant differences in re- rupture rate although a trend favoring surgery. Surgical patients had significant better early functional outcomes and also returned to work earlier, indicating that their rehabilitation is faster combined with early mobilization. Further randomized controlled trials will be needed in regards to understand the interplay between acute surgical or non- surgical treatment and the rehabilitation regimen for the overall outcome of Achilles tendon treatment.

130. Complications after acute Achilles tendon rupture. A registry study of 324 patients from the Danish Patient Insurance Association
Thor-Magnus Sveen , Kristoffer W. Barfod , Lars Ebskov, Anders Troelsen
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark

Background: The best treatment of acute Achilles tendon rupture (ATR) has been discussed for decades. High quality meta-analysis comparing surgical and non-surgical treatment show a lower re-rupture rate but a higher overall complication rate among surgically treated patients. There are no studies evaluating the impact of different complications.
Purpose / Aim of Study: To investigate: 1) the number and types of complications reported to the Danish Patient Insurance Association (DPIA) after treatment for ATR, and 2) if complications are correlated to the treatment given.
Materials and Methods: This registry study examined the DPIA database. 324 patients with ATR reported in the period 1992 to 2010 were identified. All patient records were reviewed and data were assessed to confirm correct registration of diagnosis and complications.
Findings / Results: Awarded compensation for the 12 year period totaled 18,147,202Dkk. Out of 180 operatively treated patients, 79 received a total compensation of 14,051,377Dkk, averaging 177,865Dkk per patient. Of 114 non-operatively treated patients, 39 received a compensation of 3,715,224Dkk, averaging 95,262Dkk per patient. In the group of operatively treated patients there were 48 infections, 23 nerve damages, 23 re- ruptures, 9 deep venous thrombosis and 6 tendon elongations. Among the non- operatively treated patients there were 24 re-ruptures and 21 tendon elongations.
Conclusions: Approximately 10 cases of ATR were accepted for compensation in the DPIA per year; 1/3 after non-operative treatment and 2/3 after operative treatment. The average compensation after operative treatment was twice that after non-operative treatment indicating more severe complications after operative treatment.

131. Prospective comparative study comparing the results of proximal crescentic osteotomies and open wedge osteotomies to patients with severe hallux valgus
Jens Ulrik Wester, Niels Herold, Palle Bo Hansen, Johnny Frøkjær
Orthopedic, Odense University Hosptial

Background: Different techniques of proximal osteotomies have been introduced in correcting severe hallux valgus. The open wedge osteotomi is a newly introduced method for proximal osteotomi .
Purpose / Aim of Study: The aim of this prospective randomised study was to compare the radiological and clinical results 4 and 12 months after the operation to patients with severe hallux valgus, comparing the open wedge osteotomi to the crescentric osteotomi.
Materials and Methods: 45 patients with severe hallux valgus HV-angle >35, and IM angle > 15 were included in this study. The treatment was proximal open wedge osteotomi and fixation with plate (Hemax) group 1, or operation with proximal crescentic osteotomi and fixation with 3 mm canulated screw (Synthes) group 2. Clinical and radiological follow-up was performed 4 and 12 months after the operation.
Findings / Results: The Aofas score was improved form 59,3 to 81,5 group 1, in group 2 the improvement increased from 61,7 to 84,8 after 12 months. In group 1 the hallux valgus ankle decreased from 39,1 to 23,1 after 4 months and 26,6 after 12 months. In group 2 the angle preoperative was 39,1, 22,5 after 4 months and 27,2 after 12 months. The intermetatarsal angle in group 1 was 19,0 before operation, 11,6 after 4 months and 12,5 after 12 months. In group 2 the mean intermetatarsal angle was 18,9 preoperatively, 12 after 4 months and 12,6 after 12 months. The length of the 1. metatarsal compared to 2. metatarsal bone was 0,884 preoperatively and 0,875 postoperatively in group 1. In group 2 0,872 preoperatively and 0,88 after 12 months.
Conclusions: : In both groups the hallux valgus angle had a tendency to recur in time after the operation, no statistical difference were found in the study. There was a tendency to gain length of the first metatarsal using the open wedge osteotomi compared to the crescentic osteotomi. If the patient has a tendency to instability or if the TMT joint is big one should consider Lapidus procedure as the primary operation procedure.