Session 6: Sports/Shoulder

Torsdag den 24. oktober
13:30 – 15:00
lokale: Reykjavik
Chairmen: Ilija Ban / Uffe Jørgensen

50. Failed Osteochondral Repair by MayoRegen® Scaffolds in Patients with Ostochondritis Dissecans
Christensen Bjørn Borsøe, Foldager Casper Bindzus, Eric Bünger Cody, Lind Martin
Ortopædisk forskningslaboratorium, Aarhus Universitetshospital; Idrætssektoren, ortopædkirurgisk afdeling, Aarhus Universitetshospital

Background: Osteochondral injuries are very difficult to treat and existing treatment options are often expensive and relatively ineffective.
Purpose / Aim of Study: To evaluate the osteochodral repair in patients treated with a nano-composite multi- layered biomaterial consisting of collagen type I and hydroxyapatite (MaioRegen®).
Materials and Methods: Ten patients with osteochondritis dissecans (OCD) in the knee (n=6) or on the talus (n=4) were treated with the MaioRegen® scaffold. The patients underwent CT and MRI 1 year postoperatively and the bone and cartilage formation was evaluated, the latter using MOCART.
Findings / Results: One patient was excluded due to severe swelling of the knee and implant removal 5 days postoperatively. Two additional patients experienced swelling of the knee, but were treated conservatively and recovered. MRI: One of nine patients had complete filling of the osteochondral defect (Hypertrophy n=3, incomplete repair n=5), and complete integration with adjacent tissue was seen in two of nine patients. In all nine patients the surface of the repair tissue was damaged and the tissue had a heterogeneous structure. In all nine patients the signal intensity of the repair tissue was hyperintense compared to native cartilage. The subchondral lamina and the subchondral bone were not intact in any of the cases. CT: No patients had complete regeneration of the bone. In five patients there was no evidence of bone formation in the defect.Two patients had between 25-50% bone filling. CT two patients were not available.
Conclusions: Treatment of OCD with MayoRegen® resulted in incomplete cartilage repair and a profound lack of bone formation. Three patients experienced postoperative swelling, which may be attributed to the implant. This study illustrates the importance of thorough clinical follow-up in patients treated with novel devices.

51. 2 years follow-up after TruFit® implantation for full thickness cartilage defects in the knee.
Lars Konradsen, Michael R. Krogsgaard
Idrætskirurgisk sektion, Ortopædkirurgisk afdeling, Bispebjerg Hospital

Purpose / Aim of Study: To present our short-term experience with an artificial osteochondral scaffold plug for cartilage repair in the knee.
Materials and Methods: 22 patients treated over a 2 year period. Median patient age 37.5 years (range 24-49). 8 women. 20 medial femoral condyle defects. Median defect size 1 cm2 (range 0.6 to 3). All defects previously debrided or microfractured. 1 plug implanted in 13 cases, 2 in 7, 3 in 1, and 4 in 1 case. KOOS and Tegner scores and standard MRI pre-op, and 1 and 2 years post-op. CT scans 1 and 2 years post-op.
Findings / Results: KOOS values: Dimensions: Symptoms; Pain; Function in daily living; Sport; Quality of Life. Pre-op: 62; 39; 43; 2; 11 1 year post-op: 73; 64; 66; 25; 30 2 years post-op: 79; 69; 79; 34; 34 Normals: 89; 88; 90; 78; 80 For comparison: Normals: age- matched subjects without knee problems. Tegner: pre-op: median 2; 2 years post- op: 3. Between 1 and 2 years post-op: plugs removed in 3 cases; MACI performed in one of these cases. CT scans after 1 year: Volume with no evidence of trabecular bone occupied 115-120% of the primary plug volume. At 2 years: median 80% of the primary plug volume without evidence of trabecular bone. MRI showed partial fill of the cartilage defects after both 1 and 2 years.
Conclusions: KOOS scores improved but were far from normal, and Tegner activity scores remained low for this young and previously active group. CT showed evidence of early bone resorption changing into very limited bony tissue fill of the intraosseos part of the plug. Substantial surface defects were still present in the plug areas after 2 years. Artificial scaffold plugs were believed to be a treatment option for medium size full thickness femoral condyle cartilage defects. However, after 2 years we found that the effect on patient reported outcome was marginal.

52. Incidence and clinical presentation of groin injuries in sub-elite male soccer
Per Hölmich, Kristian Thorborg, Christian Dehlendorff, Kim Krogsgaard, Christian Gluud
Artroskopisk Center Amager, Amager-Hvidovre Hospital; Danish Cancer Society Research Center, Danish Cancer Society Research Center; Copenhagen Trial Unit, Centre for Clinical Intervention Research , Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet

Background: Groin injuries are prevalent and often long- standing in soccer.
Purpose / Aim of Study: The aim of the present study was to describe the occurrence and clinical presentation of groin injuries in a cohort of sub-elite soccer players during a season.
Materials and Methods: Physiotherapists allocated to each of the participating 44 soccer clubs recorded baseline characteristics and groin injuries sustained by a cohort of 998 sub-elite male soccer players during a full 10-month season. All players with groin injuries were examined using the clinical entity approach, which utilises standardised reproducible examination techniques to identify the injured anatomical structures. The exposure time and the injury time were recorded. Injury time was analysed using multiple regression on the log of the injury times as the data was highly skewed. Effects are thus reported at relative injury time (RIT).
Findings / Results: Adductor-related groin injury was the most common entity found followed by iliopsoas- related and abdominal-related injuries. The dominant leg was significantly more often injured. Age and previous groin injury were significant risk factors for sustaining a groin injury. Groin injuries were generally located in the same side as previously reported groin injuries. Adductor-related injuries with no abdominal pain had significantly longer injury times compared to injuries with no adductor and no abdominal pain (RIT 2.28, 95% CI 1.22 to 4.25, P=0.0096). Having both adductor and abdominal pain also increased the injury time significantly compared to injuries with no adductor and no abdominal pain (RIT=4.56, 95% CI 1.91 to 10.91, P=0.001).
Conclusions: Adductor-related groin injury was the most common clinical presentation of groin injuries in male soccer players and cause long injury time, especially when combined with abdominal-related injury.

53. High injury incidence in adolescent female soccer: The influence of weekly soccer exposure and playing level
Mikkel Bek Clausen, Mette Zebis, Merete Møller, Per Hölmich, Niels Wedderkopp, Kristian Thornorg
Artroskopisk Center Amager, Copenhagen University Hospital; Gait Analysis Laboratory, Hvidovre University Hospital; Department of Public Health , Aarhus University; Ortopædkirurgisk afd. SLB, Inst. for Regional Sundhedsforskning

Background: In a health-perspective, soccer has important benefits, such as reduced risk of obesity and diabetes, but also includes an inherent risk of injury. Soccer is increasingly popular among adolescent females. Previous studies report varying injury-rates (2.4-5.3 injuries per 1.000 hours), using traditional medical-staff or coach reports, methods that significantly underestimate injury-rates when compared to self-report via text-messaging (SMS).
Purpose / Aim of Study: The aim of this study was to investigate the injury-incidence and the association between soccer-exposure, playing-level and injury-risk, using self-report via SMS.
Materials and Methods: 499 girls aged 15-18 years reported soccer-injuries and exposure weekly, by answering standardised SMS questions, followed by individual injury-interviews, during a full soccer season (February-June, 2012). Generalized Estimating Equation with Poisson-link was used to estimate injury-rates and relative risks, as players were clustered within teams. A priori, soccer-exposure and playing-level were chosen as independent variables.
Findings / Results: A total of 424 soccer-injuries were recorded. Total injury incidence was 15.3(13.1-17.8) and time-loss injury-incidence was 9.7(8.2-11.4) per 1.000 hours of soccer-exposure. Higher average weekly exposure in injury-free weeks was associated with lower injury-risk (p-value for trend<0.001), and players with low exposure (≤1 hours/week) were up to 10 times more likely to sustain a time-loss injury compared to other players (p<0.01). Playing-level was not associated with the risk of time-loss injury (p>0.05).
Conclusions: The injury-incidence in adolescent female soccer is high, and players with low soccer-attendance have a significantly increased injury-risk. Future studies should investigate the causal mechanism for this association.

54. Identification of the femoral attachment point for medial patellofemoral ligament (MPFL) reconstruction without the use of fluoroscopy -A cadaver study
Claus Ol Hansen, Mikkel Attrup, Per Hölmich
Artroskopisk Center Amager, Amager-Hvidovre Hospital

Background: Anatomically reconstruction of the MPFL as suggested by Schöttle is a well established technique. A free gracillis graft is fixated on the proximal medial boarder of the patella and tunnelled under the second layer of the medial patello- femoral soft tissue complex and fixated at the anatomical femoral attachment point for the native MPFL. A reproducible anatomical and radiographic point for the femoral attachment point has been established in a cadaver study. Incorrect femoral attachment can lead to an unsuccessful result of the surgery. The use of peroperative fluoroscopy to identify the anatomical femoral attachment point for the MPFL is not routine in many centres.
Purpose / Aim of Study: Evaluation of the accuracy of identification of the femoral MPFL insertion point without use of fluoroscopy under standardized conditions.
Materials and Methods: Twelve fresh frozen cadaver knees were used in this study. Five experienced surgeons in sports traumatology were asked to dissect and mark the femoral MPFL point with a nail according to the description by Schöttle. Fluoroscopic examination was done, in the true lateral position. The 12 knees with the nail markings were then calibrated into a “standard knee size” by means of a zooming tool, to correct for differences in sizes of the individual knees.
Findings / Results: Only 4 of the 12 MPFL markings were placed within a distance from 5 mm. of the anatomical MPFL point. Furthermore there was a trend that the individual surgeons placed their markings within a limited area - even when suboptimal.
Conclusions: This study indicates that the ability to identify the femoral MPFL attachment point without use of fluoroscopy is low. We recommend the use of peroperative fluoroscopy for identification of the femoral attachment point in MPFL reconstruction surgery.

55. Increased medial foot-loading during drop jump and single leg squat in individuals with patellofemoral pain – a cross-sectional study
Michael Rathleff, Camilla Richter, Jesper Bencke, Thomas Bandholm, Per Hölmich, Kristian Thorborg
Orthopedic Surgery Research Unit, Aalborg Hospital; A-Physiotherapy, Solrød Strand; Gait Analysis Laboratory, Hvidovre Hospital; Physical Medicine and Rehabilitation Research (PMR-C), Orthopedic Department, Clinical Research Cent, Hvidovre Hospital; Arthroscopic Centre Amager, Orthopedic Departement, Hvidovre Hospital; Arthroscopic Centre Amager, Physical Medicine and Rehabilitation Research (PMR-C), Orthopedic Depart, Hvidovre Hospital

Background: Symptoms from patellofemoral pain (PFP) occur during high load activities such as jumping and squatting. The forces imposed on the patellofemoral joint during these activities are transmitted from the foot and up to the patellofemoral joint.This implies that the pattern of foot loading is important for the pathogenesis of PFP. No studies have yet investigated loading of the foot duringjumping and squatting in individuals with PFP.
Purpose / Aim of Study: To compare medial-to-lateral plantar forces during drop jump and single leg squat in patients with PFP and healthy controls.
Materials and Methods: 23 young adults with PFP were compared to 20 age and gender matched individuals without knee pain. Foot loading (plantar pressure distribution) was collected during drop jump and single leg squat using pressure sensitive Pedar insoles. Plantar pressure data from the most pain-full side was used in individuals with PFP, including an identical proportion of right and left feet among pain-free individuals. Primary outcome was medial-to-lateral peak force calculated as the peak force under the medial forefoot in percent of the total peak force under the entireforefoot during drop jump. Mean forces under the forefoot were analysed using the same approach. Both measures were found to have high test-retest reliability (Limits of Agreement mean ± 15%).
Findings / Results: On average, individuals with PFP had a 22-32% higher medial-to-lateral peak force during drop jump and single leg squat, p<0.03, and 19-23% higher medial-to-lateral mean force, during the same activities, p<0.04.
Conclusions: Individuals with PFP have a more medially directed foot loading compared to healthy controls during high load activities. This may influence the distribution of forces transmitted proximally to the knee, and be an important factor in the development of PFP.

56. Patient reported outcome, revision rate and reason for revision following resurfacing hemiarthroplasty in patients diagnosed with osteoarthritis: 837 operations reported to the Danish Shoulder Arthroplasty Registry.
Jeppe Rasmussen, Anne Polk, Sørensen Anne Kathrine , Stig Brorson, Bo S Olsen
Department of Orthopaedic Surgery, Herlev University Hospital

Background: Resurfacing hemiarthroplasties in the shoulder for the treatment of osteoarthritis is commonly used but previous studies have not been able to adequately describe revision rates and reasons for revision.
Purpose / Aim of Study: The primary aim was to evaluate patient reported outcome, revision rate and reasons for revision following resurfacing hemiarthroplasty in patients diagnosed with osteoarthritis. The secondary aims were to compare arthroplasty designs and to evaluate age as a possible risk factor.
Materials and Methods: We included all patients reported to the Danish Shoulder Arthroplasty Registry between 2006 and 2010 diagnosed with osteoarthritis and treated with resurfacing hemiarthroplasty. 837 arthroplasties in 772 patients were eligible. Western Ontario Osteoarthritis of the Shoulder index (WOOS) was used to evaluate outcome 1 year postoperatively. Revision rates were calculated by checking reported revisions to DSR until December 2011 and by checking deaths with the Danish National Register of Persons.
Findings / Results: 82.2 % returned a complete questionnaire. Mean WOOS was 67.4 range 0.0-100.0. Patients aged 55 years or younger had a statistically and clinically significant worse adjusted WOOS compared to older patients (mean difference 14.2 [8.8; 19.6 CI 95%], P<0.001). There was no significant difference in WOOS between resurfacing hemiarthroplasty designs. Sixty three (7.5 %) of the arthroplasties were revised. The most common reason for revision was glenoid attrition (n=18). There were no differences in revision rates or adjusted risk of revision with regard to age or resurfacing hemiarthroplasty design.
Conclusions: Resurfacing hemiarthroplasty for the treatment of osteoarthritis of the shoulder joint is, at the short term, associated with a good patient reported outcome but a relatively high revision rate.

57. Implant survival after total elbow arthroplasty: A retrospective study of 324 procedures performed from 1980 to 2008
Hans Christian Plaschke, Theis Thillemann, Stig Brorson, Bo Olsen
Shoulder and Elbow Department, Herlev University Hospital; Orthopaedic Department, Horsen Hospital

Background: Total elbow arthroplasty (TEA) is an established treatment for late stage arthritis of the elbow. Recent literature advocates TEA in comminute distal humeral fractures in the elderly. However, information on implant survival and risk factors for revision is sparse.
Purpose / Aim of Study: The aim of this retrospective study was to evaluate the survival and risk factors for revision of TEAs inserted in eastern part of Denmark in the period from 1980 till 2008.
Materials and Methods: The Danish National Patient Registry, (NPR) provided social security numbers on patients, who underwent TEA procedures in the period from 1980 till 2008. Based on review of medical reports and linkage to the NPR we calculated revision rates and evaluated potential risk factors for revision including, age, gender, indication for TEA, and implant design.
Findings / Results: 324 primary TEA procedures performed on 234 patients were evaluated at a mean follow up of 8.8 years (range 3-27 years). The overall 5- and 10-year survival rates were 90% (95 % CI = 88-94) and 81% (95% CI= 76-86), respectively. TEAs performed due to fracture were associated with an increased RR of revision of 2.28 (95% CI=1.19-4.36) compared to rheumatoid arthritis (RA). Furthermore, age above 60 years was associated with an increased RR for revision of 2,2 (95% CI = 1.4-4.0) There were no differences in revision rates related to gender or implant design.
Conclusions: We found acceptable implant survival after 5 and 10 years. There were no significant differences in revision rates between linked and unlinked design. However, primary TEA due to fracture and advanced age at time of surgery was associated with an increased risk for revision.

58. The effective analgesic dose of dexamethasone after outpatient shoulder surgery: a randomized, blinded trial.
Karen Toftdahl Bjørnholdt, Peter Nørgaard Mønsted, Lone Nikolajsen, Kjeld Søballe
Department of Orthopaedics, Horsens Regional Hospital; Department of Orthopaedics , Horsens Regional Hospital; Department of Anaesthesiology, Danish Pain Research Centre, Aarhus University Hospital

Background: It is well established that dexamethasone, given in a single dose of 4-16 mg preoperatively, prevents postoperative nausea and vomiting. Dexamethasone has also been shown to reduce pain after surgery, but the optimal dose is unknown.
Purpose / Aim of Study: We hypothesized that a higher dose of dexamethasone could provide or improve an analgesic effect, and therefore compared the current (antiemetic) dose of 8 mg to a high dose of 40 mg.
Materials and Methods: This was a GCP-monitored, blind, parallel group, placebo-controlled, randomized clinical trial conducted at Horsens Regional Hospital. Seventyfive patients undergoing arthroscopic subacromial decompression and/or acromioclavicular joint resection as outpatient surgery were randomized to receive either dexamethasone 8 mg (D8), dexamethasone 40 mg (D40) or placebo (D0) intravenously before surgery. Primary outcome was pain intensity (numeric rating scale 0-10) 8 hours after surgery. Secondary outcomes were average and worst pain during the first night and on the following morning, and analgesic consumption in the recovery room. Pain intensity, analgesic consumption and side effects were recorded by patients for four days after discharge, and a final follow-up regarding side effects was made after two months.
Findings / Results: There was no difference in pain intensity after 8 hours between D8 and D40 (median (IQR): D40: 2 (1-4), D8: 2(1- 3), p=0.60). For D0 results were (median (IQR)) 4 (2-7). D40 was significantly different from D0 (p=0.02), also during the first night and on the following morning. No difference was found in use of analgesics. No serious side effects were observed.
Conclusions: Dexamethasone 40 mg has a significant analgesic effect continuing into the day after surgery, but does not significantly reduce pain intensity compared to dexamethasone 8 mg.

59. Primary total elbow arthroplasty in complex fractures of the distal humerus: a retrospective study of 24 consecutive cases
Brian Weng Sørensen, Stig Brorson, Bo Sanderhoff Olsen
Orthopaedic surgery, Hillerød Hospital; Orthopaedicsurgery, Herlev University Hospital

Background: Osteoporotic fractures of the distal humerus has increased within the last 40 years. The results of osteosynthesis on distal humerus fractures in elderly are variable and studies show up to 42 percent less-than-good results according to Mayo Elbow Performance score (MEPS). Total Elbow Arthroplasty (TEA) has gained popularity in the treatment of complicated distal humerus fractures in elderly, but only few results have been reported.
Purpose / Aim of Study: To evaluate short- to medium term outcome of TEA in complex fractures of the distal humerus.
Materials and Methods: A consecutive series of 24 complex distal humerus fractures operated with TEA at Herlev Hospital in the period 2006-2012 was evaluated with the MEPS, plain radiographs, complications and overall satisfaction.
Findings / Results: 18 patients were followed up. 6 patients, of which 3 had died, were lost to follow up. AO classification: 15 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 20 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 109 degrees (range 90-140). According to MEPS there were 14 excellent, 3 good and 1 fair result. Patient satisfaction: 7 excellent, 9 good, 2 fair and 1 poor. There was one revision due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt. 5/24 (21%) presented complications to the surgery of which 3 (12,5%) were severe.
Conclusions: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome. However, the optimal treatment for complex fractures of the distal humerus has yet to be determined.

60. Short term reults after arthroscopic resection of synovial plicae in the radiohumeral joint: a case series of 68 procedures.
Jens Brahe Pedersen
Ortopædkirurgisk Afdeling , Regionshospitalet Horsens

Background: Synovial plica in the posterolateral corner of the radiohumeral joint has previously been described as a differential diagnosis to lateral epicondylitis of the elbow. Small case series have shown promising results after artrhoscopic resection of these plicae.
Purpose / Aim of Study: The aim of this study was to evaluate the short term results after plica resection of the elbow.
Materials and Methods: In this follow-up study, we included a consecutive series of 68 arthroscopies (62 patients) with arthroscopic plica resection of the elbow . Inclusion criteria were 6 months of lateral elbow pain and unsuccessful conservative treatment. Patients had either ultrasonography verified plicae or pain on palpation of the plica. Patients were evaluated with an Oxford Elbow Score (OES) preoperatively, after 3 months and after mean 22 months (range:12-31) of follow-up. Furthermore, baseline characteristics were recorded including, gender, age, BMI, occupation, smoking and cartilage damage.
Findings / Results: Mean age was 44 years (range:18-66). In 13 elbows, International Cartilage Repair Society (ICRS) grade 1 lesions were present in association with the plica. Preoperatively mean OES was 18 (95%CI:17-20). At 3 and 22 month followup OES increased to 34 (95%CI: 31-36) and 35 (95%CI 32-38), respectively (p<0,01). Cartilage injury and gender did not affect the outcome. We reported no complications.
Conclusions: Arthroscopic plica resection of the elbow indicates an improved OES after 3 and 22 months. A randomized prospective trial is needed to validate the effect of arthroscopic treatment of synnovial elbow plicae.