Session 10a: Hip/knee
Session 10b: Trauma

Fredag den 24. oktober
09:00 – 10:30
Lokale: Reykjavik
Chairmen: Kiril Gromov / Claus Emmeluth

97. Risk of readmission, reoperation and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011
Eva Natalia Glassou, Alma Becic Pedersen, Torben Bæk Hansen
Department of Orthopedic Surgery, Regional Hospital West Jutland, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark

Background: Fast track programs are widely adopted in the treatment of hip and knee arthroplasties. Several clinical studies have shown that fast track programs reduce adverse events. This study evaluates fast track programs in a population based cohort.
Purpose / Aim of Study: The aim was to compare risk of readmission, reoperation and mortality within 90 days of surgery in orthopedic departments with well documented fast track arthroplasty programs with all other orthopedic departments in Denmark from 2005 to 2011.
Materials and Methods: The Danish Hip and Knee Arthroplasty Registers were used to identify patients with primary total hip and knee arthroplasty. Information about readmission, reoperation and mortality was obtained from national databases. The fast track cohort consisted of departments participating in the Lundbeck Foundation Centre for Fast- track Hip and Knee Replacement. The national cohort consisted of all other departments. Cohorts were divided into 3 periods; 2005-2007, 2008-2009 and 2010-2011. Regression methods were used to calculate relative risk (RR) for adverse events adjusting for age, sex, type of fixation and co- morbidity.
Findings / Results: 79,098 arthroplasties were included; 17,284 in the fast track cohort and 61,814 in the national cohort. Median length of stay (LOS) was less for the fast track cohort in all 3 periods (4/3/3 vs. 6/4/3 days). RR of readmission due to infection was higher in the fast track cohort in 2005-2007 (1.3, 95% CI 1.1-1.6). RR of readmission due to thrombo-embolic event was lower in the fast track cohort in 2010-2011 (0.7, CI 0.6-0.9).
Conclusions: The general reduction in LOS indicates that fast track programs are widely implemented. Concurrently it seems that dedicated fast track departments are able to optimize the fast track program further without a rise in readmission, reoperation and mortality.

98. Low Occurrence of Thromboembolic Events After Routine Use of Tranexamic Acid in Hip and Knee Arthroplasty
Rune Vinther Madsen, Christian Skovgaard Nielsen, Thomas Kallemose, Henrik Husted, Anders Troelsen
CORH - Clinical Orthopaedic Research Hvidovre, Dept. of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Denmark

Background: Tranexamic acid (TXA) has, for many years, been used to reduce bleeding in both elective and trauma patients. TXA´s blood reducing effect is well documented. However, the still existing skepticism for routine use of TXA in elective hip and knee replacement surgeries is due to the lack of studies with larger cohorts providing documentation of the risk for thromboembolic complications after routine administration of TXA.
Purpose / Aim of Study: The objective of this study was to investigate the occurrence of thromboembolic complications after routine use of TXA in hip and knee replacement surgeries.
Materials and Methods: We identified all 3175 patients, who underwent surgery with hip or knee replacement at Hvidovre Hospital between November 2007 and March 2013. Data was then extracted from The Danish National Patient Registry focusing on post-operative thromboembolic complications, which were divided into subgroups (deep venous thrombosis, acute myocardial infarction and pulmonary embolism), occurring up to 90 days post-operatively. TXA, bolus i.v. 1 g, was administered pre-operatively, and patients were admitted in a well-documented fast-track set-up focusing on early mobilization.
Findings / Results: Of the 3175 patients, 398 did not receive TXA during their hip or knee replacement surgery. Of the remaining 2777 patients, who all received TXA during their surgery, respectively 13 (=0.5%), 6 (=0.2%) and 8 (=0.3%) patients suffered from symptomatic deep venous thrombosis, pulmonary embolism or acute myocardial infarction within 90 days post-operatively.
Conclusions: The findings suggest that routine use of TXA in hip and knee replacement surgeries is safe with a low occurrence of thromboembolic complications. However, other factors, such as early mobilization, may play a significant role in diminishing thromboembolic events.

99. The use of a primary knee prosthesis as articulating spacer in two-stage revision of infected knee arthroplasty.
Rasmus Juul, Jesper Fabrin, Klaus Poulsen, Jeannette Østergaard Penny
Department of Orthopaedic Surgery, Køge Hospital

Background: Gold standard for treating chronic prosthetic infection is two-stage revision. Traditional static spacers impair the rehabilitation whereas articulating spacers allow weight bearing and maintain joint movement. We created an articulating spacer using a new P.F.C.® Sigma® femoral component and a cemented tibial polyethylene insert (NFI spacer).
Purpose / Aim of Study: The aim of this study is to report the infection control after two-stage revision using the NFI spacer.
Materials and Methods: From December 2010 to March 2013 two-stage revision using NFI spacer was performed on 31 patients (32 knees), 18 women and 13 men, with an average age of 64 years. The patient’s medical records were reviewed retrospectively. The diagnosis was verified from microbiologic examination of tissue cultures obtained at first-stage surgery. Successful result was considered when eradication of infection was achieved with two-stage revision using only one NFI spacer.
Findings / Results: Nine patients were excluded because of negative tissue cultures and 1 patient due to prior surgery with static cement spacers. 2 patients died from unrelated medical reason and were lost to follow-up. 1 patient had bilateral NFI spacers. The left NFI spacer was excluded as the patient choose to have above knee amputation due to a tendency to luxation in the spacer. The remaining 19 patients (19 knees), mean time follow-up was 24 months, all had positive tissue cultures except one patient that had negative tissue culture but the intraoperative findings were obvious purulent. 3 patients (16 %) had recurrence of infection after second-stage surgery. 16 patient (84 %) required only one NFI spacer.
Conclusions: Successful eradication of infection was achieved in 16 of 19 cases (84%) with infected TKA. This is comparable to others studies describing the use of articulation spacer.

100. Arthrodesis of the knee after failed knee arthroplasty
Tinne B Gottfriedsen Tinne Brandt Gottfriedsen, Anders Odgaard Anders Odgaard, Henrik M Schrøder Henrik Morville Schrøder
Department of Orthopaedics, Copenhagen University Hospital Gentofte

Background: Existing data on arthrodesis for failed knee arthroplasty is limited. Data from the Danish Knee Arthroplasty Register (DKR) suggests that only 74 arthrodeses have been performed since 1997.
Purpose / Aim of Study: To identify the incidence and causes of arthrodesis after failed knee arthroplasty.
Materials and Methods: Nationwide data was extracted from the Danish Hospital Episodes Statistics and DKR. Relevant patient notes were retrospectively reviewed.
Findings / Results: We identified 89,545 primary knee arthroplasties performed in Denmark from 1997-2013. 153 arthroplasties were followed by arthrodesis corresponding to an overall crude incidence of 0.17%. Of these, 152 were performed for causes related to the knee arthroplasty corresponding to an incidence of 0.17% (range among regions, 0.07-0.28%, p=0.0002). Survival data will be presented. Mean age was 69.6 years (58.5-73.1, p=0.01). Mean time between primary knee arthroplasty and arthrodesis was 2.2 years (1.9-3.0, p=0.81). The patients underwent an average of 2.3 knee surgeries prior to arthrodesis (1.9-3.2, p=0.04). 57% of cases were assessed at a highly specialised hospital (22-100%, p<0.0001). Indications for arthrodesis included infection in 140 cases (92%), extensor mechanism disruption in 44 cases (29%), soft tissue deficiency in 22 cases (14%), bone loss in 11 cases (7%), pain in 9 cases (6%), periprosthetic fracture in 5 cases (3%) and chronic knee dislocation in one case (0.7%). In 74 cases (49%) there were at least two or more indications for arthrodesis.
Conclusions: We found significantly more arthrodeses than reported to DKR. There was large variation in the incidence among Danish regions. The main causes of arthrodesis were infection and extensor mechanism disruption. Surgeons should consider new treatment options for these complications.

101. Can low knee awareness and higher function after primary TKA be predicted? A cross-sectional study of 316 patients 1 to 4 years after surgery.
Morten Grove Thomsen, Roshan Latifi, Thomas Kallemose, Henrik Husted, Anders Troelsen
Dept. of Orthopedic surgery, Copenhagen University Hospital of Hvidovre, Denmark

Background: Low knee awareness and high knee function during activities of daily living has become the main goal after primary TKA. Evidence based information regarding the influence of patient derived factors on knee awareness and functional outcome after TKA, however, is sparse.
Purpose / Aim of Study: To investigate the influence of age, gender, KL-grade, prosthetic design, year of surgery and pre- and postoperative knee alignment on postoperative Forgotten Joint Score (FJS) and Oxford knee score (OKS).
Materials and Methods: Through database search we randomly selected 360 patients receiving a previous generation standard CR TKA, a newer generation CR TKA or mobile bearing TKA at our institution between 2010 and 2012 (1 to 4 years follow-up). Age at surgery, gender, KL-grade, prosthetic design, year of surgery and pre- and postoperative knee alignment was documented. Patients were asked to complete the FJS and OKS questionnaires. 316 patients completed the survey and were eligible for analysis. A predictive linear regression model evaluating the impact of patient derived factors on FJS and OKS scores was created.
Findings / Results: We found that female gender (p=0.002), low preoperative KL-grade (p=0.03) or a previous generation CR TKA prosthetic design (p=0.04) led to statistically significant lower postoperative FJS scores. Regarding the OKS scores, we found that female gender (p=0.001), preoperative valgus mal- alignment (p=0.04) or a previous generation CR TKA prosthetic design (p=0.005) led to statistically significant lower postoperative scores.
Conclusions: A good result after TKA is influenced by gender, kl-grade, pre-operative knee alignment and prosthetic design. Knee awareness and function during activities of daily living, however, was not influenced by postoperative knee alignment, time since surgery or age at surgery at 1 to 4 years follow-up.

102. Does knee awareness and functional outcome differ between knees of bilateral simultaneous total knee arthroplasty (BSTKA) and unilateral total knee arthroplasty (UTKA)? A cross-sectional, matched, case control study.
Roshan Latifi, Morten G. Thomsen, Thomas Kallemose, Henrik Husted, Anders Troelsen
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre

Background: Considerable controversy exists regarding the practice of BSTKA compared with UTKA. Published studies have primarily focused on perioperative complications, short-term outcome and mortality, whereas publications comparing longer term functional outcome and knee awareness between BSTKA and UTKA are lacking.
Purpose / Aim of Study: To compare the knee awareness (Forgotten Joint Score–FJS) and functional scores (Oxford Knee Score–OKS) of patients treated with BSTKA compared with UTKA, thereby to assess if BSTKA knees obtain a result different from that of UTKA knees.
Materials and Methods: Through database search we identified 69 patients receiving BSTKA and 240 randomly selected patients receiving UTKA at our institution between 2010 and 2012.The mean follow up time was 3.2 years. All patients were asked to complete the FJS and OKS questionnaires. 210 of UTKA patients and 65 of BSTKA patients completed the survey.Patients were matched regarding age, gender, year of surgery, KL-score, pre- and postoperative knee alignment leaving a study cohort of 94 knees in 47 patients in the BSTKA and 94 knees in 94 patients in the UTKA group.The FJS and OKS scores of the two groups were then compared.All TKAs were cemented and cruciate retaining (AGC, Biomet).
Findings / Results: The mean value of the OKS score in BSTKA and UTKA were 37.6(SD: 9.0) and 36.1(SD: 9.9) respectively. The mean value of FJS score in BSTKA and UTKA were 59.9(SD: 27.5) and 57.5(SD: 28.8) respectively. Mixed-effect models were used to evaluate the difference between BSTKA and UTKA, giving a mean difference of 2.3(p- value=0.59) and 1.5(p-value=0.22) in FJS and OKS scores respectively.
Conclusions: Patients undergoing BSTKA have similar knee function and knee awareness compared with patients undergoing UTKA. Our results support the use of BSTKA in patients suffering from bilateral osteoarthritis.

103. Hip fractures: Can Thrombelastography (TEG) on admission predict overall blood loss
Peter Toft Tengberg, Henrik Palm, Nicolai Foss, Jakob Stensballe, Thomas Kallemose, Anders Troelsen
CORH, Hvidovre Hospital; Anesthesiologic dept, Hvidovre Hospital; the blood bank, Rigshospitalet

Background: Blood loss increases mortality and morbidity following major orthopedic surgery, particularly among the frail hip fracture patients. The ability to predict patients at risk of a large blood loss could be a valuable tool to optimize care pathways. Thrombelastography (TEG) is used routinely to monitor hemostasis in patients with massive bleeding, in order to guide and reduce transfusion requirements. The advantage of TEG over conventional coagulation tests is that is measures real time clot formation reflecting the multifactorial causes for hemostasis deficits.
Purpose / Aim of Study: To test the viability of TEG as a routine blood sample, taken on admission, in hip fracture patients, with the purpose of identifying patients at risk of large blood losses.
Materials and Methods: The study was a prospective observational study. TEG results were blinded. From December 2013 to April 2014 all patients admitted with a hip fracture were subjected to TEG analysis on admission. Of the 227 consecutively admitted and operated patients, 180 completed a full data collection and were included into the study.
Findings / Results: Mean overall blood loss, calculated as decrease in hemoglobin from admission to the fourth-postoperative day, was 1679 ml (1114). A linear regression model for prediction of blood loss was constructed. The model included several interactions between the four TEG variables (R, K, angle and MA), with a significant effect (both p < 0.03). The effect of the inclusion of the individual TEG variables in the model was tested and found no significant effect for any one of them (all p > 0.09).
Conclusions: There are several factors that determine the overall blood loss. Coagulation status on admission, as measured by TEG, is only one of them. TEG may very well have a role in guiding transfusion therapy for hip fracture patients

104. Validation of the Danish version of the Quick-DASH questionnaire.
Jesper Ougaard Schønnemann
Orthopedic Department, Sygehus Sønderjylland, Åbenrå

Background: The Quick Disabilities of Arm, Shoulder and Hand(Quick-DASH) questionnaire is a 11-item region specific questionnaire used to measure the effect of clinical treatment to disorders and injuries to the upper extremity. The Quick-DASH has under its original development been shown as a valid and reliable outcome measure. Such a study has never been published regarding the Danish version of the Quick-DASH.
Purpose / Aim of Study: The purpose of this study is to validate the Danish version of the Quick-DASH in patients with wrist fractures, using the Nottingham Health Profile(NHP) as an evaluation tool
Materials and Methods: We included patients with wrist fractures. Patients either received conservative or operative treatment They all answered the Quick-DASH and NHP during their ambulatory follow-up. We investigated time to complete questionnaire. Internal consistency expressed by Cronbach´s alpha and test-retest reliability as intraclass correlation coefficient, Bland- Altmans 95% Limits of agreement and difference of mean. Convergent validity calculated as correlation to the domains pain and physical mobility in the NHP, and content validity to demonstrate floor and ceiling effect.
Findings / Results: Study population consisted of 61 patients. Time burden, Cronbach´s alpha and intraclass correlation coefficient were excellent and comparable to other studies. Spearman´s correlation for convergent validity was high for both pain and physical mobility, and we found divergent validity for the other domains of the NHP(sleep, energy, emotional reation and social isolation). We found good distribution of items showing no floor or ceiling effect.
Conclusions: The Danish version of the Quick-DASH is a valid and practical questionnaire for use with Danish patients with wrist fractures.

105. Primary brachial plexus reconstructon outcomes in 12 consecutive patients with traumatic brachial plexus injury, treated at the National Center for Brachial Plexus Injuries in Odense between 2010 and 2013.
Jerzy Stiasny, Anders Lorentsen, Peter Birkeland
Division of Hand Surgery, Orthopaedic Department, Odense University Hospital , Denmark; Håndsektor, Ortopædkirurgisk Afd. O, OUH; Neurokirurgisk Afd., OUH

Background: The brachial plexus (BP) lesions result in severe functional impairment of the affected exstremity. For that reason improvement in restoration of the brachial plexus function is strongly desirable.
Purpose / Aim of Study: - to analyse the results of primary BP reconstruction at our institution during the first 3 years of activity. - to draw conclusions considering improvement of the results in the future.
Materials and Methods: We analysed the data of 12 patients operated on between 2010 and 2013 with 7 partial and 5 total BP injuries. We performed a total of 14 operations where a primary BP restructure was done. Average postoperative follow-up was 27 months, patients were operated on average, 4 months after the injury. In the cases of rupture of the BP structures where the stumps were available we performed a total of 15 different types of nerve grafting. In the cases of root avulsion or non graftable roots, a total of 13 different neurotisation types were utilised.
Findings / Results: In the group of patients with partial BP lesions we achieved, in all cases, shoulder stabilisation and some shoulder movement. All patients in this group recovered useful elbow flexion of, at least, grade M3 strength according to Medical Research Council scale. In the group of 5 patients with complete BP injuries we achieved in 2 cases a stable shoulder joint with some abduction and in 4 cases some of elbow flexion, albeit weak ( grade M1 or M2).
Conclusions: In our material, satisfactory results were achieved in all cases of partial BP lesions. In the group of total BP lesions only 1 patient recovered a useful function of the limb. Improvement of the results can be achieved by means of more frequent use of neurotisation options and long nerve grafts directly into the target muscles, instead of short grafts within the nerve root and trunks.

106. Osseointegrated prosthesis for the trans-femoral amputees.
Peter Holmberg Jørgensen, Klaus Kjær Petersen, Jens Ulrik Petersen, Rene Lessmann Hansen
Orthopedic Surgery, University Hospital of Aarhus; Videncenter for Sårheling, Bispebjerg Hospital

Background: Osseointegrated (OI) prosthesis for trans-femoral amputees is as a new treatment option in Denmark. The OI- prostheses can often be used when socket prosthesis is not an option e.g. in very short residual bone length.
Purpose / Aim of Study: To evaluate the results of the first 20 patients operated with an OI-prosthesis.
Materials and Methods: 20 trans-femoral amputees, mean age 48 (range 30-66), were operated through a two stage procedure (S1 ,S2). At S1, a titanium implant (fixture) was inserted into the distal part of femur. At S2, 6 months later, a rod (abutment) was inserted into the fixture exiting through the skin at the other end to be connected to an external prosthesis. The patients were rehabilitated for six months with increasing load on the OI implant until full weight bearing. Evaluation: Walking ability, Q-TFA questionnaire, complications.
Findings / Results: 15 patients report increased walking ability, osseoperception, increased sitting comfort and easier change of external prosthesis. 13 patients are using the external prosthesis all day, 2 use it regularly. 5 patients don’t use the prosthesis: one developed severe pain and sensory disturbances of the operated femur after a fall accident, one developed reflex dystrophia which disappeared after removing the abutment, one implant was removed due to loosening and two were removed due to deep infection. One patient developed a soft tissue infection after two years which responded to antibiotic treatment. 3 patients had a soft tissue correction made due to overhang at the prosthetic knee.
Conclusions: Osseointegrated prosthesis for trans- femoral amputees is an alternative to a socket prosthesis, and for some patients it is the only option to be ambulatory. Deep infection is a severe complication which aims for further studies on prophylactic procedures.

107. Preoperative in-cast intermittent pneumatic compression of malleolar fractures
jesper Schønnemann, rasmus Buck Bendtson
Orthopedic, sygehus sønderjylland, Aabenraa

Background: Malleolar fractures are often complicated by tissue swelling due to soft tissue injury, haemorrhage and secondary inflammation. In these situations the patients operation is typically delayed until it is safe to operate again. In order to prevent delay for surgery, studies has shown that the use of intermittent pneumatic compression (IPC) has the potential benefit of reducing oedema and tissue swelling.
Purpose / Aim of Study: In a prospective patient cohort measure diagnosis-to-surgery time when using IPC, and comparing it to a similar retrospective patient cohort.
Materials and Methods: For a 3 month period all patients admitted at Sygehus Sønderjylland, Åbenrå orthopedic department requiring surgery because of malleolar fractures will be fitted with IPC (Flowtron footcompression bandage) in the Emergency Department after, if necessary, reposition, and then a cast. The time for diagnosis-to-surgery will be registered as primary outcome. The data collected in the three month period will be compared to the similar data from the department’s treatment of malleolar fractures one year prior to the start of this study.
Findings / Results: In the prospective cohort we included 17 patients, mean age 55(24-93) with an average diagnosis-to surgery time of 12 (3-26) hours. No patients were delayed due to swelling. In the retrospective cohort we identified 15 patients, mean age 63(20-89) ) with an average diagnosis-to surgery time of 42(4-138) hours. Three patients were delayed due to swelling.
Conclusions: The use of in-cast intermittent pneumatic compression (IPC), may have an influence on swelling after a malleolar fracture, and has the potential benefit of reducing the diagnosis-to-surgery time. Further research should include a randomized study.

108. Retrospective study of fifth metatarsal fractures.
Jesper Høeg Vinther, Fanny Olsen
Deparment of Orthopaedic Surgery, Kolding

Background: Fractures of the fifth metatarsal are common in active people, and are one of the most common fractures of the foot, with the majority being managed conservatively. It is our experience that fifth metatarsal fractures are conservatively treated in many different regimes, and without distinguising to different fracture subtypes. Most types of fifth metatarsal fractures have a favourable prognosis and can be treated conservatively.
Purpose / Aim of Study: The aim of our study was to describe the distribution of different treatments in relation to different fracture subtypes and describe treatment types used in different age- groups.
Materials and Methods: In this study we included a consecutive series of 165 patients with fifth metatarsal fractures who presented to our department over a period from 2005–2013. Clinical notes and radiographs of included patients were analysed retrospectively, and fractures were classified according to location (zone 1-5, 1e). Serial radiographs were studied to identify displacement. All radiographs were reviewed by first and second authors and any dispute was settled by mutual agreement.
Findings / Results: Patients in our population were on average 38 (sd=22) years old, and 54% were males. The zone 1 fracture was the most common fracture (49%). Overall, most fractures were managed conservatively (86%). The zone 1e and 5 fractures were most frequently treated with elastic bandage or spica, and patients in these groups were in general younger with mean age 28 (sd=20) and 28 (sd= 24), respectively. Generally, treatment lasting > 6 weeks were seldom used.
Conclusions: In our study we found that patients with fifth metatarsal fractures have most common a fracture in zone 1. Age and fracture type may influence on the decision of treatment, although a general pattern cannot be found.