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.