Session 4: Foot/ankle

Torsdag den 23. oktober
09:30 – 10:30
Lokale: Reykjavik
Chairmen: Jørgen Baas / Johnny Frøkjær

37. Postoperative oxygenation and metabolism of the soft tissue covering total ankle replacement
Frank Linde, Niels Christian Jensen, Kristian Kibak Nielsen, Hanne Birke-Sørensen
Department of Orthopaedics, University Hospital of Aarhus

Background: Up to one third of total ankle replacements (TAR) are followed by wound healing complications. Even minor complications are potentially catastrophic as they may lead to loss of the prosthesis.
Purpose / Aim of Study: The aim was to obtain knowledge regarding the oxygen pressure and the metabolism in the soft tissue after TAR.
Materials and Methods: Fifteen TAR patients were included. Transcutaneous oxygen tension (tcpO2) was measured at both sides of the incision site preoperatively, 3 hours postoperatively and daily the following 6 days or until discharge from the hospital and finally at 3 weeks follow-ups. Microdialysis catheters were placed subcutaneously at both sides of the incision during the operation. Samples for analysis of the local metabolism were harvested each half hour for 3 hours after the operation and then every 2 hours during daytime
Findings / Results: TcpO2 was normal the first 3 hours postoperatively. At the 2nd postoperative day it has dropped to median 20% of the preoperative values and stayed low until the 4th day. Day 6 it has increased to median 45%, and 3 weeks postoperatively it had reached a normal level. No sign of anaerobic metabolism was found, and none of the 15 patients developed skin complications.
Conclusions: The oxygen tension in the soft tissue adjacent to the skin incision after TAR may be critical low during the 2nd to 4th day after operation. These data may serve as guide for timing and duration of interventions for optimization postoperative care after TAR and other major foot operations.

38. Completeness and data validity in the Danish Achilles Tendon Rupture Database
Michael Bilde Kuhlman, Anders Troelsen, Kristoffer Barfod
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark

Background: Orthopaedic surgeons treat acute Achilles tendon rupture (ATR) differently as there is currently no consensus on the preferred treatment. Data from the Danish Achilles Tendon Rupture Database (DADB) can, for the first time, offer quality monitoring of treatment and may shed light on outcomes of different treatments provided that data are complete and valid.
Purpose / Aim of Study: The aim of this study was to test the completeness and validity of data in DADB.
Materials and Methods: DADB was established in April 2012. Currently, five Danish Orthopaedic Departments enter data such as general patient demographics and acute ATR treatment and outcome specifics. The study period was 1st of October 2012 to 30th of September 2013. Two primary outcome parameters were assessed: 1) Completeness of data was assessed using data generated at one institution. Data from DADB was compared to medical records. The proportion of patients with acute ATR registered in DADB was assessed. Eighty percent completeness was considered satisfactory. 2) Validity of data entered in to DADB was performed on the same dataset. Data from DADB was compared to medical records. Only complete (100%) agreement between DADB and medical records were considered valid.
Findings / Results: Eighty-five patients were registered in DADB. Of these, 73 (86%) were males. Median age was 40.3 years (25-75% IQR: 35.0-51.9). Overall, 87.1% of data from DADB was consistent with medical records. The validity (consistency with medical records) of the individual parameters assessed range from 50.6-92.9%. Data completeness in DADB was 82.5%.
Conclusions: In conclusion, this study shows that DADB offer satisfactory data completeness and validity for future purposes of quality monitoring and research. Improved data validity can be achieved through clarifying data parameter definitions.

39. Survival of 308 total ankle replacement. A 1-14 years follow-up.
Niels Chr. Jensen
Orthopaedic, University Hospital Aarhus

Background: As total ankle replacement (TAR) becomes a white spread solution to degenerative ankle disease it is important to know the results after TAR.
Purpose / Aim of Study: The aim of this study is to describe the failure pattern and the survival rate of the STAR TAR.
Materials and Methods: It is a single center prospective study of 308 STAR TAR. 231 with osteoarthrosis (OA) and 77 had rheumatoid arthritis (RA) were done in a period from 1998 to the 1. of June 2012. Failure was defined as failure of one or more prosthetic component.
Findings / Results: Twenty-five with OA and 17 with RA were failures. Fifteen OA and 4 RA were late failures where only the polyethylene component was broken or worn. Seven OA and 3 RA patients had a revision. Ten RA and 7 OA had an arthrodesis. One, 5 and 10 Year survival rate survival rate for OA was 0.97, 0,90 and 0,77 respectively. One, 5 and 10 year survival rate for RA was 0,90, 0,84 and 0,75.
Conclusions: There is a relatively high early failure rate especially for the RA patients the late failures are dominated by failure of the polyethylene component. Despite the relatively high failure rate 223(97%) of 231 OA TAR is still in place and 67(87%) of 77 RA TAR is still in place.

40. Five year survival rate of STAR ankle replacement
Johnny Frøkjær, Lasse Petersen
Orthopedic department, foot & ankle section, Odense University Hospital; Orthopedic department, Odense University Hospital

Background: Total ankle replacement has become a good alternative to arthrodesis in the treatment of ankle arthrosis in selected patients. Results have been variable, therefore we find it of interest to report our results.
Purpose / Aim of Study: The aim of the study was to find our five year survival rate, for the STAR ankle replacement, at our institution.
Materials and Methods: We evaluated the intermediate prosthesis survival rate of 200 STAR ankle replacements, inserted in 196 patients between 2004 and 2013 at our department. 109 were men and 87 women. Four patients were operated bilaterally. Surgical concept was to align the ankle during first surgical procedure, if there was any alignment. Patients were seen annually until at least six years after index surgery. We retrospectively evaluated the prosthesis survival, using our database, where data were continously registred at surgery and at follow up. Furthermore patient records were used, to exclude surgery at other hospitals. Revision was defined as "removal or exchange of one or more components with the exception of incidental exchange of the polyethylene insert" The surgical guide system was changed during this period
Findings / Results: Ten patients had a revision performed, four of these were among the first ten patients operated - illustrating the steep learning curve. Additional three patients had the polyethylene liner exchanged. Using the above mentioned end point, 5 year survival rate for the STAR ankle replacement is 94% (95% CI-interval 0,89-0,99)
Conclusions: We find the intermediate survival rate of the STAR ankle replacement excellent. Learning curve problems could only be detected for the first surgeon, while problems for next two surgeons were eliminated. We will continue to follow our patients, with regular controls, and will report further survival rates.

41. No correlation between Bone cyst volume and clinical symptoms in patients with ankle replacement
Ellen Hamborg-Petersen, Trine Torfing, Janni Jensen, Johnny Frøkjær
Ortopædkirurgisk Afdeling, OUH; Radiologisk Afdeling, OUH

Background: Periprosthetic bone cysts are a known side effect following a total ankle replacement (TAR), possibly threatening the long-term survival of the implant.
Purpose / Aim of Study: The primary purpose of this retrospective study was to investigate the correlation between AOFAS score, VAS score, function, age of implant and periprosthetic cyst volume after TAR.
Materials and Methods: 40 consecutive patients with a Scandinavian Total Ankle Replacement were seen for a yearly control from 16.09.11-17.05.12. Forty- one ankles were evaluated, mean age was 61.6 years (40-79) and mean follow up time was 36 months (3-72). The replacements were radiologically evaluated for cysts using Weight- bearing Multi-Planar Reconstructed Fluoroscopic imaging followed by clinical tests measuring the patients AOFAS score, VAS score and function. Plots of the residual did not fulfill the normal distribution. For this reason all analyses were performed using non-parametric tests (Spearman rho).
Findings / Results: No statistical significant correlation was found between the cyst volume and any of the variables: AOFAS score (rho=0.005, p=0.974, 95% CI:-0.307 to 0.316), VAS score (rho=0.137, p=0.399, 95% CI:-0.182 to 0.430), Function (rho=-0.062, p=0.706, 95% CI:-0.371 to 0.258) and ankle replacement age (rho=0.229, p= 0.149, 95% CI:-0.084 to 0.502).
Conclusions: No correlation between total cyst volume and AOFAS score, VAS score and function was found. No correlation between age of TAR and total cyst volume was found. The significance of periprosthetic cysts in ankles is still not clear. All patients will be followed with regular controls in the future to observe further cyst development and aseptic loosening of the prosthesis.

42. Clinical outcome in 308 total ankle replacement. A 1-14 years follow-up.
Kristian Kibak Nielsen, Niels Christian Jensen, Claus Sundstrup, Frank Linde
Section of foot and Ankle Surgery., University Hospital of Aarhus. Aarhus. Denmark.

Background: As total ankle replacement (TAR) becomes a generally accepted treatment for degenerative ankle disease, it is important to know the clinical outcome after TAR.
Purpose / Aim of Study: The aim of this study is to describe the clinical outcome in STAR TAR
Materials and Methods: This is a single centre prospective study of 308 STAR TAR, performed from 1998 to 1. June 2012. Two hundred and thirty one patients with osteoarthrosis (OA) and 77 with rheumatoid arthritis (RA). There was 197 TAR in OA patients and 56 TAR in RA patients who had the primary TAR in place and a complete standard scoring at follow up. The AOFAS hind foot score and retrospective VAS-score for pain was used for evaluation
Findings / Results: In the RA group the preoperativ AOFAS hind foot score changed from 31 to a postoperative score of 73. In the OA group the score changed from preoperative 49, to a postoperative score of 75. All RA patients and 89% of the OA patients had a significant improvement in VAS pain score.
Conclusions: Both RA and OA patients improves after TAR in both AOFAS hind foot score and VAS pain score.

43. Functional rehabilitation of patients with acute Achilles tendon rupture: A meta-analysis of current evidence.
Kristoffer Weisskirchner Barfod, Troels Mark-Christensen, Thomas Kallemose, Anders Troelsen
Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre; , Physiotherapist at Fysiocenter Århus

Background: The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non- operative treatment may not be as important as the following rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization.
Purpose / Aim of Study: The purpose of this meta-analysis of randomized, controlled trials (RCT’s) was to compare functional rehabilitation to immobilization in the rehabilitation of ATR.
Materials and Methods: This meta-analysis was conducted using the databases: PubMed, Embase, Rehabilitation & Sports Medicine Source, Amed, Cinahl, Cochrane and PEDro using the search terms: “Achilles tendon”, “rupture”, “mobilization” and “immobilization”. Seven RCT’s involving 427 participants were eligible for inclusion, with a total of 211 participants treated functionally and 216 treated with immobilization.
Findings / Results: Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction was examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.
Conclusions: Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. There is a trend towards earlier return to work and a significant increased patient satisfaction using functional rehabilitation. The present literature is of low to average quality and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.

44. Severely reduced functional outcome at mean 9 year follow-up after complications associated with acute Achilles tendon rupture
Kristoffer Weisskirchner Barfod, Thor Magnus Sveen, Ann Ganestam, Lars Bo Ebskov, Marko Nabergoj, Anders Troelsen
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Køge

Background: Treatment of acute Achilles tendon rupture is highly debated. In the pursuit of the best treatment severity of complications is important.
Purpose / Aim of Study: To investigate the long term effect of deep infection, sural nerve injury and re-rupture in the treatment of acute Achilles tendon rupture.
Materials and Methods: 324 patients made a claim to the Danish Patient Insurance in the period 1992 to 2010 due to a complication after acute Achilles tendon rupture. Of those 150 agreed to receive written information concerning the investigation and 98 patients (m/f = 63/35) returned the Achilles tendon Total Rupture Score (ATRS) and the Short Form-36 (SF- 36) questionnaires. Patients suffering from deep infection (n=8), Sural nerve injury (n=5) and re-rupture (n=16) were invited to participate in a follow up investigation.
Findings / Results: The mean follow up period was 8.9 years (3;21). Looking at the whole population a mean ATRS of 50 (SD 30) was found; in comparison healthy subjects have a median of 100 (94;100). The summary scores of SF-36 were PCS = 42 (SD 12) and MCS = 52 (SD 11); in comparison healthy subjects have a mean of 50 for both scores. No differences were found comparing the subpopulations who suffered from a deep infection, injury to the Sural nerve or re-rupture. The physical evaluation investigating tendon length and heel-rise work revealed a statistically significant difference between the affected and the unaffected limb after re-rupture (p<0.01) but not after injury to the Sural nerve (n.s.) and deep infection (n.s.).
Conclusions: The investigated patients who suffered from a complication after acute Achilles tendon rupture had a remarkable reduction of the ATRS and PCS at mean 9 year follow up. Patients suffering from re-rupture had a significant elongation of the tendon and reduction of strength in the affected limb.