Session 5: Pediatric / Foot

Torsdag den 22. oktober
09:00 – 10:30
Lokale: Stockholm/Copenhagen
Chairmen: Vilhelm Engell / Jeannette Ø. Penny

49. The effect of early vs. late weightbearing in conservatively treated acute Achilles tendon rupture: A meta- analysis
Ali Imad Akkawi,, Rajzan Joanroy,, Kristoffer Weisskirchner Barfod, MD, PhD, Thomas Kallemose, statistician, Søren Skydt Kristensen, MD, Prof, Dr.Med, Bjarke Viberg, MD, PhD
Odense, University of Southern Denmark; Clinical Orthopedic Researh, Dept of Orthopedics, Copenhage university hospital, Hvidovre; Clinical and research department, Copenhagen university hospital, Hvidovre; Dept of Orthopedics, Odense university hospital

Background: Achilles tendon ruptures can be conservatively treated with immobilization and early functional mobilization but early weight bearing is more uncertain.
Purpose / Aim of Study: To conduct a meta-analysis comparing the effect of early versus late weight bearing in conservatively treated Achilles tendon ruptures in adult patients. Primary endpoint was re-rupture and secondary endpoints were strength, ’Quality of life during treatment’, range of motion, deep venous thrombosis, return to sport, and return to work.
Materials and Methods: A search string was constructed using the keywords “Achilles tendon” and “rupture” and applied in PubMed, EMBASE and The Cochrane library. Two reviewers independently screened the studies by title, then by abstract and finally by full text reading. 3 studies met the inclusion criteria. The reference lists of the included studies were screened and 1 further RCT study was included. Experts on this field were asked and no further studies were identified. The CASP checklist was applied for the study appraisal. Data was extracted according to the purpose of this study. For the meta- analyses the Mantel-Haenszel method was used for the effect estimates. A fixed effect model was chosen. and the results were presented in forest plots.
Findings / Results: There were no statistically significant differences between the two treatment groups concerning re-rupture: OR 0.99 (95 % CI 0.31; 3.18), p= 0.981, return to sports: OR 1.34 (0.62; 2.90), p= 0.455, and return to work: MD (Mean difference) 1.62 (-20.89; 24.13), p= 0.888. For the other endpoint it was not possible to conduct a meta- analysis.
Conclusions: There was no statistically significant difference between early and late weight bearing in conservative treatment of Achilles tendon rupture concerning the outcomes of this study.

50. The effect of 15 minutes postoperative daily arm bicycling on oxygenation of the soft tissue after total ankle replacement
Claus Sundstrup, Niels Christian Jensen, Kristian Kibak Nielsen, Frank Linde
Foot and Ankle Section, Department of Orhtopaedics, Aarhus University Hospital; Foot and Ankle Section, Department of Orthopaedics, Aarhus University Hospital

Background: Wound healing complications after total ankle replacement are reported as frequent as 30%. Although most minor, they are occasionally serious and may lead to loss of the prosthesis. Recent studies have shown that the oxygenation of the soft tissue around the ankle decreases significantly the day after total ankle replacement, and does not reached normal level until the 6th postoperative day.
Purpose / Aim of Study: The purpose of the present study was to study the effect of postoperative exercise by arm bicycling in the bed on the oxygenation of the soft tissue at the lower leg.
Materials and Methods: Eleven patients who had a total ankle replacement had a 15 minutes training session every postoperative day until the 4th postoperative day. The training intensity was individually adjusted to approximately 70% of maximal level. Trancutaneous oxygen tension (tcpO2) was measured at the operated ankle using the Radiometer TCM400 system. TcpO2 of the non-operated ankle and the upper part of both lower legs served as controls. TcpO2 was measured preoperatively and every postoperative day at rest (before exercise), during exercise, and during restitution.
Findings / Results: TcpO2 at the operated ankle decreased from median 58 mmHg preoperatively to median 22 mmHg the 1st postoperative day. TcpO2 at rest the following 3 days was 15 mmHg, 9 mmHg and 13 mmHg respectively. During exercise tcpO2 increased to 44 mmHg, 34 mmHg, 22 mm Hg, and 23 mmHg (p<0,05, Wilcoxon sign test). However, after exercise, tcpO2 had decreased to the pre-exercise level within 30 min.
Conclusions: The postoperative oxygenation of the soft tissue around the ankle after total ankle replacement increased significantly during arm exercise. However, the effect on tissue oxygenation vanished within 30 min. rest.

51. The flexible adult flatfoot. An evaluation of three different etiology-pathogenesis hypotheses. A case-control study.
Lotte Dalsgaard Petersen, Merete Frick Jeopsen, Henrik Lopdrup, Frank Linde
School of Physiotherapy, VIA University College, Aarhus ; Foot and Ankle Section, Department of Orthopaedics, Aarhus University Hospital

Background: Several hypotheses have been proposed for the etiology and the pathogenesis of the flexible flatfoot.
Purpose / Aim of Study: The purpose was to test three different hypotheses. 1) a short Achilles tendon, 2) increased laxity of the 1st ray, 3) incomplete axial rotation of the medial ray in relation to the lateral ray of the foot.
Materials and Methods: 16 young adults (20-29 years) with a flexible flatfoot were selected from a group of 65 volunteers. A flatfoot was defined as a foot fulfilling two criteria: The Foot Posture Index (FPI-6, Redmond 2005) above 7 and the heel in more than 5 degrees valgus in the weight bearing position. 16 volunteers with neutral feet matched for sex, age, weight and foot length served as controls. The length of the Achilles tendon was determined as the degree of dorsiflexion of the ankle examined with the person in the prone position with the knee flexed 90 degrees and the heel in neutral position. The stability of the first ray was determined as the dorsal-plantar laxity in relation to the second ray. The axial rotation (pronation) was measured with the ankle and the heel fixed in neutral position as the maximal pronation of the forefoot.
Findings / Results: The length of the Achilles tendon in the flat foot group was median 28 degrees compared to 24 degrees in the control group (p=0,024, Wilcoxon test). Laxity of the 1 ray was median 6 mm in the flat foot group compared to 4 mm in the control group (p=0.006). No significant difference was found regarding pronation of the foot.
Conclusions: It is a general statement that the flexible flat foot is associated with a short Achilles tendon. It could not be demonstrated in this group of young adults. In contrary the Achilles tendon was found to be longer in the flat foot group. This study support general laxity as the most probable etiology for the flexible flatfoot.

52. Achilles Tendon Total Rupture Score at 3 months can predict patient’s ability to return to sport at 12 months. A registry study on 366 patients from the Danish Achilles Tendon Database.
Maria Swennergren Hansen, Marianne Christensen, Thomas Budolfsen, Thomas Kallemose, Anders Troelsen, Kristoffer Weisskirchner Barfod
Physiotherapy, Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Occupational therapy and Physiotherapy, Orthopaedic surgery, Danish Achilles Tendon Database, Aalborg University Hospital, Denmark; Physiotherapy, Danish Achilles Tendon Database, Copenhagen University Hospital, Hvidovre, Denmark; Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Clinical Research , Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark

Background: It is desirable to identify predictors of outcome after acute Achilles tendon rupture in order to individualize treatment. It is unknown if the Achilles tendon Total Rupture Score (ATRS) correlates to patients ability to return to sport and work. The Danish Achilles Tendon Database (DADB) was founded in 2012.
Purpose / Aim of Study: To investigate how ATRS 3 and 12 months after injury correlates with the patient’s ability to return to work and sport. Furthermore to investigate if sex and age influences ATRS 3 and 12 months after injury.
Materials and Methods: This is a retrospective study analyzing data from DADB including 366 patients from 5 hospitals in Denmark. Logistic regression was conducted to describe the effect of ATRS on return to work and sport after 1 year (adjusted for age and sex). The effect of age and sex on ATRS was analyzed by linear regression.
Findings / Results: Three months after injury patients had a significantly increased chance for return to sport after one year with increased ATRS score (OR = 1.06 for each point, CI = 1.02-1.09, p = 0.002), but non-significant effect for work. After one year patients had a significantly increased probability of having returned to sport (OR =1.11, CI = 1.05-1.17, p < 0.001) and returned to work (OR = 1.05, CI =1.01-1.09, p = 0.007) with increased ATRS score. Men had an average 6.6 (CI = 1.9 - 11.4, p = 0.006) point higher ATRS score at 3 months and average 22.3 (CI = 6.7 – 37.9, p = 0.006) point higher at 12 month. Age showed no significant effect on the ATRS score at 3 or 12 month.
Conclusions: ATRS is correlated to patient’s ability to return to sport and work. ATRS at 3 months can be used as a predictor of patient’s ability to return to sport one year after injury. Men obtain a noticeable higher ATRS score3 and 12 months after injury.

53. 10-year survival analysis of 217 primary Hintegra total ankle artroplasties from an independent center
Mina Zafar, Lars Ebskov, Jeannette Østergaard Penny
Orthopeadic department, Hvidovre Hospital

Background: Total Ankle arthroplasty (TAA) have larger revision rates than hip and knee prosthetics. Almost half of all publications concerning TAA come from the developer’s center, which often publish better survival rates than those from registries. There are currently no larger independent survival studies of the Hintegra TAA.
Purpose / Aim of Study: To examine the indications for and survival rates of our primary Hintegra TAAs and what different factors affect the success and/or revision-rate.
Materials and Methods: 487 surgeries between 2004-2014 coded as ankle implant was reviewed. 217 were operated with a primary Hintegra TAA, 109 female and 108 males, median age 61 (23 to 80). We used the 2nd generation implant (CrCo-HA coating) until 2007 and 3rd generation (Ti-HA coating) from 2008. Cause of OA, revision surgery and reason to revise was recorded. A Cox proportional hazard model evaluated gender, age, cause of OA and implant generation as risk factors.
Findings / Results: 62 implants were revised. The cause of revision was pain (18), loosening (18), infection (12) or mixed others (14). The 5 year survival rate (95% CI) was 72 (62-80) %, 7 year = 64 (55-75) % and 10 year = 47 (29-76) %. Fifty nine percent of the 217 primary implants had post traumatic OA, 32% idiopathic and 9% RA, which had no impact on revision risk. Nor had age or gender. Of the 34 2.nd generation implants only 11 was revised, making them 5 times (1 to 18) less likely to be revised (p= 0.02).
Conclusions: Our revision rates are slightly above the Swedish registry and well above those of the developer. Our patients are different but that has no statistical impact on revision. The larger risk found for the 3rd generation in this study is not found in the developers results. Further studies on preoperative angles and implant position may help clarify our relative high revision rates.

54. Fracture dislocation of the midfoot (Lisfrancs injury): Early results of ORIF at Koege Hospital
Zaid Issa, Anna Kathrine Pramming, Jens Kurt Johansen
Ortopaedic Department, Koege Hospital

Background: Lisfranc injury (LI) involves ligament tear, fracture and joint disruption at the midfoot, involving 1 or more tarsometatarsal (TMT) joints. LI constitutes 0,2% of all fractures. Direct axial force is a common cause of injury generating tensile forces at the plantar ligaments of the TMT- joints. Indirect force generated through rotation or twisting on a plantarflexed foot is another cause of injury. Severity of the soft tissue injury and non-anatomic reduction are negative prognostic factors. LI are managed by foot surgeons at Koege orthopedic clinic since 2012.
Purpose / Aim of Study: To evaluate results of LI treated by ORIF over a 3 year period.
Materials and Methods: 15 consecutive patients, 9 males and 6 females, were included. Patients were identified using ICD10 diagnosecodes. Medical records and postop x-rays were reviewed. Radiologic alignment was accessed. Age ranged from 16 to 73 years, mean age 45 years.ORIF with screws, bridging plates and in some cases k- wires were used. Acute closed reduction and K-wire fixation was done in 2 cases due to soft tissue concerns, ORIF was performed secondarily. Primary arthrodesis of the 1.TMT joint was done in 1 case.A-VI Foot Pump was used in the early postoperative fase.Follow-up ranged from 6-24 weeks
Findings / Results: 11 patients were Grade 1, 4 patients were Grade 2 on Tscherne Score.10 patients are painfree and have returned to their pre-injury activities (work and sports).5 patients have mild pain.1 patient had hardware removal due to pain. 1 patient had wound breakdown but healed uneventfully.Anatomic alignment was achieved in 14 cases.
Conclusions: Outcome of current treatment of LI at Koege Hospital seems satisfactory regarding alignment and complication rate. Long term follow up and patient related outcome measure is suggested to provide more information regarding patient satisfaction.

55. subtalar arthroereisis by minimal invasive surgery
Frantz Nørregaard, Gert Rahbek Andersen
, ; Dept. of Orthopaedics, Rigshospitalet

Background: Calcaneus-valgus often develops in children with cerebral palsy. This can cause gait disturbance and pain. There are several surgical options to correct the valgus postion. Extra articular subtalo arthrodesis or arthroereisis are among these, and they include procedure in sinus tarsi, and are thereby extensive and irreversibel procedures. The present study is minimal invasiv surgery and is reversible.
Purpose / Aim of Study: We want to present our results from charts to see if our procedure is comparable to more extensive procedures and to share the possible risk of failure in our method.
Materials and Methods: 20 feet (11 patients) operated from 2009- 2014 with the present procedure was retrospectively found from charts from Rigshospitalet, Copenhagen. The operative technic was a stab wound dorsal over the neck of the talus. A K-wire was inserted through the neck and sinus tarsi, to the calcaneus, when the hindfoot is held in a correct hindfoot position. A cannulated 7 mm screw secure the correct subtalar joint position, and a low leg cast in 6 weeks allowing full weight bearing.
Findings / Results: 19/20 feet had satisfactory hindfoot position with no prolonged pain or implant failure. 1/20 feet was found with prolonged pain at the site of the screwhead, and removal was necessary. The international results are comparable with presented rates of failure in 5-10 % of the feet.
Conclusions: The present procedure seems to be safe. The reversability enables the surgeon to try the internal fixation without the risk of chronic pain or otherwise unsatisfactory results

56. Obesity increases risk of deep infection in ankle fracture surgery
Lasse Lykkebo Olsen, Rune Sort, Ann Merete Møller, Stig Brorson
Department of Anaesthesiology , Herlev University Hospital; Department of Orthopaedics, Herlev University Hospital

Background: Surgical site infections are common after open reduction and internal fixation (ORIF) of ankle fractures. Deep infections lead to re- operations, thus adding to both the risks and cost of the patient course. Smoking, obesity and alcohol overuse have been suggested as risk factors for post-operative complications after ankle fracture surgery but evidence is limited.
Purpose / Aim of Study: To examine if smoking, obesity and alcohol overuse are risk factors for developing deep infection following ORIF of ankle fractures.
Materials and Methods: We retrospectively reviewed all patients undergoing ORIF of ankle fractures at Herlev University Hospital from 01.01.2008 to 31.12.2013. Patients, who were not primarily treated with ORIF or did not attend the outpatient follow up, were excluded. We reviewed patient records and collected demographic-, surgical- and postoperative data. Deep infection was defined as being re- operated on the indication of infection. We tested for associations to current smoking (yes/no), obesity (BMI≥30) and alcohol overuse (exceeding Danish Board of Health recommendations). We analysed data using both univariate and multivariate analyses adjusting for demographic factors and diabetes.
Findings / Results: 1044 patients were included in the study. Patients with BMI≥30 were found to have an increased risk of being re-operated for an infection both in the univariate (RR=2,08 [1,21:3,59], p<0,05) and multivariate analysis (OR=2,16 [1,13:4,15], p<0,05). Alcohol overuse was also found to increase the risk but this was not statistically significant (RR=1,70 [1,03;2,78], p=0,053).We were not able to show any risk increase connected to smoking.
Conclusions: Obesity increases the risk of deep infection after primary ORIF of ankle fractures.

57. Seating performance in children with cerebral palsy in relation to hip reconstructive surgery
Line Kjeldgaard Pedersen, Ole Rahbek, Bjarne Møller-Madsen
Department of Childrens Orthopedics, Aarhus University Hospital

Background: Excessive pelvic tilt impedes sitting function and can cause pressure ulcers, which might have an impact on quality of life in children with cerebral palsy (CP). Seated sagittal plane anterior tilt is affected by iliopsoas, hamstring and rectus contraction, weakness or spasticity. Posterior tilt with a decreased lumbar lordosis is seen in hypotonic children or after scoliosis surgery and is characterized as a more vertically placed sacrum, potentially causing painful sitting and ulcers over the sacro-coccygeal area. Seated coronal plane pelvic tilt may display either right or left pelvic obliquity and is common in children with tetraplegia, asymmetrical adductor contractures, scoliosis or hip dislocation. Seated transverse plane obliquity presents as rotation of the pelvis and is primarily seen in relation to scoliosis.
Purpose / Aim of Study: To assess seating performance and pelvic tilt in children with CP undergoing hip reconstructive surgery.
Materials and Methods: Eighteen children with CP, GMFCS III- V, scheduled for unilateral hip reconstruction were included. The Tekscan CONFORMat Seat Sensor with a resolution of 1 sensor per cm2 and frequency of 66 frames/second was used for assessing seating performance with 30 seconds recordings performed pre- and postoperatively.
Findings / Results: Analysis of the area, force, pressure, peak force and peak pressure showed that all measures decreased on the operated side after hip reconstruction. The pressure asymmetry index decreased (diff: 11%) indicating decreased coronal plane obliquity. A decrease of peak pressures (diff: 22 mmHg and 30 mmHg) in the two columns flanking the midline was seen postoperatively indicating increased pelvic anterior tilt and elevation of the sacrum.
Conclusions: Changes in seated pelvic tilt after hip reconstruction can be evaluated by assessment of seating performance.

58. Intra-variability of outcome measures for seating performance and pelvic tilt in 65 healthy children
Line Kjeldgaard Pedersen, Polina Martinkevich, Søren Quist Ege, Sofie Gjessing, Ole Rahbek, Bjarne Møller-Madsen
Department of Childrens Orthopedics, Aarhus University Hospital

Background: Normal sitting function is perceived instinctly, though many biomechanical aspects are present in the process of sitting. The three-dimensional bony base of support in sitting is formed by the ischial tuberosities and sacrum. The interface between body and support is defined by the sagittal, coronal and transverse plane pelvic tilt, which contributes to measures of pressure distribution, balance and symmetry. Balance parameters have been presented. A flexible pressure mat for measuring seating performance may be a new method for analyzing seating performance and pelvic tilt.
Purpose / Aim of Study: To define outcome measures and determine the intra-variability of measures of seating performance.
Materials and Methods: Sixty-five healthy children aged 7-14 years were included at a primary school. The Tekscan CONFORMat Seat Sensor with a resolution of 1 sensor per cm2 and frequency of 66 frames/second was used. Three recordings were done with the child seated with a relaxed back position, followed by three recordings with an up-right back position increasing the pelvic anterior tilt.
Findings / Results: The measures of area, force, pressure, peak force and peak pressure establish a normal material. Intra-Class Correlations (ICC) for these measures ranged between 0.87 and 0.99 indicating excellent intra-variability of the measures of seating performance. Asymmetry indices comparing left and right side were calculated. The lowest index was seen for contact area indicating good symmetry and the highest index was seen for peak pressure. A significant decrease of peak pressures in the two midline columns was seen when the back position was changed to up-right (p<0.05; p<0.05), reflecting an anterior pelvic tilt and elevation of the sacrum.
Conclusions: A normal material and a definition of validated measures of seating performance have been determined.

59. The pattern of bicycle injuries and the use of helmets among children aged 6-14 years 1980-2014.
Martine Solheim, Jens Martin Lauritsen, Christian Færgemann
Department of Orthopedics and Traumatology, Odense University Hospital

Background: There has been an increase in bicycle helmet use since 1990. Studies have shown that the incidence of severe head injuries can be reduced by 65 % when wearing a bicycle helmet. Does the increasing use of helmets change the injury pattern from bicycle accident among children seen in an ED.
Purpose / Aim of Study: The purpose of this study was to describe the injury pattern in bicycle accidents among children in relation to the use of a bicycle helmet.
Materials and Methods: We included all children aged 6-14 years with injuries from bicycle accidents treated at the ED at Odense University Hospital 1980-2014. Age, gender, helmet use, and diagnoses were analyzed. We defined head injuries as all injuries involving the head excluding injuries to the face. We defined severe head injuries as skull fractures and intracranial injuries including concussions, intracranial haemorrhages, lacerations of brain etc.
Findings / Results: We included 13661 children, 58.8 % were boys. The use of helmets at the time of injury increased from 0 to 19.6 % in girls and 16.9 % in boys. There was a gradual decrease in head injuries from 30.7 % to 14.3 % and a gradual decrease in severe head injuries from 5.9 % to 3.2 % in the study period. The proportion of head injuries and severe head injuries among children wearing helmets and children not wearing helmets were 13.9 % vs. 26.6 % and 2.8 % vs. 4.5 %. In the study period the proportion of facial injuries, bone fractures, spine/columna injuries, and deep injuries in thorax/abdomen remained unchanged. Eighteen children died from their injuries. All had severe head injuries and none of them wore a helmet.
Conclusions: The proportion of head injuries from bicycle accidents among children has been reduced by about 50 % over the last decades concurrent with increase in helmet use. None of the 18 deceased children wore a helmet.

60. Congenital Clubfoot treated by the Ponseti method. Evaluated by the CAP at age 4.
Vilhelm Engell, Niels Wisbech Pedersen, Bjarne Lundgaard, Søren Overgaard
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark.

Background: Despite the advances in the treatment of clubfoot, with the advance of The Ponseti method, there is still no widely accepted method to evaluate the outcome. The Clubfoot Assessment Protocol (CAP) was developed for follow-up of children treated for congenital clubfoot. It is a comprehensive standardized measurement instrument to evaluate the clubfoot with respect to mobility, muscle function, morphology and motion.
Purpose / Aim of Study: The aim of this study is to report our results of the Ponseti method evaluated with CAP at age 4 years.
Materials and Methods: In this consecutive prospective cohort series we included all 44 children referred to the department with congenital idiopathic clubfoot from October 2006 to January 2009. A total of 44 children, with 67 clubfeet were treated. We excluded 1 patient since the clubfeet were part of Athrogryposis Multiplex Congenita, since the treatment and also the clubfoot is different from the idiopathic cases. A total of 9 patients were lost for follow-up. So, 34 children (77%) with 52 CTEV were our study population. However, only a total of 28 patients were CAP-scored. Two children were excluded because they couldn’t cooperate due to mental retardation and 4 children didn’t want to participate.
Findings / Results: The Clubfeet scores lower than the normal feet in all CAP subgroups. This is statistically significant in CAP1 Passive mobility, CAP2 Muscle function and CAP5 Motion quality II not so in CAP3 Morphology and CAP4 Motion quality I. We found differences with the clubfeet scoring lower in Dorsiflexion at the ankle, Muscle function of M. Peroneus and Hop on one leg.
Conclusions: The CAP is a comprehensive tool for follow-up of clubfeet. In this study 3 parameters shoved differences between normal and clubfeet at age 4 years (ankel dorsiflexion, peroneal function and one leg jump).