Session 8: Sportstrauma

Torsdag den 22. oktober
13:00 – 14:30
Lokale: Stockholm/Copenhagen
Chairmen: Morten Boesen / Kristoffer Barfod

85. Self-reported shoulder function, strength, range of motion and pain in patients with subacromial impingement: A direct comparison of patients being candidates versus patients not being candidates for subacromial decompression
Adam Witten, Mikkel Bek Clausen, Mikkel Attrup, Kristian Thorborg, Per Hölmich
Sports Orthopedic Research Center , Copenhagen, Department of Orthopedics, Copenhagen University Hospital, Amager & Hvidovre, Denmark; Metropolitan University College, Department of Physiotherapy and Occupational Therapy, Copenhagen, Denmark

Background: Subacromial impingement (SIS) is associated with impairments in rotator cuff strength and range of motion (ROM), low self-reported shoulder function and pain. We hypothesized that patients being candidates for subacromial decompression (SAD) have more pronounced symptomatology and impairments than non-candidates.
Purpose / Aim of Study: To compare rotator cuff muscle strength, ROM, self- reported shoulder function and pain between candidates and non-candidates for SAD.
Materials and Methods: Self-reported shoulder function (Q-DASH and SPADI), maximum isometric muscle strength in shoulder abduction (AB-strength) and external rotation (ER-strength), active abduction ROM (AB- ROM) and passive internal rotation ROM (IR-ROM) were measured. Pain during each test and pain during the last week was reported on the Numeric Pain Rating Scale (NRS 0-10). Patients were categorized as candidates or non-candidates for SAD based on the first consultation by an orthopedic specialist, blinded to test results.
Findings / Results: From 156 SIS-patients, 25 were candidates for SAD, while 131 were not. SAD-candidates had significantly lower AB-ROM (87° vs 112°, p=0,011) and IR-ROM (114° vs 123°, p=0,026) additional to higher pain during test of AB-strength (5.3 vs 3.7, p=0.02). No differences were found between candidates and non- candidates in self-reported shoulder function, AB- strength, ER-strength, pain during test of ER- strength and pain during last week. No differences in age, gender, weight and duration of symptoms between the groups were found.
Conclusions: ROM impairments and pain during AB-strength testing is associated with being considered a candidate for SAD, while self-reported function, pain last week and actual rotator cuff strength is not. As differences seems minor, the relation between impairments and the choice of treatment needs further clarification.

86. Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction: A 1-year analysis of 23 patients
Andreas Chatterton, Ole Gade Sørensen, Torsten Nielsen, Martin Lind
Sportstraumatology, University of Århus

Background: Medial patellofemoral ligament reconstruction (MPFL-R) has in the last decade become the standard surgical treatment for patella instability. Limited knowledge exist concerning causes for failure of MPFL-R and outcome after revision MPFL-R.
Purpose / Aim of Study: To evaluate causes for MPFL-R failure and clinical outcome after revision MPFL-R.
Materials and Methods: Twentythree patients with failed MPFL-R underwent either isolated revision MPFL-R or combined with tibial tuberosity osteotomy. There were 6 males and 17 females. Mean age was 23 (SD±8.6). Prior to surgery dysplasia of the patello- femoral joint, cartilage lesions, tibial tubercle-trochlea groove distance (TTTG) and tunnel placement were evaluated with MRI. Subjective outcome evaluation, visual analog scale (VAS) pain score and Kujala Score were performed prior to surgery and at 1 year post-operatively. Radiographic charateristics and clinical outcome was compared with a 240 patient cohort of primary MFPL-R.
Findings / Results: Non-anatomical fixation of the graft at the medial femoral condyle after primary MPFL-R was seen in 52 % (12) of patients with anterior/proximal malplacement in most cases. Severe trochlea dysplasia Dejour Type C+D was seen in 36 % of patients compared to 30 % in primary MPFL patients (NS) Mean Kujala score at 1 year follow up was 60 compared to 80 in primary MPFL patients (P<0.01). Mean VAS pain score at rest was 3.0 compared to 1.7 in primary MPFL patients (P<0.01).
Conclusions: Non-anatomical graft position appears to be an important cause for MPFL-R failure. Subjective outcome after revision MPFL-R is poorer than after primary MPFL-R.

87. Outcome after arthroscopic labral surgery in patients treated with periacetabular osteotomy. A follow-up study of 45 patients.
Charlotte Hartig-Andreasen, Bent Lund, Grønbeck Nielsen Torsten , Kjeld Søballe, Martin Lind
Orthopedic Surgery, Aarhus University Hospital; Division of Sports Trauma, Orthopedic Department , Aarhus University Hospital

Background: Hip arthroscopy (HA) in the treatment of patients with persisting hip symptoms after periacetabular osteotomy (PAO) remains unclear.
Purpose / Aim of Study: The aim of this study is; 1) to identify factors predicting failure after HA with previous PAO defined as a conversion to total hip replacement (THR) and 2) to evaluate the patient reported outcome measurement scores after HA in patients with previous PAO.
Materials and Methods: Of the 55 hips treated with HA after PAO from Aug 2008 to 2012 at University Hospital of Aarhus, 45 hips were included in the study (median age: 34.1 yrs, range 13.2-61.4 yrs). Indications for HA were a positive FABER and impingement test and signs of labral damage on MR-arthrography when available. PROM questionnaires (mHHS, HOS) were completed by 37 (82.2 %) patients.
Findings / Results: Defining THR as an end point the Kaplan-Meier analysis showed a hip joint survival rate of 53.2% (95% CI, 0.1%-0.8%) at 6.5 years after HA. Using Cox regression analysis the following statistically significant predictors of conversion to THR were identified: joint space width after PAO < 3.0 mm and a Tönnis grade of >2. Twelve hips (27%) needed revision HA. Labral damage was present in 84.4% of the hips. In 42.2% of the hips an ICRS grade 3 or 4 changes were found in the acetabulum. Median mHHS and HOS scores were 63.8 and 67.1 respectively. At follow-up a NRS pain score of >3 in rest and during activity were present in 43% and 64% of the pt..
Conclusions: Patients with symptomatic hips after PAO may benefit from HA, but half of the joints underwent total hip replacement at short-term follow-up. Signs of joint degeneration after PAO are important risk factors and to be considered when offering patients arthroscopy. Pt. cannot expect to be pain free. Further studies are needed to clarify what role HA should play in this patient group.

88. Arthroscopic treatment of degenerative meniscal tears: importance of age and osteoarthritis
Jens Jørgsholm, Claus Hjorth Jensen, Anders Odgaard
Dept. of Orthopaedics, Copenhagen University Hospital Gentofte

Background: Arthroscopic partial meniscectomy is one of the most commonly performed orthopedic procedures; still the indication for treatment and evidence is controversial.
Purpose / Aim of Study: This data-based study was conduced to determine the outcome of arthroscopic partial meniscectomy. The aim was to determine whether age and knee osteoarthritis are predictive factors for the outcome of arthroscopic partial meniscectomy.
Materials and Methods: Prospectively collected data was retrieved from a local hospital register. The data included knee arthroscopic procedures and pre- and postoperative PROMs from June 2013 to May 2015. Patients were divided into two age groups: ≥60 years and ≤40 years. Preoperative X-rays were examined for all patients ≥ 60 years (n = 59) to determine the level of osteoarthritis using the classification of Kellgren and Lawrence (K&L). They were then divided into different groups according to the degree of osteoarthritis. The primary outcome was measured in the difference in Oxford Knee Score (OKS) and patient satisfaction at 3 months.
Findings / Results: At 3 months, OKS was significantly improved for both age groups, 6,6 (95% CI 4,44 to 8,69) for patients ≥60 years (n=72) and 7,4 (95% CI 4,43 to10,65) for patients ≤40 years (n=48). The patient satisfaction was 66% for patients ≥60 years (n = 79) and 73% for patients ≤40 years (n = 78). There was no significant difference between the age groups in OKS and patient satisfaction. Patients with no osteoarthritis (K&L 0) had significantly better outcome than patients with severe osteoarthritis (K&L 3), (p = 0,044).
Conclusions: According to the outcome scores there was a significant postoperative improvement in both age groups. The study failed to demonstrate a significant difference between the age groups. Preoperative osteoarthritic changes correlated negatively with patient satisfaction.

89. Minimal Important Change for the Knee injury and Osteoarthritis Outcome Score in patients undergoing anterior cruciate ligament reconstruction
Lina Holm Ingelsrud, Caroline Terwee, Lars-Petter Granan, Lars Engebretsen, Ewa Roos
Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam; Department of Physical Medicine and Rehabilitation, Department of Pain Management and Research, Divi, Oslo University Hospital; Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of medicine, Oslo; Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark

Background: Important change in the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients undergoing anterior cruciate ligament reconstruction (ACLR) is unknown.
Purpose / Aim of Study: To determine Minimal Important Change (MIC) for the KOOS in patients undergoing ACLR.
Materials and Methods: 1197 patients undergoing unilateral primary ACLR were extracted from the Norwegian Knee Ligament Register: 397 at 6 months, 400 at 12 months and 400 at 24 months postoperatively. KOOS was completed postoperatively accompanied by anchor questions with 7-point scales ranging from “better, an important improvement” to “worse, an important worsening”. Preoperative KOOS scores were extracted from the register. Two anchor-based MIC approaches were used: 1) Receiver operating curve (ROC) by using the point of least misclassification between the improved and unchanged groups, and 2) the mean change in KOOS score for patients being “somewhat better, enough to be importantly improved”.
Findings / Results: 71% (n=357) and 74% (n=385) reported an important improvement in sport and recreational activities (Sport/Rec) and quality of life (QOL), respectively. Correlations between anchor question and KOOS subscales were above 0.4 at all time-points for Sport/Rec and QOL, except Sport/Rec at 24 months (0.37). For all other subscales correlations were below 0.39, besides Symptoms at 12 months (0.49). ROC and Mean Change MIC values for Sport/Rec were at 6 months: 22.5 and 17.4, 12 months: 2.5 and 23.7 and 24 months: 10 and 24.3. MIC values for QOL were at 6 months: 21.9 and 29.7, 12 months: 15.6 and 24.3 and 24 months: 21.9 and 29.3.
Conclusions: MIC values varied based on methodology, subscale and time to follow-up. Our findings emphasize that MIC values must be interpreted with caution and that one MIC value cannot be applied across different contexts.

90. Translation, cross-cultural adaptation, reliability and discriminative validity of the Danish version of the short questionnaire to assess health-enhancing physical activity (SQUASH)
Lotte Sørensen, Lone Ramer Mikkelsen, Julie Sandell Jacobsen, Inger Mechlenburg
Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark ; Elective Surgery Centre, Silkeborg Regional Hospital, Denmark; Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark

Background: There is abundant evidence that physical activity has a fundamental role in the prevention and treatment of chronic disease. Questionnaires are simple and inexpensive to apply to measure physical activity.
Purpose / Aim of Study: Translate and cross-cultural adapt the short questionnaire to assess health-enhancing physical activity (SQUASH) to Danish and to investigate the reliability and discriminative validity of the Danish version.
Materials and Methods: The study was conducted according to the COSMIN guidelines. The reliability was evaluated in 50 healthy individuals, mean age 47.2 ± 12.6 years and mean period 37.1 ± 14.9 days between test and retest. The relative reliability was assessed with intraclass correlation coefficient (ICC) and the absolute reliability with standard error of measurement (SEM) and smallest detectable change (SDC). The discriminative validity was evaluated in 22 patients with hip dysplasia, mean age 34.8 ± 7.9 years, who were compared with 26 healthy individuals matched on age.
Findings / Results: For the total activity score ICC was 0.71 (95% CI: 0.54; 0.82), SEM was 2351 MET x min/week (25% of the grand mean) and the SDC was 6517 MET x min/week (70% of the grand mean). There was no significant difference between healthy adults and patients with hip dysplasia in total activity score but a significant difference in time spent on activities of high intensity.
Conclusions: Relative raliability was acceptable and indicates that the Danish version of SQUASH can distinguish between individuals, but the absolute reliability was poor and SQUASH is not considered suitable for measuring physical activity on an individual level. SQUASH was unable to discriminate between healthy individuals and patients with hip dysplasia with respect to total activity score, but was able to discriminate on time spent on activities of high intensity.

91. Incidence and outcome after PCL reconstruction. Results from the danish registry for knee ligament reconstructions
Martin Lind, Lene Rahr-Wagner, Kristian Behrndtz
Orthopedics, Aarhus Univerisity Hospital

Background: Outcome after posterior cruciate ligament (PCL) reconstruction is poorly described in the literature due to rare incidence. The Danish ACL Registry has since 2005 monitored development and outcome of PCL reconstruction.
Purpose / Aim of Study: This study presents the epidemiology and outcome after PCL reconstructions in Denmark.
Materials and Methods: A total of 585 PCL reconstructions out of a total of 23.253 knee liagment reconstructions was registered in the ACL Registry in the period 2005-2014. Type of reconstruction isolated or multiligament as well as cause of injury and concomitant meniscus and cartilage injuries were extracted. Outcome at one year follow-up was reported by KOOS score and Tegner function score. Outcome data was compared with data from primary ACL reconstructions.
Findings / Results: Isolated PCL reconstruction was performed in 32 % of cases. Meniscus lesions and cartilage lesions was seen in 17 and 13 % of cases respectively. The main causes for PCL injury was sports 39 %, and traffic 34 %. The KOOS scores at 1 year follow-up for isolated PCL reconstruction was 71 for symptoms, 77 for pain, 83 for ADL, 49 for Sports and 53 for QoL. For multiligament PCL reconstruction scores were 69 for symptoms, 78 for pain, 83 for ADL, 46 for Sports and 51 for QoL. Tegner function score for isolated and multiligament PCL reconstruction was 4.3 and 3.9 respectively. PCL reconstructions overall had poorer subjective outcome than ACL reconstructions.
Conclusions: PCL reconstructions represent only 2.5 % of all knee ligament reconstructions in Denmark. Sports and traffic is the main causes for injury. Meniscus and cartilage injuries are seen frequently with PCL injury. PCL reconstructions had poorer outcome than ACL reconstructions. There was no difference in subjective outcome between isolated and multiligament PCL reconstructions.

92. The injured exerciser - in risk of depression?
Mia B. Lichtenstein, Uffe Jørgensen
Institute of Psychology, University of Southern Denmark; Orthopedic Department, Odense University Hospital

Background: Regular exercise is effective in health promotion and disease prevention. It has favorable effects on both physical and mental well-being. But injuries can lead to periods with reduced exercise levels. How do these periods affect the exercisers' emotional condition?
Purpose / Aim of Study: The aim of this study was to measure emotional responses (depression and stress) associated with severe musculoskeletal injury in regular exercisers. We also wanted to identify risk factors to be able to detect the depression and stress prone patient.
Materials and Methods: We conducted a cross-sectional study on a orthopedic department at a local hospital. A total of 694 consecutive patients with musculoskeletal injuries at foot, knee or shoulder completed a questionnaire. It consisted of questions related to injury and exercise habits. Further we estimated depressive symptoms with the Major Depression Inventory (MDI), clinical stress with the Perceived Stress Scale (PSS) and quality of life with the EQ-5D.
Findings / Results: We found that 18.7% participants with symptoms of depression. Among those with depression we found that 99 participants to some extent had experienced that life was not worth living. The stress-test showed that 39.1% had symptoms of mild stress while 29.9% reported clinical stress. The participants with severe symptoms of depression or stress were significantly younger, had more days absent from work due to injury and had decreased quality of life.
Conclusions: Exercisers with injuries in the musculoskeletal system seem to experience symptoms of depression and stress which is associated with reduced quality of life. The MDI and the PSS are useful in the detection of depression and stress. Psychological treatment seems to be an important supplement to the medical interventions. This could prevent severe and expensive depression courses.

93. Distribution of muscle fibres with centralized nuclei close to the myotendinous junction in humans
Niels Jakobsen, Abigail Mackey, Jens Jakobsen, Michael Krogsgaard
Department of sportstraumatology M51, Bispebjerg Hospital; Institute for sportsmedicine, M51, Bispebjerg Hospital

Background: Strain injuries often occur at the myotendinous junction (MTJ) and yet little is known about the constant state of remodelling of fibres close to the MTJ. During muscle fibre remodelling, nuclei can be observed centrally in contrast to the normal peripherally located nuclei. Heavy resistance exercise (HRE) significantly reduces the risk of strain injuries in the hamstrings but no studies have analysed human MTJ material to investigate this.
Purpose / Aim of Study: To investigate if muscle fibres close to the MTJ contain more central nuclei than further away from the MTJ and to see if HRE affects this pattern.
Materials and Methods: 9 patients scheduled for ACL reconstruction with hamstring grafts were randomized into a control or HRE group (5 HRE, 4 control). The MTJ samples from semitendinosus and gracilis were embedded in TissueTech and frozen in liquid Nitrogen, cut on a cryostat and stained immunohistochemically for nuclei and collagen type 12 and 22. Muscle fibres were divided into 3 groups depending on their distance to MTJ: [0 µm], [1-200 µm] and [201-400 µm]. We measured the percentage of muscle fibres with central nuclei in each group and calculated the median and range
Findings / Results: In the HRE group, adjacent to MTJ [0 µm], the median of fibres with central nuclei was 46% (range: 11 – 88). [1 – 200 µm] from MTJ, 22% (0 – 22). [201 - 400 µm], 7% (2 – 25). In the control group, adjacent to MTJ [0 µm], the median was 31% (25 – 61). [1 – 200 µm], 26% (11 – 33). [201 – 400 µm], 13% (7 – 17).
Conclusions: It appears that a higher proportion of the fibres closest to the MTJ have centrally located nuclei. A similar analysis is being performed with collagen 22 as a specific marker for MTJ to confirm these findings and allow statistical comparisons between control and HRE groups

94. Large improvements in patient-reported outcome occur after hip arthroscopy within the first year – but HAGOS finds continued markedly reductions in patient’s ability to perform desired physical activity and in their quality of life.
Otto Kraemer, Anne-Dorthe Madsen, Per Hölmich, Kristian Thorborg
Orthopedic dept., Arthroscopic Center Amager, Sports Orthopedic Research Centre - Copenhagen (SOR-C), Amager and Hvidovre Hospital

Background: Improvements in modified Harris Hip Score (mHHS) following hip arthroscopy are well-known, with no additional improvements within one year. One-year results from the Copenhagen Hip And Groin Outcome Score (HAGOS) in patients undergoing hip arthroscopy are still unknown.
Purpose / Aim of Study: To evaluate and compare outcomes at 3, 6 and 12 months following hip arthroscopy for cam impingement and/or labral injury using mHHS and HAGOS.
Materials and Methods: From October 2011 to February 2014, 108 consecutive patients, 63 females, mean age 39(11) and 45 males, mean age 38(11), underwent hip arthroscopy . Standardised post- operative rehabilitation instructions were provided. Outcomes were evaluated using mHHS and HAGOS preoperatively and at 3, 6, and 12 months.
Findings / Results: Preoperative mHHS status, mean(SD), was: 62(14) and corresponding HAGOS status, mean(SD) was: Pain:54 (19); Symptoms:48(17); ADL:57(23); Sport:37(20); PA:20(23); QOL:26(16). Large improvements were seen at 3 months for all scales (p<0.001), except HAGOS, PA-subscale. Significant improvements between 3 and 6 months, and from 3 to 12 months, were only seen for HAGOS subscales Sport and PA, (p<0.05), with no improvement from 6-12 months. Status, mean(SD) at 12 months was: mHHS: 83 (17) and corresponding HAGOS status was: Pain:80(18); Symptoms:73(18); ADL:94(8); Sport:70 (25); PA:56(38); QOL:61(28).
Conclusions: Large improvements in mHHS and HAGOS subscale scores were seen at 3 months for all scales following hip arthroscopy, however, further improvements from 3 to 6 months, and from 3 to 12 months, were only seen in HAGOS subscales Sport and PA. Specific subscales of the HAGOS (PA and QOL) suggests that the ability to participate in desired physical activities and quality of life is still markedly reduced in patient undergoing hip arthroscopy at 1-year follow-up.

95. Muscle strength symmetry of the hip flexors and extensors in patients with femoroacetabular impingement included in the HAFAI-cohort – preliminary data
Signe Kierkegaard, Ulrik Dalgas, Bent Lund, Kjeld Søballe, Inger Mechlenburg
Department of Orthopaedic Surgery, Horsens Hospital; Section of Sport Science, Department of Public Health, Aarhus University

Background: Isometric muscle strength of hip extensors and flexors is reduced in the primary affected leg of patients with femoroacetabular impingement (FAI) compared to matched healthy controls. Muscle strength asymmetry between legs has been related to decreased physical performance. Hence, it is relevant to investigate if muscle strength differences exist between the primary affected leg and the contralateral leg in patients with FAI.
Purpose / Aim of Study: To compare maximally muscle strength of the hips in patients with FAI. We hypothesised, that muscle strength of the primary affected leg would be lower than in the contralateral leg.
Materials and Methods: Sixteen patients scheduled for hip arthroscopic surgery for FAI were included. Maximum voluntary contraction (MVC) of the hip flexors and extensors were tested for both legs in a randomised order. Patients completed two submaximal familiarisation trials followed by 3-4 MVC trials performed isometrically at 45 degrees and isokinetically at 60 degrees/second. Pain levels were registered during testing, using a 100 mm Visual Analog Scale.
Findings / Results: The primary affected leg was significantly weaker than the contralateral leg for all MVC tests. Concentric, isometric and eccentric hip flexion strength of the primary affected leg was respectively median (interquartile range) 12(2-31) %, 7(5-17)% and 17(11-23)% lower than of the contralateral leg while a deficit of 11(1-29)%, 10(3-20)% and 10(2- 23)% was observed for hip extension. Median (range) pain during test, affected leg: flexion 25(0- 82) mm, extension 15(0-75) mm, contralateral leg: flexion 0 (0-59) mm and extension 0 (0-50) mm.
Conclusions: In patients with FAI hip extensor and flexor muscle strength of the primary affected leg is significantly lower than in the contralateral leg which could be affected by difference in pain levels.

96. 2 year FU after hip arthroscopy with labral repair in children and adolescents
Søren Winge, Christian Dippmann, Kristian Thorborg, Otto Kraemer, Per Hølmich
Orthopaedic Department, Copenhagen Private Hospital; Section for Sports Traumatology M51, Department of Orthopedic Surgery, Bispebjerg Hospital; Arthroscopic Center Amager, Copenhagen University Hospital

Background: Femoroacetabular impingement (FAI) is also being recognized in children and adolescent as a cause of hip pain. Hip arthroscopy in children and adolescents is technically demanding and although widely accepted as treatment of FAI in adults little is know about the results in this age group.
Purpose / Aim of Study: The purpose of this study was to investigate the self-reported outcome of Hip arthroscopy with labral repair in children and adolescents 2 years after surgery.
Materials and Methods: From November 2010 to February 2013 16 consecutive patients (mean age 16,2 years) 6M and 10F, underwent hip arthroscopy with labral repair at Copenhagen Private Hospital. Modified Harris Hip Score (mHHS) and a Visual Analogue Score (VAS) for pain were used as outcome measures. All patients completed both measures pre-op. and 2 years post-op. Data were collected prospectively and analyzed using non – parametric statistics.
Findings / Results: Significant statistical improvements were seen for both outcome measures (p < 0,001) at 24 months. The VAS pain score improved from mean 53 (37-80) to mean 11 after 24 months (0-55). MHHS increased from mean 57 (37-71) to mean 97 (73-100) at 2 years. The 2 worst patients had the 2 lowest CE angles (22 dg and 26 dg). These 2 patients increased mean 44 point in mHHS from 37 to 81 and decreased mean 21 point in VAS score from 79 to 58.
Conclusions: Hip arthroscopy in children and adolescents provide promising results equal to those achieved for active, non-arthritic adults. Two years after surgery we found clinically relevant improvements. CE angle close to or within the dysplasia grey zone (20-25 degrees) might lead to less optimal results. Overall the results are promising, but further investigation, including long-term results are needed.