Postersession II

Onsdag den 23. oktober
11:00 – 12:00
lokale: Stockholm/Copenhagen
Chairmen: Henrik Eckardt / Lars Konradsen

158. Results after plate removal in midshaft clavicle fracture surgery: Focus on coexsisting soft-tissue shoulder injuries.
Ban Ilija, Poulsen Heidi , Troelsen Anders
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre

Background: Primary surgical treatment has become the preferred treatment for displaced, midshaft clavicle fractures. Several studies have shown that plate osteosynthesis is a safe procedure associated with good outcome. However, in close to 30 % of all patients treated with a precontoured plate the implant is removed due to soft-tissue irritation. This high rate of implant removal is neglected in the overall discussions that compare surgical treatment to non-surgical treatment of acute midshaft, clavicle fractures.
Purpose / Aim of Study: To evaluate results, in terms of complications and reoperations, of implant removal of clavicle plates.
Materials and Methods: 54 patients (41 males) operated between 2007 and 2012 at our institution with removal of clavicle plates were included. We retrospectively assessed complication and reoperation rates by inquiry to patient files and radiographs.
Findings / Results: In 47 of 54 patients, precontoured locking plates were removed and in the remaining 7 patients reconstruction plates were removed. In 49 cases the plate was removed within the first 2 years following primary fracture surgery, with 25 removed during the first postoperative year. The plate was removed due to soft-tissue irritation in 43 cases, 2 had neurological deficits and 4 suffered profound pain or discomfort. Another 4 plates were removed for unknown reasons and 1 due to patient demand. A total of 6 patients had deficits (decreased mobility in 4 cases) or complications (re-fracture in 2 cases) following implant removal. All patients with decreased mobility were, following plate removal, diagnosed with a structural soft-tissue injury of the shoulder.
Conclusions: Plate removal following a midshaft clavicle fracture seems safe but patients with profound pain or decreased mobility should be examined for a structural soft- tissue injury of the shoulder.

159. Early experiences with the DHS blade in treating femoral neck fractures
Rasmus Stokholm, Lise Hellegaard, Steffen Skov Jensen
Orthopaedic dept., Regionshospitalet Viborg

Background: The most common complications related to internal fixation of femoral neck fractures (FNF) is non-union and avascular necrosis. Failure rates of 6.5 - 13% for undisplaced and 49% for displaced fractures has been reported with reoperation rates of 7,7 – 13 % and 20 – 36 % respectively. Randomised trials of different implants for internal fixation of FNF are inconclusive. Biomechanical studies have indicated that DHS blade is superior in resisting displacement forces compared to conventional DHS. To our knowledge no report has ever been made on the DHS blade for internal fixation of FNF.
Purpose / Aim of Study: To evaluate the outcome of patients submitted with a FNF, internally fixated with a DHS blade, at the Orthopaedic department, Regionshospitalet Viborg from 2008 to 2012.
Materials and Methods: 68 patients, mean age 76,2 yrs (32 - 98) submitted with a FNF treated with internal fixation with a DHS blade at regionshospitalet Viborg 2008-2012. No specific criteria were applied for choosing DHS blade, as opposed to conventional DHS, but considerations were: age, osteoporosis, grade of dislocation, general- and mental health status of the patient. Decision to choose DHS blade was made in plenum or at the discretion of the attending surgeon. Mean follow up time was 24,3 months (6 - 62).
Findings / Results: 50 undislocated and18 dislocated fractures were treated with DHS blade. The total number of failures registered in the follow up period was 8. 5 undislocated (10%) and 3 dislocated (16,7%). All were reoperated with convertion to THA. Mean time to reoperation was 6,5 months (3 – 16). 17 patients died in the follow up period.
Conclusions: Our early experiences with the DHS blade indicate that it is an equal implant option for internal fixation of FNF. Further investigation is needed to evaluate the DHS blade and its place in treatment of FNF.

160. Retrospective review of radiographic referral, interpretation and treatment plan in a Danish emergency department in comparison to an international benchmark.
Mohamed Shalaby, Wajeha Malik , Christine Hilbrandt, Valentina Makolli, Thomas Houe
Orthopedic surgery, Slagelse hospital; Emergency department, Slagelse hospital

Background: Though Denmark had dramatic changes in the emergency department (ED) system organization, still lacks designated ED doctors and specialists.
Purpose / Aim of Study: To evaluate discrepancies in plain X-ray interpretation, treatment plan and referral rate for radiography in a Danish hospital emergency department (ED) between junior house officers, residents and orthopedic surgeons, and their clinical spectrum and outcome.
Materials and Methods: Primary Emergency journals for ED patients and their radiograph reports were reviewed (by a radiologist and a senior orthopedic surgeon) during 3 months. All discrepancies and their management were noted on a computerized data base.
Findings / Results: A total of 6724 patient were examined in the ED, 3056 of them had injuries with potential need for radiographic examination. Of these, 1363 patient were photographed, with a referral rate 44.6%. Out of 1363 cases, there were 85 (6.2%) diagnostic or management errors, 39 (2.8%) fractures were missed, 22 (1.6%) cases were diagnosed but inadequately treated, and 35 (2.5%) errors were insignificant without impact on the patient’s treatment.
Conclusions: A radiographic referral rate of 44.6% is appropriate to referral rate benchmark in UK (44%). However 3.7% of ED patients had significant diagnostic or treatment errors which prompted a change in management after joint radiographic-orthopedic conference next working day. This is relatively high in comparison to other similar studies in UK (0.3%-1%) and US (0.4%-2.8%). A possible explanation for this could be a longer history of ED medicine sub-specialty in the countries used for benchmark in our study and the results calls for further evaluation and focus on ED education and supervision but also emphasizes the importance of routine joint radiographic-orthopedic evaluation in close relation to hospital ED treatment.

161. Feasibility of progressive strength training immediately after hip fracture surgery.
Lise Kronborg, Thomas Bandholm, Henrik Palm, Henrik Kehlet, Morten Tange Kristensen
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital at Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, , Copenhagen University Hospital at Hvidovre; Department of Orthopedic Surgery, Copenhagen University Hospital at Hvidovre; Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University

Background: Muscle strength relates to functional performance in patients with a hip fracture. During the first week in the acute orthopedic ward, patients with a hip fracture loose more than 50% of their knee-extension muscle strength in the fractured limb when compared to the non-fractured limb.
Purpose / Aim of Study: The aim of this study was to examine the feasibility of progressive strength training when initiated in the acute ward based on pre-specified criteria for feasibility.
Materials and Methods: Thirty-six patients (9 men and 27 women) with a hip fracture having a mean (SD) age of 79.4 (8.3) years. They followed a daily (on weekdays) program of progressive knee-extension strength training for the fractured limb, using ankle weight cuffs as loading. At each session, they performed 3 sets of 10 repetition maximum (RM) loadings (adjusted on a set-by-set basis). Maximal isometric knee-extension strength of both limbs was measured with a fixated dynamometer.
Findings / Results: The training load (kilograms lifted) increased progressively by an average of 2.7 (1.5) kg from 1.6 (0.8) to 4.3 (1.7) kg (p<0.001) over 4.3 (2.2) training sessions. Strength training was initiated 2.4 (0.7) days after surgery and ended at mean day 8.6 (4.2). The average knee-extension strength deficit in the fractured limb decreased from 50% (34%) to 32% (25%) of the non-fractured limb at discharge. More than 80% of patients reported no or just light hip pain during the strength training sessions.
Conclusions: Progressive knee-extension strength training of the fractured limb in hip fracture patients commenced in the acute orthopedic ward seems feasible and may reduce knee- extension strength asymmetry. Hip fracture- related pain did not compromise strength training or testing. The clinical value of early progressive strength training will be studied in a randomized design.

167. Surgery for Kyphoscoliosis in Parkinson's Disease
Ebbe Stender Hansen, Dharmendra Singh, Cody Bünger
Department of Orthopedic Surgery, Aarhus University Hospital; Department of orthopedic Surgery, Aarhus University Hospital

Background: A frequent complication to Parkinsons disease is camptocormia, i.e. severe, involuntary, reversible thoracolumbar kyphosis during standing and walking. With time, the spine tends to develop structural degenerative kyphoscoliosis with spondylosis, spinal stenosis, pain and severe loss of function. The international literature on scoliosis surgery in this condition is extremely scarce, mostly case reports of failures.
Purpose / Aim of Study: This is a review of our first six cases, in fact the lagest material published so far.
Materials and Methods: In 2000 - 2010 we performed corrective scoliosis surgery in six Parkinson patients with camptocormia and kyphoscoliosis, age 58-70 years, four men, two women. Surgery included Smith Petersens osteotomies and PSO where needed, long posterior fixation with pedicle screws/rods, and auto- plus allografting.
Findings / Results: Operation time was 4 to 10 hours, the initial postop care was in ICU in 5 of 6 cases, and hospitalization ranged from 8 - 32 days. Correction was good initially in all cases. One developed a hematoma, which was evacuated, two had hallucinations postoperatively, and three developed pneumonia. All six experienced implant breakage and/or screw loosening, and three were reoperated upon several times. The total numer of reoperations was 13 in the series. In spite of this, five patients reported good satisfaction. Four are still active, two are in nursing home for other reasons..
Conclusions: This case series represents a llearning curve. Scoliosis surgery in Parkinsons disease is feasible but challenging. Surgery should extend distally to the ileum. Correction should aim at complete restoration of balance. Complications and reoperations should be expected. It has been a taxing but rewarding endeavour for the surgeons and for most patients. We now plan more patients for the procedure.

168. The physical and mental outcome of 100 patients having a Percutaneous Vertebroplasty because of pathological vertebral fractures.
Søren Lykke Lorentzen, Rikke Rousing, Stephan Hummel
ortopædkirurgisk afdeling, Kolding; Sector for Spine Surgery and Research, Region of southern Denmark , Vejle Sygehus

Background: Percutaneous vertebroplasty (PVP) is a therapeutic procedure performed to reduce pain in pathological vertebral fractures. PVP has been performed since the eighties and a lot of clinical studies have confirmed the benefit of the operation. Lately two double blind randomised studies have questioned the pain relieving effect compared to conservative treatment. To test this statement a new double blind study is performed at the Sector for Spine Surgery and Research, Region of Southern Denmark. PVP is still performed on patients not attending this study because of exclusion criteria. The effect on mental and physical health is documented in DaneSpine, the Danish database for spine operated patients.
Purpose / Aim of Study: The aim of this study is to describe the quality of life and the physical and mental outcome of the first 100 patients having a PVP at the Sector for Spine Surgery and Research, Region of southern Denmark due to painful pathological fractures.
Materials and Methods: All patients are operated by specialists in spine surgery. The data is collected in DaneSpine. STATA is used for statistical work. Well-known and validated questionnaires are used for assessment of mental and physical health and for quality of life, SF-36, ODI, and EuroQol. VAS is used for pain estimation.
Findings / Results: The mental and physical health has improved significantly one year after surgery based on the mental and physical score of SF-36. The VAS score for back pain is lowered significant and the quality of life estimated by EuroQol, has improved significantly one year after surgery.
Conclusions: PVP relieves the pain for patients with pathological vertebral fractures and the patients improve in mental and physical health. Further conclusions on PVP may be made after the ending of the double-blind randomised study.

172. Artificial Meniscal scaffold Implantation and Meniscal Allograft Transplantation.
Martin Rathcke, Peter Lavard, Michael Krogsgaard
Dept. of orthopaedics, Bispebjerg Hospital

Background: Loss of meniscal function alters the pressure distribution within the knee joint leading to increased cartilage wear Restoration of meniscal function with artificial meniscal scaffold implantation (AMSI) or meniscal allograft transplantation (MAT) might prevent this. Indication for AMSI was pain with intact meniscal horns and rim.
Purpose / Aim of Study: To present two years of experience using AMSI and MAT, including our treatment algoritm.
Materials and Methods: Eigthteen knees (8 ‰/10 Š) in seventeen patiens fullfilled the indication for either AMSI or MAT. 4 had a history of discoid meniscus. In eleven knees AMSI was primarily implanted, 6 medial and 5 lateral. 7 had earlier ACL reconstruction. Until now 5 have failure of AMSI and were changed to MAT, including 4 of the ACL reconstructed patients. In seven knees MAT was primarily implanted, 2 medial and 5 lateral, but none with ACL reconstruction. In further five knees MAT was secondary implanted, 4 medial and 1 lateral. In all 12 MAT, plus one revision.
Findings / Results: Nearly all patients showed initially reduction in pain at 3 month. In the AMSI group a large number of patients were revised. Earlier ACL reconstruction seems to be a negative prognostic factor. Contraindications, timing and a learning curve might also influence results. Nearly all patients showed improvement in pain and function at postoperative controls. The one MAT revision was due to under sizing of the transplanted graft.
Conclusions: Biological joint preservation with AMSI or MAT is now a possibility in Denmark. The patients often have a long complicated surgical history, and in many patients additional procedures are needed. History with ACL reconstruction have a high failure rate in AMSI, and MAT should be considered as the primary operation.

173. Does bony hip morphology affect the outcome of treatment for patients with adductor-related groin pain? – long term results of a randomized controlled trial
Per Hölmich, Kristian Thorborg, Per Nyvold, Jakob Klit, Michael Bachmann Nielsen, Anders Troelsen
Artoskopisk Center Amager, Amager-Hvidovre Hospital; Ortopædkirurgisk afdeling, Amager-Hvidovre Hospital; Radiology, Rigshospitalet; Ortopædkirurgisk, Amager-Hvidovre Hospital

Background: Adductor-related groin pain and bony morphology such as femoroacetabular impingement (FAI) or hip dysplasia can co- exist clinically. A previous RCT, in which athletes with adductor-related groin pain underwent either passive (PT) or active (AT) treatment, showed good results in the AT group.
Purpose / Aim of Study: The primary purpose of the present study was to evaluate if radiological signs of FAI or hip dysplasia, seem to affect the clinical outcome, initially and at 8-12 year follow- up.
Materials and Methods: Forty-seven patients (80%) were available for follow-up. The clinical result was assessed by a standardised clinical outcome, combining patient-reported activity, symptoms and physical examination. Anterior-posterior pelvic radiographs were obtained and the center- edge angle of Wiberg, alpha angle, presence of a cross-over sign and Tönnis grade of osteoarthritis were assessed by a blinded observer, using a reliable protocol.
Findings / Results: No significant between-group differences regarding the distribution of radiological morphologies were found. There was a decrease over time in clinical outcome in the AT group with alpha angles >55° compared to those with alpha angles <55° (p=0.047). In the AT group there was no significant difference in the distribution of Tönnis grades between hips that had an unchanged or improved outcome compared with hips that had a worse outcome over time (p=0.145).
Conclusions: No evidence was found that bony hip morphology related to FAI or dysplasia prevents successful outcome of the exercise treatment programme with results lasting 8-12 years. The entity of adductor- related groin pain in physically active adults can be treated with AT even in the presence of morphological changes to the hip joint.

174. Custom-made orthotics decrease medial foot loading during drop jump and single-leg squat in individuals with patellofemoral pain
Michael Rathleff, Camilla Richter, Jesper Bencke, Thomas Bandholm, Per Hölmich, Kristian Thorborg
Orthopedic Surgery Research Unit, Aalborg Hospital; A-Physiotherapy, Solrød Strand; Gait Analysis Laboratory, Hvidovre Hospital; Physical Medicine and Rehabilitation Research (PMR-C), Orthopedic Department, Clinical Research Cent, Hvidovre Hospital; Arthroscopic Centre Amager, Orthopedic Departement, Hvidovre Hospital; Arthroscopic Centre Amager, Physical Medicine and Rehabilitation Research (PMR-C), Orthopedic Depart, Hvidovre Hospital

Background: We have previously shown that individuals with PFP have a more medially directed foot-loading pattern (20- 30%) compared to healthy individuals during high load activities. This may increase lateral forces acting on the patella.Foot orthotics may be a simple approach to help normalise foot loading. However, no one has yet investigated the effect of foot orthotics on foot loading patterns during jumping and squatting in individuals with PFP.
Purpose / Aim of Study: To investigate the effect of foot orthotics on medial-to-lateral plantar forces during drop jump and single-leg squat in individuals with PFP.
Materials and Methods: 23 young adults with PFP were tested before and after a custom-made orthotic was inserted into both a standard shoe (Le coq Sportif).The order of testing was random. Foot loading (plantar pressure distribution) was collected from the most painful side during drop jump and single-leg squat using pressure sensitive Pedar insoles. Primary outcome was the medial-to- lateral peak force under the forefoot during drop jump. Mean forces under the forefoot were analysed using the same approach. Test-retest reliability for this procedure was substantial, with no systematic bias from test to retest.
Findings / Results: Orthotics caused a relative reduction in peak force of 7% (p=0.01), during drop jump, while mean forces were reduced by 10%, p<0.01. Peak force was reduced by 12%, (p=0.08) during single- leg squat, and mean forces were reduced by 20%, p=0.03.
Conclusions: Foot orthotics decrease medially directed foot loading among individuals with PFP, which may decrease lateral forces acting on the patella. However, the orthotics did not normalise medial foot-loading patterns completely suggesting that strategies such as medial foot wedges or movement corrective exercises may be relevant to consider.

175. DHAR – the Danish Hip Arthroscopy Register
Bent Lund, Søren Winge, Otto Kraemer, Svend Erik Christiansen, Martin Lind
Dept. of Sportstraumatology, University Hospital of Aarhus; , Københavns Privathospital

Background: Hip arthroscopy as a treatment modality was included in the Danish Board of Health speciality plan in 2010 as a regional function.
Purpose / Aim of Study: The background was to make sure that surgeons performed a sufficient number of procedures to be proficient in this demanding type of surgery. 10 departments and clinics were allowed to perform hip arthroscopy. The Danish Society for Sportstraumatology and Arthroscopy (SAKS) supported the establishment of a national clinical registry for hip arthroscopy to be able monitor development and outcome of hip arthroscopy surgery. The purpose of present study is to present the Danish Hip Arthroscopy Register and data from the registry.
Materials and Methods: The registry opened February 1st 2012. Surgeons enter data on radiology and operative procedures. These are CE-angle, Alfa angle, labral and cartilage surgery, CAM and Pincer surgery, OR- and traction time, antibiotics and DVT prophylaxis. Extraarticular procedures and complications are noted. Patients enter Patients Related outcome Measures (PROM) preoperatively and at 1, 2 and 5 years follow-up. The following PROM are used: pain score at rest and after 15 min. Walk, iHOT12, HAGOS, EQ5D and HSAS score.
Findings / Results: Data from 554 procedures are included. 8 out of 10 departments have reported their operations. Mean number of surgeries was 77. Mean OR-time was 95 minutes and mean traction time 56 minutes. Mean CE- angle was 33 (15-65) and mean Alfa-angle 69 (30-108). 487 patients had a labral tear and 471 had labral surgery performed. The labrum was reinserted in 384 patients. The depth of bumpectomy for CAM was recorded (mean 4,4 mm’s) and extent of the rimtrimming was 3,7 mm.
Conclusions: This descriptive report about the Danish Hip Arthroscopy Register shows that a National Register can give valuable details about hip arthroscopy surgery.