Session 1: Sports/ arthroscopy

Onsdag den 23. oktober
09:00 – 10:00
lokale: Stockholm/Copenhagen
Chairmen: Kristoffer Barfod / Martin Lind

1. The influence of early weight-bearing after non-operative treatment of acute Achilles tendon rupture on biomechanical properties of the plantar-flexor muscle-tendon complex. A blinded, randomized, controlled trial.
Jesper Bencke, Kristoffer W Barfod, Hanne Bloch Lauridsen , Christian Dippmann, Lars Ebskov, Anders Troelsen
Gait Analysis Laboratory, dept. of Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Copenhagen University Hospital, Bispebjerg, Denmark, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark

Background: Early weight-bearing has several potential advantages during treatment of Achilles tendon rupture, including better healing of the tendon. This may affect the biomechanical properties of the plantar- flexor muscle-tendon complex (PMTC) with possible consequences for functional performance and risk of re-injury.
Purpose / Aim of Study: To compare the biomechanical properties of the PMTC of both legs in patients randomized to early weight-bearing (WB) or non-WB in non-operative treatment of ATR.
Materials and Methods: The study was conducted as a RCT randomising 60 patients into two groups. In both groups, patients were treated non- operatively with dynamic rehabilitation. The intervention group was allowed full WB from day 1 of treatment. The control group was non-WB for 6 weeks. After 6 and 12 months the passive torque at 20 degrees dorsiflexion and stiffness during slow stretching in early, medium and late dorsiflexion (DF) were measured in both the affected (A) and unaffected (UA) leg.
Findings / Results: There were no significant differences between the WB and the non-WB groups when evaluating the PMTC properties. Compared to UA, the passive torque was significantly lower for A only at 6 months (91% (p=0.01) and 98% (ns.) at 6 and 12 months, respectively). Stiffness was significantly lower for A during the early part of DF at 6 months, and remained inferior at 12 months despite significant improvement (p=0.019) (71% (p<0.001) and 83% (p<0.001) at 6 and 12 months, respectively).
Conclusions: There was no effect of WB on the biomechanical properties of PMTC compared with non-WB. The reduced stiffness in A in the early part of DF may have implications for coordination of i.e. gait and running, and the fact that the stiffness is not normalised after 12 months may indicate a need for prolonged physiotherapy, irrespective of initial treatment regime.

2. Reconstruction of the medial patellofemoral ligament in adolescents with open growth plates
Ditte Enderlein, Torsten Nielsen, Peter Faunø, Svend Erik Christiansen, Martin Lind
Orthopaedic Department, division of Sports Trauma, Aarhus University Hospital

Background: Medial patellofemoral ligament reconstruction (MPFL-R) has recently been broadly accepted as primary surgical treatment in adults. Reconstruction techniques with osseous fixation in femur cannot be used for patients with open growth plates. Operative treatment of patella instability in children therefore is a challenge and requires alternative MPFL-R techniques. Limited knowledge exists concerning outcome after MPFL-R in children and adolescents.
Purpose / Aim of Study: This study presents clinical outcome in a consecutive single clinic series of children treated with paediatric (MPFL-R) using a soft tissue femoral fixation technique.
Materials and Methods: 23 children aged 8-16 operated with 25 MPFL-R between 2008 and 2011 are included. Indication for surgery was two or more patella dislocations and ADL limitations. Surgical technique: Gracilis tendon was looped around the adductor magnus tendon and fixed through drillholes in the proximal medial patella edge. Clinical outcome were evaluated with Kujala score and NRS pain score preoperatively and at 1 year follow-up including incidences of recurrent instability episodes.
Findings / Results: Kujala score improved from 64 to 81. NRS pain score improved from 2,9 to 0,6 in activity. 4 patients (16%) experienced re- dislocation within the 1st year. 5 patients (20%) experienced subluxations. 1 patient with a re-dislocation was re-operated with adult MPFL technique. Cartilage injury was seen in 5 patients. 4 out of 5 patients with cartilage injury had recurrent instability.
Conclusions: There are clinical relevant improvements in knee function and pain after paediatric MPFL-R. Stability and strength of the reconstruction though seem to be inferior to adult MPFL-R techniques postoperatively. Cartilage injury is correlated to recurrent patella instability.

3. Traction related complications during hip arthroscopy.
Lone Frandsen, RN, Bent Lund, M.D, Svend Erik Christiansen, M.D, Torsten Grønbech Nielsen, PT, Martin Lind, Prof. M.D.
Dept of Sportstraumatology, Aarhus University Hospital

Background: Complications can arise from the traction during hip arthroscopy.
Purpose / Aim of Study: The aim of this investigation was to investigate traction related complications. We also investigated how the patients perceive and cope with traction related problems.
Materials and Methods: The investigation is based on a prospective cohort study partly supplemented with interviews. Data were collected by questionnaires from patients who had undergone hip arthroscopy as well as data from the patients files. 100 consecutive patients were included in the study. The questionnaire was used 10 and 90 days postoperatively. Questions were related to location and duration of symptoms. The questionnaire was supplemented with a semi-structured interview with 6 patients, who had experienced complications related to the traction.
Findings / Results: The results demonstrated that 74% of the patients had minimum one complication at the groin, knee or foot level. 32% had complications in the groin or perineal area in the form of swelling, scratches/bruising or sensibility changes. 49% had complications at knee level in the form of swelling, laxity feeling or sensibility changes. 37% had complications at foot or ankle level in the form of swelling, bruising or sensibility changes. Generally the complications were limited and disappeared within 2-4 weeks. Females had more complications than males. No difference was found in traction times between patients with and without complications (36/39 minutes). The interviews revealed that patients lacked information about complications in general the duration of complications and what they should to do to handle them.
Conclusions: The results are surprising as the existing literature report much lower complication rates related to traction than found in the present study.

4. ACL reconstruction in children. Results from the Danish Registry for Knee Ligament Reconstruction
Peter Faunø, Lene Wagner, Martin Lind
Dept. of Sports Traumatology, Aarhus University Hospital

Background: An increasing number of ACL ruptures are registered in children and adolescents. More information on the fate of ACL reconstruction is needed, since the evidence for surgical treatment in the young patient is low
Purpose / Aim of Study: To describe the outcome of ACL reconstruction in children and adolescents based on data from the Danish ACL Registry
Materials and Methods: The data are subtracted from the Danish national ACL registry. The analysis is based on population of 14.806 ACL reconstructed patients. Outcome was evaluated by risk of ACL revision, subjective outcome score (KOOS), Tegner function score and objective laxity scores. Three age groups (A: <13, B: 13-15, and C: 15-20 years) were compared to D: patients 20 years and older (adults). 95 patients in group A. 337 in B, 2.888 in C and 11.496 were above 20 years (group D)
Findings / Results: We found significantly increased risk for revision surgery in the age group B (6,7%) and C (4,9%) compared to adults (2,0%). Objective laxity did not differ between the four groups. Group A, B and C had higher KOOS4 (79.6, 76.6, 73.1 respectively)) score compared to the adults (69.7). Group B had higher KOOS QOL (76.6/73.1) and sports (71.1/66.4) scores than group C. Tegner activity score did not differ between the four groups. We could not detect any impact of the use of extracortical graft fixation in the youngest age group.
Conclusions: Patients between 13-20 years have an increased risk of graft failure. This is in contrast to the better subjective and objective knee function scores in the same age groups. These findings indicates that young ACL patients could benefit from a more careful guidance in their postoperative activity.

5. Outcome after posterior cruciate ligament (PCL) reconstruction.
Bjarne Mygind-Klavsen, Svend Erik Christiansen, Bent Lund, Peter Faunø, Mads Uldum Roesgaard, Martin Lind
Division of Sports Trauma, Department of Orthopedic Surgery, Aarhus University Hospital

Background: PCL reconstruction are rarely performed compared to anterior cruciate ligament reconstruction.
Purpose / Aim of Study: The purpose of this study was to evaluate the clinical and functional outcome after PCL reconstruction either isolated or as multiligament reconstruction.
Materials and Methods: 197 patients who underwent PCL reconstruction during the period 2005 to 2010 were included. We performed a standardized follow-up in 2012/2013 consisting of subjective scores (Tegner activity score, KOOS and subjective IKDC) and objective measures including knee laxity (KT1000, 70 dgr), extension strength and overall IKDC score. We compared these follow-up data with data from the Danish Registry for Knee Ligament Reconstruction.
Findings / Results: 100 patients were available for follow-up, 42% with isolated PCL and 58% with multiligament injury. Mean follow up time was 60 month (37-99). KOOS scores at follow- up in the isolated PCL group was respectively: sympt. (73), pain (77), ADL (83), sport (57) and QOL (58). And in the multiligament group: sympt. (75), pain (81), ADL (86), sport (60) and QOL (58). Tegner scores was respectively 4.9 and 5.6 and subjective IKDC was 68 and 65. Comparison with data from the Danish Registry for Knee Ligament Reconstruction shows only minor differences in subjective outcome between Primary ACL reconstruction KOOS data and PCL reconstruction patients from this study. The average side to side difference in knee laxity was in the isolated PCL group 2.2 mm compared to 3.2 mm in the multiligament group.
Conclusions: Although the average side to side knee laxity between the two groups is 1 mm the functional outcome score is almost identical. Regarding KOOS scores after primary ACL reconstruction versus isolated or combined PCL reconstruction surgery there is only a minor difference in subjective outcome.

6. Clinical outcome after PCL support bracing treatment for patients with acute posterior cruciate ligament injury
Sinan Said, Martin Lind, Torsten Grønbech Nielsen, Christina Mikkelsen, Bjørn Engstrøm
orthopedic , Aalborg University Hospital; orthopedic, Aarhus University Hospital; , capio artro clinic in stockholm

Background: Posterior cruciate ligament (PCL) injury occurs typically due to high energy trauma. Patients with grade 3 injuries are often treated operatively while those with grade 1 & 2 can be managed conservatively by bracing.
Purpose / Aim of Study: The aim of the study is to evaluate the outcome of non-operative management of acute isolated PCL injuries.
Materials and Methods: From March 2004 to April 2012, 36 patients with isolated acute (< 4 weeks) PCL injury were treated with PCL support brace (Jack brace). A brace with tibial supporters designed to prevent posterior displacement at the knee. 29 ptt were from Capio Arthro Clinic in Stockholm and 7 ptt from Aarhus University hospital. 23 pt were present for a median follow up of 43 months. Functional outcomes were evaluated with Lysholm score, International Knee Documentation Committee subjective (IKDC), KOOS, Tegner, Werner scores as well as one leg hop test and anterior/posterior knee stability measured with KT-1000 arthrometer.
Findings / Results: There were 10 females and 13 males. Average age at the time of injury was 23 yrs. Mean Lysholm score was 86, median Tegner was 7, objective IKDC 2000 score showed 57% were nearly normal and 43% abnormal, KOOS scores for pain, symptoms, ADL, sport, QOL was 90,86,93,76,74 respectively. Average Werner score was 43, Average knee function (one leg hop) compared to non-injured knee was 96%. Average side-to-side difference at 70 degrees of knee flexion was 1mm.
Conclusions: PCL support bracing with attached tibial supporters designed to prevent posterior displacement at the knee yielded satisfactory clinical and functional results in the majority of the cohort study group.

7. A validation study of the Danish Knee Ligament Reconstruction Registry.
Lene Rahr-Wagner, Theis Thillemann, Martin Lind, Alma Pedersen
Orthopedic, Aarhus University Hospital; Clinical Epidemiology, Aarhus University Hospital

Background: The Danish Knee Ligament Reconstruction Registry (DKRR) is a population-based database. The validity of the database is not known. It is of crucial importance to evaluate the registration completeness and to validate the data quality in such a database in order to be able to draw valid and reliable conclusions.
Purpose / Aim of Study: The aim of this study was to validate the DKRR by assessing the registration completeness of the ACL reconstruction (ACLr) code and detecting the validity of important key variables. Furthermore, we assessed data quality of patient-related outcome scores
Materials and Methods: All operation codes for ACLr from 2005 to 2011 were identified in the Danish National Registry of Patients and compared with the cases registered in the DKRR to compute the completeness of registration in the DKRR. We also assessed the validity of key variables using medical records as a gold standard to compute the positive predictive value (PPV). Finally, we assessed potential differences between responders and non- responders to subjective patient- related outcome scores (KOOS and Tegner scores) one year after surgery.
Findings / Results: The completeness of registration of patients in the DKRR rose from 60% (2005) to 86% (2011). Large-volume hospitals had a significantly higher completeness than small-volume hospitals. With a PPV between 85% and 100%, the validity of key variables was good. KOOS vs. Tegner scores for responders and non-responders were comparable.
Conclusions: The results show a good registration of ACLr procedures in the DKRR, but there is room for improvement mainly at small-volume hospitals. Overall, the validity of the key variables in the DKRR was good and no difference was found in KOOS and Tegner scores for responders vs. non- responders. Therefore, we conclude that the DKRR is a valid source for future research.

8. Patient reported outcomes are strongly associated by lower limb loading pattern, mechanical muscle strength and functional performance in acl-patients-a cross-sectional study
Anders Holsgaard-Larsen, Carsten Jensen, Per Aagaard
Orthopaedic Research Unit, Department of Orthopaedics and Traumatology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark; Institute of Sports Science and Clinical Biomechanics, Muscle Research Cluster (SMRC), University of Southern Denmark

Background: Despite, being considered as two distinct constructs, associations between objective measures and self- reported outcomes (i.e. Knee Injury and Osteoarthritis Outcome Score (KOOS)) may specify focus areas in the rehabilitation of ACL-patients.
Purpose / Aim of Study: To investigate the extent to which a test-battery of 15 objective outcome measures of physical function are associated with KOOS-subscales in ACL-reconstructed patients, with the perspective of identifying areas of intervention that potentially could facilitate rehabilitation in this patient- group.
Materials and Methods: This cross sectional study was performed in 23 ACL-reconstructed men (mean age: 27.2±7.5 years and BMI: 25.4±3.2) 18-30 month post- surgery. KOOS-questionnaire was filled out and subsequently, patients performed a test-battery composed by: (i) bilateral and (ii) unilateral maximal counter movement jumps (CMJ). Kinematic data were synchronously recorded by a 6-camera Vicon MX system. Furthermore, patients performed (iii) one-leg maximal jump for distance and (iv) maximal isometric knee extensor and flexor strength (MVC). Backward multiple stepwise linear regression analysis was conducted using each of the 5 KOOS- subscales as the depended variables, and the 15 objective outcomes from the test-battery as independed variables.
Findings / Results: Strong associations between objective outcomes and KOOS subscales were observed: QOL (r2=0.89, p < 0.001), Pain (r2=0.74, p < 0.002), Sport/Rec (r2=0.71, p < 0.001) and ADL (r2=0.57, p < 0.001) along with a moderate association for Symptoms (r2=0.18, p < 0.05).
Conclusions: A very large proportion (57-89%) of the variation in KOOS (QOL, Pain, Sport/Rec, and ADL) was explained by the current objective test-battery. Thus, future research on ACL-rehabilitation should emphasise areas of intervention evaluated by the current test-battery.